SMART (stroke-like migraine attacks after radiation therapy) syndrome responded to steroid pulse therapy: Report of a case and review of the literature

Successful identification and management of a stroke-like migraine attacks after radiation therapy syndrome occurring 36 years after cranial irradiation

Stroke-like migraine attacks after radiation therapy syndrome is a rare, late-onset neurological disorder observed in patients with a history of cranial radiation therapy. It presents with stroke-like symptoms, including hemiparesis, hemianopsia, seizures, and migraines, often occurring years or decades post-therapy. We report a case of stroke-like migraine attacks after radiation therapy syndrome in a 51-year-old male, manifesting 36 years after treatment for oligodendroglioma with whole-brain irradiation. The patient developed sudden worsening of left hemiparesis, focal seizures, and bilateral frontotemporal headaches. Brain MRI revealed hyperintensity on T2 fluid-attenuated inversion recovery sequence and gyral enhancement in the right parieto-occipital cortex. The patient responded favourably to a 5-day course of steroid pulse therapy (1000mg/day), with significant clinical improvement and resolution of MRI abnormalities. This case highlights one of the longest documented latencies for stroke-like migraine attacks after radiation therapy syndrome and emphasizes the importance of considering this diagnosis in patients after irradiation, even after extended latency periods, to prevent misdiagnosis and inappropriate treatment.

Resolution of Refractory Status Epilepticus With Ketamine Without Intubation in a Patient With Stroke-Like Migraine Attacks After Radiation Therapy (SMART) Syndrome

Stroke-like migraine attacks after radiation therapy (SMART) syndrome is an infrequently reported complication arising years after radiation therapy that manifests as a reversible syndrome marked by migraine-like headaches, focal neurologic signs, and/or seizures. Refractory status epilepticus (RSE) associated with SMART syndrome is rare and can be challenging to treat. Valproic acid has been reported to improve seizures in RSE in SMART syndrome in a few case reports and may be ideal for SMART syndrome, given its use in the treatment of migraines and seizures. Ketamine has been used in RSE and a few instances in SMART syndrome. Here, we present a case of refractory focal status epilepticus in a patient with SMART syndrome who was treated with ketamine, which resolved seizures without the need for intubation.

Early-onset stroke-like migraine attacks after radiation therapy syndrome: A case report and review of the literature

PURPOSE

Stroke-like migraine attacks after radiation therapy (SMART) syndrome is characterized by migraines, seizures, and stroke-like symptoms following brain irradiation. Diagnosis consists of clinical signs, history of brain irradiation, and radiographic evaluation. The latency to onset varies widely among individual patients, ranging from 1 to 35 years. Herein, we review the literature and present a case of SMART syndrome with an onset of five months after stereotactic radiosurgery for a benign meningioma.

METHODS

A systematic review of the literature was conducted in line with the PRISMA guidelines. The PubMed, Cochrane, and Web of Science databases were searched for cases of SMART syndrome with reported time of onset and radiation dosage. Finally, we report the presentation, history, radiographic findings, and clinical outcomes of a 48-year-old female with suspected SMART syndrome.

RESULTS

Of 101 articles reviewed, 23 articles were selected for inclusion in the present study. A total of 27 cases were identified. The mean age at presentation was 43 years (range: 11-70), and 71.4 % of patients were male. The mean latency to onset was 11.2 years after radiation. Based on case descriptions, none of the patients were definitively treated with single fraction radiosurgery.

CONCLUSION

SMART syndrome may present with variations in latency to onset, radiation dose, outcome, and clinical course. The present case of SMART syndrome highlights the variety in clinical presentation of this disease. Further work should be considered to better determine whether clinical and radiographic criteria for diagnosing SMART syndrome diagnosis are sufficient to encompass patients with a non-traditional presentation.

