Is Routine Carotid Imaging Warranted Following Radiation Treatment of Head and Neck Cancer

  • Benjamin E. Onderdonk
  • Daniel J. HarafEmail author
Part of the Difficult Decisions in Surgery: An Evidence-Based Approach book series (DDSURGERY)


Radiation demonstrates a prominent role in the definitive management of many head and neck cancers. As patients are living longer, they are at a higher risk for neurovascular events from radiation-induced carotid injury. This chapter summarizes the available literature regarding carotid artery surveillance with B-Mode Ultrasound, Doppler Ultrasound, Duplex Ultrasound, and Contrast-Enhanced Ultrasound after head and neck radiation. This chapter also provides guidance for screening from a radiation oncologist’s perspective.


Head and neck Cancer Radiation Carotid Atherosclerosis Stenosis Cerebrovascular accident 


  1. 1.
    Dorresteijn LDA, et al. Increased risk of ischemic stroke after radiotherapy on the neck in patients younger than 60 years. J Clin Oncol. 2002;20(1):282–8.PubMedCrossRefGoogle Scholar
  2. 2.
    De Bruin ML, et al. Increased risk of stroke and transient ischemic attack in 5-year survivors of Hodgkin lymphoma. J Natl Cancer Inst. 2009;13(1):928–37.CrossRefGoogle Scholar
  3. 3.
    Plummer C, Henderson RD, O’Sullivan JD, Read SJ. Ischemic stroke and transient ischemic attack after head and neck radiotherapy: a review. Stroke. 2011;42(9):2410–8.PubMedCrossRefGoogle Scholar
  4. 4.
    Sidhu PS, et al. The extracranial carotid artery in familial hypercholesterolaemia: relationship of intimal-medial thickness and plaque morphology with plasma lipids and coronary heart disease. J Cardiovasc Risk. 1996;3(1):61–7.PubMedCrossRefGoogle Scholar
  5. 5.
    European Stroke Organization. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the task force on the diagnosis and treatment of peripheral artery diseases of the European Society of Cardiology (ESC). Eur Heart J. 2011;32(22):2851–906.CrossRefGoogle Scholar
  6. 6.
    Rosenthal DI, et al. Simple carotid-sparing intensity-modulated radiotherapy technique and preliminary experience for T1-2 glottic cancer. Int J Radiat Oncol Biol Phys. 2010;77(2):455–61.PubMedCrossRefGoogle Scholar
  7. 7.
    Zumsteg ZS, et al. Carotid sparing intensity-modulated radiation therapy achieves comparable locoregional control to conventional radiotherapy in T1-2N0 laryngeal carcinoma. Oral Oncol. 2015;51(7):716–23.PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Chera BS, Amdur RJ, Morris CG, Mendenhall WM. Carotid-sparing intensity-modulated radiotherapy for early-stage squamous cell carcinoma of the true vocal cord. Int J Radiat Oncol Biol Phys. 2010;77(5):1380–5.PubMedCrossRefGoogle Scholar
  9. 9.
    Janssen S, Glanzmann C, Huber G, Studer G. Risk-adapted partial larynx and/or carotid artery sparing modulated radiation therapy of glottic cancer. Radiat Oncol. 2014;13(9):136.CrossRefGoogle Scholar
  10. 10.
    Louis EL, McLoughlin MJ, Wortzman G. Chronic damage to medium and large arteries following irradiation. J Can Assoc Radiol. 1974;25(2):94–104.PubMedGoogle Scholar
  11. 11.
    Smith GL, et al. Cerebrovascular disease risk in older head and neck cancer patients after radiotherapy. J Clin Oncol. 2008;26(31):5119–25.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Swisher-McClure S, et al. Risk of fatal cerebrovascular accidents after external beam radiation therapy for early-stage glottic laryngeal cancer. Head Neck. 2014;36(5):611–6.PubMedCrossRefGoogle Scholar
  13. 13.
    Ten KGL, et al. Current status and future developments of contrast-enhanced ultrasound of carotid atherosclerosis. J Vasc Surg. 2013;57(2):539–46.CrossRefGoogle Scholar
