Cardiovascular Complications of Cranial and Neck Radiation
- 388 Downloads
Cancer survivors who receive head and neck radiation are at increased risk for cerebrovascular events. This is mediated via damage to the hypothalamus-pituitary axis leading to the metabolic syndrome and extracranial arterial injury leading to carotid artery stenosis. Head and neck radiation can also lead to intracranial injury that can present as moyamoya, especially in children. Survivors require lifelong periodic follow-up for the development of pan-hypopituitarism or its individual components as well as for dyslipidemia and obesity. Aggressive control of traditional cardiovascular risk factors is recommended to reduce cardiovascular morbidity and mortality. There are no specific guidelines for the surveillance and management of asymptomatic carotid artery disease in cancer survivors. However, regular detailed examination for carotid bruits and neurological symptoms is recommended. Treatment of significant radiation-induced carotid artery disease has not been specifically studied and is based upon recommendations for patients with atherosclerotic carotid stenosis. Carotid endarterectomy can be difficult in radiation patients due to anatomic concerns and the risk of post-operative cranial nerve injury and wound complications but should be considered in patients with suitable anatomy and neck architecture. Carotid artery stenting, while successful, may be associated with greater long-term mortality and neurologic complications. Regardless of the strategy employed, radiation patients are at increased risk for restenosis and should undergo routine surveillance even after revascularization.
KeywordsCardio-oncology Carotid artery disease Radiation
Compliance with Ethical Standards
Conflict of Interest
Syed S. Mahmood and Anju Nohria each declare no potential conflicts of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: •• Of major importance
- 1.Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA: Cancer J Clin. 2013;63:11–30.Google Scholar
- 2.Kero A, Madanat‐Harjuoja L, Järvelä L, Malila N, Matomäki J, Lähteenmäki P. Cardiovascular medication after cancer at a young age in Finland: a nationwide registry linkage study. Int J Cancer. 2015.Google Scholar
- 13.Groarke JD, Nguyen PL, Nohria A, Ferrari R, Cheng S, Moslehi J. Cardiovascular complications of radiation therapy for thoracic malignancies: the role for non-invasive imaging for detection of cardiovascular disease. Eur Heart J. 2013:eht114.Google Scholar
- 17.Bulow B, Link K, Ahren B, Nilsson AS, Erfurth EM. Survivors of childhood acute lymphoblastic leukaemia, with radiation-induced GH deficiency, exhibit hyperleptinaemia and impaired insulin sensitivity, unaffected by 12 months of GH treatment. Clin Endocrinol (Oxf). 2004;61:683–91.CrossRefGoogle Scholar
- 19.••Mueller S, Fullerton HJ, Stratton K, et al. Radiation, atherosclerotic risk factors, and stroke risk in survivors of pediatric cancer: a report from the Childhood Cancer Survivor Study. Int J Radiat Oncol Biol Phys. 2013;86:649–55. Analysis of the Childhood Cancer Survivor Study showing the increased risk of stroke in children exposed to CRT compared to their untreated siblings. It also describes the predictors and timing of stroke occurrence in these patients.CrossRefPubMedPubMedCentralGoogle Scholar
- 20.••Long-term follow up guidelines for survivors of childhood, adolescent, and young adult cancers: version 4.0.www.survivorshipguidelines.org Children’s Oncology Group 2014. Accessed 15 Apr 2016. Consensus guidelines for the surveillance and treatment of childhood cancer survivors.
- 23.••Bashar K, Healy D, Clarke-Moloney M, Burke P, Kavanagh E, Walsh S-R. Effects of neck radiation therapy on extra-cranial carotid arteries atherosclerosis disease prevalence: systematic review and a meta-analysis. PLoS One. 2014;9, e110389. Meta-analysis of eight case-control and randomized controlled trials evaluating extracranial carotid artery stenosis in adult survivors of head and neck cancers. Results showed that risk was higher in the CRT patients compared to non-irradiated controls.CrossRefPubMedPubMedCentralGoogle Scholar
- 26.Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. J Am Coll Cardiol. 2011;57:e16–94.CrossRefPubMedGoogle Scholar
- 41.Follin C, Thilen U, Ahren B, Erfurth EM. Improvement in cardiac systolic function and reduced prevalence of metabolic syndrome after two years of growth hormone (GH) treatment in GH-deficient adult survivors of childhood-onset acute lymphoblastic leukemia. J Clin Endocrinol Metab. 2006;91:1872–5.CrossRefPubMedGoogle Scholar