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Adereti CO, Burke JE, Pace JR. A Rare Case of Diffuse Leptomeningeal and Cortical Enhancement Secondary to Stroke-Like Migraine Attacks After Radiation Therapy (SMART) Syndrome in a Patient With a History of Childhood Medulloblastoma. Cureus 2024; 16:e69435. [PMID: 39411645 PMCID: PMC11474250 DOI: 10.7759/cureus.69435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2024] [Indexed: 10/19/2024] Open
Abstract
Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare complication of craniospinal irradiation (CSI). Patients commonly present with headaches, seizures, and paroxysmal focal neurological deficits. There is a dearth of studies reported in the literature with an estimated fewer than 100 cases described since it was initially defined in the mid-1990s. The authors present the case of a 23-year-old patient with a history of childhood medulloblastoma and prior ventriculoperitoneal shunt (VPS), chemotherapy, and CSI who presented with headaches and new-onset seizures. Magnetic resonance imaging (MRI) of the brain showed diffuse left temporoparietal and occipital leptomeningeal and cortical enhancement. However, cerebrospinal fluid (CSF) analysis was unremarkable for neoplastic, infectious, or inflammatory etiology. Initiation of systemic steroid therapy resulted in drastic improvement of the patient's symptoms and prompted antiepileptic drug (AED) wean and persistent resolution of leptomeningeal and cortical contrast enhancement on brain MRI. When evaluating MRI evidence of leptomeningeal enhancement, neurosurgeons should consider SMART syndrome in the differential diagnosis, especially when extensive workup rules out more common causes of this finding such as leptomeningeal disease (LMD). Proper identification of SMART syndrome can lead to timely treatment, avoidance of invasive procedures such as tissue biopsy, and improved clinical outcomes.
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Affiliation(s)
| | - Joy E Burke
- Neurology, Lahey Hospital and Medical Center, Burlington, USA
| | - Jonathan R Pace
- Neurosurgery, Lahey Hospital and Medical Center, Burlington, USA
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Valappil AV, Ahammed Pk D, Karunanidhi S, Sp HB, Janardhanan S. Stroke-Like Migraine Attacks After Radiation Therapy (SMART) Syndrome: A Case Report. Cureus 2024; 16:e63599. [PMID: 39087141 PMCID: PMC11290572 DOI: 10.7759/cureus.63599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2024] [Indexed: 08/02/2024] Open
Abstract
Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare and delayed complication of brain irradiation involving impaired cerebrovascular autoregulation, and diagnosis is based on distinct clinic-radiographic findings and exclusion of differentials. We report a 38-year-old man, who received cranial irradiation 28 years before and developed episodes of headache and visual aura, followed by left hemianopia, aphasia, behavioral disturbances, and focal seizures. An MRI of the brain revealed gyral swelling with restricted diffusion and mild contrast enhancement over the right temporoparietal and occipital region, and fludeoxyglucose-FDG PET scan showed hyperperfusion in the corresponding brain region. He improved completely with pulse steroids and antiseizure medications. The recognition of this syndrome is important as we can reassure patients and their families and help avoid unnecessary and invasive diagnostic tests.
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Affiliation(s)
- Ashraf V Valappil
- Neurology, Aster Malabar Institute of Medical Sciences Ltd (MIMS) Hospital Calicut, Kozhikode, IND
| | - Danish Ahammed Pk
- Neurology, Aster Malabar Institute of Medical Sciences Ltd (MIMS) Hospital Calicut, Kozhikode, IND
| | - Sellam Karunanidhi
- Nuclear Medicine, Aster Malabar Institute of Medical Sciences Ltd (MIMS) Hospital Calicut, Kozhikode, IND
| | - Harish Babu Sp
- Radiology, Aster Malabar Institute of Medical Sciences Ltd (MIMS) Hospital Calicut, Kozhikode, IND
| | - Sujith Janardhanan
- Radiology, Aster Malabar Institute of Medical Sciences Ltd (MIMS) Hospital Calicut, Kozhikode, IND
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3
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Ibáñez-Juliá MJ, Picca A, Leclercq D, Berzero G, Jacob J, Feuvret L, Rosso C, Birzu C, Alentorn A, Sanson M, Tafani C, Bompaire F, Bataller L, Hoang-Xuan K, Delattre JY, Psimaras D, Ricard D. Late-onset vascular complications of radiotherapy for primary brain tumors: a case-control and cross-sectional analysis. J Cancer Surviv 2024; 18:59-67. [PMID: 37142871 PMCID: PMC10867030 DOI: 10.1007/s11764-023-01350-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/13/2023] [Indexed: 05/06/2023]
Abstract
PURPOSE Radiotherapy (RT) is a recognized risk factor for cerebrovascular (CV) disease in children and in adults with head and neck cancer. We aimed to investigate whether cerebral RT increases the risk of CV disease in adults with primary brain tumors (PBT). METHODS We retrospectively identified adults with a supratentorial PBT diagnosed between 1975 and 2006 and with at least 10 years follow-up after treatment. We analyzed demographic, clinical, and radiological features with special attention to CV events. We also described CV events, vascular risk factors, and intracranial artery modifications in a cross-sectional study of irradiated patients alive at the time of the study. RESULTS A total of 116 patients, treated with RT (exposed group), and 85 non-irradiated patients (unexposed group) were enrolled. Stroke was more frequent in irradiated PBT patients than in the unexposed group (42/116 (36%) vs 7/85 (8%); p < 0.001), with higher prevalence of both ischemic (27/116 (23%) vs 6/85 (7%); p = 0.004) and hemorrhagic (12/116 (10%) vs 1/85 (1%); p = 0.02) stroke. In the irradiated group, patients with tumors near the Willis Polygon were more likely to experience stroke (p < 0.016). Fourty-four alive irradiated patients were included in the cross-sectional study. In this subgroup, intracranial arterial stenosis was more prevalent (11/45, 24%) compared to general population (9%). CONCLUSIONS Stroke prevalence is increased in long-surviving PBT patients treated with cranial RT. IMPLICATIONS FOR CANCER SURVIVORS CV events are frequent in long survivors of PBT treated with cerebral RT. We propose a check list to guide management of late CV complications in adults treated with RT for PBT.
