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

Gómez-Cibeira, Emilio; Calleja-Castaño, Patricia; Aleja, Jesús González de la; Sierra-Hidalgo, Fernando; Morales, Juan Ruiz; Álvarez, Elena Salvador; Ramos-González, Ana

doi:10.1111/jon.12227

Cited by 13 publications

(10 citation statements)

References 14 publications

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“…2 Gomez-Cibeira et al. 10 described magnetic resonance (MR) spectroscopy findings in a patient with SMART syndrome with decreased N-acetyl-aspartate (NAA), increased creatine, and mild elevation of choline peaks. A lactate peak was not noted suggesting that mitochondrial dysfunction, vasospasm, or ischemic mechanisms were not involved.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2017

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A 26-year-old female presented with vision loss accompanied by migraine-like headaches. A contrast-enhanced magnetic resonance imaging of the brain was performed which revealed findings suggestive of stroke-like migraine attacks after radiation therapy (SMART) syndrome. SMART syndrome is a delayed complication of brain radiation characterized by neurologic symptoms including migraine-like headaches, seizures, and hemispheric impairment. The purpose of this article is to make the readers aware of this rare complication of brain irradiation. Appropriate diagnosis of SMART syndrome is essential to avoid invasive tests.

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Section: Discussionmentioning

confidence: 99%

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

et al. 2017

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“…[1][2][3][4][5][6] However, there are additional conventional MR imaging features reported, such as superficial siderosis, diffusion restriction, and brain stem lesions. 2,7,8 Other reported imaging findings include hypermetabolism of the lesion on [ 18 F] FDG-PET/CT, increased CBV on perfusion imaging, and decreased NAA with increased Cr and Cho peaks on MRS. 7,[9][10][11] However, these imaging features are mainly reported by case reports or small case series because of the rarity of the disease.…”

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confidence: 99%

Prognostic Factors of Stroke-Like Migraine Attacks after Radiation Therapy (SMART) Syndrome

Ota¹,

Leung

Lin

et al. 2022

AJNR Am J Neuroradiol

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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 ¼ 11; median age, 44 years; 2 women) and the incompletely recovered group (n ¼ 9; median age, 55 years; 3 women) in age, months of follow-up, and the presence of steroid treatment at diagnosis (P ¼ .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 ¼ .01; 0/11 versus 4/9, P ¼ .026; and 2/11 versus 7/9, P ¼ .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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“…The hallmark features of SMART on MRI are reversible, transient, unilateral cortical gadolinium enhancement as well as the correlative abnormal T2 and FLAIR (fluid attenuated inversion recovery) signal [ [1] , [2] , [3] , [4] ]. However, in most cases, MRI abnormalities persist over weeks to months [ 4 ].…”

Section: Discussionmentioning

confidence: 99%

“…Therefore, steroid pulse therapy can be recommended in the case of possible SMART for earlier determination of SMART from non-SMART including recurrence. “Blood-brain barrier disruption” in SMART is described in some literatures, possibly leading to edema or inflammation in the nervous system [ 1 , 4 ]. Steroid therapy can be reasonable from this point of view.…”

Section: Discussionmentioning

confidence: 99%

“…SMART (stroke-like migraine attacks after radiation therapy) is a syndrome presumed to be a delayed complication of brain irradiation wherein patients have recurrent attacks of complex neurological symptoms, often including headache and seizures that begin many years after radiation therapy, and demonstrates characteristic imaging findings [ 1 ]. Since it was first described in 1995, about 40 cases of SMART have been reported in the literature [ 2 ].…”

Section: Introductionmentioning

confidence: 99%

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SMART (stroke-like migraine attacks after radiation therapy) syndrome responded to steroid pulse therapy: Report of a case and review of the literature

et al. 2018

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This report presents a case of stroke-like migraine attacks after radiation therapy (SMART) syndrome in a 31-year-old man in whom symptoms and radiological findings resolved with steroid pulsed therapy and reviews the literatures with special emphasis on the use of steroids against SMART syndrome. The patient had a past history of left temporal anaplastic astrocytoma and was treated with surgery followed by local 72 Gy radiation therapy and chemotherapy using Nimustine Hydrochloride. Four years after the surgery, he was suffering from subacute progressing symptoms of headache, right hemianopia, right hemiparesis and aphasia from 2 to 4 days before admission to our hospital. At first he was diagnosed as symptomatic epilepsy but after extensive examination, the final diagnosis was SMART syndrome. His symptoms soon improved with steroid pulse therapy. In the literature, steroid pulse therapy is not necessarily a standard of care for SMART syndrome, but it seemed to decrease the need of biopsy. As the lesions of SMART syndrome require differential diagnosis from recurrences, biopsy was performed in some cases. However, lack of benefit and possible detriment is reported with biopsy of SMART lesions. Through this experience we suggest that steroid pulse therapy may provide speedy recovery from symptoms, and it should be considered before other invasive investigations or treatments.

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

Cited by 13 publications

References 14 publications

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

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

Prognostic Factors of Stroke-Like Migraine Attacks after Radiation Therapy (SMART) Syndrome

SMART (stroke-like migraine attacks after radiation therapy) syndrome responded to steroid pulse therapy: Report of a case and review of the literature

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