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Ota Y, Liao E, Shah G, Srinivasan A, Capizzano AA. Comprehensive Update and Review of Clinical and Imaging Features of SMART Syndrome. AJNR Am J Neuroradiol 2023; 44:626-633. [PMID: 37142432 PMCID: PMC10249687 DOI: 10.3174/ajnr.a7859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/20/2023] [Indexed: 05/06/2023]
Abstract
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.
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Affiliation(s)
- Y Ota
- From The Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - E Liao
- From The Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - G Shah
- From The Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - A Srinivasan
- From The Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - A A Capizzano
- From The Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
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Panigrahy N, Aedma S, Lee M. Stroke-Like Migraine Attacks After Radiation Therapy (SMART) Syndrome Presenting With Recurrent Seizures: A Case Study. Cureus 2022; 14:e25691. [PMID: 35812558 PMCID: PMC9258967 DOI: 10.7759/cureus.25691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 11/05/2022] Open
Abstract
Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare, delayed complication of radiation therapy to the brain. We present a case of a 49-year-old female with a past medical history of malignant neoplasm of the brain status following resection and radiation. She initially presented with increased work of breathing. Initial labs and a chest X-ray were suggestive of aspiration pneumonia leading to sepsis. Upon hospitalization, seizure-like activity was noted. Electroencephalogram showed electrographic seizures originating from the left occipital and parietal lobe. She received numerous medications to control the seizures with minimal improvement. Magnetic resonance imaging was performed to characterize the origin of seizures, which showed extensive post-radiation changes including a new meningioma. The patient was subsequently managed with magnesium and Solu Medrol. After this regimen, her condition improved and there were no clinical seizures present.
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Affiliation(s)
- Neha Panigrahy
- Medicine, Carle Illinois College of Medicine, Champaign, USA
| | - Surya Aedma
- Internal Medicine, Carle Foundation Hospital, Urbana, USA
| | - Matthew Lee
- Internal Medicine, Carle Foundation Hospital, Champaign, USA
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Stroke-Like Migraine Attacks After Radiation Therapy (SMART) Syndrome: A Comprehensive Review. Curr Pain Headache Rep 2021; 25:33. [PMID: 33761013 DOI: 10.1007/s11916-021-00946-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 10/21/2022]
Abstract
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.
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Singh TD, Hajeb M, Rabinstein AA, Kunchok AC, Pittock SJ, Krecke KN, Bartleson JD, Black DF. SMART syndrome: retrospective review of a rare delayed complication of radiation. Eur J Neurol 2020; 28:1316-1323. [PMID: 33159349 DOI: 10.1111/ene.14632] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/24/2020] [Accepted: 10/30/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND SMART (stroke-like migraine attacks after radiation therapy) is a rare, delayed complication of brain radiation. In this study, we wanted to review the spectrum of symptoms, neuroradiological findings, autoimmune status, and outcomes in SMART syndrome patients. METHODS We conducted a retrospective cohort study of all consecutive adult patients (≥18 years) diagnosed with SMART syndrome at Mayo Clinic, Rochester between January 1995 and December 2018. RESULTS We identified 25 unique patients with SMART syndrome and a total of 31 episodes and 15 (60%) patients were male. The median age at onset was 46 (interquartile range [IQR] 43-55) years and the median latency of onset after the initial radiation was 21.6 (IQR 14.4-28.2) years. Magnetic resonance imaging (MRI) showed gyral edema and enhancement in all cases with the temporal (25, 80.6%) and parietal (23, 74.2%) lobes being the most commonly affected. The median follow-up of the patients in our cohort was 10 (IQR 6-32) weeks. On univariate analysis, factors associated with an increased risk of recurrent SMART episodes were female gender (odds ratio [OR] 8.1, 95% confidence interval [95% CI] 1.1-52.6, p = 0.019) and absence of electrographic seizure discharges during initial symptoms (OR 7.4, 95% CI 1.1-45.9, p = 0.032). We could not identify an autoimmune etiology. Longer duration of symptoms (>10 weeks) correlated with an older age (p = 0.049), temporal lobe involvement (p < 0.001), and diffusion restriction (p = 0.043). CONCLUSIONS SMART is a syndrome with characteristic imaging findings and clinical features. Incomplete recovery by 10 weeks occurred in one-third of individuals and was associated with older age, temporal lobe involvement, and restricted diffusion on MRI.