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Affiliation(s)
- María-José Ibáñez-Juliá
- Department of Neurology Mazarin, Hôpitaux Universitaires Pitié-Salpêtrière Charles Foix. Assistance Publique Hôpitaux de Paris (APHP), Paris, France
- Department of Neurology, Ascires Biomedical Group, Valencia, Spain
| | - Alberto Picca
- Department of Neurology Mazarin, Hôpitaux Universitaires Pitié-Salpêtrière Charles Foix. Assistance Publique Hôpitaux de Paris (APHP), Paris, France
- OncoNeuroTox Group: Center for Patients With Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière Charles Foix, Hôpital d'Instruction Des Armées Percy, Paris, France
- Sorbonne Universités, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, HP, Paris, France
| | - Delphine Leclercq
- OncoNeuroTox Group: Center for Patients With Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière Charles Foix, Hôpital d'Instruction Des Armées Percy, Paris, France
- Department of Neuroradiology, Hôpitaux Universitaires Pitié-Salpêtrière Charles Foix. Assistance Publique Hôpitaux Paris (APHP), Paris, France
| | - Giulia Berzero
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Julian Jacob
- OncoNeuroTox Group: Center for Patients With Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière Charles Foix, Hôpital d'Instruction Des Armées Percy, Paris, France
- Department of Radiotherapy, Hôpitaux Universitaires Pitié-Salpêtrière Charles Foix. Assistance Publique Hôpitaux de Paris (APHP), Paris, France
| | - Loïc Feuvret
- OncoNeuroTox Group: Center for Patients With Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière Charles Foix, Hôpital d'Instruction Des Armées Percy, Paris, France
- Department of Radiotherapy, Hôpitaux Universitaires Pitié-Salpêtrière Charles Foix. Assistance Publique Hôpitaux de Paris (APHP), Paris, France
- Radiation Therapy Department, Hospices Civils de Lyon, Lyon, France
| | - Charlotte Rosso
- Department of Vascular Neurology, Hôpitaux Universitaires Pitié-Salpêtrière Charles Foix. Assistance Publique Hôpitaux de Paris (APHP), Paris, France
| | - Cristina Birzu
- Department of Neurology Mazarin, Hôpitaux Universitaires Pitié-Salpêtrière Charles Foix. Assistance Publique Hôpitaux de Paris (APHP), Paris, France
- Sorbonne Universités, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, HP, Paris, France
| | - Agusti Alentorn
- Department of Neurology Mazarin, Hôpitaux Universitaires Pitié-Salpêtrière Charles Foix. Assistance Publique Hôpitaux de Paris (APHP), Paris, France
- Sorbonne Universités, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, HP, Paris, France
| | - Marc Sanson
- Department of Neurology Mazarin, Hôpitaux Universitaires Pitié-Salpêtrière Charles Foix. Assistance Publique Hôpitaux de Paris (APHP), Paris, France
- Sorbonne Universités, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, HP, Paris, France
| | - Camille Tafani
- Department of Neurology, Hôpital d'Instruction Des Armées Percy, Service de Santé Des Armées, Clamart, France
| | - Flavie Bompaire
- Department of Neurology, Hôpital d'Instruction Des Armées Percy, Service de Santé Des Armées, Clamart, France
| | - Luis Bataller
- Neurology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Khê Hoang-Xuan
- Department of Neurology Mazarin, Hôpitaux Universitaires Pitié-Salpêtrière Charles Foix. Assistance Publique Hôpitaux de Paris (APHP), Paris, France
- Sorbonne Universités, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, HP, Paris, France
| | - Jean-Yves Delattre
- Department of Neurology Mazarin, Hôpitaux Universitaires Pitié-Salpêtrière Charles Foix. Assistance Publique Hôpitaux de Paris (APHP), Paris, France
- Sorbonne Universités, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, HP, Paris, France
| | - Dimitri Psimaras
- Department of Neurology Mazarin, Hôpitaux Universitaires Pitié-Salpêtrière Charles Foix. Assistance Publique Hôpitaux de Paris (APHP), Paris, France.
- OncoNeuroTox Group: Center for Patients With Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière Charles Foix, Hôpital d'Instruction Des Armées Percy, Paris, France.
