Stroke-Like Migraine Attacks After Radiation Therapy (SMART) Syndrome - a Decade After Cranial Irradiation

Sep 29, 2026

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Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare late complication of cranial radiotherapy marked by recurrent neurological symptoms, such as headaches, hemiparesis, aphasia, seizures, and confusion. It typically appears years after exposure, with MRI showing transient reversible cortical abnormalities in previously irradiated regions. Although recovery is often self-limited, neurological improvement may be incomplete. A clinical case describes stepwise assessment, seizure-focused workup, optimized antiepileptic therapy, and gradual improvement with good neurological recovery.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages8

Reading Time20 min

AccessFree to download

Abstract

Introduction

Case Presentation

Diagnostic Workup

Imaging and Seizure Evaluation

Discussion

How to Cite

Review began 11/14/2025 Review ended 12/01/2025 Published 12/04/2025 © Copyright 2025 Aggarawal et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CCBY 4.0. , which permits unrestricted use , distribution , and reproduction in any medium , provided the original author and source are credited. DOI: 10.7759/cureus.98494 Open Access Case Report Stroke-Like Migraine Attacks After Radiation Therapy (SMART) Syndrome: A Diagnostic Challenge a Decade After Cranial Irradiation Akshayaa K. Aggarawal 1 , Nang Soe Yamin Mon 2, Mansoor Gazi 2 1. Internal Medicine, Walsall Manor Hospital, Birmingham, GBR 2. Acute Internal Medicine, Walsall Manor Hospital, Walsall, GBR Corresponding author: Akshayaa K. Aggarawal, [akshayaa.aggarawal@nhs.net](akshayaa.aggarawal@nhs.net) Abstract Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare, late complication of cranial radiotherapy characterized by recurrent neurological symptoms, which may include headaches, hemiparesis, aphasia, seizures and confusion. The condition typically manifests years after radiation exposure, with magnetic resonance imaging (MRI) showing transient, reversible cortical abnormalities in previously irradiated regions. Although often self-limiting, neurological recovery may be incomplete in some cases. We present the case of a 64-year-old elderly male with a prior history of cranial irradiation received in 2015 who was admitted with abnormal body movements. Initial blood investigations and a non-contrast CT head were unremarkable. The MRI brain scan demonstrated deep white matter ischemic changes with no new focal lesions compared to a prior scan. Cerebrospinal fluid analysis was normal. Electroencephalography revealed focal onset seizures with secondary generalization. Following neurology review, antiepileptic therapy was optimized. Based on the clinical history, radiological findings, and seizure disorder, a diagnosis of SMART syndrome was made. The patient gradually improved his level of consciousness with a decrease in seizure activity with good neurological recovery. Categories: Neurology, Radiation Oncology Keywords: brain scans, epileptic seizures, episodic migraine, neuro oncology, stroke Introduction Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare, delayed complication of cranial irradiation, characterized by transient and occasionally recurrent neurological deficits. The condition was first described in children by Shuper and colleagues in 1995, who reported complicated migraine-like episodes in patients experiencing severe, intermittent unilateral headaches accompanied by nausea several years after receiving cranial irradiation and chemotherapy. Importantly, these episodes did not necessarily indicate stroke, vasculitis, or tumor recurrence, although their clinical presentation commonly mimics these conditions. While cerebral angiography may aid in differentiating SMART syndrome from other pathologies, its use has been associated with transient exacerbation of symptoms [1] . Fewer than 150 cases have been reported globally, underscoring both the rarity of SMART syndrome and the diagnostic challenges it poses [2,3] . Patients typically present years to decades after cranial irradiation with a constellation of symptoms, including headaches, seizures, visual disturbances, hemiparesis, aphasia, and migraine-like episodes. The latency between radiation exposure and symptom onset is highly variable, ranging from as early as one year to as long as 37 years [4,5] . Although the diagnosis traditionally relies on the reversibility of clinical and radiological findings, Black et al. reported in 2013 that a substantial proportion of patients may experience incomplete recovery, challenging earlier assumptions about its benign course [6] . Prior to confirming SMART syndrome, alternative etiologies such as local tumor recurrence, l

FAQs

What is SMART syndrome and why is it diagnostically challenging?

SMART syndrome is a rare, delayed complication of cranial radiotherapy that can mimic stroke and other neurologic disorders. Its symptoms and imaging patterns may resemble tumor recurrence, vasculitis, or ischemic disease, requiring careful exclusion of alternative causes.

When does SMART syndrome typically occur after radiation therapy?

Symptoms usually develop years to decades after cranial irradiation. The latency is highly variable, reported as early as one year and as late as about 37 years.

What clinical and diagnostic findings support a diagnosis of SMART syndrome in this case?

The case involves a history of prior cranial irradiation, neurological symptoms with seizure activity, and MRI findings of reversible abnormalities without new focal lesions. Normal cerebrospinal fluid and EEG-confirmed seizures, followed by neurology review, supported the SMART diagnosis.

Sep 29, 2026

Uploaded by Dipper