A Rare Case of Diffuse Leptomeningeal and Cortical Enhancement Secondary to Stroke-Like Migraine Attacks After Radiation Therapy (SMART) Syndrome in a Patient With a History of Childhood Medulloblastoma

Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare complication of craniospinal irradiation (CSI). Patients commonly present with headaches, seizures, and paroxysmal focal neurological deficits. There is a dearth of studies reported in the literature with an estimated fewer than 100 cases described since it was initially defined in the mid-1990s. The authors present the case of a 23-year-old patient with a history of childhood medulloblastoma and prior ventriculoperitoneal shunt (VPS), chemotherapy, and CSI who presented with headaches and new-onset seizures. Magnetic resonance imaging (MRI) of the brain showed diffuse left temporoparietal and occipital leptomeningeal and cortical enhancement. However, cerebrospinal fluid (CSF) analysis was unremarkable for neoplastic, infectious, or inflammatory etiology. Initiation of systemic steroid therapy resulted in drastic improvement of the patient's symptoms and prompted antiepileptic drug (AED) wean and persistent resolution of leptomeningeal and cortical contrast enhancement on brain MRI. When evaluating MRI evidence of leptomeningeal enhancement, neurosurgeons should consider SMART syndrome in the differential diagnosis, especially when extensive workup rules out more common causes of this finding such as leptomeningeal disease (LMD). Proper identification of SMART syndrome can lead to timely treatment, avoidance of invasive procedures such as tissue biopsy, and improved clinical outcomes.

Case Report: Stroke-like migraine attacks after radiation therapy syndrome: a rare complication 26 years after cranial radiotherapy

Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare delayed complication of cranial radiotherapy, that may present decades after brain irradiation. Here we present a case of 41-year old patient with a history of grade 3 oligodendroglioma, epilepsy and migraine, 26 years after brain radiation therapy, who was admitted with right hemicranial headache, nausea, left homonymous hemianopsia, weakness of the left arm and left-sided hemihypesthesia. After considering alternate diagnoses, we ultimately diagnosed SMART syndrome. Despite its rare occurrence and unknown pathophysiology, there are more case reports of SMART syndrome reported due to advancements in oncology treatment and increasing patients' survival rates. Therefore, diagnosis of SMART syndrome should always be considered in patients with a history of cranial radiation presenting with focal neurologic deficits and migraine, especially with a change in pattern of their usual migraine attack.

SMART Syndrome: Case Report and Review of the Literature

Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare condition characterized by stroke-like deficits, seizures, and headache that can occur years after radiation therapy (RT) to the brain. RT is a cornerstone in the treatment of primary brain tumours and is indicated in more than 90% of patients. It is therefore essential to be aware of this entity to prevent misdiagnosis leading to inappropriate treatment. In this article, typical imaging findings of this condition are presented through a case report and review of the literature.

Comprehensive Update and Review of Clinical and Imaging Features of SMART Syndrome

Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a delayed complication of cranial irradiation, with subacute onset of stroke-like symptoms including seizures, visual disturbance, speech impairment, unilateral hemianopsia, facial droop, and aphasia, often associated with migraine-type headache. The diagnostic criteria were initially proposed in 2006. However, the diagnosis of SMART syndrome is challenging because clinical symptoms and imaging features of SMART syndrome are indeterminate and overlap with tumor recurrence and other neurologic diseases, which may result in inappropriate clinical management and unnecessary invasive diagnostic procedures. Recently, various imaging features and treatment recommendations for SMART syndrome have been reported. Radiologists and clinicians should be familiar with updates on clinical and imaging features of this delayed radiation complication because recognition of this entity can facilitate proper clinical work-up and management. This review provides current updates and a comprehensive overview of the clinical and imaging features of SMART syndrome.

SMART syndrome: two cases highlighting a complex and rare complication of brain irradiation

Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare complication of radiotherapy with complex neurological impairment. Patients present with neurological symptoms and signs such as migraine, hemianopsia, hemiplegia, aphasia and/or seizures-without recurrence of neoplastic disease. In this report, we describe SMART syndrome in two adult patients 4 and 14 years following brain irradiation, respectively.

Case Report: SMART ANTON: Anton-Babinski Syndrome in Stroke-Like Migraine Attacks (SMART) After Radiation Therapy: Two Rare Syndromes, One Case

Introduction

We describe the case of a 57-years-old patient who presented an Anton-Babinski syndrome in the context of a stroke-like migraine attack after radiation therapy (SMART).

