We report three cases of SMART syndrome presenting years to decades after cranial irradiation for various intracranial tumors. The first case involved a 55-year-old man with prior right temporal glioblastoma who developed progressive left-sided visual field loss, neglect, visual hallucinations and seizures. MRI revealed right parietal cortical enhancement, and symptoms resolved with antiepileptics and steroid taper over three weeks. The second case describes a 74-year-old man with a history of head and neck squamous cell carcinoma treated with radiation, who presented with subacute aphasia and confusion. MRI findings and clinical course were consistent with SMART syndrome, with marked improvement following corticosteroid therapy. The third case involved a 74-year-old man with a history of right frontotemporal meningioma treated radiation, presenting with acute left hemiparesis and visual field deficits. MRI and EEG findings supported the diagnosis of SMART syndrome, and the patient improved with antiepileptics and a short course of steroids. 

It often mimics acute stroke or tumor recurrence, leading to diagnostic challenges and potential for unnecessary interventions. MRI is essential for diagnosis revealing characteristics include  unilateral cortical enhancement and edema. While most patients experience symptom resolution, a minority may have persistent deficits. Corticosteroids and antiepileptics are commonly used, but optimal management strategies remain undefined.