- Sorbonne Universités, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, HP, Paris, France.
| | - Damien Ricard
- OncoNeuroTox Group: Center for Patients With Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière Charles Foix, Hôpital d'Instruction Des Armées Percy, Paris, France
- Department of Neurology, Hôpital d'Instruction Des Armées Percy, Service de Santé Des Armées, Clamart, France
- Centre Borelli, Université Paris-Saclay, ENS Paris-Saclay, CNRS, Service Desanté Des Armées, Université de Paris, Saclay, France
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Blagosklonny MV. My battle with cancer. Part 1. Oncoscience 2024; 11:1-14. [PMID: 38188499 PMCID: PMC10765422 DOI: 10.18632/oncoscience.593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/26/2023] [Indexed: 01/09/2024] Open
Abstract
In January 2023, diagnosed with numerous metastases of lung cancer in my brain, I felt that I must accomplish a mission. If everything happens for a reason, my cancer, in particular, I must find out how metastatic cancer can be treated with curative intent. This is my mission now, and the reason I was ever born. In January 2023, I understood the meaning of life, of my life. I was born to write this article. In this article, I argue that monotherapy with targeted drugs, even when used in sequence, cannot cure metastatic cancer. However, preemptive combinations of targeted drugs may, in theory, cure incurable cancer. Also, I share insights on various topics, including rapamycin, an anti-aging drug that can delay but not prevent cancer, through my personal journey.
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Duranikova O, Straka I, Melichercik L, Marcek P, Gmitterova K, Valkovic P. Case Report: Stroke-like migraine attacks after radiation therapy syndrome: a rare complication 26 years after cranial radiotherapy. Front Oncol 2023; 13:1202918. [PMID: 37849814 PMCID: PMC10577217 DOI: 10.3389/fonc.2023.1202918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 09/18/2023] [Indexed: 10/19/2023] Open
Abstract
Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare delayed complication of cranial radiotherapy, that may present decades after brain irradiation. Here we present a case of 41-year old patient with a history of grade 3 oligodendroglioma, epilepsy and migraine, 26 years after brain radiation therapy, who was admitted with right hemicranial headache, nausea, left homonymous hemianopsia, weakness of the left arm and left-sided hemihypesthesia. After considering alternate diagnoses, we ultimately diagnosed SMART syndrome. Despite its rare occurrence and unknown pathophysiology, there are more case reports of SMART syndrome reported due to advancements in oncology treatment and increasing patients' survival rates. Therefore, diagnosis of SMART syndrome should always be considered in patients with a history of cranial radiation presenting with focal neurologic deficits and migraine, especially with a change in pattern of their usual migraine attack.
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Affiliation(s)
- Olga Duranikova
- 2nd Department of Neurology, Faculty of Medicine, Comenius University in Bratislava, University Hospital Bratislava, Bratislava, Slovakia
| | - Igor Straka
- 2nd Department of Neurology, Faculty of Medicine, Comenius University in Bratislava, University Hospital Bratislava, Bratislava, Slovakia
| | - Lubomir Melichercik
- Department of Magnetic Resonance Imaging, Dr. Magnet Ltd., Bratislava, Slovakia
| | - Peter Marcek
- 2nd Department of Neurology, Faculty of Medicine, Comenius University in Bratislava, University Hospital Bratislava, Bratislava, Slovakia
| | - Karin Gmitterova
- 2nd Department of Neurology, Faculty of Medicine, Comenius University in Bratislava, University Hospital Bratislava, Bratislava, Slovakia
| | - Peter Valkovic
- 2nd Department of Neurology, Faculty of Medicine, Comenius University in Bratislava, University Hospital Bratislava, Bratislava, Slovakia
- Institute of Normal and Pathological Physiology, Centre of Experimental Medicine, Slovak Academy of Sciences, Bratislava, Slovakia
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Ota Y, Liao E, Shah G, Srinivasan A, Capizzano AA. Comprehensive Update and Review of Clinical and Imaging Features of SMART Syndrome. AJNR Am J Neuroradiol 2023; 44:626-633. [PMID: 37142432 PMCID: PMC10249687 DOI: 10.3174/ajnr.a7859] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/20/2023] [Indexed: 05/06/2023]
Abstract
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.
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Affiliation(s)
- Y Ota
- From The Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - E Liao
- From The Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - G Shah
- From The Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - A Srinivasan
- From The Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - A A Capizzano
- From The Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
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Neth BJ, Lachance DH, Uhm JH, Ruff MW. Management and Long-Term Outcomes of Patients With Recurrent Stroke-Like Episodes After Cranial Radiotherapy. Neurologist 2022:00127893-990000000-00042. [DOI: 10.1097/nrl.0000000000000470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Blakstad H, Wohlleben C, Saxhaug C, Brandal P. SMART syndrome: two cases highlighting a complex and rare complication of brain irradiation. BMJ Case Rep 2022; 15:e249599. [PMID: 36167430 PMCID: PMC9516215 DOI: 10.1136/bcr-2022-249599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2022] [Indexed: 11/03/2022] Open
Abstract
Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare complication of radiotherapy with complex neurological impairment. Patients present with neurological symptoms and signs such as migraine, hemianopsia, hemiplegia, aphasia and/or seizures-without recurrence of neoplastic disease. In this report, we describe SMART syndrome in two adult patients 4 and 14 years following brain irradiation, respectively.
