Recurrent Ischemic Stroke Two Decades After Craniospinal Radiotherapy for Suprasellar Germinoma: A Case of Suspected Radiation-Induced Cerebrovascular Disease

Choon Peng Sun; Ahmad Affan bin Hassannuddin

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Recurrent Ischemic Stroke Two Decades After Craniospinal Radiotherapy for Suprasellar Germinoma: A Case of Suspected Radiation-Induced Cerebrovascular Disease

Author: Choon Peng Sun ¹ ; Ahmad Affan bin Hassannuddin ¹
Author Information

1. Hospital Teluk Intan
Publication Type:Journal Article
MeSH: Ischemic Stroke; Germinoma
From: Journal of the ASEAN Federation of Endocrine Societies 2026;41(S1):98-
CountryPhilippines
Language:English
Abstract: Introduction:Cranial radiotherapy is an established treatment for intracranial germinoma but may lead to late cerebrovascular complications including radiation-induced vasculopathy, cavernoma formation, and premature intracranial atherosclerosis. These complications may manifest many years after treatment and represent an important cause of stroke in young adult survivors of brain tumors.
Case:We report a 39-year-old male with a history of suprasellar germinoma treated with transsphenoidal surgery followed by craniospinal radiotherapy in 2006. He subsequently developed panhypopituitarism requiring lifelong hormone replacement therapy. In October 2024, he experienced a cerebrovascular accident resulting in mild residual right-sided weakness. Brain magnetic resonance imaging demonstrated multifocal old infarcts, small vessel disease (Fazekas grade 2), and multiple susceptibility artifacts suggestive of radiation-induced cavernomas.In March 2026, he presented with new onset right-sided weakness and facial asymmetry. Initial neurological examination revealed right-sided motor power of 4/5. Computed tomography of the brain showed no acute intracranial hemorrhage but confirmed multiple old infarcts and small vessel ischemic changes. Computed tomography angiography revealed intracranial atherosclerotic disease with 25–50% stenosis of the cavernous segments of both internal carotid arteries and mild irregularities of posterior circulation vessels without evidence of large vessel occlusion or aneurysm. Radiation-induced vasculopathy is a recognized delayed complication of cranial irradiation, often presenting 5–25 years after treatment. Pathophysiological mechanisms include endothelial injury, accelerated atherosclerosis, and progressive arterial stenosis. In rare cases, cranial irradiation may also lead to secondary Moyamoya syndrome, characterized by progressive stenosis of the intracranial internal carotid arteries with development of collateral vessels. Although this patient’s vascular imaging did not demonstrate the characteristic collateral network seen in Moyamoya syndrome, it remains an important differential diagnosis in young patients presenting with recurrent stroke after cranial irradiation. In this patient, young age, prior cranial irradiation, multifocal infarcts, and coexisting radiation-induced cavernomas strongly suggest radiationrelated cerebrovascular disease as a major contributor to recurrent stroke.
Conclusion:Long-term survivors of intracranial germinoma treated with cranial radiotherapy remain at risk of delayed cerebrovascular complications. Early recognition and aggressive secondary stroke prevention, along with continued neurological surveillance, are essential to reduce morbidity in this population.
Full text:2026080416215446848EP_A142.pdf