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.

Brain necrosis is a possible complication caused by radiation therapy used in the treatment of head and neck cancer. This complication has variable neurological symptoms according to the site of brain damage, including motor deficits, aphasia, altered consciousness, seizures, and intracranial hypertension and also a variable time for presentation ranging from 3 months to 10 years. Once established, brain injury is irreversible and it is characterized by non-specific radiological image that submits the questions about its etiology: is it secondary to radionecrosis? Tumor progression? Primary tumor? The clinical report here described demonstrates the possibility of such differential diagnosis in a patient with brain lesion as a consequence of radiotherapy for a skin cancer.

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