1
|
Winter SF, Vaios EJ, Shih HA, Grassberger C, Parsons MW, Gardner MM, Ehret F, Kaul D, Boehmerle W, Endres M, Dietrich J. Mitigating Radiotoxicity in the Central Nervous System: Role of Proton Therapy. Curr Treat Options Oncol 2023; 24:1524-1549. [PMID: 37728819 DOI: 10.1007/s11864-023-01131-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 09/21/2023]
Abstract
OPINION STATEMENT Central nervous system (CNS) radiotoxicity remains a challenge in neuro-oncology. Dose distribution advantages of protons over photons have prompted increased use of brain-directed proton therapy. While well-recognized among pediatric populations, the benefit of proton therapy among adults with CNS malignancies remains controversial. We herein discuss the role of protons in mitigating late CNS radiotoxicities in adult patients. Despite limited clinical trials, evidence suggests toxicity profile advantages of protons over conventional radiotherapy, including retention of neurocognitive function and brain volume. Modelling studies predict superior dose conformality of protons versus state-of-the-art photon techniques reduces late radiogenic vasculopathies, endocrinopathies, and malignancies. Conversely, potentially higher brain tissue necrosis rates following proton therapy highlight a need to resolve uncertainties surrounding the impact of variable biological effectiveness of protons on dose distribution. Clinical trials comparing best photon and particle-based therapy are underway to establish whether protons substantially improve long-term treatment-related outcomes in adults with CNS malignancies.
Collapse
Affiliation(s)
- Sebastian F Winter
- Department of Neurology and MGH Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117, Berlin, Germany.
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Clinician Scientist Program, 10117, Berlin, Germany.
| | - Eugene J Vaios
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Clemens Grassberger
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael W Parsons
- Department of Psychiatry, Psychology Assessment Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Melissa M Gardner
- Department of Psychiatry, Psychology Assessment Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Felix Ehret
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Clinician Scientist Program, 10117, Berlin, Germany
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Berlin, Germany; German Cancer Consortium (DKTK), partner site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - David Kaul
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Berlin, Germany; German Cancer Consortium (DKTK), partner site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Wolfgang Boehmerle
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117, Berlin, Germany
| | - Matthias Endres
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- ExcellenceCluster NeuroCure, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
| | - Jorg Dietrich
- Department of Neurology and MGH Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| |
Collapse
|
2
|
Duranikova O, Straka I, Melichercik L, Marcek P, Gmitterova K, Valkovic P. Case Report: Stroke-like migraine attacks after radiation therapy syndrome: a rare complication 26 years after cranial radiotherapy. Front Oncol 2023; 13:1202918. [PMID: 37849814 PMCID: PMC10577217 DOI: 10.3389/fonc.2023.1202918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 09/18/2023] [Indexed: 10/19/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Olga Duranikova
- 2nd Department of Neurology, Faculty of Medicine, Comenius University in Bratislava, University Hospital Bratislava, Bratislava, Slovakia
| | - Igor Straka
- 2nd Department of Neurology, Faculty of Medicine, Comenius University in Bratislava, University Hospital Bratislava, Bratislava, Slovakia
| | - Lubomir Melichercik
- Department of Magnetic Resonance Imaging, Dr. Magnet Ltd., Bratislava, Slovakia
| | - Peter Marcek
- 2nd Department of Neurology, Faculty of Medicine, Comenius University in Bratislava, University Hospital Bratislava, Bratislava, Slovakia
| | - Karin Gmitterova
- 2nd Department of Neurology, Faculty of Medicine, Comenius University in Bratislava, University Hospital Bratislava, Bratislava, Slovakia
| | - Peter Valkovic
- 2nd Department of Neurology, Faculty of Medicine, Comenius University in Bratislava, University Hospital Bratislava, Bratislava, Slovakia
- Institute of Normal and Pathological Physiology, Centre of Experimental Medicine, Slovak Academy of Sciences, Bratislava, Slovakia
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
McKevitt FM. What neurologists can do for neuro-oncology patients. Pract Neurol 2023:pn-2022-003665. [PMID: 37019612 DOI: 10.1136/pn-2022-003665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2023] [Indexed: 04/07/2023]
Abstract
Neuro-oncology is a branch of medical science concerned with managing central nervous system tumours and neurological complications of cancer. Patients with brain tumours need a multidisciplinary approach to their care and neurologists can play a key part within that team. This review shows how neurologists can contribute to the care of patients with neuro-oncological disease at various points during the illness, including at initial diagnosis, during symptom management and at end of life assisting with palliative seizure management. The review focuses on brain tumour-related epilepsy, the complications of brain tumour treatments and the neurological complications of systemic cancer treatments including immunotherapies.
Collapse
Affiliation(s)
- Fiona M McKevitt
- Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| |
Collapse
|
5
|
Straub S, Bürkle E, Grimm A. [Stroke-like migraine attacks after radiation therapy (SMART) syndrome: a rare sequelae after cerebral radiotherapy]. DER NERVENARZT 2023; 94:145-148. [PMID: 36484788 PMCID: PMC9898321 DOI: 10.1007/s00115-022-01413-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/30/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Stephanie Straub
- Abteilung Neurologie mit Schwerpunkt Epileptologie, Universitätsklinik Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Deutschland
| | - Eva Bürkle
- Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Tübingen, Tübingen, Deutschland Hoppe-Seyler Str. 3
| | - Alexander Grimm
- Abteilung Neurologie mit Schwerpunkt Epileptologie, Universitätsklinik Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Deutschland
| |
Collapse
|
6
|
Neth BJ, Lachance DH, Uhm JH, Ruff MW. Management and Long-Term Outcomes of Patients With Recurrent Stroke-Like Episodes After Cranial Radiotherapy. Neurologist 2022:00127893-990000000-00042. [DOI: 10.1097/nrl.0000000000000470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
7
|
Blakstad H, Wohlleben C, Saxhaug C, Brandal P. SMART syndrome: two cases highlighting a complex and rare complication of brain irradiation. BMJ Case Rep 2022; 15:e249599. [PMID: 36167430 PMCID: PMC9516215 DOI: 10.1136/bcr-2022-249599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Hanne Blakstad
- Department of Oncology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | | | - Petter Brandal
- Department of Oncology, Oslo University Hospital, Oslo, Norway
- Institute for Cancer Genetics and Informatics, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
8
|
Nagysomkuti Mertse N, Müri R. Case Report: SMART ANTON: Anton-Babinski Syndrome in Stroke-Like Migraine Attacks (SMART) After Radiation Therapy: Two Rare Syndromes, One Case. Front Neurol 2022; 13:887287. [PMID: 35832180 PMCID: PMC9271741 DOI: 10.3389/fneur.2022.887287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/16/2022] [Indexed: 11/17/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Nicolas Nagysomkuti Mertse
- Department of Neurology, University Hospital Bern, Bern, Switzerland
- Department of Psychiatry, University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
- Translational Research Center, University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
- *Correspondence: Nicolas Nagysomkuti Mertse
| | - René Müri
- Department of Neurology, University Hospital Bern, Bern, Switzerland
| |
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
SMART syndrome: a case report. Acta Neurol Belg 2022:10.1007/s13760-022-01965-6. [PMID: 35587312 DOI: 10.1007/s13760-022-01965-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/25/2022] [Indexed: 11/01/2022]
Abstract
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.
