SMART syndrome (stroke-like migraine attacks after radiation therapy) in adult and pediatric patients

Comparison of Risks of Late Effects From Radiation Therapy in Children Versus Adults: Insights From the QUANTEC, HyTEC, and PENTEC Efforts

Pediatric Normal Tissue Effects in the Clinic (PENTEC) seeks to refine quantitative radiation dose-volume relationships for normal-tissue complication probabilities (NTCPs) in survivors of pediatric cancer. This article summarizes the evolution of PENTEC and compares it with similar adult-focused efforts (eg, Quantitative Analysis of Normal Tissue Effects in the Clinic [QUANTEC] and Hypofractionated Treatment Effects in the Clinic [HyTEC]) with respect to content, oversight, support, scope, and methodology of literature review. It then summarizes key organ-specific findings from PENTEC in an attempt to compare NTCP estimates in children versus adults. In brief, select normal-tissue risks within developing organs and tissues (eg, maldevelopment of musculoskeletal tissue, teeth, breasts, and reproductive organs) are primarily relevant only in children. For some organs and tissues, children appear to have similar (eg, brain for necrosis, optic apparatus, parotid gland, liver), greater (eg, brain for neurocognition, cerebrovascular, breast for lactation), less (ovary), or perhaps slightly less (eg, lung) risks of toxicity versus adults. Similarly, even within the broad pediatric age range (including adolescence), for some endpoints, younger children have greater (eg, hearing and brain for neurocognition) or lesser (eg, ovary, thyroid) risks of radiation-associated toxicities. NTCP comparisons in adults versus children are often confounded by marked differences in treatment paradigms that expose normal tissues to radiation (ie, cancer types, prescribed radiation therapy dose and fields, and chemotherapy agents used). To add to the complexity, it is unclear if age is best analyzed as a continuous variable versus with age groupings (eg, infants, young children, adolescents, young adults, middle-aged adults, older adults). Further work is needed to better understand the complex manner in which age and developmental status affect risk.

Headache in Brain Tumors

The prevalence of brain tumors in patients with headache is very low; however, 48% to 71% of patients with brain tumors experience headache. The clinical presentation of headache in brain tumors varies according to age; intracranial pressure; tumor location, type, and progression; headache history; and treatment. Brain tumor-associated headaches can be caused by local and distant traction on pain-sensitive cranial structures, mass effect caused by the enlarging tumor and cerebral edema, infarction, hemorrhage, hydrocephalus, and tumor secretion. This article reviews the current findings related to epidemiologic details, clinical manifestations, mechanisms, diagnostic approaches, and management of headache in association with brain tumors.

Neurologic Complications in Adult Cancer Survivorship

Over the past decade, the improvement in cancer diagnostics and therapeutics has extended the overall survival of patients diagnosed with cancer including brain cancer. However, despite these unprecedented medical successes, patients continue to experience numerous neurologic complications after treatment that interfere with their independence, functionality, and overall quality of life. These include, among others, cognitive impairment, endocrinopathies, peripheral and cranial neuropathies, and vasculopathy. This article describes the long-term neurologic complications cancer survivors commonly experience to increase awareness of these complications and discuss treatments when available. Further research is necessary to understanding of mechanisms of neurologic injury and advance diagnosis and treatment. Effective patient education, monitoring, and managing neurologic issues after cancer treatment may improve independence, functionality, and quality of life during survivorship.

Complications of Cancer Therapy in Children: A Comprehensive Review of Neuroimaging Findings

ABSTRACT

Complications of cancer therapy in children can result in a spectrum of neurologic toxicities that may occur at the initiation of therapy or months to years after treatment. Although childhood cancer remains rare, increasing survival rates mean that more children will be living longer after cancer treatment. Therefore, complications of cancer therapy will most likely occur with increasing frequency.At times, it is very difficult to differentiate between therapeutic complications and other entities such as tumor recurrence, development of secondary malignancy, and infection (among other conditions). Radiologists often play a key role in the diagnosis and evaluation of pediatric patients with malignancies, and thus, awareness of imaging findings of cancer complications and alternative diagnoses is essential in guiding management and avoiding misdiagnosis. The aim of this review article is to illustrate the typical neuroimaging findings of cancer therapy-related toxicities, including both early and late treatment effects, highlighting pearls that may aid in making the appropriate diagnosis.

