Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare brain irradiation complication occurring years later and presents with reversible migraines, seizures, stroke-like symptoms, and unilateral cortical enhancement with corresponding T2 FLAIR hyperintensity on imaging.

A 32-year-old female with history of medulloblastoma status post radiation and resection at age 5 presented with 10 days of transient headache, fever, altered mental status and hallucinations. Neurologic exam was normal except for mild impairment in attention and concentration. MRI brain showed new nodular leptomeningeal and cortical enhancement of the right parietal, occipital and temporal lobes without corresponding T2 FLAIR hyperintensity concerning for recurrent malignancy, infection, inflammatory process or SMART syndrome. Extensive spinal fluid testing was negative for infectious, inflammatory, and neoplastic processes. MR spectroscopy showed increased creatinine and decreased N-acetyl-aspartate (NAA) suggestive of nonspecific gliosis but malignancy could not be excluded.  Biopsy was considered but deferred due to improvement in headaches, mental status and hallucinations. Repeat imaging one month later showed improvement in imaging findings without intervention making SMART syndrome the likely diagnosis.

We present a case of SMART syndrome with unique imaging findings of cortical enhancement that occurred in absence of corresponding T2 FLAIR hyperintensity not reported in the literature. Furthermore, MR spectroscopy showed an increase in creatinine and decrease in N-acetyl-aspartate seen in only one prior case report. Recognition of MRI and MR spectroscopy findings in SMART syndrome can avoid unnecessary invasive procedures like biopsy.