Case Report

The patient was brought to the emergency room following a sudden loss of vision in the context of a pre-existing left-sided hemianopia after excision of a right occipital astrocytoma followed by radio-chemotherapy 35 years prior to his admission in our services. At admittance, he also presented hyperthermia, hypertension, and a GCS of 7. The MRI showed a leptomeningeal enhancement in the left temporal, parietal, and occipital lobes. After exclusion of other differential diagnoses, we diagnosed a cortical blindness in the context of a SMART syndrome affecting the left hemisphere. While the symptoms improved under corticosteroid therapy, the patient successively presented an Anton-Babinski syndrome, a Riddoch syndrome and a visual associative agnosia before finally regaining his usual sight.

Discussion

This is, to our knowledge, the first report of an Anton-Babinski syndrome in the context of a SMART syndrome. A dual etiology is mandatory for cortical blindness in SMART syndrome since the latter affects only one hemisphere. A SMART syndrome affecting the contralateral hemisphere in respect to the radiation site seems to be uncommon, which makes this case even more exceptional.

SMART syndrome: a case report

INTRODUCTION

Stroke-like migraine attacks after radiation therapy (SMART) syndrome, is a late complication of brain radiotherapy (1). Symptoms are commonly subacute in onset and involve migraine type of headache, seizures, focal neurologic deficits (2). Magnetic resonance imaging (MRI) findings are usually unilateral and posterior predominant cortical-subcortical hyperintensity, swelling and prominent gyriform (cortical and leptomeningeal) gadolinium enhancement in the areas of the brain that underwent irradiation with or without diffusion restriction (1). There is no standard treatment protocol for SMART syndrome. Antiepileptics and corticosteroids are commonly used drugs.

CASE REPORT

A 65 years old woman was diagnosed with breast cancer with brain metastases and treated with more than 50 Gy brain radiotherapy. The patient presented with acute right-sided weakness and numbness, episodic myoclonic jerking of the right arm and leg, and gait instability five months later. MRI and magnetic resonance angiography of the brain with gadolinium revealed left parietooccipital cortical diffusion restriction and accompanying dilatation of the left posterior cerebral artery as new findings. Computed tomography (CT) perfusion revealed increased perfusion in the affected area. The patient was diagnosed with SMART syndrome.

MANAGEMENT AND OUTCOME

The patient was treated with dexamethasone (16 mg/day) and anticonvulsant therapy. Myoclonic seizures had almost completely remitted. However, her cognitive impairment persisted, then the patient was arrested because of aspiration a month later.

DISCUSSION

Besides confirming SMART syndrome, diagnostic investigations are also important to exclude other etiologies. Posterior reversible encephalopathy syndrome, post-ictal changes, meningoencephalitis, and cerebrovascular diseases are radiological differential diagnoses considered (3). Proper and early diagnosis of SMART syndrome is significant in preventing unnecessary aggressive approaches and appropriate treatment to avoid lesions of sequela.

Review: Neurological Complications From Therapies for Pediatric Brain Tumors

Surgery, chemotherapy and radiation have been the mainstay of pediatric brain tumor treatment over the past decades. Recently, new treatment modalities have emerged for the management of pediatric brain tumors. These therapies range from novel radiotherapy techniques and targeted immunotherapies to checkpoint inhibitors and T cell transfer therapies. These treatments are currently investigated with the goal of improving survival and decreasing morbidity. However, compared to traditional therapies, these novel modalities are not as well elucidated and similarly has the potential to cause significant short and long-term sequelae, impacting quality of life. Treatment complications are commonly mediated through direct drug toxicity or vascular, infectious, or autoimmune mechanisms, ranging from immune effector cell associated neurotoxicity syndrome with CART-cells to neuropathy with checkpoint inhibitors. Addressing treatment-induced complications is the focus of new trials, specifically improving neurocognitive outcomes. The aim of this review is to explore the pathophysiology underlying treatment related neurologic side effects, highlight associated complications, and describe the future direction of brain tumor protocols. Increasing awareness of these neurologic complications from novel therapies underscores the need for quality-of-life metrics and considerations in clinical trials to decrease associated treatment-induced morbidity.