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Affiliation(s)
- Tarun D Singh
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mania Hajeb
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Amy C Kunchok
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Karl N Krecke
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - David F Black
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Stroke-like migraine attacks after radiation therapy (SMART) syndrome—a case series and review. Neurol Sci 2020; 41:3123-3134. [DOI: 10.1007/s10072-020-04586-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 07/06/2020] [Indexed: 10/23/2022]
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Wang Y, Miao A, Shi Y, Ge J, Wang L, Yu C, Xu H, Yu Y, Huang S, Li Y, Wang X. Influencing electroclinical features and prognostic factors in patients with anti-NMDAR encephalitis: a cohort follow-up study in Chinese patients. Sci Rep 2020; 10:10753. [PMID: 32612192 PMCID: PMC7329850 DOI: 10.1038/s41598-020-67485-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 06/04/2020] [Indexed: 12/17/2022] Open
Abstract
The clinical manifestations of patients with anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis in East China and factors associated with prognosis were analyzed. A retrospective study of 106 patients (58 females; 48 males) with anti-NMDAR encephalitis in East China was carried out from June 2015 to February 2019. Clinical features and factors influencing outcomes were reviewed. Behavioral changes were observed in 74.5% (79/106) of patients, and comprised the initial symptoms in 61.3% (65/106). Seizures were observed in 67% (71/106) of patients, and served as initial symptoms in 31.1% (33/106). A total of 54.9% (39/71) of seizures were focal seizures. More clinical symptoms were observed in female patients than in male patients (P = 0.000). Similarly, background activity (BA) with high cerebrospinal fluid (CSF) antibody titers at the peak stage was more severe in female patients than in male patients (P = 0.000). The Binary logistic regression and receiver operating characteristic (ROC) curve analyses revealed the factors associated with poor outcomes included consciousness disturbance (OR 4.907, 95% CI 1.653-14.562, P = 0.004; area: 65.4%, sensitivity: 44.2%, specificity: 86.5%, P = 0.014), EEG BA (OR 3.743, 95% CI 1.766-7.932, P = 0.001; area: 76.6%, sensitivity: 73%, specificity: 75%, P = 0.000), number of symptoms (OR 2.911, 95% CI 1.811-4.679, P = 0.000; area: 77.1%, sensitivity: 59.5%, specificity: 78.6%, P = 0.000) and CSF antibody titer (OR 31.778, 95% CI 8.891-113.57, P = 0.000; area: 83.9%, sensitivity: 89.2%, specificity: 78.6%, P = 0.000). EEG BA and number of symptoms were associated with CSF antibody titers. Consciousness disturbances, EEG BA, number of symptoms and CSF antibody titers served as predictors of poor outcomes.
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Affiliation(s)
- Yingxin Wang
- Department of Neurology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing Medical University, Guang Zhou Road 264, Nanjing, 210029, Jiangsu, China
| | - Ailiang Miao
- Department of Neurology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing Medical University, Guang Zhou Road 264, Nanjing, 210029, Jiangsu, China. .,Department of Video-Electroencephalogram, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, Jiangsu, China.
