Stroke-like migraine attacks after radiation therapy syndrome: Case report and review of the literature

Case Report: Stroke-like migraine attacks after radiation therapy syndrome: a rare complication 26 years after cranial radiotherapy

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.

Women and Ischemic Stroke

Although men are at higher risk of stroke throughout most of their lifespan, the incidence of stroke in women climbs with age, increasing after menopause and rising sharply after 85 years. This, combined with women's longer life expectancy, results in most of the stroke deaths occurring in women. In addition to accounting for a larger proportion of strokes, women may also suffer a survival disadvantage, which may be due to several factors. In many families, women are the primary caretakers. When they become disabled, there may be limited options to care for them. Others suggest that some of the disparities in stroke outcomes in women may be related to age, pre-stroke functional status, and comorbidities. Regardless of the cause, the increased disability and post-stroke care requirements of women, particularly in our aging population, highlight the importance of determining successful strategies for stroke prevention, acute stroke treatments, optimization of stroke rehabilitation, and effective secondary prevention measures in women.

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.

SMART syndrome: a case report

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.

SMART Syndrome (Stroke-like migraine attacks after radiation therapy): When to suspect it?

Background:

Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a benign complication of brain radiation therapy, which presents circa a decade after radiation treatment. Symptoms are stroke-like deficits, epileptic seizures, and migraine. Cranial magnetic resonance imaging is characteristic for alterations in the form of unilateral cortical hyperintensities and gyriform enhancement, most prominent in the parieto-occipital regions. Prompt diagnosis is essential to avoid unnecessary investigations (e.g., brain biopsy and angiography).

Case Description:

We describe a 51-year-old female patient treated initially with cranial irradiation for a left-sided occipital metastatic lung adenocarcinoma. Five years later, she presented with migraine headache, aphasia, and a right sided hemiparesis.

Conclusion:

The triad of migraine, seizure, and hemiparesis within the context of a prior brain radiotherapy should promptly raise the suspicion of SMART syndrome. Prompt diagnosis is essential to avoid unnecessary invasive investigations.

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.

SMART syndrome: a late-onset and not always reversible complication of radiotherapy

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.

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.

SMART Syndrome Identification and Successful Treatment

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.

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

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.

Migraine and risk of stroke

Migraine and stroke are two common and heterogeneous neurovascular disorders responsible for a significant burden for those affected and a great economic cost for the society. There is growing evidence that migraine increases the overall risk of cerebrovascular diseases. In this review, based on available literature through a PubMed search, we found that ischaemic stroke in people with migraine is strongly associated with migraine with aura, young age, female sex, use of oral contraceptives and smoking habits. The risk of transient ischaemic attack also seems to be increased in people with migraine, although this issue has not been extensively investigated. Although migraine appears to be associated with haemorrhagic stroke, the migraine aura status has a small influence on this relationship. Neuroimaging studies have revealed a higher prevalence of asymptomatic structural brain lesions in people with migraine. They are also more likely to have unfavourable vascular risk factors; however, the increased risk of stroke seems to be more apparent among people with migraine without traditional risk factors. The mechanism behind the migraine-stroke association is unknown. In light of the higher risk of stroke in people with migraine with aura, it is important to identify and modify any vascular risk factor. There is currently no direct evidence to support that a migraine prophylactic treatment can reduce future stroke in people with migraine.

Stroke in a young man: a late complication of radiation therapy

This 37-year-old man presented with left sided facial warmth and numbness associated with new sudden-onset right hemiparesis. The patient first developed sudden numbness of his left lip and warmth in left ear which travelled to the rest of left face. His past medical history was significant for hypertension, Hodgkin lymphoma treated with radiation therapy at the age of 10, and sleeve gastrectomy for obesity 1 year ago complicated by bilateral ischaemic cerebral infarctions with residual left hemiparesis. No acute infarcts were found on MRI. Transesophageal echocardiography revealed a complex atheroma near the sinotubular junction in ascending aorta.