Stroke-like Migraine Attacks After Radiation Therapy Research Articles

Early clinical, radiological and EEG improvement following L-arginine infusion in SMART syndrome

ObjectivesTo report the clinical, radiological (MRI) and neurophysiological (EEG) changes in a case of SMART (stroke-like migraine attacks after radiation therapy) syndrome following treatment with intravenous L-arginine. MethodsA 60-year-old woman had, ten years prior, been diagnosed with primary CNS diffuse large B cell lymphoma, and was successfully treated with curative chemotherapy and whole brain radiotherapy. She presented acutely with left-sided headache, teichopsia and dysphasia following a chest infection. MRI of the brain showed striking left parieto-occipital gyral swelling, diffusion restriction, leptomeningeal enhancement, and increased cerebral blood volume. Her EEG showed an excess of slow activity diffusely, particularly over the left temporal lobe. A diagnosis of SMART syndrome was made. Intravenous L-arginine (0.5 g/kg) was administered. ResultsA few hours post infusion, her migrainous headache subsided and her mentation improved. Her MRI brain performed six days post infusion showed reduced cortical swelling and hyperperfusion, and her EEG showed less temporal slowing. She continued to improve cognitively. DiscussionThis is the first report of SMART syndrome with a response to L-arginine, reflected clinically by a measurable improvement in cognition, brain perfusion and EEG parameters, encouraging further clinical studies.

Comprehensive Update and Review of Clinical and Imaging Features of SMART Syndrome.

Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a delayed complication of cranial irradiation, with subacute onset of stroke-like symptoms including seizures, visual disturbance, speech impairment, unilateral hemianopsia, facial droop, and aphasia, often associated with migraine-type headache. The diagnostic criteria were initially proposed in 2006. However, the diagnosis of SMART syndrome is challenging because clinical symptoms and imaging features of SMART syndrome are indeterminate and overlap with tumor recurrence and other neurologic diseases, which may result in inappropriate clinical management and unnecessary invasive diagnostic procedures. Recently, various imaging features and treatment recommendations for SMART syndrome have been reported. Radiologists and clinicians should be familiar with updates on clinical and imaging features of this delayed radiation complication because recognition of this entity can facilitate proper clinical work-up and management. This review provides current updates and a comprehensive overview of the clinical and imaging features of SMART syndrome.

Uncommon Presentation of an Uncommon Disease: Stroke-like Migraine Attacks after Radiation Therapy in a Patient with Sudden Onset Expressive Aphasia and Cryptogenic Fevers (P3-5.029)

<h3>Objective:</h3> To present a case of stroke-like migraine attacks after radiation therapy (SMART) syndrome accompanied by fever. <h3>Background:</h3> SMART syndrome is an uncommon condition that presents as migraines with focal neurologic deficits in patients who have undergone brain radiation. This syndrome can present decades after completion of radiation therapy and therefore represents a unique diagnostic challenge. <h3>Design/Methods:</h3> Case report. <h3>Results:</h3> A 26-year-old man with a history of myxopapillary ependymoma status post whole brain radiation therapy 15 years prior presented with 3 days of headaches, sudden onset aphasia, and fevers. Initial exam was significant for severe expressive aphasia with only 1–2 words of speech production. Head CT was unremarkable. CT angiography demonstrated slightly decreased arborization of the distal MCA territory vessels in the left cerebral hemisphere but was otherwise unremarkable. Patient was empirically treated for CNS infection with antimicrobial therapy. CSF analysis was unremarkable, as was the remainder of his infectious workup. Long term EEG monitoring showed focal slowing in the left hemisphere but did not show any epileptiform activity. MRI was completed with arterial spin labeling (ASL) sequence, which showed increased perfusion in the left cerebral hemisphere, consistent with SMART syndrome. Patient’s exam gradually improved over the following week. He followed up in clinic 6 weeks later and his symptoms had significantly improved. He was almost back to baseline. Fevers and headaches had completed resolved. <h3>Conclusions:</h3> This case of SMART syndrome has the typical findings of sudden onset migraines and focal neurologic deficits in a patient who previously underwent brain radiation therapy. Our case was unique in that the patient had fevers of unknown origin; a phenomenon that has only been reported in one prior case. The use of MRI perfusion or ASL can aid in the diagnosis; in this case showing increased perfusion over the affected cerebral hemisphere. <b>Disclosure:</b> Dr. Gill has nothing to disclose. Dr. Gill has nothing to disclose. Dr. Avila has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Alnylam Pharmaceuticals. Dr. Avila has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Alnylam Pharmaceuticals. Dr. Avila has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Akcea Therapeutics. Gino Mongelluzzo has nothing to disclose.

