Radiation-Induced Large Vessel Cerebral Vasculopathy in Pediatric Patients with Brain Tumors Treated with Proton Radiotherapy

Purpose The purpose of this research is to evaluate the incidence, time to development, imaging patterns, risk factors, and clinical significance of large vessel cerebral vasculopathy in pediatric patients with brain tumors treated with proton radiotherapy. Materials and Methods A retrospective study was performed on 75 consecutive pediatric patients with primary brain tumors treated with proton radiotherapy. Radiation-induced large vessel cerebral vasculopathy (RLVCV) was defined as intracranial large vessel arterial stenosis or occlusion confirmed on MRA, CTA, and/or catheter angiography within an anatomic region with previous exposure to proton beam therapy and not present prior to radiotherapy. Clinical records were used to determine the incidence, timing, radiation dose to the large vessels, and clinical significance associated with the development of large vessel vasculopathy in these patients. Results RLVCV was present in 5/75 (6.7%) of patients and included tumor pathologies of craniopharyngioma (2), ATRT (1), medulloblastoma (1), and anaplastic astrocytoma (1). Median time from completion of radiotherapy to development was 1.5 years (mean 3.0 years; range 1.0-7.5 years). Neither mean age at time of radiotherapy (5.1 years) nor mean radiotherapy dose to the large vessels (54.5 Gy) were statistically significant risk factors. Four of the five patients with RLVCV presented with acute stroke, and demonstrated MRI evidence of acute infarcts in the expected vascular distributions. Angiography studies demonstrated collateral vessel formation in only two of the patients with RLVCV. No patients demonstrated acute hemorrhage or aneurysm. Two patients were treated with pial synangiomatosis surgery. Conclusion RLVCV can occur in pediatric patients with brain tumors treated with proton radiotherapy. Further studies are necessary to determine potential risk factors for large vessel vasculopathy with proton radiotherapy in comparison with conventional photon radiotherapy