Case of the Week
Section Editors: Matylda Machnowska1 and Anvita Pauranik2
1University of Toronto, Toronto, Ontario, Canada
2BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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March 28, 2019
Radiation-induced vasculopathy with pontine hematoma
- Background
- The major cause of hematomas in the the pons is systemic arterial hypertension (other causes may be ruptured AVMs, bleeding of cavernomas or tumors, and vasculopathy).
- However, in this case, the patient had a history of surgery and irradiated brain tumor of the posterior fossa, without clinical history of hypertension.
- Brain radiation therapy may be associated with multiple vascular disorders with early or late clinical manifestations, including telangiectasias, ischemic or haemorrhagic strokes, microbleeds, Moya Moya syndrome or arteriovenous malformations.
- Clinical Presentation
- Radiation-induced vasculopathy can cause symptoms related to limited blood flow (ischemia) to the brain – stroke or TIA.
- Symptoms may include sudden hemiparesis, confusion, aphasia, dysarthria, dizziness, and loss of balance or coordination.
- Radiation-induced vasculopathy can also result in sudden bleeding in the brain, i.e. hemorrhagic stroke. Symptoms of a hemorrhagic stroke depend on the location.
- In the pons, this may present as decreased level of consciousness (most common), long tract signs, cranial nerve palsies, and/or Cheyne-Stokes respiration.
- Key Diagnostic Features
- Radiation induced vasculopathy is usually associated with multifocal vessel stenosis and microbleeds within the irradiated territory.
- The vascular changes can also cause ischemic strokes.
- The localization of abnormalities to the irradiated territory, and absence of microbleeds in the basal ganglia and thalami (locations characteristic of hypertension) such as in this case, suggests the diagnosis of radiation-induced vasculopathy.
- Differential Diagnoses
- Systemic arterial hypertension
- Ruptured AVM
- Multiple cavernomas or hemorrhagic metastases
- Cerebral amyloid angiopathy
- Treatment
- The treatment options for radiation induced vasculopathy are limited, but may include angioplasty or bypass when possible.