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HaNDL Syndrome and Seizures: An Unusual Presentation. Clin Neurol Neurosurg 2022; 223:107515. [DOI: 10.1016/j.clineuro.2022.107515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/01/2022] [Accepted: 11/04/2022] [Indexed: 11/06/2022]
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Black DF, Bartleson JD, Bell ML, Lachance DH. SMART: Stroke-Like Migraine Attacks After Radiation Therapy. Cephalalgia 2016; 26:1137-42. [PMID: 16919065 DOI: 10.1111/j.1468-2982.2006.01184.x] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We describe two adults with stroke-like migraine attacks after radiation therapy (SMART syndrome), propose revised diagnostic criteria, and review the previously reported patients. ‘SMART’ is an acronym for a newly recognized syndrome which occurs as a delayed consequence of cerebral irradiation and consists of prolonged, unilateral, migrainous neurological symptoms with transient, dramatic cortical gadolinium enhancement of the affected cerebral hemisphere and is sometimes punctuated by generalized seizures and ipsilateral EEG slowing. Although the neurological symptoms can last for weeks, full recovery occurs. An appropriate evaluation should exclude alternative explanations.
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Affiliation(s)
- D F Black
- Mayo Clinic College of Medicine, Department of Neurology, Rochester, MN 55905, USA.
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Nelson S, Taylor LP. Headaches in brain tumor patients: primary or secondary? Headache 2016; 54:776-85. [PMID: 24697234 DOI: 10.1111/head.12326] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2014] [Indexed: 01/03/2023]
Abstract
BACKGROUND Headaches occur commonly in all patients, including those who have brain tumors. It has been argued that there is a classic "brain tumor headache type" - defined by the International Headache Society as one that is localized, progressive, worse in the morning, aggravated by coughing or bending forward, develops in temporal and often spatial relation to the neoplasm, and resolves within 7 days of surgical removal or treatment with corticosteroids. METHODS Using the search terms "headache and brain tumors," "intracranial neoplasms and headache," and "facial pain and brain tumors," we reviewed the literature from the past 20 years on brain tumor-associated headache and reflected upon the International Classification of Headache Disorders-3 (ICHD-3). In a separate, complementary paper, the proposed mechanisms of brain tumor headache are reviewed. RESULTS We discuss multiple clinical presentations of brain tumor headaches, present the ICHD-3 diagnostic criteria for each type of headache, and then apply our findings to the ICHD-3. Our primary and major finding was that brain tumor headaches can present similarly to primary headaches in those with a predisposition to headaches, suggesting that following ICHD-3 criteria could cause a clinician to overlook a headache caused by a brain tumor. We further find that some types of headaches are not explicitly discussed in the ICHD-3 and also propose that the International Headache Society formally define SMART (Stroke-like Migraine Attacks after Radiation Therapy) syndrome given the increasing amount of literature on this disorder. CONCLUSION Our literature review revealed that brain tumor headache uncommonly presents with classic brain tumor headache characteristics and often satisfies criteria for a primary headache category such as migraine or tension-type. Thus, clinicians may miss headaches due to brain tumors in following ICHD-3 criteria, and the distinction between primary and secondary headache disorders may not be so clear-cut.
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Affiliation(s)
- Sarah Nelson
- Departments of Neurology, Tufts Medical Center, Boston, MA, USA
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Zheng Q, Yang L, Tan LM, Qin LX, Wang CY, Zhang HN. Stroke-like Migraine Attacks after Radiation Therapy Syndrome. Chin Med J (Engl) 2015; 128:2097-101. [PMID: 26228225 PMCID: PMC4717966 DOI: 10.4103/0366-6999.161393] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To summarize the clinical presentation, pathogenesis, neuroimaging, treatment, and outcome of stroke-like migraine attacks after radiation therapy (SMART) syndrome, and to propose diagnostic criteria for this disorder. DATA SOURCES We searched the PubMed database for articles in English published from 1995 to 2015 using the terms of "stroke-like AND migraine AND radiation." Reference lists of the identified articles and reviews were used to retrieve additional articles. STUDY SELECTION Data and articles related to late-onset effects of cerebral radiation were selected and reviewed. RESULTS SMART is a rare condition that involves complex migraines with focal neurologic deficits following cranial irradiation for central nervous system malignancies. The recovery, which ranges from hours to days to weeks, can be partial or complete. We propose the following diagnostic criteria for SMART: (1) Remote history of therapeutic external beam cranial irradiation for malignancy; (2) prolonged, reversible clinical manifestations mostly years after irradiation, which may include migraine, seizures, hemiparesis, hemisensory deficits, visuospatial defect, aphasia, confusion and so on; (3) reversible, transient, unilateral cortical gadolinium enhancement correlative abnormal T2 and fluid-attenuated inversion recovery signal of the affected cerebral region; (4) eventual complete or partial recovery, the length of duration of recovery ranging from hours to days to weeks; (5) no evidence of residual or recurrent tumor; (6) not attributable to another disease. To date, no specific treatment has been identified for this syndrome. CONCLUSIONS SMART is an extremely rare delayed complication of brain irradiation. However, improvements in cancer survival rates have resulted in a rise in its frequency. Hence, awareness and recognition of the syndrome is important to make a rapid diagnosis and avoid aggressive interventions such as brain biopsy and cerebral angiography.