Ischemic Stroke in Patients With Malignancy

Approximately one-quarter to one-third of patients with ischemic stroke have an embolic stroke of undetermined source (ESUS). An estimated 5% to 10% of patients with ESUS have an active cancer diagnosis. Presence of cancer potentially increases the risk of acute ischemic stroke through various mechanisms such as cancer-related hypercoagulability, intracranial tumors leading to an arterial compression, or intracardiac tumors leading to cardioembolism. Certain cancer therapeutics can also contribute to risk of ischemic stroke. Multiple vascular lesions involving bilateral anterior and posterior circulations, high plasma D-dimer levels, and elevated inflammatory markers might suggest cancer-related ischemic stroke. Patients with ischemic stroke related to malignancy are also at higher risk of stroke recurrence, early neurologic deterioration, and mortality. Cancer screening in acute ischemic stroke patients can be considered when no other etiology for stroke can be established and clinical history such as tobacco use, unexplained constitutional symptoms such as fever or night sweats, or unexplained weight loss suggests an underlying malignancy. Selection of antithrombotics for secondary stroke prevention remains controversial as clinical trial data for use of antiplatelet therapy vs anticoagulation in ESUS and cancer patients is limited. Future clinical trials should specifically focus on patients with ischemic stroke related to malignancy are needed to guide appropriate therapeutic agent selection.

SMART syndrome: two cases highlighting a complex and rare complication of brain irradiation

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.

Stroke-Like Migraine Attacks After Radiation Therapy Syndrome and Radiation Necrosis After Cerebral Proton Beam Radiation: A Case Report of Dual Radiotherapy Complications

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.

Review: Neurological Complications From Therapies for Pediatric Brain Tumors

Surgery, chemotherapy and radiation have been the mainstay of pediatric brain tumor treatment over the past decades. Recently, new treatment modalities have emerged for the management of pediatric brain tumors. These therapies range from novel radiotherapy techniques and targeted immunotherapies to checkpoint inhibitors and T cell transfer therapies. These treatments are currently investigated with the goal of improving survival and decreasing morbidity. However, compared to traditional therapies, these novel modalities are not as well elucidated and similarly has the potential to cause significant short and long-term sequelae, impacting quality of life. Treatment complications are commonly mediated through direct drug toxicity or vascular, infectious, or autoimmune mechanisms, ranging from immune effector cell associated neurotoxicity syndrome with CART-cells to neuropathy with checkpoint inhibitors. Addressing treatment-induced complications is the focus of new trials, specifically improving neurocognitive outcomes. The aim of this review is to explore the pathophysiology underlying treatment related neurologic side effects, highlight associated complications, and describe the future direction of brain tumor protocols. Increasing awareness of these neurologic complications from novel therapies underscores the need for quality-of-life metrics and considerations in clinical trials to decrease associated treatment-induced morbidity.

Hemiplegic-Migraine-like Attacks as First Manifestation of Diffuse Leptomeningeal Glioneuronal Tumor: A Case Report

BACKGROUND

Diffuse leptomeningeal glioneuronal tumor (DLGNT) is a low-grade tumor characterized by diffuse leptomeningeal infiltrates. Symptoms are usually secondary to hydrocephalus. Hemiplegic migraine (HM)-like episodes have never been associated with DLGNT, but they have been reported with different inflammatory and tumoral entities involving leptomeninges.

OBSERVATIONS

We report the case of a 10-year-old boy with recurrent episodes of right hyposthenia, aphasia, and headache lasting hours to days with complete remission. The electroencephalogram during the attack showed diffuse slower activity on the left hemisphere, which improved together with the symptoms. DLGNT was discovered during a follow-up magnetic resonance imaging and confirmed by biopsy.

CONCLUSIONS

This is the first report of HM-like attacks in DLGNT. We discuss the pathogenetic hypotheses of our case and previously reported cases of "symptomatic" HM with leptomeningeal involvement.

Short and Long-Term Toxicity in Pediatric Cancer Treatment: Central Nervous System Damage

Simple Summary

The purpose of this review is to describe central nervous system side effects in the treatment of pediatric cancer patients. Unfortunately, we must consider that the scarce data in the literature does not allow us to expand on some issues, especially those related to innovative immunotherapy. We have described the major neurotoxicities arising with the various types of treatment to help specialists who approach these treatments recognize them early, prevent them, and treat them promptly.

