Presentation
Recurrent seizures at home, not coping. Worsening left sided weakness. Background of previous right frontal brain tumor (meningioma) treated with surgery and radiotherapy.
Patient Data
Previous right frontal craniotomy, encephalomalacia, and established gliosis in the right frontal lobe, milder gliosis in the left frontal lobe. Dilated ventricles, most prominently the frontal horns and bodies of the lateral ventricles.
No acute findings.
Contiguous enhancement of the right frontal and insular cortex.
Minor changes on DWI relate to T2 shine-through, with no abnormal ADC values.
No abnormal enhancement within the resection cavity (so no residual or recurrent tumor).
Multiple SWI abnormalities compatible with microbleeds, and some cavernomas also evident on T2W sequences.
Case Discussion
The patient underwent resection and radiotherapy (RT) for a meningioma 15 years prior to this presentation. There is evidence of long term post-RT effects with diffuse white matter change, volume loss and microbleeds/cavernomas. This acute presentation with headaches, stroke-like symptoms and contiguous cortical enhancement is a recognized phenomenon called SMART syndrome (Stroke-like Migraine attacks After Radiation Therapy).