<scp>Stroke‐like migraine attacks after radiation therapy</scp>: A misnomer?

Fan, Emily Peien; Gabriel, Harald; Gerard, Elizabeth E.; Schuele, Stephan

doi:10.1111/epi.13963

Cited by 26 publications

(37 citation statements)

References 35 publications

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“…Hypotheses have included deranged autoregulation caused by endothelial damage and radiation vasculopathy, as well as some form of cerebral hyperexcitability leading to seizures, headache, and months of slow‐to‐recover neural impairment. Some studies have suggested that SMART should not be considered a distinct diagnosis and have hypothesized that it could be an expression of either migrainous phenomena or seizures unrelated to prior radiation [14, 15]. We agree that seizures are often a component of SMART syndrome; however, nearly half the patients in our study did not have epileptiform discharges while all had the characteristic radiological abnormalities and very similar clinical signs and symptoms.…”

Section: Discussionsupporting

confidence: 59%

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

Singh

Hajeb

Rabinstein

et al. 2020

Euro J of Neurology

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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.

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Section: Discussionsupporting

confidence: 59%

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

Singh

Hajeb

Rabinstein

et al. 2020

Euro J of Neurology

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“…Epileptic seizures may be related to SMART and may be underdiagnosed in this condition. 9 On the one hand, in our case, the presence of ischemia could represent another source of seizure trigger, given the far less severe SMART-related imaging changes compared to the initial presentation, when no seizures had occurred. On the other hand, fluctuating levels of consciousness had been reported to have occurred during a period of 2 weeks prior to the second admission, thus most likely before the ischemia.…”

Section: Discussionmentioning

confidence: 63%

“…In our case, the recurrent headache is most likely an expression of SMART itself. Epileptic seizures may be related to SMART and may be underdiagnosed in this condition . On the one hand, in our case, the presence of ischemia could represent another source of seizure trigger, given the far less severe SMART‐related imaging changes compared to the initial presentation, when no seizures had occurred.…”

Section: Discussionmentioning

confidence: 74%

SMART – Not Always Only “Stroke‐Like”

2018

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Stroke‐like migraine attacks after radiation therapy (SMART) is a syndrome observed in a delayed fashion in patients following brain radiation therapy. It is a rare but important differential diagnosis of migraine in these patients, often presenting with migraine‐like headache. In addition, there may be focal neurological deficits or seizures. In general, it is regarded as a reversible condition, therefore termed stroke‐like. Our case illustrates that there may also be ischemic stroke associated with SMART leading to an unfavorable course, even after prior remission.

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“…Выявлена значительная экспрессия этих белков в нейронах и эндотелии мозга, вероятно потенцируемая эпилептической активностью, что может, в свою очередь, вызвать усиленный транспорт аминокислоты, преимущественно в нейроны [14]. Более того, включение в протокол обследования 6 больных с подозрением на SMART-синдром видео-ЭЭГ мониторинга, дало основание рассматривать этот феномен как потенциально эпилептический синдром [20]. Усиление транспорта аминокислот в эпилептогенном очаге установлено и при ПЭТ с 11 С-метионином [21].…”

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“…В настоящее время значимость эпилепсии и эпилептической активности мозга выходят на первый план в обсуждении SMART-синдрома. Его аббревиатура описывает приступы мигрени как основной спектр симптомов и оставляет без внимания наличие эпилептического процесса, который может играть более существенную роль в патогенезе, чем это представлялось ранее, поэтому само название кажется неправильным [20].…”

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Metabolic Pseudoprogression as New Phenomenon on [11c]methionine Pet/Ct During Treatment Monitoring of Patients With Malignant Cerebral Glioma

Skvortsova

Savintseva

Гурчин

et al. 2019

Lučevaâ diagn. ter.

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With improved treatment for cerebral gliomas leading to longer survival, late rare complications of radiation therapy on the brain are more frequently observed. The paper presents the results of positron emission tomography (PET) with [11C]methionine in 4 patients with malignant cerebral glioma, in whom the phenomenon of transient diffuse high [11C]methionine uptake in the cerebral cortex was detected during treatment monitoring. The unilateral high [11C]methionine uptake in the posterior portion of the cerebral hemisphere was stereotyped and easy to recognize. Nevertheless high amino acid uptake on PET did not match with structural abnormalities on MRI and was not accompanied by aggravation of neurological symptoms or by epileptic seizures. The results of the follow-up examinations excluded tumor recurrence. The control PET/CT scans showed complete resolution of the abnormal [11C]methionine uptake. The clinical and instrumental similarity of the presented cases allowed to establish the diagnostic criteria for the phenomenon of metabolic pseudoprogression and to compare them with the criteria of the SMART syndrome (stroke-like migraine attacks after radiation therapy). Two cases with SMART syndrome are presented as a comparison group. The similarities and discrepancies of unusual metabolic hyperfunction with previously known phenomena and possible mechanisms for their development are discussed. It is important for clinicians and radiologists to be aware of the characteristic imaging findings of the metabolic pseudoprogression on PET with [11C] methionine to avoid overdiagnosis of the brain tumor recurrence and aggressive treatment approach.

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Stroke‐like migraine attacks after radiation therapy: A misnomer?

Cited by 26 publications

References 35 publications

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

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

SMART – Not Always Only “Stroke‐Like”

Metabolic Pseudoprogression as New Phenomenon on [11c]methionine Pet/Ct During Treatment Monitoring of Patients With Malignant Cerebral Glioma

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