Abstract

Neurotoxicity caused by traditional chemotherapy and radiotherapy is well known and widely described. New therapies, such as biologic therapy and immunotherapy, are associated with better outcomes in pediatric patients but are also associated with central and peripheral nervous system side effects. Nevertheless, central nervous system (CNS) toxicity is a significant source of morbidity in the treatment of cancer patients. Some CNS complications appear during treatment while others present months or even years later. Radiation, traditional cytotoxic chemotherapy, and novel biologic and targeted therapies have all been recognized to cause CNS side effects; additionally, the risks of neurotoxicity can increase with combination therapy. Symptoms and complications can be varied such as edema, seizures, fatigue, psychiatric disorders, and venous thromboembolism, all of which can seriously influence the quality of life. Neurologic complications were seen in 33% of children with non-CNS solid malign tumors. The effects on the CNS are disabling and often permanent with limited treatments, thus it is important that clinicians recognize the effects of cancer therapy on the CNS. Knowledge of these conditions can help the practitioner be more vigilant for signs and symptoms of potential neurological complications during the management of pediatric cancers. As early detection and more effective anticancer therapies extend the survival of cancer patients, treatment-related CNS toxicity becomes increasingly vital. This review highlights major neurotoxicities due to pediatric cancer treatments and new therapeutic strategies; CNS primary tumors, the most frequent solid tumors in childhood, are excluded because of their intrinsic neurological morbidity.

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).

Stroke-Like Migraine after Radiation Treatment Syndrome in Children with Cancer

Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a symptom complex of transient neurological deficits, headache, and abnormal cortical contrast enhancement on brain MRI. Pathophysiology is unclear, but exposure to cranial radiation (RT) is a sine qua non. We report five children with SMART syndrome treated with RT therapy for medulloblastoma (n = 3), atypical teratoid rhabdoid tumor (n = 1), and pleomorphic xanthoastrocytoma (n = 1). Median age at tumor diagnosis was 9.4 years (range 5.1–14.7). Median follow-up from cancer diagnosis was 3.1 years (range 1.4–12.9). All patients had 54 Gy focal RT treatment and medulloblastoma children had additional 36 Gy craniospinal irradiation. Median time from the end of RT to first transient neurological deficit was 1 year (range 0.7–12.1). The median follow-up since first SMART episode was 0.6 years (range 0.3–2.6). Presenting symptoms included the gradual development of unilateral weakness (n = 4), non-fluent dysphasia (n = 1), somnolence (n = 1), and headaches (n = 3). Neurological deficits resolved within 30 minutes to 10 days. Transient cortical enhancement on magnetic resonance imaging (MRI) was confirmed in two children and was absent in the other three. Two children had a single and three had multiple episodes over the next few months. Two children with protracted symptoms responded to 3 days treatment with high dose intravenous methylprednisolone. Symptoms ultimately resolved in all patients. SMART syndrome is a rare disorder characterized by slow evolution of neurological deficits with variable abnormal cortical contrast enhancement. The use of steroids may improve symptoms and speed resolution.

A Case of Postoperative SMART Syndrome in a Medulloblastoma Survivor

Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare neurological phenomenon characterized by reversible symptoms of headache, seizure, hemiparesis, and visual changes associated with a remote history of cranial irradiation. We describe a case of a medulloblastoma survivor, presenting with postoperative neurological deficits, along with neuroimaging findings and subsequent resolution of symptoms, highly suggestive of SMART syndrome. We have also reviewed the common epidemiological and diagnostic factors associated with this rare disease, as well as discussed pathophysiological mechanisms.

Persistent Nontumoral High-Amino-Acid Uptake on Brain [11C]Methionine PET/CT in a Patient After Combined Glioma Treatment

ABSTRACT

A 44-year-old man after combined left temporal low-grade glioma treatment presented with daily multiple series of seizures. MRI demonstrated diffuse cortical swelling in the left frontal lobe with intensive gyral enhancement. PET with [11C]methionine (PET-MET) revealed increased radiotracer uptake strictly confined to the cortical ribbon of the left cerebral hemisphere, which persisted for 3 months. Tumor recurrence was suggested, and biopsy was performed. No evidence of recurrent tumor was found. During a 2-year follow-up, a diffuse gyral enhancement in the left hemisphere has persisted on MRI; PET has shown high [11C]methionine uptake in the left frontal and parietal cortex with gradual positive dynamics.

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

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.

