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

Abstract

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.

Keywords: Glioma; Radiation; SMART syndrome; Steroid pulse therapy.

Fig. 1

Imaging findings with the clinical course. Patient's preoperative T1-weighted image (T1WI) with contrast enhancement shows a left temporal anaplastic astrocytoma (A). Postoperative examination demonstrates removal of the lesion (B). T1WI with contrast enhancement and FLAIR (fluid attenuated inversion recovery) signal on admission revealed new enhancement at left parietal lobe (C, white arrow), and mild swelling of left frontal and temporal gyri (C, E, white dashed arrows). Three days after steroid pulse therapy, the enhancement and swelling had disappeared (D, F). Clinical course (G).