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Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare late complication of brain irradiation.
Patients experience recurrent attacks of headaches, seizures, and paroxysmal focal neurological deficits including aphasia, negligence, or hemianopsia.
Seizures are frequent, occurring in up to 80% of cases.
Its range of onset is between one and 35 years after radiation.
The average time of onset after treatment is approximately 20 years.
Symptoms usually reversible or partially reversible.
Brain MRI findings: transient unilateral cortical gadolinium enhancement, increased T2 signal within temporal, parietal, and occipital cortices, with no restriction on diffusion-weighted imaging.
Both hyper- and hypoperfusion reversible hemispheric abnormalities are seen.
In cases of suspected SMART syndrome neuroimaging with gadolinium enhanced brain MRI or CT arteriography, lumbar puncture for CSF analysis, EEG and blood pressure monitoring are necessary to rule out alternative diagnoses.
Treatment: no clear consensus regarding effective treatment: responses to corticosteroids, anti seizure meds, and a role for calcium channel blockers.
Diagnosis requires a high index of suspicion and a history of brain radiation.
About 15% of patients exhibit permanent sequelae.
It is suggested that the syndrome’s underlying vascular dysfunction predisposes to cerebrovascular events and possible permanent symptoms .
Indeed, complete recovery occurs in 55–85%.
In patients with a history of brain irradiation, SMART is to considered before more aggressive procedures are performed, such as brain biopsy.
Calcium channel antagonists may have a role in acute-phase treatment.