Rare and rarer: co-occurrence of stroke-like migraine attacks after radiation therapy and Charles Bonnet syndromes

Abstract

A 30-year-old man presented with new onset severe headache and homonymous hemianopia, with a subsequent seizure, on a background of a right parietal astrocytoma resected at age 5 with adjuvant chemotherapy and radiotherapy. Magnetic resonance imaging of the brain revealed post-surgical and radiotherapy changes only and a clinical diagnosis of Stroke-like Migraine Attacks after Radiation Therapy (SMART) syndrome was made. Vision subsequently recovered gradually over a 6-week period, however, during the recovery phase he reported well formed hallucinations in the affected hemi-field consisting of small mammals, particularly possums, which gradually became less distinct as vision recovered; a phenomenon which was felt likely to represent the Charles Bonnet syndrome.

Figure 1:

MRI scan performed on Day 3 post-onset of headache. (A) Axial, T2 FLAIR, showing giant Virchow–Robin spaces in the previous radiotherapy field (red arrow) and surgical bed with surrounding non-specific T2 high signal. (B) T1-weighted post-contrast sequence with no evidence of local enhancement.