| | - Yongwei Shi
- Department of Neurology, Taizhou Fourth People's Hospital, Taizhou, Jiangsu, China
| | - Jianqing Ge
- Department of Neurology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing Medical University, Guang Zhou Road 264, Nanjing, 210029, Jiangsu, China
| | - Lingling Wang
- Department of Neurology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing Medical University, Guang Zhou Road 264, Nanjing, 210029, Jiangsu, China
| | - Chuanyong Yu
- Department of Neurology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing Medical University, Guang Zhou Road 264, Nanjing, 210029, Jiangsu, China
| | - Haiyan Xu
- Medical Records Room, Nanjing Brain Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yuanwen Yu
- Medical Records Room, Nanjing Brain Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Shuyang Huang
- Department of Neurology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing Medical University, Guang Zhou Road 264, Nanjing, 210029, Jiangsu, China
| | - Yihan Li
- Department of Neurology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing Medical University, Guang Zhou Road 264, Nanjing, 210029, Jiangsu, China
| | - Xiaoshan Wang
- Department of Neurology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing Medical University, Guang Zhou Road 264, Nanjing, 210029, Jiangsu, China.
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Jaraba S, Reynés-Llompart G, Sala-Padró J, Veciana M, Miró J, Pedro J, Puig O, Mora J, Falip M. Usefulness of HMPAO-SPECT in the diagnosis of nonconvulsive status epilepticus. Epilepsy Behav 2019; 101:106544. [PMID: 31753769 DOI: 10.1016/j.yebeh.2019.106544] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 09/03/2019] [Accepted: 09/03/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND The diagnosis of nonconvulsive status epilepticus (NCSE) can pose a challenge. Electroencephalogram (EEG) patterns can be difficult to interpret, and the absence of an EEG correlate does not rule out the diagnosis of NCSE. In this setting, neuroimaging tools to help in the diagnosis are crucial. Our aim was to evaluate the role of 99mTc-hexamethyl propyleneamine oxime (HMPAO) single photon emission computed tomography (SPECT) and quantitative HMPAO-SPECT (QtSPECT) in patients with clinical suspicion of NCSE, and to evaluate their value in the final diagnosis of NCSE. METHODS We recruited consecutive patients admitted in our center with suspicion of NCSE, and selected those who underwent an HMPAO-SPECT. All patients were admitted to the neurology ward and underwent an EEG. We divided the patients into those who were finally with diagnosed NCSE (NCSE-p) and those who were not (non-NCSE) according to the Salzburg Diagnostic EEG criteria. Sensitivity and specificity of the diagnostic tools were calculated. The SPECTs were acquired in a Skylight SPECT (Philips Healthcare, Amsterdam). The injections were done during the clinical episode suspected of being an NCSE. The HMPAO-SPECT was analyzed by two experts and was also quantified. All data were normalized to the SPM SPECT template. We used an external healthy normal database to obtain a Z-score map for each individual versus the normal database. The Z-score maximum (Zmax) was extracted from each region of the AAL atlas as was the percentage of voxels with a Z-score higher than 2.5 (N(%)). A logistic regression combining the Zmax, N(%), and the effect of patient age was fitted to predict the final NCSE diagnosis. A receiver operator characteristic (ROC) curve and the area under the curve (AUC) were obtained to evaluate the classification performance. RESULTS We included 55 patients, 21 of them women (38.9%), with a median age of 62.1 years old (range 25-84). Thirty-six patients were with diagnosed NCSE (62.9%). Initial EEG had a sensitivity of 61.1% and a specificity of 89%. Most of the patients were critically ill with diagnostic difficulties, and it could be one of the main reasons to find low sensitivity of the Salzburg diagnostic EEG criteria. The Zmax and N(%) were significantly higher in NCSE-p than in non-NCSE (p = 0.005 and p < 0.001, respectively). The HMPAO-SPECT qualitative analysis had a sensitivity of 80.5% and specificity of 89.5% while QtSPECT had a sensitivity of 82% and specificity of 81%. CONCLUSION Both 99mTc-HMPAO-SPECT and QtSPECT can be useful in the diagnosis of NCSE. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".
