title: Ischemic stroke and transient ischemic attack after head and neck radiotherapy: a review.
abstract: OBJECTIVE
  Cerebrovascular disease can complicate head and neck radiotherapy and result in transient ischemic attack and ischemic stroke. Although the incidence of radiation vasculopathy is predicted to rise with improvements in median cancer survival, the pathogenesis, natural history, and management of the disease are ill defined.
  
  
  METHODS
  We examined studies on the epidemiology, imaging, pathogenesis, and management of medium- and large-artery intra- and extra-cranial disease after head and neck radiotherapy. Controlled prospective trials and larger retrospective trials from the last 30 years were prioritized.
  
  
  RESULTS
  The relative risk of transient ischemic attack or ischemic stroke is at least doubled by head and neck radiotherapy. Chronic radiation vasculopathy affecting medium and large intra- and extra-cranial arteries is characterized by increasing rates of hemodynamically significant stenosis with time from radiotherapy. Disease expression is the likely consequence of the combined radiation insult to the intima-media (accelerating atherosclerosis) and to the adventitia (injuring the vasa vasorum). Optimal medical treatment is not established. Carotid endarterectomy is confounded by the need to operate across scarred tissue planes, whereas carotid stenting procedures have resulted in high restenosis rates.
  
  
  CONCLUSIONS
  Head and neck radiotherapy significantly increases the risk of transient ischemic attack and ischemic stroke. Evidence-based guidelines for the management of asymptomatic and symptomatic (medium- and large-artery) radiation vasculopathy are lacking. Long-term prospective studies remain a priority, as the incidence of the problem is anticipated to rise with improvements in postradiotherapy patient survival.
authors.affiliation: Center for Neurosciences and Neurological Research, St Vincent's Hospital, Level 5 Daly Wing, 35 Victoria Parade, Fitzroy, Victoria, Australia, 3065. chris.plummer@svhm.org.au
authors.forename: Chris
authors.initials: C
authors.lastname: Plummer
authors.forename: Robert D
authors.initials: RD
authors.lastname: Henderson
authors.forename: John D
authors.initials: JD
authors.lastname: O'Sullivan
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Read
mesh_terms: D002545:Brain Ischemia / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D005260:Female; D006258:Head and Neck Neoplasms / Q000532:radiotherapy*; D006801:Humans; D008297:Male; D011832:Radiation Injuries / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D011878:Radiotherapy / Q000009:adverse effects*; D012307:Risk Factors; D020521:Stroke / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D013997:Time Factors