Stroke-like migraine attacks after radiation therapy (SMART) syndrome: a rare sequelae after cerebral radiotherapy

Stroke-like migraine attacks after radiation therapy (SMART) syndrome: a rare sequelae after cerebral radiotherapy

MR-PET Findings in SMART (Stroke-Like Migraine Attacks after Radiation Therapy) Syndrome.

MR-PET Findings in SMART (Stroke-Like Migraine Attacks after Radiation Therapy) Syndrome.

115 SMART: A rare syndrome with potentially devastating consequences

Stroke like migraine attacks after radiation therapy (SMART) is an uncommon delayed complication after cranial irradiation. Whilst classically reported as a reversible syndrome, SMART can have serious neurologi- cal sequelae. We report three cases with differing neurological presentations and outcomes.A 57 year old female with previous cranial radiotherapy for a frontal astrocytoma treated 9 years earlier presented with a two week history of headache, aphasia and right sided hemiparesis. MRI Brain demon- strated new extensive left hemispheric enhancement with extensive effacement of the ipsilateral cerebral sulci. 40 days following her presentation she started to improve and is now in rehabilitation.A 33 year old female with a background of medulloblastoma treated with cranio-spinal radiotherapy 19 years earlier presented with worsening confusion. Her GCS continued to deteriorate and she was intubated and ventilated. MRI Brain showed extensive symmetrical signal anomalies with cortical enhancement along the occipital, temporal and parietal lobe borders. 2 months later she remains in a minimally conscious state.A 65 year old male with a background of acute lymphoblastic leukaemia treated 30 years earlier who was treated prophylactic cranial irradiation presented with headache and unintelligible speech. His symptoms settled after 7 days and he made an almost complete recovery.*Aravindhan Baheerathan and David Lynch are joint first authors c.c.blindheim@gmail.com

Prognostic Factors of Stroke-Like Migraine Attacks after Radiation Therapy (SMART) Syndrome.

Prognostic factors of stroke-like migraine attacks after radiation therapy (SMART) syndrome have not been fully explored. This study aimed to assess clinical and imaging features to predict the clinical outcome of SMART syndrome. We retrospectively reviewed the clinical manifestations and imaging findings of 20 patients with SMART syndrome (median age, 48 years; 5 women) from January 2016 to January 2020 at 4 medical centers. Patient demographics and MR imaging features at the time of diagnosis were reviewed. This cohort was divided into 2 groups based on the degree of clinical improvement (completely versus incompletely recovered). The numeric and categoric variables were compared as appropriate. There were statistically significant differences between the completely recovered group (n = 11; median age, 44 years; 2 women) and the incompletely recovered group (n = 9; median age, 55 years; 3 women) in age, months of follow-up, and the presence of steroid treatment at diagnosis (P = .028, .002, and .01, respectively). Regarding MR imaging features, there were statistically significant differences in the presence of linear subcortical WM susceptibility abnormality, restricted diffusion, and subcortical WM edematous changes in the acute SMART region (3/11 versus 8/9, P = .01; 0/11 versus 4/9, P = .026; and 2/11 versus 7/9, P = .022, respectively). Follow-up MRIs showed persistent susceptibility abnormality (11/11) and subcortical WM edematous changes (9/9), with resolution of restricted diffusion (4/4). Age, use of steroid treatment at the diagnosis of SMART syndrome, and MR imaging findings of abnormal susceptibility signal, restricted diffusion, and subcortical WM change in the acute SMART region can be prognostic factors in SMART syndrome.

Be Smart to Identify the Stroke-Like Migraine Attacks After Radiation Therapy (SMART) Syndrome

Stroke-like migraine attacks after radiation therapy (SMART) are uncommon, often occurring years or decades after brain radiation therapy. This syndrome is a diagnosis of exclusion, and only about 40 cases describing SMART have been published, each one describing a constellation of symptoms and findings. Because symptoms can arise years after initial radiation therapy, the ability of physicians to recognize SMART and rule out other possible causes of symptoms is critical for the long-term care of oncology patients who have undergone cranial radiation. Here we present the case of a 55-year-old man who experienced SMART nine years after radiation therapy and who was successfully treated with steroids.