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Affiliation(s)
- Sonia Jaraba
- Neurology Service, Epilepsy Unit, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain; Neurology Department, Hospital de Viladecans, Viladecans, Barcelona, Spain.
| | - Gabriel Reynés-Llompart
- Image Diagnostic Institute (IDI), Nuclear Medicine Department, PET Unit, Hospital de Bellvitge, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Jacint Sala-Padró
- Neurology Service, Epilepsy Unit, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Misericordia Veciana
- Neurology Service, Neurophysiology Department, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Júlia Miró
- Neurology Service, Epilepsy Unit, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Jordi Pedro
- Neurology Service, Neurophysiology Department, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Oriol Puig
- Image Diagnostic Institute (IDI), Nuclear Medicine Department, SPECT Unit, Hospital Universitari de Bellvitge, Image Diagnostic Institute, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Jaume Mora
- Image Diagnostic Institute (IDI), Nuclear Medicine Department, SPECT Unit, Hospital Universitari de Bellvitge, Image Diagnostic Institute, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Mercè Falip
- Neurology Service, Epilepsy Unit, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
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Makary MS, Awan U, Puduvalli VK, Slone HW. Stroke-Like Migraine Attacks after Radiation Therapy Syndrome: Clinical and Imaging Characteristics. J Clin Imaging Sci 2019; 9:5. [PMID: 31448156 PMCID: PMC6702857 DOI: 10.25259/jcis-9-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 11/21/2018] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Mina S Makary
- Division of Neuroradiology, Department of Radiology, The Ohio State University Medical Center Columbus, OH 43210 USA
| | - Usama Awan
- Division of Neuroradiology, Department of Radiology, The Ohio State University Medical Center Columbus, OH 43210 USA
| | - Vinay K Puduvalli
- Department of Neurology, Division of Neuro-Oncology Columbus, OH 43210 USA.,Department of Neurological Surgery, The Ohio State University Medical Center Columbus, OH 43210 USA
| | - Hasel W Slone
- Division of Neuroradiology, Department of Radiology, The Ohio State University Medical Center Columbus, OH 43210 USA
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Boyer PN, Devlin M, Boggild M. Rare and rarer: co-occurrence of stroke-like migraine attacks after radiation therapy and Charles Bonnet syndromes. Oxf Med Case Reports 2018; 2018:omy077. [PMID: 30323940 PMCID: PMC6172599 DOI: 10.1093/omcr/omy077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 07/18/2018] [Accepted: 07/28/2018] [Indexed: 11/18/2022] Open
Abstract
A 30-year-old man presented with new onset severe headache and homonymous hemianopia, with a subsequent seizure, on a background of a right parietal astrocytoma resected at age 5 with adjuvant chemotherapy and radiotherapy. Magnetic resonance imaging of the brain revealed post-surgical and radiotherapy changes only and a clinical diagnosis of Stroke-like Migraine Attacks after Radiation Therapy (SMART) syndrome was made. Vision subsequently recovered gradually over a 6-week period, however, during the recovery phase he reported well formed hallucinations in the affected hemi-field consisting of small mammals, particularly possums, which gradually became less distinct as vision recovered; a phenomenon which was felt likely to represent the Charles Bonnet syndrome.