Prognostic Factors of Stroke-Like Migraine Attacks after Radiation Therapy (SMART) Syndrome

BACKGROUND AND PURPOSE

Prognostic factors of stroke-like migraine attacks after radiation therapy (SMART) syndrome have not been fully explored. This study aimed to assess clinical and imaging features to predict the clinical outcome of SMART syndrome.

MATERIALS AND METHODS

We retrospectively reviewed the clinical manifestations and imaging findings of 20 patients with SMART syndrome (median age, 48 years; 5 women) from January 2016 to January 2020 at 4 medical centers. Patient demographics and MR imaging features at the time of diagnosis were reviewed. This cohort was divided into 2 groups based on the degree of clinical improvement (completely versus incompletely recovered). The numeric and categoric variables were compared as appropriate.

RESULTS

There were statistically significant differences between the completely recovered group (n = 11; median age, 44 years; 2 women) and the incompletely recovered group (n = 9; median age, 55 years; 3 women) in age, months of follow-up, and the presence of steroid treatment at diagnosis (P = .028, .002, and .01, respectively). Regarding MR imaging features, there were statistically significant differences in the presence of linear subcortical WM susceptibility abnormality, restricted diffusion, and subcortical WM edematous changes in the acute SMART region (3/11 versus 8/9, P = .01; 0/11 versus 4/9, P = .026; and 2/11 versus 7/9, P = .022, respectively). Follow-up MRIs showed persistent susceptibility abnormality (11/11) and subcortical WM edematous changes (9/9), with resolution of restricted diffusion (4/4).

CONCLUSIONS

Age, use of steroid treatment at the diagnosis of SMART syndrome, and MR imaging findings of abnormal susceptibility signal, restricted diffusion, and subcortical WM change in the acute SMART region can be prognostic factors in SMART syndrome.

Be Smart to Identify the Stroke-Like Migraine Attacks After Radiation Therapy (SMART) Syndrome

Stroke-like migraine attacks after radiation therapy (SMART) are uncommon, often occurring years or decades after brain radiation therapy. This syndrome is a diagnosis of exclusion, and only about 40 cases describing SMART have been published, each one describing a constellation of symptoms and findings. Because symptoms can arise years after initial radiation therapy, the ability of physicians to recognize SMART and rule out other possible causes of symptoms is critical for the long-term care of oncology patients who have undergone cranial radiation. Here we present the case of a 55-year-old man who experienced SMART nine years after radiation therapy and who was successfully treated with steroids.

Stroke-like migraine attacks after radiation therapy (SMART) syndrome presenting as a migraine copycat: A case report

Background:

Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a possible long term consequence of cranial beam radiation therapy and may present as a perfect mimic of migraine with or without aura.

Methods and Results:

We present a 57-year-old man suffering from diffuse astrocytoma and presenting with SMART syndrome perfectly mimicking his antecedent migraine with visual aura. He was treated with intravenous steroid therapy inducing rapid response.

Conclusion:

SMART syndrome is a rare complex delayed complication of brain radiation therapy, which may present as an isolated migraine with or without aura even decades after cranial radiation. Thus, a sudden intensification or relapse of a previous migraine in a patient with remote cranial radiotherapy constitutes a red flag even decades after cranial irradiation and cured or stable tumor disease on a recent brain MRI. Moreover, SMART syndrome adds to the list of secondary headaches not yet listed in the current International Classification of Headache Disorders, 3rd edition (ICHD3).

Stroke-Like Migraine Attacks After Radiation Therapy (SMART) Syndrome: A Comprehensive Review

PURPOSE OF REVIEW

SMART syndrome is a delayed complication of cranial irradiation that can be misconstrued as tumor recurrence or some other intracranial neurological disease. Recognition of this clinical syndrome is imperative as it can obviate the need for invasive diagnostic testing and can provide reassurance to both the patient and their loved ones.

