Evaluation and treatment of children with radiation-induced cerebral vasculopathy

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Stenoocclusive cerebral vasculopathy is an infrequent delayed complication of ionizing radiation. It has been well described with photon-based radiation therapy but less so following proton-beam radiotherapy. The authors report their recent institutional experience in evaluating and treating children with radiation-induced cerebral vasculopathy.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>Eligible patients were age 21 years or younger who had a history of cranial radiation and subsequently developed vascular narrowing detected by MR arteriography that was significant enough to warrant cerebral angiography, with or without ischemic symptoms. The study period was January 2011 to March 2019.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Thirty-one patients met the study inclusion criteria. Their median age was 12 years, and 18 (58%) were male. Proton-beam radiation therapy was used in 20 patients (64.5%) and photon-based radiation therapy was used in 11 patients (35.5%). Patients were most commonly referred for workup as a result of incidental findings on surveillance tumor imaging (n = 23; 74.2%). Proton-beam patients had a shorter median time from radiotherapy to catheter angiography (24.1 months [IQR 16.8–35.4 months]) than patients who underwent photon-based radiation therapy (48.2 months [IQR 26.6–61.1 months]; p = 0.04). Eighteen hemispheres were revascularized in 15 patients. One surgical patient suffered a contralateral hemispheric infarct 2 weeks after revascularization; no child treated medically (aspirin) has had a stroke to date. The median follow-up duration was 29.2 months (IQR 21.8–54.0 months) from the date of the first catheter angiogram to last clinic visit.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>All children who receive cranial radiation therapy from any source, particularly if the parasellar region was involved and the child was young at the time of treatment, require close surveillance for the development of vasculopathy. A structured and detailed evaluation is necessary to determine optimal treatment.</jats:p></jats:sec>

Use of the Posterior Auricular Artery for Indirect Bypass in Moyamoya: A Pediatric Case Series

“…None has had a post-EDAS stroke. These results, combined with the results of Hersh et al [16], support consideration of the PAA for indirect revascularization procedures in children and adolescents when the STA is not a suitable candidate or when an additional donor artery is desired.…”

“…Ten hemispheres in this study underwent PAA EDAS, and the authors found similar Matsushima grades [15] in patients who underwent PAA versus STA EDAS. In addition, Hersh et al [16] reported use of the PAA for indirect revascularization in 2 pediatric patients with radiation-induced cerebral vasculopathy as part of a larger study in which various external carotid branches, including the STA and OA, were used; they reported robust collateralization formation at 1 year post-surgery, with no post-surgical infarctions.…”

“…Although the ivy sign seemed to have improved after surgery, how contrast affects the ivy sign on FLAIR seems to be variable. A paper by Yoon et al [16] found that contrast increased the ivy sign in 7 of 28 hemispheres of children with moyamoya and decreased it in 4; it was unchanged in the rest. Our latter patient did have later postoperative FLAIR imaging without contrast on which the ivy sign also appeared to have improved, but these were performed after the patient had an ipsilateral OA EDAS, another confounding factor.…”

Pediatric Neuro-oncology

“…Data are limited for antithrombotic therapy for secondary stroke prevention in children and are mostly extrapolated from adults. Antiplatelet therapy is recommended for patients with moyamoya disease 73,76,77 . Surgical revascularization is considered in patients with clinical symptoms concerning for transient ischemic attacks or strokes, chronic subclinical ischemia, progressive vasculopathy, and high-grade vascular stenosis 76,77 .…”

“…73,76,77 Surgical revascularization is considered in patients with clinical symptoms concerning for transient ischemic attacks or strokes, chronic subclinical ischemia, progressive vasculopathy, and high-grade vascular stenosis. 76,77 Current recommendations for brain tumor survivors who have received RT include yearly neurologic examinations and brain MRI with DWI and MR angiography (MRA) as clinically indicated. 78,79 Radiation necrosis can be seen as early as immediately after completion of RT but can also present years later.…”