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Affiliation(s)
- Qian Zheng
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Li Yang
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Li-Ming Tan
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Li-Xia Qin
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Chun-Yu Wang
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Hai-Nan Zhang
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
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Surgically Induced SMART Syndrome: Case Report and Review of the Literature. World Neurosurg 2014; 82:240.e7-12. [DOI: 10.1016/j.wneu.2013.01.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2012] [Revised: 08/27/2012] [Accepted: 01/07/2013] [Indexed: 11/19/2022]
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Armstrong AE, Gillan E, DiMario FJ. SMART syndrome (stroke-like migraine attacks after radiation therapy) in adult and pediatric patients. J Child Neurol 2014; 29:336-41. [PMID: 23364656 DOI: 10.1177/0883073812474843] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
SMART syndrome (stroke-like migraine attacks after radiation therapy) is a rare condition that involves complex migraines with focal neurologic findings in patients following cranial irradiation for central nervous system malignancies. Little is known about the mechanisms behind the disorder, making successful treatment challenging. We report 2 new cases of SMART syndrome in pediatric patients as well as review all documented cases of the syndrome. Each of our 2 pediatric patients suffered multiple episodes. Attacks were characterized by severe headache, visual disturbance, aphasia, and weakness. Recovery occurred over several days to weeks. The data from all documented reports of SMART syndrome indicate a greater prevalence for male gender. An age-dependent pattern of onset was also observed, with a greater variability of syndrome onset in patients who received cranial irradiation at a younger age. SMART appears to be a reversible, recurrent long-term complication of radiation therapy with possible age- and gender-related influences.
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Affiliation(s)
- Amy E Armstrong
- 1University of Connecticut School of Medicine, Farmington, CT, USA
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Diniz FDV, Lopes LCG, Castro LHM, Nitrini R, Leite CDC, Lucato LT. SMART syndrome: a late reversible complication of radiotherapy. ARQUIVOS DE NEURO-PSIQUIATRIA 2013; 71:336-7. [DOI: 10.1590/0004-282x20130033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 12/17/2012] [Indexed: 11/21/2022]
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Truntzer P, Monjour A, Gaultier C, Ahle G, Guillerme F, Boutenbat G, Stilhart B, Salze P, Atlani D. SMART Syndrome : à propos d’un cas d’une complication rare après radiothérapie cérébrale et revue de la littérature. Cancer Radiother 2012; 16:295-301. [DOI: 10.1016/j.canrad.2012.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 03/26/2012] [Accepted: 03/28/2012] [Indexed: 10/28/2022]
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Renal salt-wasting syndrome in children with intracranial disorders. Pediatr Nephrol 2012; 27:733-9. [PMID: 22237777 DOI: 10.1007/s00467-011-2093-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2011] [Revised: 11/23/2011] [Accepted: 12/07/2011] [Indexed: 01/05/2023]
Abstract
Hypotonic hyponatremia, a serious and recognized complication of any intracranial disorder, results from extra-cellular fluid volume depletion, inappropriate anti-diuresis or renal salt-wasting. The putative mechanisms by which intracranial disorders might lead to renal salt-wasting are either a disrupted neural input to the kidney or the elaboration of a circulating natriuretic factor. The key to diagnosis of renal salt-wasting lies in the assessment of extra-cellular volume status: the central venous pressure is currently considered the yardstick for measuring fluid volume status in subjects with intracranial disorders and hyponatremia. Approximately 110 cases have been reported so far in subjects ≤18 years of age (male: 63%; female: 37%): intracranial surgery, meningo-encephalitis (most frequently tuberculous) or head injury were the most common underlying disorders. Volume and sodium repletion are the goals of treatment, and this can be performed using some combination of isotonic saline, hypertonic saline, and mineralocorticoids (fludrocortisone). It is worthy of a mention, however, that some authorities contend that cerebral salt wasting syndrome does not exist, since this diagnosis requires evidence of a reduced arterial blood volume, a concept but not a measurable variable.
