Delayed vasculopathy associated with prior brain irradiation is a known cause of stroke. Radiation is implicated in large-vessel stenosis, cavernous malformations and, rarely, small-vessel disease. There have been no reported cases of fulminant ischaemic and haemorrhagic strokes secondary to radiation vasculopathy. We present the case of a 40-year-old woman with a history of childhood leukaemia and whole-body and cranio-cervical radiation. The patient presented with recurrent acute neurological deficits over a 4-month period resulting from haemorrhagic and ischaemic strokes. Imaging revealed numerous cavernomas and small-vessel acute infarctions. No traditional stroke aetiology was identified. Delayed radiation-induced vasculopathy should be considered in patients with a history of brain irradiation and ischaemic or haemorrhagic strokes, and can present in a fulminant manner with recurrent strokes over a short period of time.

Cerebral small-vessel alterations play a central role in determining lesions of subcortical structures and eventually may lead to cognitive impairment. Small-vessel diseases are classified according to the pathological viewpoint. The most important ones are the changes in small arteries and arterioles caused by prolonged hypertension. These small-vessel changes may result in ischemic damage to the brain parenchyma and blood-barrier alterations. Both mechanisms are thought to contribute to the occurrence of white-matter changes and lacunar infarcts. Modern magnetic resonance techniques such as diffusion, perfusion, and spectroscopy may allow the in vivo study of the pathophysiology of small-vessel diseases and the consequences on the brain parenchyma.