Stroke-like migraine attacks after radiation therapy (SMART) syndrome presenting as a migraine copycat: A case report

Background: Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a possible long term consequence of cranial beam radiation therapy and may present as a perfect mimic of migraine with or without aura. Methods and Results: We present a 57-year-old man suffering from diffuse astrocytoma and presenting with SMART syndrome perfectly mimicking his antecedent migraine with visual aura. He was treated with intravenous steroid therapy inducing rapid response. Conclusion: SMART syndrome is a rare complex delayed complication of brain radiation therapy, which may present as an isolated migraine with or without aura even decades after cranial radiation. Thus, a sudden intensification or relapse of a previous migraine in a patient with remote cranial radiotherapy constitutes a red flag even decades after cranial irradiation and cured or stable tumor disease on a recent brain MRI. Moreover, SMART syndrome adds to the list of secondary headaches not yet listed in the current International Classification of Headache Disorders, 3rd edition (ICHD3).

Clinical Presentation and Management of SMART Syndrome.

Stroke-like migraine attacks after radiation therapy (SMART) syndrome represents a rare but serious condition manifesting years after cranial radiation therapy (RT).1 Characterized by migraine-type headaches, stroke-like deficits, seizures, and MRI abnormalities, including cortical gyriform enhancement in irradiated brain regions, SMART is diagnostically and therapeutically challenging.2-6 Distinction from tumor progression is difficult and treatment options are limited.2 Although frequently reversible,5 SMART episodes can recur6 and effectuate persistent neurologic or imaging sequelae.3

Stroke-Like Migraine Attacks After Radiation Therapy (SMART) Syndrome: A Case Series (4314)

Stroke-Like Migraine Attacks After Radiation Therapy (SMART) Syndrome: A Case Series (4314)

Stroke-like Migraine Attacks after Radiation Therapy (SMART) Syndrome: “Stroke-Like Migraine or Migrainous Stroke?” (4076)

Stroke-like Migraine Attacks after Radiation Therapy (SMART) Syndrome: “Stroke-Like Migraine or Migrainous Stroke?” (4076)

Stroke-like leukopathy in children with acute lymphoblastic leukemia

There are considerable variations in the reported incidence methotrexate-induced neurotoxicity in children with malignancies. The etiology of acute neurological deficit in pediatric patients with malignancies during polychemotherapy can be diverse: cerebrovascular disease (arterial ischemic stroke, intracranial hemorrhage, venous sinus thrombosis, or their combination), stroke-like migraine attacks after radiation therapy (SMART), posterior reversible encephalopathy syndrome (PRES), thrombotic microangiopathy, toxic leukoencephalopathy (include strokelike leukoencephalopathy). The tactics of a neurologist largely depends on the reasons that caused the neurological deficit. The doctor needs knowledge not only of the clinical picture and the characteristics of the course of the underlying disease, but also of possible complications arising both as a result of the disease itself and due to the therapy being carried out. Timely diagnosis and correct interpretation of emerging neurological events make it possible to determine rational accompanying therapy. The article presents case histories of children with acute lymphoblastic leukemias and acute neurological deficits, with an analysis of their possible causes.

Stroke-Like Migraine Attacks After Radiation Therapy (SMART) Syndrome: A Comprehensive Review.

SMART syndrome is a delayed complication of cranial irradiation that can be misconstrued as tumor recurrence or some other intracranial neurological disease. Recognition of this clinical syndrome is imperative as it can obviate the need for invasive diagnostic testing and can provide reassurance to both the patient and their loved ones. SMART syndrome is generally considered a reversible clinical syndrome; however, neurological deficits may become permanent. Pathophysiology of SMART syndrome may involve cerebrovascular autoregulation impairment, neuronal dysfunction leading to trigeminovascular system impairment and/or cortical spreading depression, and seizures. In addition to MRI brain with gadolinium, other imaging modalities, such as CT perfusion, MR perfusion, MR spectroscopy, and FDG PET/CT, aid in arriving to the diagnosis sooner. Patients should also undergo electroencephalogram in order to promptly identify and treat seizures. There are currently no clear guidelines on how to effectively treat SMART syndrome, but treatment may involve anti-seizure medication, anti-hypertensives, anti-platelet, and steroid therapy. This review provides a comprehensive understanding of the clinical characteristics of SMART syndrome from presentation to diagnostic evaluation. We also discuss radiographic features and treatment strategies for this rare disease. With increased radiotherapy utilization, prompt clinical recognition of SMART syndrome and further development of a comprehensive diagnostic approach to SMART syndrome utilizing newer radiographic modalities as well as treatment algorithms to effectively treat this clinical condition will be imperative.