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Affiliation(s)
- Hanne Blakstad
- Department of Oncology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | | | - Petter Brandal
- Department of Oncology, Oslo University Hospital, Oslo, Norway
- Institute for Cancer Genetics and Informatics, Oslo University Hospital, Oslo, Norway
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Nagysomkuti Mertse N, Müri R. Case Report: SMART ANTON: Anton-Babinski Syndrome in Stroke-Like Migraine Attacks (SMART) After Radiation Therapy: Two Rare Syndromes, One Case. Front Neurol 2022; 13:887287. [PMID: 35832180 PMCID: PMC9271741 DOI: 10.3389/fneur.2022.887287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/16/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction We describe the case of a 57-years-old patient who presented an Anton-Babinski syndrome in the context of a stroke-like migraine attack after radiation therapy (SMART). Case Report The patient was brought to the emergency room following a sudden loss of vision in the context of a pre-existing left-sided hemianopia after excision of a right occipital astrocytoma followed by radio-chemotherapy 35 years prior to his admission in our services. At admittance, he also presented hyperthermia, hypertension, and a GCS of 7. The MRI showed a leptomeningeal enhancement in the left temporal, parietal, and occipital lobes. After exclusion of other differential diagnoses, we diagnosed a cortical blindness in the context of a SMART syndrome affecting the left hemisphere. While the symptoms improved under corticosteroid therapy, the patient successively presented an Anton-Babinski syndrome, a Riddoch syndrome and a visual associative agnosia before finally regaining his usual sight. Discussion This is, to our knowledge, the first report of an Anton-Babinski syndrome in the context of a SMART syndrome. A dual etiology is mandatory for cortical blindness in SMART syndrome since the latter affects only one hemisphere. A SMART syndrome affecting the contralateral hemisphere in respect to the radiation site seems to be uncommon, which makes this case even more exceptional.
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Affiliation(s)
- Nicolas Nagysomkuti Mertse
- Department of Neurology, University Hospital Bern, Bern, Switzerland
- Department of Psychiatry, University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
- Translational Research Center, University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
- *Correspondence: Nicolas Nagysomkuti Mertse
| | - René Müri
- Department of Neurology, University Hospital Bern, Bern, Switzerland
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Panigrahy N, Aedma S, Lee M. Stroke-Like Migraine Attacks After Radiation Therapy (SMART) Syndrome Presenting With Recurrent Seizures: A Case Study. Cureus 2022; 14:e25691. [PMID: 35812558 PMCID: PMC9258967 DOI: 10.7759/cureus.25691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 11/05/2022] Open
Abstract
Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare, delayed complication of radiation therapy to the brain. We present a case of a 49-year-old female with a past medical history of malignant neoplasm of the brain status following resection and radiation. She initially presented with increased work of breathing. Initial labs and a chest X-ray were suggestive of aspiration pneumonia leading to sepsis. Upon hospitalization, seizure-like activity was noted. Electroencephalogram showed electrographic seizures originating from the left occipital and parietal lobe. She received numerous medications to control the seizures with minimal improvement. Magnetic resonance imaging was performed to characterize the origin of seizures, which showed extensive post-radiation changes including a new meningioma. The patient was subsequently managed with magnesium and Solu Medrol. After this regimen, her condition improved and there were no clinical seizures present.
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Affiliation(s)
- Neha Panigrahy
- Medicine, Carle Illinois College of Medicine, Champaign, USA
| | - Surya Aedma
- Internal Medicine, Carle Foundation Hospital, Urbana, USA
| | - Matthew Lee
- Internal Medicine, Carle Foundation Hospital, Champaign, USA
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SMART syndrome: a case report. Acta Neurol Belg 2022:10.1007/s13760-022-01965-6. [PMID: 35587312 DOI: 10.1007/s13760-022-01965-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/25/2022] [Indexed: 11/01/2022]
Abstract
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). Magnetic resonance imaging (MRI) findings are usually unilateral and posterior predominant cortical-subcortical hyperintensity, swelling and prominent gyriform (cortical and leptomeningeal) gadolinium enhancement in the areas of the brain that underwent irradiation with or without diffusion restriction (1). There is no standard treatment protocol for SMART syndrome. Antiepileptics and corticosteroids are commonly used drugs. CASE REPORT A 65 years old woman was diagnosed with breast cancer with brain metastases and treated with more than 50 Gy brain radiotherapy. The patient presented with acute right-sided weakness and numbness, episodic myoclonic jerking of the right arm and leg, and gait instability five months later. 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 (CT) perfusion revealed increased perfusion in the affected area. The patient was diagnosed with SMART syndrome. MANAGEMENT AND 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 was arrested because of aspiration a month later. DISCUSSION Besides confirming SMART syndrome, diagnostic investigations are also important to exclude other etiologies. Posterior reversible encephalopathy syndrome, post-ictal changes, meningoencephalitis, and cerebrovascular diseases are radiological differential diagnoses considered (3). Proper and early diagnosis of SMART syndrome is significant in preventing unnecessary aggressive approaches and appropriate treatment to avoid lesions of sequela.
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Huang D, Dixit KS. Stroke-Like Migraine Attacks After Radiation Therapy Syndrome and Radiation Necrosis After Cerebral Proton Beam Radiation: A Case Report of Dual Radiotherapy Complications. Neurohospitalist 2022; 12:567-570. [DOI: 10.1177/19418744221102290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare, delayed complication of cranial radiation therapy that consists of migraine-like headaches and focal neurologic deficits such as visual loss, aphasia, hemiparesis, hemisensory loss, and unconsciousness. SMART syndrome may be mistaken for tumor recurrence, radiation necrosis, and stroke. Timely recognition of SMART syndrome prevents unnecessary brain biopsies and enables appropriate anticipatory guidance. We present a 38 year-old right handed male with new headaches, vertigo, visual symptoms, and left-sided paresthesias. Neuroimaging revealed a heterogeneously enhancing mass with invasion into the transverse sinus, diagnosed as an epithelioid hemangioendothelioma by surgical pathology. After resection, the patient underwent proton beam radiation for maximal tissue-sparing. Six months later, he developed radiation necrosis. After another year, he developed recurrent headaches with transient language difficulties and blurry vision during each headache. Neuroimaging was consistent with SMART syndrome, and the patient was started on valproate. Verapamil was added after a second attack. The patient’s headaches improved, but he remains dyslexic. Subsequent imaging shows resolution of gyriform contrast enhancement and continued left temporo-occipital T2/FLAIR hyperintensity. We present a case of early SMART syndrome following proton beam radiotherapy, as well as the dual occurrence of radiation necrosis and SMART syndrome in this individual. Radiation necrosis and SMART syndrome are known complications of radiotherapy, with the latter less well-described. We discuss a possible shared pathophysiology involving endothelial cell dysfunction and impaired cerebrovascular autoregulation, and we question whether proton RT increases risk of early SMART syndrome development.
