Peri-ictal pseudoprogression

Last revised by Andrew Murphy on 23 Mar 2023

Peri-ictal pseudoprogression (PIPG) is a rare complication of prior cranial radiation and is thought to be on the same spectrum as SMART syndrome, albeit less severe. 

Peri-ictal pseudoprogression is encountered in patients who have a remote history (typically >10 years) undergone prior cranial radiotherapy for the treatment of gliomas 1

Patients with peri-ictal pseudoprogression present with frequent focal seizures, often with constant subclinical epileptogenic discharges on EEG 1. Differently from SMART syndrome, peri-ictal pseudoprogression is usually characterized by absence of headeaches and no significant neurological impairment.

As SMART syndrome, in peri-ictal pseudoprogression signal alterations on MRI do not have a typical vascular distribution.

This entity is characterized by leptomeningeal and/or cortical enhancement that spares the underlying white matter 1. Diffusion and perfusion features are variable 1

Peri-ictal pseudoprogression is typically fully reversible provided seizure activity can be controlled 1.

  • SMART syndrome

    • similar epidemiology and similar imaging appearances, although cortical enhancement and swelling are more pronounced in SMART syndrome

    • clinically, SMART syndrome is characterized by headache/migraine and stroke-like deficits 1,2 

  • tumor progression

    • white matter usually involved

    • mass effect

    • usually not confined to the cortex

  • tumor pseudoprogression

    • usually occurs within the first year of treatment

    • usually not confined to the cortex

  • subacute stroke

    • usually has a vascular distribution instead

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