Atypical imaging findings of presumed stroke-like migraine attacks after radiation therapy syndrome in the brainstem

The authors present an atypical case of presumed stroke-like migraine attacks after radiation therapy (SMART) syndrome in the brainstem. A 29-year-old male, who had been treated with resection and subsequent craniospinal radiation for posterior fossa medulloblastoma 21 years before, presented with subacute progressive left hemiparesis evolving over 4 days. Hematological findings, cerebrospinal fluid (CSF), and electroencephalogram (EEG) were unremarkable. Magnetic resonance imaging (MRI) showed a round area of hyperintense FLAIR signal centered within the pons associated with central restricted diffusion, peripheral enhancement, and small paramagnetic low susceptibility signal foci consistent with petechial hemorrhage. Positron emission tomography (PET), perfusion MRI, and MR spectroscopy revealed no evidence of tumor recurrence. The diagnosis of SMART syndrome is presumed from the conventional and advanced imaging findings, clinical history, and clinical course.

Perampanel in brain tumor and SMART-syndrome related epilepsy - A single institutional experience

Epilepsy is common in patients with brain tumors and frequently presents as the first clinical manifestation of an underlying tumor. Despite a number of available antiepileptic drugs (AED), brain tumor related epilepsy (BTRE) may still be difficult to control. Recently, the AMPA (alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid)-type glutamate receptor antagonist perampanel (PER) is increasingly acknowledged as an attractive novel add-on AED for seizure control in BTRE. We present a single institutional experience reporting five individual cases with refractory BTRE treated with PER. In two of these five brain tumor patients, worsening of seizure control was caused by SMART-syndrome (stroke-like migraine attacks after radiation therapy). Efficacy of PER was assessed by the responder rate and by evaluating overall changes in seizure frequency before and during PER treatment. In our case series, a reduction in seizure frequency was observed in four out of five patients and the responder rate was 40%. In addition, both cases with symptomatic epilepsy associated with SMART-syndrome were successfully treated with PER. This case series supports the growing evidence that PER may become a promising add-on AED for the treatment of refractory BTRE as well as for seizure control in SMART-syndrome.

A Clinical Approach to Diagnosing Encephalopathy

Encephalopathy refers to dysfunction of the level or contents of consciousness due to brain dysfunction and can result from global brain insults or focal lesions. The underlying causes of encephalopathy include both primary neurologic and systemic conditions. This article discusses the differential diagnosis of encephalopathy, with a focus on primary neurologic causes. A practical schema for organizing the differential diagnosis is to group etiologies by their pace of onset and evolution (eg, sudden, acute, subacute, chronic).

Stroke-Like Migraine Attacks after Radiation Therapy Syndrome: Clinical and Imaging Characteristics

Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare, reversible phenomenon that occurs several years after radiotherapy in patients treated for intracranial neoplastic lesions. Patients typically present with symptoms of headache, seizures, and other focal neurologic deficits concerning for stroke or disease recurrence. In this report, we describe SMART syndrome in a 70-year-old male who developed a persistent right temporal headache, right-sided neck pain, and new-onset seizures 12 years after surgical resection of a temporal anaplastic ependymoma followed by irradiation. We present this case to highlight typical disease presentation, imaging characteristics, and important differential radiologic considerations. Recognition of this delayed complication of brain tumor radiation is paramount given its self-limited course and favorable response to conservative therapy and to avoid misinterpreting imaging findings as tumor recurrence.

Rare and rarer: co-occurrence of stroke-like migraine attacks after radiation therapy and Charles Bonnet syndromes

A 30-year-old man presented with new onset severe headache and homonymous hemianopia, with a subsequent seizure, on a background of a right parietal astrocytoma resected at age 5 with adjuvant chemotherapy and radiotherapy. Magnetic resonance imaging of the brain revealed post-surgical and radiotherapy changes only and a clinical diagnosis of Stroke-like Migraine Attacks after Radiation Therapy (SMART) syndrome was made. Vision subsequently recovered gradually over a 6-week period, however, during the recovery phase he reported well formed hallucinations in the affected hemi-field consisting of small mammals, particularly possums, which gradually became less distinct as vision recovered; a phenomenon which was felt likely to represent the Charles Bonnet syndrome.

