Radiation-induced cerebral vasculopathy encompasses a complex and broad range of effects on the intra- and extracranial vessels resulting from injury from radiation exposure. Manifestations can include hemorrhages and ischemic strokes, cavernoma and capillary telangiectasias, and large vessel stenosis mimicking moyamoya pattern.
Clinical symptoms are broad and depend on the underlying vasculopathy. Radiation-induced telangiectasia and microbleeds may be asymptomatic. However, patients may present with focal neurological deficits resulting from both hemorrhagic and ischemic stroke, lacunar lesions, vascular occlusive disease including moyamoya pattern, vascular malformations, and radiation-induced necrosis.
The likelihood of complications depends on individual patient factors, including age, and the specifics of the type and dose of radiation.
A number of processes occur in vessels following radiation-induced injury and are dependent on dose, however, the dominant earliest phenomenon is endothelial damage. This not only results in disruption of the blood-brain-barrier but also may result in local thrombosis and hemorrhage 5.
Following repair, vessels tend to be dilated and demonstrate endothelial proliferation, basement membrane thickening and adventitial fibrosis 5.
Relatively low doses tend to result in the development of capillary telangiectasias, whereas high doses have more profound effects including blood vessel wall necrosis 5.
Biopsy and pathological analysis of radiation-induced telangiectasias have demonstrated deposition of perivascular hemosiderin and hemorrhage adjacent to capillary-sized telangiectasia (pre-existing dilated channels rather than proliferating vascular neoplasm) 3.
Veins are affected less than arteries and capillaries 5.
The imaging features are different depending on the manifestation and are thus discussed separately, however, it should be noted that unlike sporadic cases the distribution of changes is usually confined to the radiation field.
- capillary telangiectasia
- large vessel stenosis (moyamoya pattern)
- intracranial hemorrhage
- ischemic stroke
- radionecrosis (not purely a vasculopathy)
Treatment and prognosis
Treatment is directed at the underlying specific disease and ranges from expectant (for telangiectasias) to intensive standard management of cerebral hemorrhages and ischemic strokes.
Elective angioplasty and stenting of significant large arterial stenoses may also be appropriate for high-grade lesions 5.
- 1. Li M, Wu SW, Xu WH. High-resolution MRI of radiation-induced intracranial vasculopathy. Neurology. 2015;84 (6): 631. doi:10.1212/WNL.0000000000001223 - Pubmed citation
- 2. Bitzer M, Topka H. Progressive cerebral occlusive disease after radiation therapy. Stroke. 1995;26 (1): 131-6. Pubmed citation
- 3. Gaensler EH, Dillon WP, Edwards MS et-al. Radiation-induced telangiectasia in the brain simulates cryptic vascular malformations at MR imaging. Radiology. 1994;193 (3): 629-36. doi:10.1148/radiology.193.3.7972799 - Pubmed citation
- 4. Osborns Brain. Lippincott Williams & Wilkins. ISBN:1931884218. Read it at Google Books - Find it at Amazon
- 5. Murphy ES, Xie H, Merchant TE, Yu JS, Chao ST, Suh JH. Review of cranial radiotherapy-induced vasculopathy. (2015) Journal of neuro-oncology. 122 (3): 421-9. doi:10.1007/s11060-015-1732-2 - Pubmed
Related Radiopaedia articles
external beam radiation therapy (EBRT)
- conventional (2D) radiation therapy
- 3D conformal radiation therapy
- intensity-modulated radiation therapy (IMRT)
- stereotactic radiosurgery
- electron therapy
- particle (hadronic) therapy
- sealed source radiation therapy (brachytherapy)
- unsealed source radiation therapy
- external beam radiation therapy (EBRT)
- complications related to radiation therapy
- acute radiation syndrome
- complications of cranial radiation therapy
- radiation-induced thyroid cancer
- radiation-induced neuritis
complications of thoracic radiation therapy
- soft tissues
- bony thoracic cage
- complications of abdominopelvic radiation therapy
- radiation-induced bone marrow signal changes - MRI