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.
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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.
The hallmark of SMART syndrome is prominent and transient gyral enhancement. It's also observed as cortical thickening (hyperintense in T2 and FLAIR) with or without diffusion restriction.
In a few cases there may be laminar necrosis.
Susceptibility-weighted imaging (SWI) typically demonstrates multiple microhemorrhagic foci, thought related to sequelae of remote radiation therapy.
Treatment and prognosis
Typically the condition is self limiting, and gradually resolves over the course of several weeks 4.
- prolonged seizure activity
- cerebral infarction (subacute)
- direct remote effects of radiation
- prolonged complicated migraine
- 1. Caplan LR. Caplan's Stroke, A Clinical Approach. Saunders. (2009) ISBN:1416047212. Read it at Google Books - Find it at Amazon
- 2. Bartleson JD, Krecke KN, O'neill BP et-al. Reversible, strokelike migraine attacks in patients with previous radiation therapy. Neuro-oncology. 2003;5 (2): 121-7. doi:10.1215/S1522-8517-02-00040-6 - Free text at pubmed - Pubmed citation
- 3. Kerklaan JP, Lycklama á nijeholt GJ, Wiggenraad RG et-al. SMART syndrome: a late reversible complication after radiation therapy for brain tumours. J. Neurol. 2011;258 (6): 1098-104. doi:10.1007/s00415-010-5892-x - Free text at pubmed - Pubmed citation
- 4. Bradshaw J, Chen L, Saling M et-al. Neurocognitive recovery in SMART syndrome: a case report. Cephalalgia. 2011;31 (3): 372-6. doi:10.1177/0333102410388436 - Pubmed citation
- 5. Khanipour Roshan S, Salmela MB, McKinney AM. Susceptibility-weighted imaging in stroke-like migraine attacks after radiation therapy syndrome. Neuroradiology 2015;57(11):1103-9. doi: 10.1007/s00234-015-1567-8. Epub 2015 Aug 5. http://www.ncbi.nlm.nih.gov/pubmed/26242361