Collapse
|
11
|
Jacob J, Feuvret L, Simon JM, Ribeiro M, Nichelli L, Jenny C, Ricard D, Psimaras D, Hoang-Xuan K, Maingon P. Neurological side effects of radiation therapy. Neurol Sci 2022; 43:2363-2374. [DOI: 10.1007/s10072-022-05944-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 02/05/2022] [Indexed: 10/19/2022]
|
12
|
Ota Y, Leung D, Lin E, Liao E, Kurokawa R, Kurokawa M, Baba A, Yokota H, Bathla G, Moritani T, Srinivasan A, Capizzano A. Prognostic Factors of Stroke-Like Migraine Attacks after Radiation Therapy (SMART) Syndrome. AJNR Am J Neuroradiol 2022; 43:396-401. [PMID: 35177545 PMCID: PMC8910816 DOI: 10.3174/ajnr.a7424] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 12/10/2021] [Indexed: 11/07/2022]
Abstract
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.
Collapse
Affiliation(s)
- Y. Ota
- From the Division of Neuroradiology (Y.O., E. Liao, R.K., M.K., A.B., T.M., A.S., A.A.C.)
| | - D. Leung
- Department of Radiology and Division of Neuro-Oncology (D.L.), Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - E. Lin
- Division of Neuroradiology (E. Lin), Department of Radiology, University of Rochester Medical Center, Rochester, New York
| | - E. Liao
- From the Division of Neuroradiology (Y.O., E. Liao, R.K., M.K., A.B., T.M., A.S., A.A.C.)
| | - R. Kurokawa
- From the Division of Neuroradiology (Y.O., E. Liao, R.K., M.K., A.B., T.M., A.S., A.A.C.)
| | - M. Kurokawa
- From the Division of Neuroradiology (Y.O., E. Liao, R.K., M.K., A.B., T.M., A.S., A.A.C.)
| | - A. Baba
- From the Division of Neuroradiology (Y.O., E. Liao, R.K., M.K., A.B., T.M., A.S., A.A.C.)
| | - H. Yokota
- Department of Diagnostic Radiology and Radiation Oncology (H.Y.), Graduate School of Medicine, Chiba University, Chiba, Japan
| | - G. Bathla
- Division of Neuroradiology (G.B.), Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - T. Moritani
- From the Division of Neuroradiology (Y.O., E. Liao, R.K., M.K., A.B., T.M., A.S., A.A.C.)
| | - A. Srinivasan
- From the Division of Neuroradiology (Y.O., E. Liao, R.K., M.K., A.B., T.M., A.S., A.A.C.)
| | - A.A. Capizzano
- From the Division of Neuroradiology (Y.O., E. Liao, R.K., M.K., A.B., T.M., A.S., A.A.C.)
| |
Collapse
|
13
|
Taguchi M, Bonner K, Memon AB. Be Smart to Identify the Stroke-Like Migraine Attacks After Radiation Therapy (SMART) Syndrome. Cureus 2022; 14:e21930. [PMID: 35273871 PMCID: PMC8901082 DOI: 10.7759/cureus.21930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2022] [Indexed: 11/12/2022] Open
Abstract
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.
Collapse
|
14
|
Gharehbagh SS, Nguyen NTTN, Beier D. Stroke-like migraine attacks after radiation therapy (SMART) syndrome presenting as a migraine copycat: A case report. CEPHALALGIA REPORTS 2022. [DOI: 10.1177/25158163221131323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
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).
Collapse
Affiliation(s)
| | - Nina TTN Nguyen
- Radiology Department, Odense University Hospital, Odense C, Denmark
| | - Dagmar Beier
- Neurology Department, Odense University Hospital, Odense C, Denmark
| |
Collapse
|
15
|
Ahmed QS, Sadighi ZS, Lucas JT, Khan RB. Stroke-Like Migraine after Radiation Treatment Syndrome in Children with Cancer. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0041-1740364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AbstractStroke-like migraine attacks after radiation therapy (SMART) syndrome is a symptom complex of transient neurological deficits, headache, and abnormal cortical contrast enhancement on brain MRI. Pathophysiology is unclear, but exposure to cranial radiation (RT) is a sine qua non. We report five children with SMART syndrome treated with RT therapy for medulloblastoma (n = 3), atypical teratoid rhabdoid tumor (n = 1), and pleomorphic xanthoastrocytoma (n = 1). Median age at tumor diagnosis was 9.4 years (range 5.1–14.7). Median follow-up from cancer diagnosis was 3.1 years (range 1.4–12.9). All patients had 54 Gy focal RT treatment and medulloblastoma children had additional 36 Gy craniospinal irradiation. Median time from the end of RT to first transient neurological deficit was 1 year (range 0.7–12.1). The median follow-up since first SMART episode was 0.6 years (range 0.3–2.6). Presenting symptoms included the gradual development of unilateral weakness (n = 4), non-fluent dysphasia (n = 1), somnolence (n = 1), and headaches (n = 3). Neurological deficits resolved within 30 minutes to 10 days. Transient cortical enhancement on magnetic resonance imaging (MRI) was confirmed in two children and was absent in the other three. Two children had a single and three had multiple episodes over the next few months. Two children with protracted symptoms responded to 3 days treatment with high dose intravenous methylprednisolone. Symptoms ultimately resolved in all patients. SMART syndrome is a rare disorder characterized by slow evolution of neurological deficits with variable abnormal cortical contrast enhancement. The use of steroids may improve symptoms and speed resolution.