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Affiliation(s)
- Deborah Huang
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Karan S. Dixit
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Malnati Brain Tumor Institute, Northwestern University, Chicago, IL, USA
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Jacob J, Feuvret L, Simon JM, Ribeiro M, Nichelli L, Jenny C, Ricard D, Psimaras D, Hoang-Xuan K, Maingon P. Neurological side effects of radiation therapy. Neurol Sci 2022; 43:2363-2374. [DOI: 10.1007/s10072-022-05944-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 02/05/2022] [Indexed: 10/19/2022]
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Begasse de Dhaem O, Robbins MS. Cognitive Impairment in Primary and Secondary Headache Disorders. Curr Pain Headache Rep 2022; 26:391-404. [PMID: 35239156 PMCID: PMC8891733 DOI: 10.1007/s11916-022-01039-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2022] [Indexed: 11/28/2022]
Abstract
Purpose of Review To critically evaluate the recent literature on cognitive impairment and headache. Recent Findings Neurocognitive symptoms are prevalent, debilitating, and occur often with both primary and secondary headache disorders. Summary This is a “narrative review of the current literature in PubMed on cognitive function and headache.” Migraine is associated with cognitive impairment years before a migraine diagnosis. In young and middle-aged adults, migraine is associated with deficits in attention, executive function, processing speed, and memory. It is unlikely that migraine is associated with dementia. Although methodologically difficult to assess, there does not seem to be an association between tension-type headache and cognitive dysfunction. In early to midlife, cluster headache seems to be associated with executive dysfunction. Several secondary headache syndromes relevant to clinicians managing headache disorders are associated with poorer cognitive performance or distinctive cognitive patterns, including those attributed to chronic cerebral or systemic vascular disorders, trauma, and derangements of intracranial pressure and volume, including frontotemporal brain sagging syndrome.
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Affiliation(s)
| | - Matthew S Robbins
- Department of Neurology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
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15
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Ota Y, Leung D, Lin E, Liao E, Kurokawa R, Kurokawa M, Baba A, Yokota H, Bathla G, Moritani T, Srinivasan A, Capizzano A. Prognostic Factors of Stroke-Like Migraine Attacks after Radiation Therapy (SMART) Syndrome. AJNR Am J Neuroradiol 2022; 43:396-401. [PMID: 35177545 PMCID: PMC8910816 DOI: 10.3174/ajnr.a7424] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 12/10/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE 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. MATERIALS AND METHODS 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. RESULTS 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). CONCLUSIONS 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.
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Affiliation(s)
- Y. Ota
- From the Division of Neuroradiology (Y.O., E. Liao, R.K., M.K., A.B., T.M., A.S., A.A.C.)
| | - D. Leung
- Department of Radiology and Division of Neuro-Oncology (D.L.), Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - E. Lin
- Division of Neuroradiology (E. Lin), Department of Radiology, University of Rochester Medical Center, Rochester, New York
| | - E. Liao
- From the Division of Neuroradiology (Y.O., E. Liao, R.K., M.K., A.B., T.M., A.S., A.A.C.)
| | - R. Kurokawa
- From the Division of Neuroradiology (Y.O., E. Liao, R.K., M.K., A.B., T.M., A.S., A.A.C.)
| | - M. Kurokawa
- From the Division of Neuroradiology (Y.O., E. Liao, R.K., M.K., A.B., T.M., A.S., A.A.C.)
| | - A. Baba
- From the Division of Neuroradiology (Y.O., E. Liao, R.K., M.K., A.B., T.M., A.S., A.A.C.)
| | - H. Yokota
- Department of Diagnostic Radiology and Radiation Oncology (H.Y.), Graduate School of Medicine, Chiba University, Chiba, Japan
| | - G. Bathla
- Division of Neuroradiology (G.B.), Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - T. Moritani
- From the Division of Neuroradiology (Y.O., E. Liao, R.K., M.K., A.B., T.M., A.S., A.A.C.)
| | - A. Srinivasan
- From the Division of Neuroradiology (Y.O., E. Liao, R.K., M.K., A.B., T.M., A.S., A.A.C.)
| | - A.A. Capizzano
- From the Division of Neuroradiology (Y.O., E. Liao, R.K., M.K., A.B., T.M., A.S., A.A.C.)
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Gharehbagh SS, Nguyen NTTN, Beier D. Stroke-like migraine attacks after radiation therapy (SMART) syndrome presenting as a migraine copycat: A case report. CEPHALALGIA REPORTS 2022. [DOI: 10.1177/25158163221131323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
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).