RECENT FINDINGS

SMART syndrome is generally considered a reversible clinical syndrome; however, neurological deficits may become permanent. Pathophysiology of SMART syndrome may involve cerebrovascular autoregulation impairment, neuronal dysfunction leading to trigeminovascular system impairment and/or cortical spreading depression, and seizures. In addition to MRI brain with gadolinium, other imaging modalities, such as CT perfusion, MR perfusion, MR spectroscopy, and FDG PET/CT, aid in arriving to the diagnosis sooner. Patients should also undergo electroencephalogram in order to promptly identify and treat seizures. There are currently no clear guidelines on how to effectively treat SMART syndrome, but treatment may involve anti-seizure medication, anti-hypertensives, anti-platelet, and steroid therapy. This review provides a comprehensive understanding of the clinical characteristics of SMART syndrome from presentation to diagnostic evaluation. We also discuss radiographic features and treatment strategies for this rare disease. With increased radiotherapy utilization, prompt clinical recognition of SMART syndrome and further development of a comprehensive diagnostic approach to SMART syndrome utilizing newer radiographic modalities as well as treatment algorithms to effectively treat this clinical condition will be imperative.

Incremental Utility of Tc-99m Glucohepatonate Single-Photon Emission Computed Tomography over 18F-Flourodeoxyglucose Positron Emission Tomography in Diagnosis of Brain Tumor Recurrence - Old is Gold

Detection of recurrence of a brain tumor after treatment is one of the most important and challenging diagnostic problems in neuro-oncological practice. In spite of technical advances in imaging modalities, sometimes, certain clinical presentations and manifestations can lead to a diagnostic dilemma even with the best of the technical know-how. We present a case of recurrence of anaplastic oligoastrocytoma (World Health Organization Grade III), where the patient's initial clinical presentation and the F-18 flourodeoxyglucose positron emission tomography (PET) magnetic resonance imaging findings were suggestive of stroke-like migraine attacks after radiation therapy syndrome. Due to a seizure episode before PET image acquisition, intense gyral uptake was noted in the left parietal lobe which made it difficult to ascertain the presence of a tumor recurrence. However, Tc-99m glucohepatonate single-photon emission computed tomography done after 1 week revealed radiotracer uptake within the site corresponding to the primary tumor, and a diagnosis of recurrence was made.

SMART Syndrome Identification and Successful Treatment

Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare late complication of brain irradiation. Patients commonly present recurrent attacks of headaches, seizures, and paroxysmal focal neurological deficits including aphasia, negligence, or hemianopsia. We report a 41-year-old male patient admitted to our emergency room with a reduced level of consciousness and global aphasia. One month prior to admission, he started with frequent headache attacks of moderate intensity and paroxysmal behavioral alterations, advancing to confusion, gait instability, language impairment, and somnolence. He had a history of medulloblastoma treated with surgical resection followed by craniospinal irradiation 21 years before symptom onset. After excluding more frequent causes for the patient's symptoms along with a suggestive image pattern, we started treatment for SMART syndrome with high-dose corticosteroid and calcium channel blocker verapamil. The patient gradually improved his level of consciousness and recovered from aphasia and gait instability without new seizures or neuropsychiatric symptoms. Follow-up brain magnetic resonance imaging showed resolution of the typical findings. This case displays a successful clinical evolution of a patient treated for SMART syndrome in which identification of previous radiation treatment, exclusion of other etiologies, and prompt treatment institution were key for effectively tackling this disease.

Stroke-Like Migraine Attacks after Radiation Therapy Syndrome: Clinical and Imaging Characteristics

Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare, reversible phenomenon that occurs several years after radiotherapy in patients treated for intracranial neoplastic lesions. Patients typically present with symptoms of headache, seizures, and other focal neurologic deficits concerning for stroke or disease recurrence. In this report, we describe SMART syndrome in a 70-year-old male who developed a persistent right temporal headache, right-sided neck pain, and new-onset seizures 12 years after surgical resection of a temporal anaplastic ependymoma followed by irradiation. We present this case to highlight typical disease presentation, imaging characteristics, and important differential radiologic considerations. Recognition of this delayed complication of brain tumor radiation is paramount given its self-limited course and favorable response to conservative therapy and to avoid misinterpreting imaging findings as tumor recurrence.