A 15-Year-Old Girl With Sudden Onsent Reversible Neurologic Symptoms After Cranial Irradiation for Medulloblastoma

A 15-year-old girl with history of medulloblastoma was evaluated for headache and neurologic deficits 5 years after completion of initial radiation therapy and 3 years following completion of reirradiation. Neurologic examination was notable for new-onset left hemianopia, hemiparesis, and neglect. Magnetic resonance imaging showed extensive areas of cortical T2 prolongation and thickening involving the right parietal, occipital, and temporal lobes with associated extensive gyral enhancement. Upon spontaneous resolution of her weakness after 4 days, repeat magnetic resonance imaging showed resolution of the edema and gyral enhancement, suggestive of the diagnosis of stroke-like migraine attacks after radiation therapy (SMART syndrome). A review of SMART is provided in this case report.

Stroke-like Migraine Attacks after Radiation Therapy (SMART) Syndrome Followed by Cerebral Infarction

A 36-year-old man with a history of irradiation for acute lymphoblastic leukemia developed headache with cortical dysfunction lasting for 4 weeks. The clinical features were consistent with stroke-like migraine attacks after radiation therapy (SMART) syndrome. Six months later, he developed cerebral infarction due to occlusions of the left anterior and middle cerebral arteries. This is the first case report describing SMART syndrome followed by severe cerebral infarction. Although an association between the two episodes was not assumed, this case indicates that protective therapies against infarction might need to be considered for patients with SMART syndrome.

Neurological Complications of Childhood Cancer

Though the treatment of pediatric cancers has come a long way, acute and chronic effects of cancer are still affecting the life of many children. These effects may be caused not only by the malignancy itself but also by the interventions used for the purpose of treatment. This article focuses primarily on the indirect effects of pediatric cancers and their treatment on the central and peripheral nervous system. Chemotherapy, radiation, and stem cell transplantation cause an immune-compromised state and place the patient at risk of infection, the leading cause of mortality in pediatric cancer. The underlying cancer and the treatments also cause neurovascular changes that may lead to neurological sequelae immediately or many years in the future. Chemotherapy and radiation have both immediate and long-term neurotoxic effects on the central and peripheral nervous system. Cancers may also trigger an immune response that damages nervous system components, leading to altered mental status, seizures, abnormal movements, and even psychosis. Knowledge of these effects can help the practitioner be more vigilant for the signs and symptoms of potential neurological complications during the management of pediatric cancers.

Unusual case of recurrent SMART (stroke-like migraine attacks after radiation therapy) syndrome

Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare delayed complication of cerebral radiation therapy. A 53-year-old female initially presented with headache, confusion and left homonymous hemianopia. Her medical history was notable for cerebellar hemangioblastoma, which was treated with radiation in 1987. Her initial brain MRI (magnetic resonance imaging) revealed cortical enhancement in the right temporo-parieto-occipital region. She improved spontaneously in 2 weeks and follow-up scan at 4 weeks revealed no residual enhancement or encephalomalacia. She presented 6 weeks later with aphasia. Her MRI brain revealed similar contrast-enhancing cortical lesion but on the left side. Repeat CSF studies was again negative other than elevated protein. She was treated conservatively and recovered completely within a week. Before diagnosing SMART syndrome, it is important to rule out tumor recurrence, encephalitis, posterior reversible encephalopathy syndrome (PRES) and stroke. Typically the condition is self-limiting, and gradually resolves.

Investigation of Abscopal and Bystander Effects in Immunocompromised Mice After Exposure to Pencilbeam and Microbeam Synchrotron Radiation

Out-of-field effects are of considerable interest in radiotherapy. The mechanisms are poorly understood but are thought to involve signaling processes, which induce responses in non-targeted cells and tissues. The immune response is thought to play a role. The goal of this research was to study the induction of abscopal effects in the bladders of NU-Foxn1 mice after irradiating their brains using Pencil Beam (PB) or microbeam (MRT) irradiation at the European Synchrotron Radiation Facility (ESRF) in Grenoble, France. Athymic nude mice injected with F98 glioma cells into their right cerebral hemisphere 7 d earlier were treated with either MRT or PB. After recovery times of 2, 12, and 48 h, the urinary bladders were extracted and cultured as tissue explants for 24 h. The growth medium containing the potential signaling factors was harvested, filtered, and transferred to HaCaT reporter cells to assess their clonogenic survival and calcium signaling potential. The results show that in the tumor-free mice, both treatment modalities produce strong bystander/abscopal signals using the clonogenic reporter assay; however, the calcium data do not support a calcium channel mediated mechanism. The presence of a tumor reduces or reverses the effect. PB produced significantly stronger effects in the bladders of tumor-bearing animals. The authors conclude that immunocompromised mice produce signals, which can alter the response of unirradiated reporter cells; however, a novel mechanism appears to be involved.