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Affiliation(s)
| | - Nina TTN Nguyen
- Radiology Department, Odense University Hospital, Odense C, Denmark
| | - Dagmar Beier
- Neurology Department, Odense University Hospital, Odense C, Denmark
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17
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Madera J, Sánchez-Soblechero A, Navarrete Solano P, Corro Verde U, Marco de Lucas E, Pacheco Baldor M, Prada PJ, Pascual J. Late vascular complications after cranial radiotherapy: A report of two illustrative cases. Cancer Radiother 2021; 25:786-789. [PMID: 33903008 DOI: 10.1016/j.canrad.2021.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/23/2021] [Accepted: 04/06/2021] [Indexed: 11/15/2022]
Abstract
Cranial radiotherapy (CRT) is used to treat a large variety of benign and malignant disorders. We present two cases of late neurological complications after CRT and briefly discuss its diagnosis and their shared pathophysiological aspects. The first case is a patient with cognitive impairment associated to mineralizing microangiopathy ten years after CRT for nasopharyngeal carcinoma and the second one is a woman with Stroke-like Migraine Attacks after Radiation Therapy (SMART) syndrome two years after CRT for anaplastic meningioma. Nowadays, higher survival rates might cause an increase in appearance of late neurological complications after CTR. These reported cases show that late complications can mimic a wide variety of neurological conditions and the importance of magnetic resonance image (MRI) to get a diagnosis.
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Affiliation(s)
- J Madera
- Service of Neurology, University Hospital Marqués de Valdecilla, University of Cantabria and IDIVAL, Av. Valdecilla s/n, 39008 Santander, Spain
| | - A Sánchez-Soblechero
- Service of Neurology, University Hospital Gregorio Marañón, Calle Doctor Esquerdo, 46, 28007 Madrid, Spain
| | - P Navarrete Solano
- Service of Oncology and Radiotherapy, University Hospital Marqués de Valdecilla and IDIVAL, Av. Valdecilla s/n, 39008 Santander, Spain
| | - U Corro Verde
- Service of Oncology and Radiotherapy, University Hospital Marqués de Valdecilla and IDIVAL, Av. Valdecilla s/n, 39008 Santander, Spain
| | - E Marco de Lucas
- Service of Radiology, University Hospital Marqués de Valdecilla and IDIVAL, Av. Valdecilla s/n, 39008 Santander, Spain
| | - M Pacheco Baldor
- Service of Oncology and Radiotherapy, University Hospital Marqués de Valdecilla and IDIVAL, Av. Valdecilla s/n, 39008 Santander, Spain
| | - P J Prada
- Service of Oncology and Radiotherapy, University Hospital Marqués de Valdecilla and IDIVAL, Av. Valdecilla s/n, 39008 Santander, Spain
| | - J Pascual
- Service of Neurology, University Hospital Marqués de Valdecilla, University of Cantabria and IDIVAL, Av. Valdecilla s/n, 39008 Santander, Spain.
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18
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SMART: stroke-like migraine attacks after radiation therapy or seizures with migraine-like attacks after radiation therapy? Terms do matter in clinical practice. Neurol Sci 2021; 42:3447-3448. [PMID: 33884527 DOI: 10.1007/s10072-021-05228-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
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19
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Rocha R, Ribeiro L, Correia F. SMART syndrome: a late-onset and not always reversible complication of radiotherapy. BMJ Case Rep 2021; 14:14/4/e241748. [PMID: 33858903 PMCID: PMC8055132 DOI: 10.1136/bcr-2021-241748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Stroke-like migraine attacks after radiation (SMART) syndrome is a rare and late complication of cerebral radiotherapy of unknown pathophysiology. It is characterised by hemicranial headache associated with persistent unilateral focal neurological signs and, occasionally, epileptic seizures. An increase in the frequency of SMART syndrome can be attributed to an increase in the survival rate of patients undergoing radiation therapy This study details the case of a 60-year-old woman with a history of small-cell lung carcinoma, who, in her late forties, was treated with prophylactic cranial irradiation. She presented at the emergency room with acute onset of global aphasia, lethargy and headache that started a few days before.
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Affiliation(s)
- Raquel Rocha
- Harvard Medical School, Boston, Massachusetts, USA .,Neurology Department, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Luís Ribeiro
- Neurology Department, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Filipe Correia
- Neurology Department, Hospital Pedro Hispano, Matosinhos, Portugal
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20
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Stroke-Like Migraine Attacks After Radiation Therapy (SMART) Syndrome: A Comprehensive Review. Curr Pain Headache Rep 2021; 25:33. [PMID: 33761013 DOI: 10.1007/s11916-021-00946-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF 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. RECENT FINDINGS 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.
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21
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de Oliveira Franco Á, Anzolin E, Schneider Medeiros M, Machado Castilhos R, Targa Martins R, Moser Filho HL. SMART Syndrome Identification and Successful Treatment. Case Rep Neurol 2021; 13:40-45. [PMID: 33613243 PMCID: PMC7879299 DOI: 10.1159/000510518] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 07/24/2020] [Indexed: 11/19/2022] Open
Abstract
Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare late complication of brain irradiation. Patients commonly present recurrent attacks of headaches, seizures, and paroxysmal focal neurological deficits including aphasia, negligence, or hemianopsia. We report a 41-year-old male patient admitted to our emergency room with a reduced level of consciousness and global aphasia. One month prior to admission, he started with frequent headache attacks of moderate intensity and paroxysmal behavioral alterations, advancing to confusion, gait instability, language impairment, and somnolence. He had a history of medulloblastoma treated with surgical resection followed by craniospinal irradiation 21 years before symptom onset. After excluding more frequent causes for the patient's symptoms along with a suggestive image pattern, we started treatment for SMART syndrome with high-dose corticosteroid and calcium channel blocker verapamil. The patient gradually improved his level of consciousness and recovered from aphasia and gait instability without new seizures or neuropsychiatric symptoms. Follow-up brain magnetic resonance imaging showed resolution of the typical findings. This case displays a successful clinical evolution of a patient treated for SMART syndrome in which identification of previous radiation treatment, exclusion of other etiologies, and prompt treatment institution were key for effectively tackling this disease.