  14. 14.
    Lorenz MW, et al. Carotid intima-medial thickness progression to predict cardiovascular events in the general population (the PROG-IMT) collaborative project: a meta-analysis of individual participant data. Lancet. 2012;379(9831):2053–62.PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Den Ruijter HM, et al. Common carotid intima-media thickness measurements in cardiovascular risk prediction: a meta-analysis. JAMA. 2012;308(8):796–803.CrossRefGoogle Scholar
  16. 16.
    Goff DC, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk. J Am Coll Cardiol. 2013;63(25):2935–59.PubMedCrossRefGoogle Scholar
  17. 17.
    LeFevre ML, et al. Screening for asymptomatic carotid artery stenosis: U.S. preventive services task force recommendation statement. Ann Intern Med. 2014;161(5):356–62.PubMedCrossRefGoogle Scholar
  18. 18.
    Brott TG, et al. 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: executive summary. Circulation. 2011;124:489–532.PubMedCrossRefGoogle Scholar
  19. 19.
    Muzaffar K, Collins SL, Labropoulos N, Baker W. A prospective study of the effects of irradiation on the carotid artery. Laryngoscope. 2000;11:1811–4.CrossRefGoogle Scholar
  20. 20.
    Jacoby D, et al. Carotid intima-media thickness measurement promises to improve cardiovascular risk evaluation in head and neck cancer patients. Clin Cardiol. 2015;38(5):280–4.PubMedCrossRefGoogle Scholar
  21. 21.
    Faruolo M, et al. Intimal-medial thickness and carotid arteries lumen in irradiated patients for head and neck cancer: preliminary data of an observational study. Clin Transl Oncol. 2013;15(10):861–4.PubMedCrossRefGoogle Scholar
  22. 22.
    Dorresteijn LDA, et al. Increased carotid wall thickness after radiotherapy on the neck. Eur J Cancer. 2005;41(7):1026–30.PubMedCrossRefGoogle Scholar
  23. 23.
    Lam WW, et al. Incidence of carotid stenosis in nasopharyngeal carcinoma patients after radiotherapy. Cancer. 2001;92(9):2357–63.PubMedCrossRefGoogle Scholar
  24. 24.
    Chang YJ, Change TC, Lee TH, Ryu SJ. Predictors of carotid artery stenosis after radiotherapy for head and neck cancers. J Vasc Surg. 2009;50(2):280–5.PubMedCrossRefGoogle Scholar
  25. 25.
    Greco A, et al. Carotid stenosis after adjuvant cervical radiotherapy in patients with head and neck cancers: a prospective controlled study. Clin Otolaryngol. 2012;37:376–81.PubMedCrossRefGoogle Scholar
  26. 26.
    Steele SR, et al. Focused high-risk population screening for carotid arterial stenosis after radiation therapy for head and neck cancer. Am J Surg. 2004;187(5):594–8.PubMedCrossRefGoogle Scholar
  27. 27.
    Brown PD, 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(5):1361–7.PubMedCrossRefGoogle Scholar
  28. 28.
    Cheng SW, et al. Irradiation-induced extracranial carotid stenosis in patients with head and neck malignancies. Am J Surg. 1999;178(4):323–8.PubMedCrossRefGoogle Scholar
  29. 29.
    Carmody BJ, et al. Accelerated carotid artery disease after high-dose head and neck radiotherapy: is there a role for routine carotid duplex surveillance? J Vasc Surg. 1999;30(6):1045–51.PubMedCrossRefGoogle Scholar
  30. 30.
    Shah BN, et al. Plaque neovascularization is increased in human carotid atherosclerosis related to prior neck radiotherapy: a contrast-enhanced ultrasound study. JACC Cardiovasc Imaging. 2016;9(6):668–75.PubMedCrossRefGoogle Scholar

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© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Radiation and Cellular OncologyUniversity of ChicagoChicagoUSA

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