Collapse
Affiliation(s)
- Qurratulain S. Ahmed
- Department of Medicine, Bay State Medical Center, Springfield, Massachusetts, United States
| | - Zsila S. Sadighi
- Division of Neurology, St. Jude Children's Research Hospital, Memphis, Tennessee, United States
| | - John T. Lucas
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, United States
| | - Raja B. Khan
- Division of Neurology, St. Jude Children's Research Hospital, Memphis, Tennessee, United States
| |
Collapse
|
16
|
Cirjan C, Jamal A, Mercier P, Berkovich R, Navalkele P. A Case of Postoperative SMART Syndrome in a Medulloblastoma Survivor. JOURNAL OF CHILD SCIENCE 2021. [DOI: 10.1055/s-0041-1740466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AbstractStroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare neurological phenomenon characterized by reversible symptoms of headache, seizure, hemiparesis, and visual changes associated with a remote history of cranial irradiation. We describe a case of a medulloblastoma survivor, presenting with postoperative neurological deficits, along with neuroimaging findings and subsequent resolution of symptoms, highly suggestive of SMART syndrome. We have also reviewed the common epidemiological and diagnostic factors associated with this rare disease, as well as discussed pathophysiological mechanisms.
Collapse
Affiliation(s)
- Cristian Cirjan
- Cardinal Glennon Children's Hospital, Saint Louis University School of Medicine, Saint Louis, Missouri, United States
| | - Ali Jamal
- Department of Neurology, Cardinal Glennon Children's Hospital, Saint Louis University, Saint Louis, Missouri, United States
| | - Philippe Mercier
- Department of Neurosurgery, Cardinal Glennon Children's Hospital, Saint Louis University, Saint Louis, Missouri, United States
| | - Rachel Berkovich
- Department of Radiology, Cardinal Glennon Children's Hospital, Saint Louis University, Saint Louis, Missouri, United States
| | - Pournima Navalkele
- Division of Hematology Oncology, Department of Pediatrics, Cardinal Glennon Children's Hospital, Saint Louis University, Saint Louis, Missouri, United States
| |
Collapse
|
17
|
Medical and Neurological Management of Brain Tumor Complications. Curr Neurol Neurosci Rep 2021; 21:53. [PMID: 34545509 DOI: 10.1007/s11910-021-01142-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2021] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW The diagnosis of brain tumors often leads to complications that are either related to the tumor itself or the tumor-directed and supportive therapies, increasing the burden on the patients' quality of life and even survival. This article reviews the medical and neurological conditions that commonly complicate the disease course of brain tumors patients. RECENT FINDINGS Various mechanisms have been newly identified to be involved in the pathophysiology of seizures and brain edema and can help advance the treatment of such complications. There have also been new developments in the management of thromboembolic disease and cognitive impairment. Medical and neurological complications are being identified more often in brain tumor patients with the improved survival provided by therapeutic advances. Early and proper identification and management of such complications are crucial for a better survival and quality of life.
Collapse
|
18
|
Winter SF, Klein JP, Vaios EJ, Karschnia P, Lee EQ, Shih HA, Loebel F, Dietrich J. Clinical Presentation and Management of SMART Syndrome. Neurology 2021; 97:118-120. [PMID: 33947781 DOI: 10.1212/wnl.0000000000012150] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/26/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Sebastian F Winter
- From the Massachusetts General Hospital Cancer Center (S.F.W., E.J.V., P.K., J.D.) and Center for Neuro-Oncology, Dana-Farber Cancer Institute (E.Q.L.), Harvard Medical School; Division of Neuro-Oncology, Department of Neurology (S.F.W., E.J.V., P.K., J.D.), and Department of Radiation Oncology (H.A.S.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery (S.F.W., F.L.), Charité Universitatsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Departments of Neurology and Radiology (J.P.K.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Radiation Oncology (E.J.V.), Duke Cancer Institute, Durham, NC; and Department of Neurosurgery (P.K.), Ludwig Maximilians University, Munich, Germany
| | - Joshua P Klein
- From the Massachusetts General Hospital Cancer Center (S.F.W., E.J.V., P.K., J.D.) and Center for Neuro-Oncology, Dana-Farber Cancer Institute (E.Q.L.), Harvard Medical School; Division of Neuro-Oncology, Department of Neurology (S.F.W., E.J.V., P.K., J.D.), and Department of Radiation Oncology (H.A.S.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery (S.F.W., F.L.), Charité Universitatsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Departments of Neurology and Radiology (J.P.K.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Radiation Oncology (E.J.V.), Duke Cancer Institute, Durham, NC; and Department of Neurosurgery (P.K.), Ludwig Maximilians University, Munich, Germany
| | - Eugene J Vaios
- From the Massachusetts General Hospital Cancer Center (S.F.W., E.J.V., P.K., J.D.) and Center for Neuro-Oncology, Dana-Farber Cancer Institute (E.Q.L.), Harvard Medical School; Division of Neuro-Oncology, Department of Neurology (S.F.W., E.J.V., P.K., J.D.), and Department of Radiation Oncology (H.A.S.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery (S.F.W., F.L.), Charité Universitatsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Departments of Neurology and Radiology (J.P.K.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Radiation Oncology (E.J.V.), Duke Cancer Institute, Durham, NC; and Department of Neurosurgery (P.K.), Ludwig Maximilians University, Munich, Germany
| | - Philipp Karschnia