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Affiliation(s)
| | - Eduardo Anzolin
- Neurosurgery Department, Hospital Cristo Redentor, Porto Alegre, Brazil
| | | | | | - Rodrigo Targa Martins
- Neurology Department, Hospital Nossa Senhora da Conceição (HNSC), Porto Alegre, Brazil
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22
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Kalita O, Hrabalek L, Halaj M, Hok P, Franc D, Klementova Y, Dolezel M, Cechakova E, Sporikova Z, Drabek J, Hajduch M, Tuckova L. Very late complications of oncotherapy in glioblastoma patients: A case series. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2021; 166:236-241. [PMID: 33612837 DOI: 10.5507/bp.2021.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 01/29/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Stroke-like syndrome is defined as a rare, delayed complication of brain oncotherapy. Cases with more favorable brain cancer diagnoses and longer life expectancy have been previously reported, but here we present, for the first time, three long-term survivors of glioblastoma with stroke-like syndromes. METHODS AND RESULTS Three young or middle-aged patients underwent tumor resection and chemoradiotherapy. They received regular clinical and imaging follow-up with stable neurological status and no signs of tumor recurrence. They exhibited varied signs and symptoms (motor and sensory deficits, aphasia, memory and cognitive disorders, seizures, and headache) accompanied by imaging abnormalities. Stroke-like syndromes developed within 2-5 days and resolved in 2-6 weeks. Diffusion-weighted MRI and T2 brain perfusion abnormalities were demonstrated in all patients. In addition, there was focal T1 MRI contrast enhancement due to blood-brain barrier disruption. In addition to tumor recurrence, classic stroke, encephalitis, metabolic and mitochondrial disorders, and post-seizure swelling should be excluded. The imaging indicated intensive MRI scanning and symptomatic medication (steroids supplemented by antiepileptics, vasoactive agents, etc.) for judicious management. With respect to the course, an invasive procedure was still considered an option. CONCLUSION All stroke-like syndromes are diagnoses of exclusion. To avoid misinterpretation of imaging findings as glioblastoma recurrence and avert recall oncotherapy or redundant interventions, better understanding of delayed complications of brain tumor therapy is crucial.
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Affiliation(s)
- Ondrej Kalita
- Department of Neurosurgery, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Lumir Hrabalek
- Department of Neurosurgery, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Matej Halaj
- Department of Neurosurgery, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Pavel Hok
- Department of Neurology Radiology, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - David Franc
- Department of Neurology Radiology, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Yvona Klementova
- Department of Oncology, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Martin Dolezel
- Department of Oncology, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Eva Cechakova
- Department of Oncology, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Zuzana Sporikova
- Laboratory of Experimental Medicine, Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Jiri Drabek
- Laboratory of Experimental Medicine, Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Marian Hajduch
- Laboratory of Experimental Medicine, Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Lucie Tuckova
- Department of Pathology and Laboratory of Molecular Pathology, Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
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Janzarik WG, Sander M, Rößler J, Sommerlade L, Allignol A, Reinhard M. Cerebral Autoregulation and Neurovascular Coupling after Craniospinal Irradiation in Long-Term Survivors of Malignant Pediatric Brain Tumors of the Posterior Fossa. Neuropediatrics 2021; 52:12-18. [PMID: 33065751 DOI: 10.1055/s-0040-1709452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Long-term survivors of craniospinal irradiation have an increased risk for stroke which increases with radiation dose and follow-up time. Radiotherapy induces structural changes of the cerebral vasculature, affecting both, large, and small vessels. It is unknown how these structural changes affect functional mechanisms of cerebral blood flow regulation such as cerebral autoregulation and neurovascular coupling. METHODS Using the transcranial Doppler, we compared dynamic cerebral autoregulation and neurovascular coupling of 12 patients after long-term survival of craniospinal irradiation due to a malignant pediatric brain tumor of the posterior fossa and 12 age- and sex-matched healthy patients. Mean arterial blood pressure and cerebral blood flow velocities in the middle and posterior cerebral artery were recorded at rest during normal breathing to assess cerebral autoregulation (transfer function parameters phase and gain, as well as the correlation coefficient indices Mx, Sx, and Dx), and during 10 cycles of a visual task to assess neurovascular coupling (parameters time delay, natural frequency, gain, attenuation, and rate time). RESULTS Parameters of cerebral autoregulation showed a consistent trend toward reduced cerebral autoregulation in patients that did not reach statistical significance. Neurovascular coupling was not altered after craniospinal irradiation. CONCLUSION In this pilot study, we demonstrated a trend toward reduced cerebral autoregulation, and no alteration of neurovascular coupling after irradiation in long-term survivors of malignant pediatric brain tumors of the posterior fossa.