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Rheims S, Ricard D, van den Bent M, Taillandier L, Bourg V, Désestret V, Cartalat-Carel S, Hermier M, Monjour A, Delattre JY, Sanson M, Honnorat J, Ducray F. Peri-ictal pseudoprogression in patients with brain tumor. Neuro Oncol 2011; 13:775-82. [PMID: 21727213 DOI: 10.1093/neuonc/nor082] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Recent advances in the treatment of malignant gliomas have highlighted the fact that the appearance of new contrast-enhancing lesions on magnetic resonance imaging (MRI) is not always indicative of tumor recurrence. It has been suggested that transient seizure-related MRI changes could mimic disease progression (peri-ictal pseudoprogression [PIPG]). However, the clinical and MRI features associated with this situation have not been well described. Here, we consulted the databases of 6 institutions to identify patients with brain tumor who presented during the follow-up period transient MRI lesions wrongly suggesting tumor progression in a context of epileptic seizures. Ten patients were identified. All patients but 1 were long-term survivors who had initially been treated with radiotherapy. The PIPG episode occurred after a median interval of 11 years after radiotherapy. MRI features were highly similar across patients and consisted of transient focal cortical and/or leptomeningeal enhancing lesions that erroneously suggested tumor progression. All patients improved after adjustment of their antiepileptic drugs and transient oral corticosteroids, and MRI findings were normalized 3 months after the PIPG episode. Two patients demonstrated several seizure relapses with the same clinicoradiological pattern. After a median follow-up period of 3.5 years after the initial PIPG episode, only 1 patient presented with a tumor recurrence. In conclusion, in patients with brain tumor, especially in long-term survivors of radiotherapy, the appearance of new cortical and/or leptomeningeal contrast-enhancing lesions in a context of frequent seizures should raise the suspicion of PIPG. This phenomenon is important to recognize in order to avoid futile therapeutic escalation.
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Affiliation(s)
- Sylvain Rheims
- Service de Neuro-Oncologie, Hospices Civils de Lyon, 59 boulevard Pinel, 69003 Lyon, France
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Kerklaan JP, Lycklama á Nijeholt GJ, Wiggenraad RGJ, Berghuis B, Postma TJ, Taphoorn MJB. SMART syndrome: a late reversible complication after radiation therapy for brain tumours. J Neurol 2011; 258:1098-104. [PMID: 21373901 PMCID: PMC3101343 DOI: 10.1007/s00415-010-5892-x] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Revised: 12/18/2010] [Accepted: 12/20/2010] [Indexed: 12/01/2022]
Abstract
With intensified treatment leading to longer survival, complications of therapy for brain tumours are more frequently observed. Regarding radiation therapy, progressive and irreversible white matter disease with cognitive decline is most feared. We report on four patients with reversible clinical and radiological features occurring years after radiation for brain tumours, suggestive for the so called SMART syndrome (stroke-like migraine attacks after radiation therapy). All four patients (males, age 36-60 years) had been treated with focal brain radiation for a primary brain tumour or with whole-brain radiation therapy for brain metastases. Ranging from 2 to 10 years following radiation therapy patients presented with headache and focal neurological deficits, suggestive for tumour recurrence. Two patients also presented with focal seizures. MRI demonstrated typical cortical swelling and contrast enhancement, primarily in the parieto-occipital region. On follow-up both clinical and MRI features improved spontaneously. Three patients eventually proved to have tumour recurrence. The clinical and radiological picture of these patients is compatible with the SMART syndrome, a rare complication of radiation therapy which is probably under recognized in brain tumour patients. The pathophysiology of the SMART syndrome is poorly understood but bears similarities with the posterior reversible encephalopathy syndrome (PRES). These four cases underline that the SMART syndrome should be considered in patients formerly treated with radiation therapy for brain tumours, who present with new neurologic deficits. Before the diagnosis of SMART syndrome can be established other causes, such as local tumour recurrence, leptomeningeal disease or ischemic disease should be ruled out.
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Affiliation(s)
- Joost P Kerklaan
- Department of Neurology, Medical Centre Haaglanden, Postbus 432, 2501 CK, The Hague, The Netherlands,
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Bradshaw J, Chen L, Saling M, Fitt G, Hughes A, Dowd A. Neurocognitive recovery in SMART syndrome: A case report. Cephalalgia 2010; 31:372-6. [DOI: 10.1177/0333102410388436] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Stroke-like migraine attacks after radiation therapy, or SMART syndrome, is characterised by migraine-like headache with or without aura, transient neurological dysfunction, including seizures, and gyriform enhancement on magnetic resonance imaging (MRI) which resolves over a period of weeks. Detailed neuropsychological characterisation in SMART syndrome is lacking and there are no published data on the course and pattern of neurocognitive recovery. Results: The acute clinical presentation was one of unstable, fluctuating neurocognitive disturbances, complicated by seizure activity, followed by a longer term lag in the recovery of focal neuropsychological deficits which, we believe, was due to the more slowly resolving cerebral effects of SMART. Conclusions: To our knowledge, this is the first case of SMART syndrome in which neuropsychological functioning has been comprehensively and serially examined. This case is also unique due to the development of complex partial seizures. We suggest that epileptiform activity during clinical seizures should not be regarded as inconsistent with a diagnosis of SMART, provided that the seizures do not explain the onset of the other clinical and radiological features.
