Systematic review| Volume 90, ISSUE 2, P163-165, February 2009

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Risk of cerebrovascular events after neck and supraclavicular radiotherapy: A systematic review

Published:January 27, 2009DOI:



      Although low dose radiation therapy (RT) has been used to prevent re-occlusion of coronary arteries, it may also precipitate vascular damage. Specifically, irradiation to the neck is related to subsequent vascular wall thickening and atherosclerotic plaque formation. Several investigators, reporting patients with varied disease processes and using different methods, have described an increased risk of cerebrovascular events (CVEs) after RT to the neck for head and neck cancer, breast cancer, or lymphoma. Our purpose is to determine the rate and risk of CVEs in patients after receiving radiation therapy to the neck.


      We performed a pooled analysis of the published data to document the cumulative risk of subsequent stroke after RT to the neck. An extensive MEDLINE and PUBMED search yielded five articles involving 6908 patients describing institutional series or cohort analyses comparing the frequency of CVE in irradiated versus non-irradiated patients.


      Sixty-six CVEs were reported in 2567 patients after neck RT, whereas only 12 CVEs were documented in 4119 non-irradiated patients. Crude risk of CVEs after neck RT was 2.6%, and was 0.29% in non-irradiated patients. This odds ratio of 9.0 was statistically significant (95% CI 4.9, 16.7; p < 0.0001). Data for supraclavicular RT were more difficult to analyze given differences in populations and reporting between the three studies, but it appears a significant risk is unlikely.


      Neck RT increases the likelihood of CVEs, but this risk must be reconciled with the benefits of the therapy in the specific clinical situation. For instance, consideration should be made to limiting neck RT where possible for breast cancer and lymphoma patients.


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        • Teirstein P.S.
        • Massullo V.
        • Jani S.
        • et al.
        The SCRIPPS trial – catheter-based radiotherapy to inhibit restenosis after Coronary Stenting.
        NEJM. 1997; 24: 1697-1703
        • Le on M.B.
        • Teirstein P.S.
        • Moses J.W.
        • et al.
        Localized intracoronary Gamma-radiation therapy to inhibit the recurrence of restenosis after stenting.
        NEJM. 2001; 344: 250-256
        • Smith G.L.
        • Smith B.D.
        • Buchholz T.A.
        • Giordano S.H.
        • Garden A.S.
        • Woodward W.A.
        • et al.
        Cerebrovascular disease risk in older head and neck cancer patients after radiotherapy.
        J Clin Oncol. 2008; 26: 30
        • Nilsson G.
        • Holmberg L.
        • Garmo H.
        • Terent A.
        • Blomqvist C.
        Increased incidence of stroke in women with breast cancer.
        Eur J Cancer. 2005; 41: 423-429
        • Bowers D.C.
        • McNeil D.E.
        • Liu Y.
        • Yasui Y.
        • Stovall M.
        • Gurney J.G.
        • et al.
        Stroke as a late treatment effect of Hodgkin’s Disease: a report from the childhood cancer survivor study.
        J Clin Oncol. 2005; 23: 6508-6515
        • Haynes J.C.
        • Machtay M.
        • Weber R.S.
        • Weinstein G.S.
        • Chalian A.A.
        • Rosenthal D.I.
        Relative risk of stroke in head and neck carcinoma patients treated with external cervical irradiation.
        Laryngoscope. 2002; 112: 1883-1887
        • Moser E.C.
        • Noordijk E.M.
        • van Leeuwen F.E.
        • le Cessie S.
        • Baars J.W.
        • Thomas J.
        • et al.
        Long-term risk of cardiovascular disease after treatment for aggressive non-Hodgkin lymphoma.
        Blood. 2006; 107: 2912-2919
        • Dorresteijn L.D.
        • Kappelle A.C.
        • Boogerd W.
        • Klokman W.J.
        • Balm A.J.
        • Keus R.B.
        • et al.
        Increased risk of ischemic stroke after radiotherapy on the neck in patients younger than 60 years.
        J Clin Oncol. 2002; 20: 282-288
        • Jagsi R.
        • Griffith K.A.
        • Koelling T.
        • Roberts R.
        • Pierce L.J.
        Stroke rates and risk factors in patients treated with radiation therapy for early-stage breast cancer.
        J Clin Oncol. 2006; 24: 2779-2785
        • Conomy J.P.
        • Kelermeyer R.W.
        Delayed cerebrovascular consequences of therapeutic radiation: a clinicopathologic study of a stroke associated with radiation-related carotid arteriopathy.
        Cancer. 1975; 36: 1702-1708
        • Johnstone P.A.
        • Sprague M.
        • DeLuca A.M.
        • Bacher J.D.
        • Hampshire V.A.
        • Terril R.E.
        • et al.
        Effects of intraoperative radiotherapy on vascular grafts in a canine model.
        Int J Radiat Oncol Biol Phys. 1994; 29: 1015-1025
        • Thomas E.
        • Forbus W.D.
        Irradiation injury to the aorta and the lung.
        Arch Pathol. 1959; 67: 256-263
        • Butler M.J.
        • Lane R.H.
        • Webster J.H.
        Irradiation injury to large arteries.
        Br J Surg. 1980; 67: 341-343
        • Dorresteijn L.D.
        • Kappelle A.C.
        • Scholz N.M.J.
        • Munneke M.
        • Scholma J.T.
        • Balm A.J.M.
        • et al.
        Increased carotid wall thickening after radiotherapy on the neck.
        Eur J Cancer. 2004; 41: 1026-1030
        • Fonkalsrud E.W.
        • Sanchez M.
        • Zerubavel R.
        Serial changes in arterial structure following radiation therapy.
        Surg Gynecol Obstet. 1977; 145: 395-400
        • Woodward W.A.
        • Durand J.B.
        • Tucker S.L.
        • Strom E.A.
        • Perkins G.H.
        • Oh J.
        • et al.
        Prospective analysis of carotid artery flow in breast cancer patients treated with supraclavicular irradiation 8 or more years previously.
        Cancer. 2008; 112: 268-273
        • Cheng S.W.
        • Wu L.L.
        • Ting A.C.
        • et al.
        Irradiation-induced extracranial carotid stenosis in patients with head and neck malignancies.
        Am J Surg. 1999; 178: 323-328
        • Walman B.
        • Salvian A.
        • Hay J.H.
        Carotid artery stenosis in asymptomatic patients who have received unilateral head-and-neck irradiation.
        Int J Radiat Oncol Biol Phys. 2005; 63: 1197-1205
        • Brown P.D.
        • Foote R.L.
        • McLaughlin M.P.
        • et al.
        A historical prospective cohort study of carotid artery stenosis after radiotherapy for head and neck malignancies.
        Int J Radiat Oncol Biol Phys. 2005; 63: 1361-1367
        • Hooning M.J.
        • Dorresteijn L.D.A.
        • Aleman B.M.P.
        • Kappelle A.C.
        • Klijn J.G.M.
        • Boogerd W.
        • et al.
        Decreased risk of stroke among 10-year survivors of breast cancer.
        J Clin Oncol. 2006; 24: 5388-5394
        • Woodward W.A.
        • Giordano S.H.
        • Duan Z.
        • Hortobagyi G.N.
        • Buchholz T.A.
        Supraclavicular radiation for breast cancer does not increase the 10-year risk of stroke.
        Cancer. 2006; 106: 2556-2562