Headaches in brain tumor patients: primary or secondary?

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.

Strategies to improve the quality of survival for childhood brain tumour survivors

BACKGROUND

Tumours of the central nervous system (CNS) are the most frequent solid tumours and the second most frequent type of cancer in children and adolescents. Overall survival has continuously improved in Germany, since an increasing number of patients have been treated according to standardised, multicentre, multimodal treatment recommendations, trials of the German Paediatric Brain Tumour Consortium (HIT-Network) or the International Society of Paediatric Oncology-Europe (SIOP-E) during the last decades. Today, two out of three patients survive. At least 8000 long-term childhood brain tumour survivors (CBTS) are currently living in Germany. They face lifelong disease- and treatment-related late effects (LE) and associated socioeconomic problems more than many other childhood cancer survivors (CCS).

METHOD

We review the LE and resulting special needs of this particular group of CCS.

RESULTS

Despite their increasing relevance for future treatment optimisation, neither the diversity of chronic and cumulative LE nor their pertinent risk factors and subsequent impact on quality of survival have yet been comprehensively addressed for CBTS treated according to HIT- or SIOP-E-protocols. Evidence-based information to empower survivors and stakeholders, as well as medical expertise to manage their individual health care, psychosocial and educational/vocational needs must still be generated and established.

CONCLUSION

The establishment of a long-term research- and care network in Germany shall contribute to a European platform, that aims at optimising CBTSs' transition into adulthood as resilient individuals with high quality of survival including optimal levels of activity, participation and acceptance by society.

Stroke-like Migraine Attacks after Radiation Therapy Syndrome

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.

Susceptibility-weighted imaging in stroke-like migraine attacks after radiation therapy syndrome

INTRODUCTION

Stroke-like migraine attacks after radiation therapy (SMART) syndrome has a characteristic clinical presentation and postcontrast T1WI MRI appearance. Susceptibility-weighted imaging (SWI) may help distinguish SMART from other disorders that may have a similar postcontrast MRI appearance.

METHODS

The MRI examinations of four patients with SMART syndrome are described herein, each of which included SWI, FLAIR, DWI, and postcontrast T1WI on the presenting and follow-up MRI examinations.

RESULTS

In each, the initial SWI MRI demonstrated numerous susceptibility hypointensities <5 mm in size throughout the cerebrum, particularly within the periventricular white matter (PVWM), presumably related to radiation-induced cavernous hemangiomas (RICHs). By follow-up MRI, each postcontrast examination had demonstrated resolution of the gyriform enhancement on T1WI, without susceptibility hypointensities on SWI within those previously enhancing regions.

CONCLUSION

These preliminary findings suggest that SWI may help identify SMART syndrome or at least help discriminate it from other disorders, by the findings of numerous susceptibility hypointensities on SWI likely representing RICHs, gyriform enhancement on T1WI, and postsurgical findings or appropriate clinical history.

Brain Magnetic Resonance Spectroscopy Findings in the Stroke-like Migraine Attacks after Radiation Therapy (SMART) Syndrome

A 41-year-old male presented with an acute onset of headache, confusion, seizures, and unilateral focal neurological deficit 25 years after receiving whole-brain radiation therapy to treat a cerebellar medulloblastoma. Brain magnetic resonance imaging (MRI) demonstrated a thick unilateral parieto-occipital cortical contrast enhancement. A diagnosis of "Stroke-like Migraine Attacks after Radiation Therapy" (SMART) syndrome was made. Here, we describe the brain MR spectroscopy findings of SMART, showing a decrease in N-acetyl-aspartate and increased levels of creatine and choline, corresponding with neuronal destruction or transient neuronal impairment with mild nonspecific gliosis. The absence of a lactate peak suggests that mitochondrial dysfunction, vasospasm or ischemic mechanisms were not involved.

Migraine mimics

The symptoms of migraine are non-specific and can be present in many other primary and secondary headache disorders, which are reviewed. Even experienced headache specialists may be challenged at times when diagnosing what appears to be first or worst, new type, migraine status, and chronic migraine.