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Affiliation(s)
- Jennifer Bradshaw
- University of Melbourne, Melbourne, Australia
- Austin Health, Melbourne, Australia
| | | | - Michael Saling
- University of Melbourne, Melbourne, Australia
- Austin Health, Melbourne, Australia
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Abstract
OBJECTIVES Surgical resection and adjuvant radiation are mainstays of medulloblastoma (MB) patient management. We utilized a novel 3-dimensional assay to identify how (a) radiation, (b) excision of the primary tumour aggregate, and (c) both treatments combined influence MB cell invasiveness. METHODS Five MB cell lines (UW228-1, 2 and 3; Daoy, and Madsen) were implanted onto a 3-dimensional, type I collagen gel assay to assess tumour invasion distance over five days, in response to (1) needle-assisted excision of the central cell aggregate; (2) pre-exposure to single-dose and fractionated dose irradiation in doses from 6-25 and 8-24 Gy, respectively; and (3) excision plus either single-dose or fractionated radiation. RESULTS Within hours, individual MB cells detached from the surface of the cell aggregates and invaded the collagen matrix, to distances up to 1200 microm and at rates up to 300 microm daily. The UW228-1 cell line was less invasive than the other cell lines and was dropped from further analysis. In the four remaining lines, a dose-dependent decline in tumour invasiveness was identified, both for single-dose and fractionated radiation, which achieved statistically decreased invasion distances at higher doses, especially of fractionated irradiation. Excision of the central tumour aggregate tended towards exerting a late effect on cell invasion, but exerted no significant influence on the radio-sensitivity of residual cells. CONCLUSIONS Both single-dose and fractionated dose irradiation appear to inhibit MB cell invasiveness in a dose-dependent manner, whereas excision of the central cell aggregate exerts no effect on residual invading cells.
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Cordato DJ, Brimage P, Masters LT, Butler P. Post-cranial irradiation syndrome with migraine-like headaches, prolonged and reversible neurological deficits and seizures. J Clin Neurosci 2006; 13:586-90. [PMID: 16542841 DOI: 10.1016/j.jocn.2005.04.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2004] [Accepted: 04/04/2005] [Indexed: 11/29/2022]
Abstract
Two adult patients with a background history of astrocytomas treated with resection and cranial irradiation, 18 and 16 years previously, presented with acute onset of headache associated with prolonged neurological deficits, including dysphasia and right hemiparesis. The first patient also developed seizures while in hospital. In both patients, magnetic resonance imaging brain scans failed to show evidence of acute ischaemia or tumour recurrence and symptoms reversed completely after 1 month and 7 days, respectively. A single photon emission computed tomography scan, performed on the first patient at day 8 post-admission, showed hyperperfusion in the left parieto-occipital region (in the same region as his previous tumour). The clinical histories and outcomes are consistent with the diagnosis of post-cranial irradiation syndrome with migraine-like headaches and prolonged and reversible neurological deficits. Recognition of this disorder is useful in providing reassurance of a favourable prognosis and may also help avoid invasive investigations.
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Affiliation(s)
- Dennis J Cordato
- Department of Neurology, Bankstown-Lidcombe Hospital, Eldridge Road, Bankstown 2200, New South Wales, Australia.
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Partap S, Walker M, Longstreth WT, Spence AM. Prolonged but reversible migraine-like episodes long after cranial irradiation. Neurology 2006; 66:1105-7. [PMID: 16606929 DOI: 10.1212/01.wnl.0000204178.65221.b8] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The authors describe three patients with prolonged but reversible episodes of severe headaches and focal neurologic deficits developing years after irradiation for cranial neoplasms. Despite extensive evaluations, etiology of episodes in these three and eight other previously reported patients remains undetermined. Whether they all have the same condition is uncertain. Although some had cortical gadolinium enhancement on MRI, all 11 patients returned to baseline over hours to weeks.
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Affiliation(s)
- Sonia Partap
- Division of Pediatric Neurology, Children's Hospital and Regional Medical Center, University of Washington, Seattle, WA, USA
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