SMART syndrome: retrospective review of a rare delayed complication of radiation.

SMART (stroke-like migraine attacks after radiation therapy) is a rare, delayed complication of brain radiation. In this study, we wanted to review the spectrum of symptoms, neuroradiological findings, autoimmune status, and outcomes in SMART syndrome patients. We conducted a retrospective cohort study of all consecutive adult patients (≥18years) diagnosed with SMART syndrome at Mayo Clinic, Rochester between January 1995 and December 2018. We identified 25 unique patients with SMART syndrome and a total of 31 episodes and 15 (60%) patients were male. The median age at onset was 46 (interquartile range [IQR] 43-55) years and the median latency of onset after the initial radiation was 21.6 (IQR 14.4-28.2) years. Magnetic resonance imaging (MRI) showed gyral edema and enhancement in all cases with the temporal (25, 80.6%) and parietal (23, 74.2%) lobes being the most commonly affected. The median follow-up of the patients in our cohort was 10 (IQR 6-32) weeks. On univariate analysis, factors associated with an increased risk of recurrent SMART episodes were female gender (odds ratio [OR] 8.1, 95% confidence interval [95% CI] 1.1-52.6, p=0.019) and absence of electrographic seizure discharges during initial symptoms (OR 7.4, 95% CI 1.1-45.9, p=0.032). We could not identify an autoimmune etiology. Longer duration of symptoms (>10weeks) correlated with an older age (p=0.049), temporal lobe involvement (p<0.001), and diffusion restriction (p=0.043). SMART is a syndrome with characteristic imaging findings and clinical features. Incomplete recovery by 10weeks occurred in one-third of individuals and was associated with older age, temporal lobe involvement, and restricted diffusion on MRI.

Stroke-like migraine attacks after radiation therapy (SMART) syndrome-a case series and review.

Cranial irradiation is used both prophylactically and for the treatment of brain tumors. There are various complications associated with it. The rare complication of stroke-like migraine attacks after radiation therapy (SMART) syndrome usually occurs several years after radiation therapy but is a reversible phenomenon. It usually presents with headaches, seizures, or other focal neurological deficits concerning stroke or recurrence of the underlying disease. We aim to present two cases of SMART syndrome highlighting the typical presentation, imaging findings, and differential diagnosis. We also conducted the literature review since the early recognition of this rare delayed onset complication is crucial, given its self-limited course and to avoid misinterpretations of the cases. Our extensive review favors MRI, CT, and prolonged EEG monitoring to rule out other differentials and showed that initiation of corticosteroid therapy and antiepileptic treatment were helpful in the resolution of symptoms and prevent recurrences. Therefore, future studies should be focused on early identification and management guidelines for SMART syndrome.

Stroke-Like Migraine Attacks After Radiation Therapy Syndrome.

Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a delayed complication of brain irradiation.[1][1] Symptoms are varied but typically consist of recurrent migraines with subsequent stroke-like symptoms and seizures.[2][2]-[5][3] The associated imaging findings are unusual but

Stroke-Like Migraine Attacks After Radiation Therapy (SMART): Um Caso Clínico

A síndrome stroke-like migraine attacks after radiation therapy (SMART) é uma condição extremamente rara que consisteno aparecimento de sinais e sintomas neurológicos complexosou estados confusionais, em doentes submetidos a radioterapiacerebral prévia. Encontram-se alterações características na ressonância magnética cerebral que normalizam com a resoluçãodos sintomas. O presente caso clínico descreve uma doente de64 anos com antecedentes de radioterapia cerebral e aparecimento de hemiparesia direita de novo, confusão e depressãodo estado de consciência, com alterações na ressonância magnética cerebral compatíveis com síndrome SMART. Os autorespretendem alertar para a existência desta síndrome e para o seueventual subdiagnóstico.

Protracted Recovery From Stroke-Like Migraine Attacks After Radiation Therapy (SMART) Syndrome: A Case Report

The purpose of this case report is to document a protracted course of recovery and the deficits exhibited by a person with SMART syndrome.

Sequelae of Cranial Irradiation: Stroke-like Migraine Attacks After Radiation Therapy (SMART) Syndrome (P3.6-002)

Sequelae of Cranial Irradiation: Stroke-like Migraine Attacks After Radiation Therapy (SMART) Syndrome (P3.6-002)