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NEUROIMAGE
Year : 2022  |  Volume : 70  |  Issue : 4  |  Page : 1757-1758

MR-PET Findings in SMART (Stroke-Like Migraine Attacks after Radiation Therapy) Syndrome


Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India

Date of Submission30-Sep-2019
Date of Decision24-Oct-2019
Date of Acceptance14-Jul-2020
Date of Web Publication30-Aug-2022

Correspondence Address:
Sameer Peer
A-805, Glacier Block, Brigade Gardenia, JP Nagar, 7th Phase, Bangalore - 560 078, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.355176

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How to cite this article:
Mangalore S, Peer S, Gupta AK. MR-PET Findings in SMART (Stroke-Like Migraine Attacks after Radiation Therapy) Syndrome. Neurol India 2022;70:1757-8

How to cite this URL:
Mangalore S, Peer S, Gupta AK. MR-PET Findings in SMART (Stroke-Like Migraine Attacks after Radiation Therapy) Syndrome. Neurol India [serial online] 2022 [cited 2022 Oct 7];70:1757-8. Available from: https://www.neurologyindia.com/text.asp?2022/70/4/1757/355176




A 30-year-old man presented with complaints of headache and vomiting associated with right hemiparesis of 4 days duration. He was known to have anaplastic oligodendroglioma for which he underwent gross total resection 3 years back. He had completed concurrent chemo-radiotherapy 8 months back. Hybrid magnetic resonance/18-F fluorodeoxyglucose (FDG) positron emission tomography (MR-PET) study was done to rule out recurrence and/or radiation necrosis. The patient had an episode of sudden onset headache, right focal seizures, and vomiting just before the administration of the radioactive tracer. MR images showed evidence of T2/fluid-attenuated inversion recovery (FLAIR) hyperintense signal involving gyri in the left parietal lobe and the cuneus with diffusion restriction and post-contrast enhancement [Figure 1]. On fused MR-PET images, intense uptake of tracer was noted in the areas corresponding to T2/FLAIR hyperintensity and post-contrast enhancement on MR [Figure 2]. The patient was symptomatic and had sudden onset headache, right focal seizure, and vomiting during uptake of FDG. The increased tracer uptake in the left parietal cortex could be due to seizure activity. Cortical spreading depression as seen in patients with migraines may also explain the changes in PET. The patient experienced stroke-like symptoms, headache, and seizures and had received radiotherapy for anaplastic oligodendroglioma. Based on these findings a diagnosis of SMART (stroke-like migraine attacks after radiation therapy) syndrome was made.
Figure 1: (a) T2W image showing hyperintense signal involving the left parietal lobe with gyral edema. (b) Diffusion weighted image (DWI) showing hyperintense gyral signal in the left parietal lobe corresponding to the T2 hyperintense signal. (c) Apparent diffusion coefficient (ADC) image showing hypointense areas in the left parietal gyri suggestive of diffusion restriction. (d) Post-contrast T1W Magnetization prepared rapid gradient echo (MPRAGE) image showing patchy areas of enhancement within the peri-operative region in the left parietal lobe

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Figure 2: (a) Fused axial Magnetic resonance/Positron emission tomography (MR/PET) images showing intense gyral uptake of 18-Flourine-Flourodeoxyglucose (18-F-FDG) tracer in the left parietal lobe. (b) Coronal Fused MR/PET image showing intense gyral 18-F-FDG uptake in the left parietal lobe. (c) Sagittal fused MR/PET image showing intense gyral uptake of 18-F-FDG in left parietal and occipital lobes. (d) Axial fused MR/PET image showing intense gyral uptake of 18-F-FDG in left superior parietal lobe away from the operative site

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SMART syndrome is a rare delayed complication of brain irradiation.[1] The first case of SMART syndrome was described by Shuper et al. in 1995.[2] Patients usually present with recurrent migraine-like attacks with or without aura, hemispheric dysfunction, and seizures.[1],[3] On MRI, unilateral temporoparietal cortical involvement with post-contrast enhancement is described in the literature.[3] Sequential FDG PET and MRI findings have been described previously.[4] Patients may present with reversible neurodeficits with reversible changes involving the brain parenchyma which may be similar to the changes seen in patients with migraines.[5] In our knowledge, this is the first description of simultaneous MR-PET findings in the case of SMART syndrome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jia W, Saito R, Kanamori M, Iwabuchi N, Iwasaki M, Tominaga T. SMART (stroke-like migraine attacks after radiation therapy) syndrome responded to steroid pulse therapy: Report of a case and review of the literature. eNeurologicalSci 2018;12:1-4.  Back to cited text no. 1
    
2.
Shuper A, Packer RJ, Vezina LG, Nicholson HS, Lafond D. “Complicated migrainelike episodes” in children following cranial irradiation and chemotherapy. Neurology 1995;45:1837-40.  Back to cited text no. 2
    
3.
Ramanathan RS, Sreedher G, Malhotra K, Guduru Z, Agarwal D, Flaherty M, et al. Unusual case of recurrent SMART (stroke-like migraine attacks after radiation therapy) syndrome. Ann Indian Acad Neurol 2016;19:399-401.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Bund C, Fahrer P, Gebus O, Kremer S, Blondet C, Namer I-J. Sequential FDG PET and MRI findings in a case of SMART syndrome. Seizure 2017;51:50-1.  Back to cited text no. 4
    
5.
Agarwal S, Magu S, Kamal K. Reversible white matter abnormalities in a patient with migraine. Neurol India 2008;56:182-5.  Back to cited text no. 5
[PUBMED]  [Full text]  


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