- From the Massachusetts General Hospital Cancer Center (S.F.W., E.J.V., P.K., J.D.) and Center for Neuro-Oncology, Dana-Farber Cancer Institute (E.Q.L.), Harvard Medical School; Division of Neuro-Oncology, Department of Neurology (S.F.W., E.J.V., P.K., J.D.), and Department of Radiation Oncology (H.A.S.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery (S.F.W., F.L.), Charité Universitatsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Departments of Neurology and Radiology (J.P.K.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Radiation Oncology (E.J.V.), Duke Cancer Institute, Durham, NC; and Department of Neurosurgery (P.K.), Ludwig Maximilians University, Munich, Germany
| | - Eudocia Q Lee
- From the Massachusetts General Hospital Cancer Center (S.F.W., E.J.V., P.K., J.D.) and Center for Neuro-Oncology, Dana-Farber Cancer Institute (E.Q.L.), Harvard Medical School; Division of Neuro-Oncology, Department of Neurology (S.F.W., E.J.V., P.K., J.D.), and Department of Radiation Oncology (H.A.S.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery (S.F.W., F.L.), Charité Universitatsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Departments of Neurology and Radiology (J.P.K.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Radiation Oncology (E.J.V.), Duke Cancer Institute, Durham, NC; and Department of Neurosurgery (P.K.), Ludwig Maximilians University, Munich, Germany
| | - Helen A Shih
- From the Massachusetts General Hospital Cancer Center (S.F.W., E.J.V., P.K., J.D.) and Center for Neuro-Oncology, Dana-Farber Cancer Institute (E.Q.L.), Harvard Medical School; Division of Neuro-Oncology, Department of Neurology (S.F.W., E.J.V., P.K., J.D.), and Department of Radiation Oncology (H.A.S.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery (S.F.W., F.L.), Charité Universitatsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Departments of Neurology and Radiology (J.P.K.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Radiation Oncology (E.J.V.), Duke Cancer Institute, Durham, NC; and Department of Neurosurgery (P.K.), Ludwig Maximilians University, Munich, Germany
| | - Franziska Loebel
- From the Massachusetts General Hospital Cancer Center (S.F.W., E.J.V., P.K., J.D.) and Center for Neuro-Oncology, Dana-Farber Cancer Institute (E.Q.L.), Harvard Medical School; Division of Neuro-Oncology, Department of Neurology (S.F.W., E.J.V., P.K., J.D.), and Department of Radiation Oncology (H.A.S.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery (S.F.W., F.L.), Charité Universitatsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Departments of Neurology and Radiology (J.P.K.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Radiation Oncology (E.J.V.), Duke Cancer Institute, Durham, NC; and Department of Neurosurgery (P.K.), Ludwig Maximilians University, Munich, Germany
| | - Jorg Dietrich
- From the Massachusetts General Hospital Cancer Center (S.F.W., E.J.V., P.K., J.D.) and Center for Neuro-Oncology, Dana-Farber Cancer Institute (E.Q.L.), Harvard Medical School; Division of Neuro-Oncology, Department of Neurology (S.F.W., E.J.V., P.K., J.D.), and Department of Radiation Oncology (H.A.S.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery (S.F.W., F.L.), Charité Universitatsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Departments of Neurology and Radiology (J.P.K.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Radiation Oncology (E.J.V.), Duke Cancer Institute, Durham, NC; and Department of Neurosurgery (P.K.), Ludwig Maximilians University, Munich, Germany.
| |
Collapse
|
19
|
Branfield Day L, Rajendram P, Kalia LV, Gold WL. An Intelligent Diagnosis: SMART Syndrome. Am J Med 2021; 134:863-865. [PMID: 33444593 DOI: 10.1016/j.amjmed.2020.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 11/25/2020] [Accepted: 11/26/2020] [Indexed: 11/30/2022]
Affiliation(s)
| | - Phavalan Rajendram
- Department of Medicine, University of Toronto, Ont, Canada; Division of Neurology
| | - Lorraine V Kalia
- Department of Medicine, University of Toronto, Ont, Canada; Division of Neurology
| | - Wayne L Gold
- Department of Medicine, University of Toronto, Ont, Canada; Divisions of General Internal Medicine and Infectious Diseases, University Health Network, Toronto, Ont, Canada
| |
Collapse
|
20
|
Holay Q, Monnier M, Perriguey M, Gazzola S, Dubourg O, Faivre A. Ischemic stroke: A not so unusual complication of SMART syndrome? Rev Neurol (Paris) 2021; 177:1013-1015. [PMID: 34176660 DOI: 10.1016/j.neurol.2020.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/23/2020] [Accepted: 12/04/2020] [Indexed: 10/21/2022]
Affiliation(s)
- Q Holay
- Hôpital d'Instruction des armées Sainte-Anne, service de neurologie, BP 60083800, Toulon cedex 09, France.
| | - M Monnier
- Hôpital d'Instruction des armées Sainte-Anne, service de neurologie, BP 60083800, Toulon cedex 09, France
| | - M Perriguey
- Hôpital d'Instruction des armées Sainte-Anne, service de neurologie, BP 60083800, Toulon cedex 09, France
| | - S Gazzola
- Hôpital d'Instruction des armées Sainte-Anne, service de neurologie, BP 60083800, Toulon cedex 09, France
| | - O Dubourg
- École du Val-de-grâce, Paris, France
| | - A Faivre
- Hôpital d'Instruction des armées Sainte-Anne, service de neurologie, BP 60083800, Toulon cedex 09, France
| |
Collapse
|
21
|
Abstract
Headache is a common reason for seeking medical attention. Most cases are benign primary headache disorders; however, there is significant overlap between symptoms of these disorders and secondary headaches. Differentiating these clinical scenarios requires a careful history with attention to red flag symptoms and a neurologic examination. These details can identify dangerous disorders: subarachnoid hemorrhage, reversible cerebral vasoconstriction syndrome, elevated intracranial pressure, hydrocephalus, cerebral venous sinus thrombosis, arterial dissection, central nervous system infection, and inflammatory vasculitis. Older, pregnant, or immunocompromised patients have a higher risk for secondary disorders; clinicians should have a different threshold to conduct evaluations in such patients.
