Makindo Medical Notes

Related Subjects: |Acute Stroke Assessment (ROSIER&NIHSS) |Causes of Stroke |Ischaemic Stroke |Cancer and Stroke |Cardioembolic stroke |CT Basics for Stroke

Introduction

• ⚡ Stroke can complicate head and neck radiotherapy, manifesting as TIA or ischaemic stroke.
• 🩸 It particularly affects smaller penetrating vessels in the radiation field.

💡 Key point: Radiation-induced vasculopathy is a late complication, often presenting years after treatment. Always ask about previous radiotherapy in young patients with stroke.

Delayed Effects of Radiation

• ⏳ Occlusive vasculopathy is delayed, appearing years after therapy.
• 🧠 May mimic moyamoya disease with net-like collaterals and transdural anastomoses.
• 📈 Rising cancer survival rates mean more patients are living long enough to develop these vascular complications.

Tumours Requiring Radiotherapy

• 🗣️ Squamous cell carcinoma of the head and neck.
• 🧬 Lymphoma and 🩺 breast cancer (neck fields often included).
• 🧠 Pituitary tumours (adults), optic pathway gliomas (children).
• 🌏 Nasopharyngeal carcinoma → radiation field often involves both carotid arteries.

Clinical Presentation

• ⚠️ Ischaemic stroke or TIA.
• 🚶 Often lacunar-type episodes (penetrating vessel disease in radiation field).
• 🎧 Signs of carotid stenosis may also develop (bruit, amaurosis fugax, hemispheric TIA).

📝 Exam pearl: A history of radiotherapy is a red flag for stroke in younger patients without conventional risk factors.

Investigations

• 🩻 CTA: Identifies strictures, narrowing, and collateral vessels in radiation field.
• 🧲 MRI: Detects small infarcts in affected territories.
• 🩺 Carotid Duplex: Detects carotid narrowing/stenosis.

Differential Diagnosis

• 👴 Standard small vessel disease due to hypertension, diabetes, or age.
• 🧬 Moyamoya disease (can look very similar radiographically).
• 🦠 Vasculitis (rare but important to consider).

Management

• 🏥 Standard stroke management (ABCs, risk factor control: BP, lipids, diabetes, smoking cessation).
• 🔧 Carotid endarterectomy is technically challenging due to scarred tissues from radiotherapy.
• 🧩 Stenting is often an alternative but carries higher restenosis risk.

🌟 Clinical takeaway: Always consider prior radiotherapy as a stroke risk factor. Manage aggressively like standard atherosclerotic disease, but anticipate surgical challenges.

References and Further Reading

• Ischaemic Stroke and Transient Ischaemic Attack After Head and Neck Radiotherapy. Stroke. 2011;42:2410-2418.