Peri ictal pseudoprogression

Last revised by Assoc Prof Frank Gaillard on 24 May 2021

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. 

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

Patients with PIPG present with frequent partial seizures, often with constant subclinical epileptogenic discharges on EEG 1.  

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

PIPG 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

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