Collapse
Affiliation(s)
- David Kopel
- Department of Neurology, 725 Albany Street, Suite 7B, Boston, MA 02118, USA
| | - Crandall Peeler
- Department of Ophthalmology and Neurology, 85 East Concord Street 8th Floor, Boston, MA 02118, USA
| | - Shuhan Zhu
- Department of Neurology, 725 Albany Street, Suite 7B, Boston, MA 02118, USA.
| |
Collapse
|
22
|
SMART: stroke-like migraine attacks after radiation therapy or seizures with migraine-like attacks after radiation therapy? Terms do matter in clinical practice. Neurol Sci 2021; 42:3447-3448. [PMID: 33884527 DOI: 10.1007/s10072-021-05228-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
|
23
|
Rocha R, Ribeiro L, Correia F. SMART syndrome: a late-onset and not always reversible complication of radiotherapy. BMJ Case Rep 2021; 14:14/4/e241748. [PMID: 33858903 PMCID: PMC8055132 DOI: 10.1136/bcr-2021-241748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Stroke-like migraine attacks after radiation (SMART) syndrome is a rare and late complication of cerebral radiotherapy of unknown pathophysiology. It is characterised by hemicranial headache associated with persistent unilateral focal neurological signs and, occasionally, epileptic seizures. An increase in the frequency of SMART syndrome can be attributed to an increase in the survival rate of patients undergoing radiation therapy This study details the case of a 60-year-old woman with a history of small-cell lung carcinoma, who, in her late forties, was treated with prophylactic cranial irradiation. She presented at the emergency room with acute onset of global aphasia, lethargy and headache that started a few days before.
Collapse
Affiliation(s)
- Raquel Rocha
- Harvard Medical School, Boston, Massachusetts, USA .,Neurology Department, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Luís Ribeiro
- Neurology Department, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Filipe Correia
- Neurology Department, Hospital Pedro Hispano, Matosinhos, Portugal
| |
Collapse
|
24
|
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.
Collapse
|
25
|
Ota Y, Leung D, Moritani T, Capizzano AA. Atypical imaging findings of presumed stroke-like migraine attacks after radiation therapy syndrome in the brainstem. Neuroradiology 2021; 63:1377-1381. [PMID: 33694026 DOI: 10.1007/s00234-021-02684-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/01/2021] [Indexed: 11/30/2022]
Abstract
The authors present an atypical case of presumed stroke-like migraine attacks after radiation therapy (SMART) syndrome in the brainstem. A 29-year-old male, who had been treated with resection and subsequent craniospinal radiation for posterior fossa medulloblastoma 21 years before, presented with subacute progressive left hemiparesis evolving over 4 days. Hematological findings, cerebrospinal fluid (CSF), and electroencephalogram (EEG) were unremarkable. Magnetic resonance imaging (MRI) showed a round area of hyperintense FLAIR signal centered within the pons associated with central restricted diffusion, peripheral enhancement, and small paramagnetic low susceptibility signal foci consistent with petechial hemorrhage. Positron emission tomography (PET), perfusion MRI, and MR spectroscopy revealed no evidence of tumor recurrence. The diagnosis of SMART syndrome is presumed from the conventional and advanced imaging findings, clinical history, and clinical course.
Collapse
Affiliation(s)
- Yoshiaki Ota
- Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI, 48109, USA.
| | - Denise Leung
- Division of Neuro-oncology, Department of Neurology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Toshio Moritani
- Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI, 48109, USA
| | - Aristides A Capizzano
- Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI, 48109, USA
| |
Collapse
|
26
|
Carr CM, Benson JC, DeLone DR, Diehn FE, Kim DK, Merrell KW, Nagelschneider AA, Madhavan AA, Johnson DR. Intracranial long-term complications of radiation therapy: an image-based review. Neuroradiology 2021; 63:471-482. [PMID: 33392738 DOI: 10.1007/s00234-020-02621-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 12/08/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Radiation therapy is commonly utilized in the majority of solid cancers and many hematologic malignancies and other disorders. While it has an undeniably major role in improving cancer survival, radiation therapy has long been recognized to have various negative effects, ranging from mild to severe. In this manuscript, we review several intracranial manifestations of therapeutic radiation, with particular attention to those that may be encountered by radiologists. METHODS We conducted an extensive literature review of known complications of intracranial radiation therapy. Based on this review, we selected complications that had salient, recognizable imaging findings. We searched our imaging database for illustrative examples of these complications, focusing only on patients who had a history of intracranial radiation therapy. We then selected cases that best exemplified expected imaging findings in these entities. RESULTS Based on our initial literature search and imaging database review, we selected cases of radiation-induced meningioma, radiation-induced glioma, cavernous malformation, enlarging perivascular spaces, leukoencephalopathy, stroke-like migraine after radiation therapy, Moyamoya syndrome, radiation necrosis, radiation-induced labyrinthitis, optic neuropathy, and retinopathy. Although retinopathy is not typically apparent on imaging, it has been included given its clinical overlap with optic neuropathy. CONCLUSIONS We describe the clinical and imaging features of selected sequelae of intracranial radiation therapy, with a focus on those most relevant to practicing radiologists. Knowledge of these complications and their imaging findings is important, because radiologists play a key role in early detection of these entities.
Collapse
Affiliation(s)
- Carrie M Carr
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - John C Benson
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - David R DeLone
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Felix E Diehn
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Dong Kun Kim
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Alex A Nagelschneider
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ajay A Madhavan
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Derek R Johnson
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| |
Collapse
|
27
|
Martín Guerra J, López Castro R, Martín Asenjo M, García Azorin D. SMART syndrome. NEUROLOGÍA (ENGLISH EDITION) 2021. [DOI: 10.1016/j.nrleng.2020.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
|
28
|
Síndrome de SMART. Neurologia 2021; 36:90-92. [DOI: 10.1016/j.nrl.2020.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/12/2019] [Accepted: 02/08/2020] [Indexed: 11/22/2022] Open
|
29
|
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.
Collapse
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
| |
Collapse
|
30
|
Abstract
Both the onset of various malignancies as well as the treatment of cancer can lead to neurologic symptoms which can be difficult to diagnose. In this review, we highlight the varied ways in which neurologic sequelae of cancer and its treatment manifest in children. Initial neurologic presentation may be secondary to mass effect or to immune-mediated paraneoplastic syndromes. Treatment effects on the nervous system may arise from surgery, chemotherapy, radiation, or bone marrow transplantation. In addition, the rapidly expanding field of immunotherapies for cancer has generated numerous new approaches to eradicating cancer including monoclonal antibodies, checkpoint inhibitors, and chimeric antigen receptor T cells (CAR-T cells), which have neurologic side effects mediated by immune responses that are also being recognized. Here we review common consult questions to the neurologist and our general approach to these scenarios including altered mental status, headaches, seizures, and sensorimotor complaints, considering the multifactorial nature of each.
