2026 American Academy of Neurology Abstract Website

Objective:

To present a case of Stroke-like Migraine Attacks after Radiation Therapy (SMART syndrome) with symptom onset 29 years after receiving brain radiation.

Background:

SMART syndrome consists of headaches, seizures, and focal neurological deficits that can occur years to decades after brain radiation. Understanding the clinical presentation and imaging features of SMART syndrome can prevent misdiagnosis and facilitate appropriate treatment, as this syndrome is often reversible.

Design/Methods:

Results:

A 59-year-old male presented to the hospital after a fall. He has a remote history of testicular cancer and right frontoparietal brain metastases for which he received craniectomy and brain radiation, complicated by residual left-sided weakness at the age of 30.

At baseline, the patient uses a cane for left sided weakness and came to the ED after a fall. CT head and CTA head and neck were unremarkable. While boarding in the emergency department, the patient developed right arm and leg weakness, aphasia, and status epilepticus that required three antiepileptic medications to control.

Repeat CT head and CTA head and neck were negative. Lumbar puncture showed no nucleated cells, but did have an elevated protein of 78. CSF cytology and meningitis-encephalitis panel were negative. PET scan showed no malignancy. Paraneoplastic and autoimmune panels in the serum and CSF were negative. MRI brain showed abnormal cortical and gyriform enhancement in the left hemisphere with associated FLAIR hyperintensities, a pattern characteristic of SMART syndrome.

The patient was diagnosed with SMART syndrome and given 1 gram of IV methylprednisolone for five days with improvement in symptoms and discharged on a prolonged prednisone taper.

Conclusions:

SMART syndrome can mimic other diseases, such as tumor recurrence, stroke, and other neurological diseases. It is important to recognize the clinical symptoms and imaging characteristics of SMART syndrome to facilitate appropriate workup and treatment.