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SMART syndrome

SMART syndrome, a catchy acronym for the otherwise unwieldy stroke-like migraine attacks after radiation therapy, is an uncommon delayed complication of cerebral radiation therapy. 

Clinical presentation

Patients usually present years after radiation therapy with prolonged stroke-like episodes with associated neurological dysfunction. These episodes have associated headache and are often preceded by an migraine-like aura 1-2. Occasionally patients may also present with seizures. 

Radiographic features

MRI

The hallmark of SMART syndrome is prominent and transient gyral enhancement. It`s also observed a cortical thickening (hyperintense in T2 and FLAIR) with diffusion restriction. 

In a few cases may have laminar necrosis.

Treatment and prognosis

Typically the condition is self limiting, and gradually resolves over the course of several weeks 4

Differential diagnosis

  • prolonged seizure activity
  • cerebral infarction (subacute)
  • direct remote effects of radiation
  • prolonged complicated migraine

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