Collapse
Affiliation(s)
- Caren Armstrong
- Department of Neurology, Johns Hopkins Hospital, 200 N Wolfe St Suite 2158, Baltimore, MD, 21287, USA
| | - Lisa R Sun
- Department of Neurology, Johns Hopkins Hospital, 200 N Wolfe St Suite 2158, Baltimore, MD, 21287, USA.
| |
Collapse
|
31
|
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]
|
32
|
Di Stefano V, Rispoli MG, Pellegrino N, Graziosi A, Rotondo E, Napoli C, Pietrobon D, Brighina F, Parisi P. Diagnostic and therapeutic aspects of hemiplegic migraine. J Neurol Neurosurg Psychiatry 2020; 91:764-771. [PMID: 32430436 PMCID: PMC7361005 DOI: 10.1136/jnnp-2020-322850] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/22/2020] [Accepted: 04/24/2020] [Indexed: 01/25/2023]
Abstract
Hemiplegic migraine (HM) is a clinically and genetically heterogeneous condition with attacks of headache and motor weakness which may be associated with impaired consciousness, cerebellar ataxia and intellectual disability. Motor symptoms usually last <72 hours and are associated with visual or sensory manifestations, speech impairment or brainstem aura. HM can occur as a sporadic HM or familiar HM with an autosomal dominant mode of inheritance. Mutations in CACNA1A, ATP1A2 and SCN1A encoding proteins involved in ion transport are implicated. The pathophysiology of HM is close to the process of typical migraine with aura, but appearing with a lower threshold and more severity. We reviewed epidemiology, clinical presentation, diagnostic assessment, differential diagnosis and treatment of HM to offer the best evidence of this rare condition. The differential diagnosis of HM is broad, including other types of migraine and any condition that can cause transitory neurological signs and symptoms. Neuroimaging, cerebrospinal fluid analysis and electroencephalography are useful, but the diagnosis is clinical with a genetic confirmation. The management relies on the control of triggering factors and even hospitalisation in case of long-lasting auras. As HM is a rare condition, there are no randomised controlled trials, but the evidence for the treatment comes from small studies.
Collapse
Affiliation(s)
- Vincenzo Di Stefano
- Department of Biomedicine, Neuroscience and Advanced Diagnostic (BIND), University of Palermo, Palermo, Sicilia, Italy
| | - Marianna Gabriella Rispoli
- Department of Neuroscience Imaging and Clinical Sciences, 'G. d'Annunzio' University, Universita degli Studi Gabriele d'Annunzio Chieti e Pescara, Chieti Scalo, Chieti, Italy
| | - Noemi Pellegrino
- Pediatrics, University Gabriele d'Annunzio of Chieti Pescara Department of Medicine and Aging Science, Chieti, Abruzzo, Italy
| | - Alessandro Graziosi
- Pediatrics, University Gabriele d'Annunzio of Chieti Pescara Department of Medicine and Aging Science, Chieti, Abruzzo, Italy
| | - Eleonora Rotondo
- Pediatrics, University Gabriele d'Annunzio of Chieti Pescara Department of Medicine and Aging Science, Chieti, Abruzzo, Italy
| | - Christian Napoli
- Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, Roma, Lazio, Italy
| | - Daniela Pietrobon
- Department of Biomedical Sciences & Padova Neuroscience Center, University of Padova, Padova, Italy.,CNR Neuroscience Institute, Padova, Italy
| | - Filippo Brighina
- Department of Biomedicine, Neuroscience and Advanced Diagnostic (BIND), University of Palermo, Palermo, Sicilia, Italy
| | - Pasquale Parisi
- Dipartimento di Neuroscienze Salute Mentale e Organi di Senso (NESMOS), University of Rome La Sapienza Faculty of Medicine and Psychology, Roma, Lazio, Italy
| |
Collapse
|
33
|
|
34
|
Biju RD, Dower A, Moon BG, Gan P. SMART (Stroke-Like Migraine Attacks After Radiation Therapy) Syndrome: A Case Study with Imaging Supporting the Theory of Vascular Dysfunction. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e921795. [PMID: 32221270 PMCID: PMC7161941 DOI: 10.12659/ajcr.921795] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Patient: Male, 28-year-old Final Diagnosis: SMART syndrome Symptoms: Seizure Medication: — Clinical Procedure: — Specialty: Neurosurgery
Collapse
Affiliation(s)
- Rakesh Danny Biju
- Department of Neurosurgery, Waikato District Health Board, Hamilton, Waikato, New Zealand
| | - Ashraf Dower
- Department of Neurosurgery, Waikato District Health Board, Hamilton, Waikato, New Zealand
| | - Benjamin G Moon
- Department of Radiology, Waikato District Health Board, Hamilton, Waikato, New Zealand
| | - Peter Gan
- Department of Neurosurgery, Waikato District Health Board, Hamilton, Waikato, New Zealand
| |
Collapse
|
35
|
Abstract
PURPOSE OF REVIEW To review the latest information about the interactions between cancer and cerebrovascular disease. RECENT FINDINGS Additional data support the finding that both ischemic and hemorrhagic stroke are important complications of cancer or its treatment. Reperfusion therapy is being given successfully to patients with stroke complicating cancer. Hemorrhagic stroke may occur with metastatic disease to the brain, coagulopathies from cancer, in particular leukemia, or as complications of chemotherapy. Ischemic stroke also may be a complication of metastatic disease with local invasion of vessels, a pro-thrombotic disorder such as non-bacterial thrombotic endocarditis (NBTE) or disseminated intravascular coagulation (DIC), or secondary to chemotherapy. Stroke also is a potential consequence of radiation therapy to the head and neck. Venous sinus thrombosis may develop with hematologic malignancies or chemotherapy. Although many patients will have a history of cancer at the time of stroke, a cerebrovascular event may be the initial manifestation of a malignancy.