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Affiliation(s)
- Wibke G Janzarik
- Department of Neuropediatrics and Muscle Disorders, Center for Pediatrics, University Medical Center Freiburg, University of Freiburg, Germany
| | - Milena Sander
- Department of Neuropediatrics and Muscle Disorders, Center for Pediatrics, University Medical Center Freiburg, University of Freiburg, Germany
| | - Jochen Rößler
- Department of Pediatric Hematology and Oncology, Center for Pediatrics, University Medical Center Freiburg, University of Freiburg, Germany.,Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Linda Sommerlade
- Institute for Complex Systems and Mathematical Biology, King's College, University of Aberdeen, Aberdeen, United Kingdom
| | | | - Matthias Reinhard
- Department of Neurology and Clinical Neurophysiology, Medical Center Esslingen, Academic Teaching Hospital of the University of Tübingen, Germany.,Department of Neurology and Neurophysiology, University Medical Center Freiburg, University of Freiburg, Germany
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Carr CM, Benson JC, DeLone DR, Diehn FE, Kim DK, Merrell KW, Nagelschneider AA, Madhavan AA, Johnson DR. Intracranial long-term complications of radiation therapy: an image-based review. Neuroradiology 2021; 63:471-482. [PMID: 33392738 DOI: 10.1007/s00234-020-02621-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 12/08/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Radiation therapy is commonly utilized in the majority of solid cancers and many hematologic malignancies and other disorders. While it has an undeniably major role in improving cancer survival, radiation therapy has long been recognized to have various negative effects, ranging from mild to severe. In this manuscript, we review several intracranial manifestations of therapeutic radiation, with particular attention to those that may be encountered by radiologists. METHODS We conducted an extensive literature review of known complications of intracranial radiation therapy. Based on this review, we selected complications that had salient, recognizable imaging findings. We searched our imaging database for illustrative examples of these complications, focusing only on patients who had a history of intracranial radiation therapy. We then selected cases that best exemplified expected imaging findings in these entities. RESULTS Based on our initial literature search and imaging database review, we selected cases of radiation-induced meningioma, radiation-induced glioma, cavernous malformation, enlarging perivascular spaces, leukoencephalopathy, stroke-like migraine after radiation therapy, Moyamoya syndrome, radiation necrosis, radiation-induced labyrinthitis, optic neuropathy, and retinopathy. Although retinopathy is not typically apparent on imaging, it has been included given its clinical overlap with optic neuropathy. CONCLUSIONS We describe the clinical and imaging features of selected sequelae of intracranial radiation therapy, with a focus on those most relevant to practicing radiologists. Knowledge of these complications and their imaging findings is important, because radiologists play a key role in early detection of these entities.
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Affiliation(s)
- Carrie M Carr
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - John C Benson
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - David R DeLone
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Felix E Diehn
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Dong Kun Kim
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Alex A Nagelschneider
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ajay A Madhavan
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Derek R Johnson
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Martín Guerra J, López Castro R, Martín Asenjo M, García Azorin D. SMART syndrome. NEUROLOGÍA (ENGLISH EDITION) 2021. [DOI: 10.1016/j.nrleng.2020.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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26
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Síndrome de SMART. Neurologia 2021; 36:90-92. [DOI: 10.1016/j.nrl.2020.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/12/2019] [Accepted: 02/08/2020] [Indexed: 11/22/2022] Open
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Singh TD, Hajeb M, Rabinstein AA, Kunchok AC, Pittock SJ, Krecke KN, Bartleson JD, Black DF. SMART syndrome: retrospective review of a rare delayed complication of radiation. Eur J Neurol 2020; 28:1316-1323. [PMID: 33159349 DOI: 10.1111/ene.14632] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/24/2020] [Accepted: 10/30/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND 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. METHODS We conducted a retrospective cohort study of all consecutive adult patients (≥18 years) diagnosed with SMART syndrome at Mayo Clinic, Rochester between January 1995 and December 2018. RESULTS 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 (>10 weeks) correlated with an older age (p = 0.049), temporal lobe involvement (p < 0.001), and diffusion restriction (p = 0.043). CONCLUSIONS SMART is a syndrome with characteristic imaging findings and clinical features. Incomplete recovery by 10 weeks occurred in one-third of individuals and was associated with older age, temporal lobe involvement, and restricted diffusion on MRI.
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Affiliation(s)
- Tarun D Singh
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mania Hajeb
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Amy C Kunchok
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Karl N Krecke
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - David F Black
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Alemany M, Velasco R, Simó M, Bruna J. Late effects of cancer treatment: consequences for long-term brain cancer survivors. Neurooncol Pract 2020; 8:18-30. [PMID: 33664966 DOI: 10.1093/nop/npaa039] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Late adverse effects of cancer treatments represent a significant source of morbidity and also financial hardship among brain tumor patients. These effects can be produced by direct neurologic damage of the tumor and its removal, and/or by complementary treatments such as chemotherapy and radiotherapy, either alone or combined. Notably, young adults are the critical population that faces major consequences because the early onset of the disease may affect their development and socioeconomic status. The spectrum of these late adverse effects is large and involves multiple domains. In this review we classify the main long-term adverse effects into 4 sections: CNS complications, peripheral nervous system complications, secondary neoplasms, and Economic impact. In addition, CNS main complications are divided into nonfocal and focal symptoms. Owing to all the secondary effects mentioned, it is essential for physicians to have a high level of clinical suspicion to prevent and provide early intervention to minimize their impact.
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Affiliation(s)
- Montse Alemany
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-ICO L'Hospitalet (IDIBELL), Barcelona, Spain
| | - Roser Velasco
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-ICO L'Hospitalet (IDIBELL), Barcelona, Spain
| | - Marta Simó
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-ICO L'Hospitalet (IDIBELL), Barcelona, Spain
| | - Jordi Bruna
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-ICO L'Hospitalet (IDIBELL), Barcelona, Spain
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