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Affiliation(s)
| | - Michael Devlin
- Neurology Department, Townsville Hospital and Health Service, Douglas, Queensland, Australia
| | - Mike Boggild
- Neurology Department, Townsville Hospital and Health Service, Douglas, Queensland, Australia
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Jia W, Saito R, Kanamori M, Iwabuchi N, Iwasaki M, Tominaga T. SMART (stroke-like migraine attacks after radiation therapy) syndrome responded to steroid pulse therapy: Report of a case and review of the literature. eNeurologicalSci 2018; 12:1-4. [PMID: 30003148 PMCID: PMC6040931 DOI: 10.1016/j.ensci.2018.05.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 05/22/2018] [Indexed: 01/06/2023] Open
Abstract
This report presents a case of stroke-like migraine attacks after radiation therapy (SMART) syndrome in a 31-year-old man in whom symptoms and radiological findings resolved with steroid pulsed therapy and reviews the literatures with special emphasis on the use of steroids against SMART syndrome. The patient had a past history of left temporal anaplastic astrocytoma and was treated with surgery followed by local 72 Gy radiation therapy and chemotherapy using Nimustine Hydrochloride. Four years after the surgery, he was suffering from subacute progressing symptoms of headache, right hemianopia, right hemiparesis and aphasia from 2 to 4 days before admission to our hospital. At first he was diagnosed as symptomatic epilepsy but after extensive examination, the final diagnosis was SMART syndrome. His symptoms soon improved with steroid pulse therapy. In the literature, steroid pulse therapy is not necessarily a standard of care for SMART syndrome, but it seemed to decrease the need of biopsy. As the lesions of SMART syndrome require differential diagnosis from recurrences, biopsy was performed in some cases. However, lack of benefit and possible detriment is reported with biopsy of SMART lesions. Through this experience we suggest that steroid pulse therapy may provide speedy recovery from symptoms, and it should be considered before other invasive investigations or treatments. Report a case of stroke-like migraine attacks after radiation therapy (SMART) syndrome in a 31-year-old man in whom symptoms and radiological findings resolved with steroid pulsed therapy. Lack of benefit and possible detriment is reported with biopsy of SMART lesions. Steroid pulse therapy is not necessarily a standard of care for SMART syndrome, but it seemed to decrease the need of biopsy. Steroid pulse therapy may provide recovery from symptoms of SMART, and should be considered before invasive investigations.
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Affiliation(s)
- Wenting Jia
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Masayuki Kanamori
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Naoya Iwabuchi
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Masaki Iwasaki
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
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Fan EP, Heiber G, Gerard EE, Schuele S. Stroke-like migraine attacks after radiation therapy: A misnomer? Epilepsia 2017; 59:259-268. [PMID: 29171011 DOI: 10.1111/epi.13963] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To understand the frequency of electrographic and clinical seizures in patients with stroke-like migraine attacks after radiation therapy (SMART), and determine whether SMART warrants comprehensive electroencephalographic (EEG) monitoring and aggressive seizure management. METHODS We searched our magnetic resonance brain imaging report database for all patients between January 2013 and December 2015 for suspected SMART syndrome. Clinical inclusion criteria were further applied as follows: inpatient adults (>18 years of age) with history of cranial radiation presenting with acute neurologic deficits as primary admission reason who lacked evidence of recurrent or new brain malignancy, stroke, or infectious agents in cerebrospinal fluid. Six patients were identified. All 6 patients underwent prolonged video EEG monitoring as part of our standard protocol. RESULTS All patients but 1 were found to have multiple or prolonged electrographic seizures consistent with status epilepticus during video EEG monitoring. Their neurological deficit and/or mental status change improved in parallel with resolution of the seizure activity. SIGNIFICANCE SMART is likely a misnomer that underestimates the significance of seizures and status epilepticus in the pathophysiology and clinical presentation of the syndrome. Systematic continuous EEG monitoring and appropriate seizure management is warranted to reduce symptom duration and optimize clinical outcome.
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Affiliation(s)
- Emily Peien Fan
- Department of Neurology, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Gabriel Heiber
- Department of Psychiatry, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Elizabeth E Gerard
- Department of Neurology, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Stephan Schuele
- Department of Neurology, Northwestern Memorial Hospital, Chicago, IL, USA
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Sequential FDG PET and MRI findings in a case of SMART syndrome. Seizure 2017; 51:50-51. [DOI: 10.1016/j.seizure.2017.07.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/03/2017] [Accepted: 07/19/2017] [Indexed: 11/17/2022] Open
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13
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Rigamonti A, Lauria G, Mantero V, Filizzolo M, Salmaggi A. SMART (stroke-like migraine attack after radiation therapy) syndrome: a case report with review of the literature. Neurol Sci 2015; 37:157-161. [DOI: 10.1007/s10072-015-2396-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 10/06/2015] [Indexed: 10/22/2022]
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