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CC BY-NC-ND 4.0 · Arq Neuropsiquiatr 2019; 77(03): 215
DOI: 10.1590/0004-282X20190022
Images in Neurology

Stroke-like migraine attacks after radiation therapy (SMART) syndrome

Síndrome com crises de migrânea tipo acidente vascular cerebral após radioterapia (SMART)
Diaa Hamouda 
1   University of Texas Medical Branch, Department of Neurology, Galveston, TX, USA
,
Fábio A. Nascimento
2   Baylor College of Medicine, Department of Neurology, Houston, TX, USA
,
Shiao-Pei Weathers
3   University of Texas, MD Anderson Cancer Center, Department of Neuro-Oncology, Houston, TX. USA
,
Vinodh A. Kumar
4   University of Texas, Department of Radiology, MD Anderson Cancer Center, Houston, TX, USA
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A 33-year-old, right-handed male with a left occipital hemangiopericytoma treated with resection/radiation (60 Gy) with resultant focal epilepsy, presented with severe left-sided headache, expressive aphasia/right homonymous hemianopsia and right-sided hemisensory deficits. The EEG was unremarkable. Initial MRI brain scans are shown in [Figures A and B]. He improved with analgesics and returned to his baseline in two weeks. The MRI was repeated after 16 days ([Figure C]). He was diagnosed with SMART syndrome, a rare and late complication of cranial irradiation[1],[2]. The pathophysiology is still unclear. The process seems to be driven by cerebral hyperexcitability with impaired autoregulatory mechanisms and endothelial damage as a consequence of remote radiation[1]. Clinico-radiological features are challenging. Differential diagnosis includes tumor recurrence, leptomeningeal carcinomatosis, infection, vascular disorders, mitochondrial encephalomyopathy with lactic acidosis and stroke, hemiplegic migraine, posterior reversible encephalopathy and post-ictal MRI changes. Duration of symptoms is variable (hours to weeks). Most reported cases have had full clinical and radiological recovery with symptomatic management; however, incomplete recovery may occur[2].

Zoom Image
Figure Axial T1-weighted post-contrast MRI brain image demonstrates unilateral diffuse gyriform cortical enhancement with associated grey matter thickening on axial FLAIR imaging in the left parietal/occipital lobes (A and B). Follow-up MRI brain (16 days later) showed completed resolution of the cortical enhancement (C) and improvement of the FLAIR abnormality (not shown).

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Conflict of interest:

There is no conflict of interest to declare.

  • References

  • 1 Kerklaan JP, Lycklama a Nijeholt GJ, et al. SMART syndrome: a late reversible complication after radiation therapy for brain tumors. J Neurol. 2011 Jun;258(6):1098-104. https://doi.org/10.1007/s00415-010-5892-x
  • 2 Black DF, Morris JM, Lindell EP, Krecke KN, Worrell GA, Bartleson JD, et al. Stroke-like migraine attacks after radiation therapy (SMART) syndrome is not always completely reversible: a case series. AJNR Am J Neuroradiol. 2013;34(12):2298-303. https://doi.org/10.3174/ajnr.A3602

Address for correspondence

Diaa Hamouda
University of Texas Medical Branch, 301; Galveston, TX 77555-0539
USA   

Publication History

Received: 02 August 2018

Accepted: 20 November 2018

Article published online:
21 August 2023

© 2023. Academia Brasileira de Neurologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Kerklaan JP, Lycklama a Nijeholt GJ, et al. SMART syndrome: a late reversible complication after radiation therapy for brain tumors. J Neurol. 2011 Jun;258(6):1098-104. https://doi.org/10.1007/s00415-010-5892-x
  • 2 Black DF, Morris JM, Lindell EP, Krecke KN, Worrell GA, Bartleson JD, et al. Stroke-like migraine attacks after radiation therapy (SMART) syndrome is not always completely reversible: a case series. AJNR Am J Neuroradiol. 2013;34(12):2298-303. https://doi.org/10.3174/ajnr.A3602

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Zoom Image
Figure Axial T1-weighted post-contrast MRI brain image demonstrates unilateral diffuse gyriform cortical enhancement with associated grey matter thickening on axial FLAIR imaging in the left parietal/occipital lobes (A and B). Follow-up MRI brain (16 days later) showed completed resolution of the cortical enhancement (C) and improvement of the FLAIR abnormality (not shown).