Collapse
|
36
|
Abstract
PURPOSE OF REVIEW This review details the frequency of and ways in which migraine can be both an ischemic stroke/transient ischemic attack mimic (false positive) and chameleon (false negative). We additionally seek to clarify the complex relationships between migraine and cerebrovascular diseases with regard to diagnostic error. RECENT FINDINGS Nearly 2% of all patients evaluated emergently for possible stroke have an ultimate diagnosis of migraine; approximately 18% of all stroke mimic patients treated with intravenous thrombolysis have a final diagnosis of migraine. Though the treatment of a patient with migraine with thrombolytics confers a low risk of complication, symptomatic intracerebral hemorrhage may occur. Three clinical prediction scores with high sensitivity and specificity exist that can aid in the diagnosis of acute cerebral ischemia. Differentiating between migraine aura and transient ischemic attacks remains challenging. On the other hand, migraine is a common incorrect diagnosis initially given to patients with stroke. Among patients discharged from an emergency visit to home with a diagnosis of a non-specific headache disorder, 0.5% were misdiagnosed. Further development of tools to quantify and understand sources of stroke misdiagnosis among patients who present with headache is warranted. Both failure to identify cerebral ischemia among patients with headache and overdiagnosis of ischemia can lead to patient harms. While some tools exist to help with acute diagnostic decision-making, additional strategies to improve diagnostic safety among patients with migraine and/or cerebral ischemia are needed.
Collapse
Affiliation(s)
- Oleg Otlivanchik
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, 3316 Rochambeau Avenue, Bronx, NY, 10467, USA
| | - Ava L Liberman
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, 3316 Rochambeau Avenue, Bronx, NY, 10467, USA.
| |
Collapse
|
37
|
Di Stefano AL, Berzero G, Ducray F, Eoli M, Pichiecchio A, Farina LM, Cuccarini V, Brunelli MC, Diamanti L, Condette Auliac S, Salmaggi A, Silvani A, Giometto B, Pace A, Vidiri A, Bourdain F, Bastianello S, Ceroni M, Marchioni E. Stroke‐like events after brain radiotherapy: a large series with long‐term follow‐up. Eur J Neurol 2019; 26:639-650. [DOI: 10.1111/ene.13870] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 11/07/2018] [Indexed: 11/29/2022]
Affiliation(s)
- A. L. Di Stefano
- Department of Neurology Hôpital Foch Suresnes France
- Service de Neurologie 2‐Mazarin AP‐HP Pitié‐Salpêtrière Paris France
- Inserm U 1127 CNRS UMR 7225 Institut du Cerveau et de la Moelle Épinière (ICM) Paris France
| | - G. Berzero
- Neuroncology Unit IRCCS Mondino Foundation Pavia Italy
- PhD Program in Biomedical Sciences University of Pavia Pavia Italy
| | - F. Ducray
- Department of Neuroncology Hospices Civils de Lyon Lyon France
- Department of Cancer Cell Plasticity Cancer Research Centre of Lyon INSERM U1052 CNRS UMR5286 Lyon France
- Université Claude Bernard Lyon 1 Lyon France
| | - M. Eoli
- Neuroncology Unit Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - A. Pichiecchio
- Neuroradiology Unit IRCCS Mondino Foundation Pavia Italy
- Department of Brain and Behavioral Sciences University of Pavia Pavia Italy
| | - L. M. Farina
- Neuroradiology Unit IRCCS Mondino Foundation Pavia Italy
| | - V. Cuccarini
- Neuroradiology Unit Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - M. C. Brunelli
- Department of Neurology Ospedale Ca’ Foncello Treviso Italy
| | - L. Diamanti
- Neuroncology Unit IRCCS Mondino Foundation Pavia Italy
- PhD Program in Biomedical Sciences University of Pavia Pavia Italy
| | | | - A. Salmaggi
- Neuroncology Unit Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
- SC Neurologia Ospedale A. Manzoni Lecco Italy
| | - A. Silvani
- Neuroncology Unit Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - B. Giometto
- Neurology Unit Ospedale S. Antonio Azienda ULSS6 Euganea Padova Italy
| | - A. Pace
- Neuroncology Unit Regina Elena National Cancer Institute Rome Italy
| | - A. Vidiri
- Radiology Unit Regina Elena National Cancer Institute Rome Italy
| | - F. Bourdain
- Department of Neurology Hôpital Foch Suresnes France
| | - S. Bastianello
- Neuroradiology Unit IRCCS Mondino Foundation Pavia Italy
- Department of Brain and Behavioral Sciences University of Pavia Pavia Italy
| | - M. Ceroni
- Neuroncology Unit IRCCS Mondino Foundation Pavia Italy
- Department of Brain and Behavioral Sciences University of Pavia Pavia Italy
| | - E. Marchioni
- Neuroncology Unit IRCCS Mondino Foundation Pavia Italy
| |
Collapse
|
38
|
Radiation and Chemotherapy Induced Injury. Clin Neuroradiol 2019. [DOI: 10.1007/978-3-319-61423-6_68-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
39
|
Radiation and Chemotherapy Induced Injury. Clin Neuroradiol 2019. [DOI: 10.1007/978-3-319-68536-6_68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
40
|
Johnson DR, Guerin JB, Ruff MW, Fang S, Hunt CH, Morris JM, Pearse Morris P, Kaufmann TJ. Glioma response assessment: Classic pitfalls, novel confounders, and emerging imaging tools. Br J Radiol 2018; 92:20180730. [PMID: 30412421 DOI: 10.1259/bjr.20180730] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Neuroimaging plays a pivotal role in the care of patients with infiltrating gliomas, in whom imaging changes are often the first indications of tumor response or progression. Unfortunately, evaluation of glioma response is often not straightforward, even for experienced radiologists. Post-surgical or radiation-related changes may mimic the appearance of disease progression, while medications such as corticosteroids and antiangiogenic agents may mimic tumor response without truly arresting tumor growth or improving patient survival. Immunotherapy response can result in inflammatory changes which manifest as progressively increasing tumor enhancement and edema over months. Many of these pitfalls can be minimized or avoided altogether by the use of modern brain tumor response criteria, while others will require new imaging tools before they can be fully addressed. Advanced MRI methods and novel positron emission tomography (PET) agents are proving important for this purpose, and their role will undoubtedly continue to grow in the future.
Collapse
Affiliation(s)
| | | | - Michael W Ruff
- 2 Department of Neurology, Mayo Clinic , Rochester, MN , US
| | | | | | | | | | | |
Collapse
|
41
|
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.
