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Arquivos de Neuro-Psiquiatria

Print version ISSN 0004-282X

Arq. Neuro-Psiquiatr. vol.71 no.5 São Paulo May 2013 

Images In Neurology

SMART syndrome: a late reversible complication of radiotherapy

Síndrome SMART: uma complicação tardia reversível da radioterapia

Fabio de Vilhena DinizI 

Laura Cardia Gomes LopesII 

Luiz Henrique Martins CastroII 

Ricardo NitriniII 

Claudia da Costa LeiteI 

Leandro Tavares LucatoI 

IDepartment of Radiology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP, Brazil

IIDepartment of Neurology, HCFMUSP, São Paulo SP, Brazil

A 43-year-old female had a cerebellar pilocytic astrocytoma operated 27 years ago. Reoperation and radiation therapy were employed in a recurrence 13 years ago. One week before admission, progressive drowsiness, disorientation in time and space, slurred speech and worsening of a residual right hemiparesis begun. Cerebrospinal fluid (CSF) analysis and electroencephalography (EEG) were unremarkable. She improved without specific therapy.

Recently recognized stroke-like migraine attacks after radiation therapy (SMART) is a syndrome which consists of prolonged, unilateral neurological symptoms that are spontaneously reversible 14 . Magnetic resonance (MR) findings are fundamental for diagnosis, characterized by transient, dramatic, but reversible cortical gadolinium enhancement of the affected cerebral hemisphere 13 (Figs 1 and 2). Appropriate diagnostic workup should exclude other diagnostic possibilities.

Fig 1. Magnetic resonance (MR) exam obtained in the beginning of the clinical picture. Axial FLAIR (A) and coronal T2-weighted (B) images disclose slight cortical hyperintensity in the left insula, temporal and parietooccipital regions (arrows), which presents intense gyriform enhancement in the corresponding axial T1-weighted post gadolinium image (arrowhead in D). There is also slight cortical hyperintensity in diffusion-weighted image (C), but without clear reduced diffusion in apparent diffusion coefficients map (not shown). Notice also postoperative changes in the left cerebellar hemisphere, seen in coronal T2-weighted image (B), and nonspecific hyperintense periventricular lesions in axial FLAIR image (A). 

Fig 2. Coronal reformatted images from post contrast 3D-SPGR images obtained in three distinct time frames. (A) Image obtained 16 months before the beginning of the acute clinical findings demonstrates only cerebellar postoperative changes, in a regular follow-up exam. (B) Image obtained from the same exam as Fig 1, showing the intense gyriform enhancement in the left temporal and parietooccipital regions (arrow). (C) After 14 days, a new magnetic resonance (MR) exam shows no abnormal enhancement. 


1. Bartleson JD, Krecke KN, O'Neill BP, Brown PD. Reversible, strokelike migraine attacks in patients with previous radiation therapy. Neuro Oncolo 2003;2:121-127. [ Links ]

2. Black DF, Bartleson JD, Bell ML, Lachance DH. SMART: stroke-like migraine attacks after radiation therapy. Cephalagia 2006;26:1137-1142. [ Links ]

3. Lachance DH, Black DF, Bartleson JD. SMART: stroke-like migraine attacks after radiation therapy. Neurology 2005;64:A220. [ Links ]

4. Murthy SN, Cohen ME. Pseudomigraine with prolonged aphasia in a child with cranial irradiation for medulloblastoma. J Child Neurol 2002;17:134-138. [ Links ]

Received: October 5, 2012; Received: December 10, 2012; Accepted: December 17, 2012

Correspondence: Fabio de Vilhena Diniz; Avenida Dr. Enéas C. Aguiar 255/5084; 05403-000 São Paulo SP - Brasil; E-mail:

Conflict of interest: There is no conflict of interest to declare.

Creative Commons License This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.