Introduction: Stroke-like migraine attacks after radiation therapy (SMART) syndrome, is a late complication of brain radiotherapy. (1) Symptoms are commonly subacute in onset and involve migraine type of headache, seizures, focal neurologic deficits.(2) . MRI findings are usually unilateral and posterior predominant cortical-subcortical hyperintensity, swelling and prominent gyriform (cortical and leptomeningeal) gadolinum enhancement in the areas of brain that underwent irradiation with or without diffusion restriction.(1) There is no standard treatment protocol of SMART syndrome. Antiepileptics and corticosteroids are commonly used drugs.
Case Report: A 65 years old woman diagnosed with breast cancer with brain metastases and treated with more than 50 Gy brain radiotherapy. A couple of months later patient presented with acute right sided weakness and numbness, episodic myoclonic jerking of the right arm and leg and gait instability. MRI and magnetic resonance angiography of the brain with gadolinium revealed left parietooccipital cortical diffusion restriction and accompanying dilatation of the left posterior cerebral artery as new findings. Computed tomography perfusion revealed increased perfussion in the affected area. The patient was diagnosed with SMART syndrome.
Management & Outcome: The patient was treated with dexamethasone (16 mg/day) and anticonvulsant therapy. Myoclonic seizures had almost completely remitted. However, her cognitive impairment persisted, then the patient arrested because of aspiration a month later.
Discussion: Besides confirming SMART syndrome, diagnostic investigations is also important to exclude other etiologies. Posterior reversible encephalopathy syndrome, post-ictal changes, meningoencephalitis and cerebrovascular diseases are radiological differential diagnosis which should be considered.(3) Proper and early diagnosis of SMART syndrome is significant to refrain unneccessary aggressive approaches and for appropriate treatment to prevent sequela lesions.