Collapse
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
| |
Collapse
|
42
|
Seizures with Migraine-like Attacks after Radiation Therapy (SMART): A new meaning of an old acronym. Seizure 2018; 60:94-95. [DOI: 10.1016/j.seizure.2018.06.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/12/2018] [Accepted: 06/14/2018] [Indexed: 11/20/2022] Open
|
43
|
Sun LR, Cooper S. Neurological Complications of the Treatment of Pediatric Neoplastic Disorders. Pediatr Neurol 2018; 85:33-42. [PMID: 30126755 DOI: 10.1016/j.pediatrneurol.2018.05.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 05/25/2018] [Indexed: 01/19/2023]
Abstract
Neurological complications resulting from childhood cancer treatments are common. Treatment for childhood neoplastic disorders is often multimodal and may include procedures, cranial irradiation, chemotherapy, transplant, and immunotherapy, each of which carries distinct neurological risks. Procedures, such as lumbar punctures, are commonly used in this population for diagnostic purposes as well as intrathecal medication administration. Surgery is associated with an array of potential neurological complications, with posterior fossa syndrome being a common cause of morbidity in pediatric brain tumor patients after neurosurgical resection. Cranial irradiation can cause late neurological sequelae such as stroke, cerebral vasculopathy, secondary malignancy, and cognitive dysfunction. Neurotoxic effects of chemotherapeutic agents are common and include neuropathy, coagulopathy causing stroke or cerebral sinovenous thrombosis, encephalopathy, seizures, cerebellar dysfunction, myelopathy, and neuropsychologic difficulties. Hematopoietic stem cell transplant has a high risk of neurological complications including central nervous system infection, seizures, and stroke. Immunotherapies, including chimeric antigen receptor-modified T-cells (CAR T-cells) and immune checkpoint inhibitors, are emerging as potentially effective strategies to treat some types of childhood cancer, but may carry with them substantial neurotoxicity which is just beginning to be recognized and studied. With evolving treatment protocols, childhood cancer survivorship is increasing, and the role of the neurologist in managing both the acute and chronic neurological consequences of treatment is becoming more important. Prevention, early recognition, and treatment of therapy-associated neurotoxicity are imperative to ensuring children can remain on the most effective therapeutic regimens and to improve the neurological function and quality of life of childhood cancer survivors.
Collapse
Affiliation(s)
- Lisa R Sun
- The Johns Hopkins University School of Medicine, Department of Neurology, Division of Pediatric Neurology, Baltimore, Maryland; The Johns Hopkins University School of Medicine, Department of Neurology, Division of Cerebrovascular Neurology, Baltimore, Maryland.
| | - Stacy Cooper
- The Johns Hopkins University School of Medicine, Department of Oncology, Division of Pediatric Oncology, Baltimore, Maryland
| |
Collapse
|
44
|
Duke E, Ullrich NJ. A 15-Year-Old Girl With Sudden Onsent Reversible Neurologic Symptoms After Cranial Irradiation for Medulloblastoma. Semin Pediatr Neurol 2018; 26:124-127. [PMID: 29961502 DOI: 10.1016/j.spen.2017.03.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A 15-year-old girl with history of medulloblastoma was evaluated for headache and neurologic deficits 5 years after completion of initial radiation therapy and 3 years following completion of reirradiation. Neurologic examination was notable for new-onset left hemianopia, hemiparesis, and neglect. Magnetic resonance imaging showed extensive areas of cortical T2 prolongation and thickening involving the right parietal, occipital, and temporal lobes with associated extensive gyral enhancement. Upon spontaneous resolution of her weakness after 4 days, repeat magnetic resonance imaging showed resolution of the edema and gyral enhancement, suggestive of the diagnosis of stroke-like migraine attacks after radiation therapy (SMART syndrome). A review of SMART is provided in this case report.
Collapse
Affiliation(s)
- Elizabeth Duke
- Department of Neurology, Boston Children׳s Hospital, Boston, MA
| | - Nicole J Ullrich
- Department of Neurology, Boston Children׳s Hospital, Boston, MA.
| |
Collapse
|
45
|
Takahashi H, Kimura T, Yuki N, Yoshioka A. Stroke-like Migraine Attacks after Radiation Therapy (SMART) Syndrome Followed by Cerebral Infarction. Intern Med 2018; 57:1921-1924. [PMID: 29491314 PMCID: PMC6064695 DOI: 10.2169/internalmedicine.9579-17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A 36-year-old man with a history of irradiation for acute lymphoblastic leukemia developed headache with cortical dysfunction lasting for 4 weeks. The clinical features were consistent with stroke-like migraine attacks after radiation therapy (SMART) syndrome. Six months later, he developed cerebral infarction due to occlusions of the left anterior and middle cerebral arteries. This is the first case report describing SMART syndrome followed by severe cerebral infarction. Although an association between the two episodes was not assumed, this case indicates that protective therapies against infarction might need to be considered for patients with SMART syndrome.
Collapse
Affiliation(s)
- Hisashi Takahashi
- Department of Neurology, National Hospital Organization Maizuru Medical Center, Japan
| | - Tadashi Kimura
- Department of Neurology, National Hospital Organization Maizuru Medical Center, Japan
| | - Natsuko Yuki
- Department of Neurology, National Hospital Organization Maizuru Medical Center, Japan
| | - Akira Yoshioka
- Department of Clinical Research, National Hospital Organization Maizuru Medical Center, Japan
| |
Collapse
|
46
|
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.
Collapse
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
| |
Collapse
|
47
|
Abstract
PURPOSE OF REVIEW This article reviews key principles in the identification of tumors of the central nervous system (CNS) using standard and advanced imaging modalities. This article highlights the pitfalls and pearls of the imaging evaluation of patients with cancer at time of diagnosis and during cancer therapy and discusses the challenges of the imaging evaluation of treatment-related toxicities. RECENT FINDINGS Treatment of CNS tumors with surgery, chemotherapy, or radiation alters the imaging appearance of the tumor and can be associated with a variety of treatment-related toxicities. The clinician must be familiar with how to assess response to treatment and how to differentiate tumor progression from treatment-related effects. SUMMARY Management and follow-up of neuro-oncology patients is optimized by a comprehensive radiologic approach to CNS tumors and recognition of the challenges in the assessment of response to treatments.
Collapse
|
48
|
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.
Collapse
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
| |
Collapse
|
49
|
Park JH, Park MS, Kim GM. SMART syndrome with cerebral angiographic abnormalities - A case report. J Neurol Sci 2017; 381:147-149. [DOI: 10.1016/j.jns.2017.08.3234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 08/18/2017] [Accepted: 08/21/2017] [Indexed: 11/30/2022]
|
50
|
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
|