TY - JOUR
T1 - Stroke-Like Migraine Attacks After Radiation Therapy Syndrome and Radiation Necrosis After Cerebral Proton Beam Radiation
T2 - A Case Report of Dual Radiotherapy Complications
AU - Huang, Deborah
AU - Dixit, Karan S.
N1 - Funding Information:
Several institutions have financially contributed to this project and it is my pleasant duty to thankfully acknowledge here the support of the German Academic Scholarship Foundation (Studienstiftung des deutschen Volkes), the Graduate School of Humanities Göttingen (Graduiertenschule für Geisteswis-senschaften Göttingen), the German Research Foundation (Deutsche For-schungsgemeinschaft), the ?ew York University Abu Dhabi Humanities Fellowship Program, the Gerda Henkel Foundation, the ?alzan Foundation, the ahkr Department of the University of ?ergen, and the School of Historical Studies of the Institute for Advanced Study, Princeton. I am moreover grateful to the 2018 committees of the Christian-Gottlob-Heyne Prize of the University of Göttingen and the ?alcom H. Kerr Dissertation Award of the ?iddle East Studies Association of ?orth America for choosing my work for these awards.
Publisher Copyright:
© The Author(s) 2022.
PY - 2022/7
Y1 - 2022/7
N2 - Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare, delayed complication of cranial radiation therapy that consists of migraine-like headaches and focal neurologic deficits such as visual loss, aphasia, hemiparesis, hemisensory loss, and unconsciousness. SMART syndrome may be mistaken for tumor recurrence, radiation necrosis, and stroke. Timely recognition of SMART syndrome prevents unnecessary brain biopsies and enables appropriate anticipatory guidance. We present a 38 year-old right handed male with new headaches, vertigo, visual symptoms, and left-sided paresthesias. Neuroimaging revealed a heterogeneously enhancing mass with invasion into the transverse sinus, diagnosed as an epithelioid hemangioendothelioma by surgical pathology. After resection, the patient underwent proton beam radiation for maximal tissue-sparing. Six months later, he developed radiation necrosis. After another year, he developed recurrent headaches with transient language difficulties and blurry vision during each headache. Neuroimaging was consistent with SMART syndrome, and the patient was started on valproate. Verapamil was added after a second attack. The patient’s headaches improved, but he remains dyslexic. Subsequent imaging shows resolution of gyriform contrast enhancement and continued left temporo-occipital T2/FLAIR hyperintensity. We present a case of early SMART syndrome following proton beam radiotherapy, as well as the dual occurrence of radiation necrosis and SMART syndrome in this individual. Radiation necrosis and SMART syndrome are known complications of radiotherapy, with the latter less well-described. We discuss a possible shared pathophysiology involving endothelial cell dysfunction and impaired cerebrovascular autoregulation, and we question whether proton RT increases risk of early SMART syndrome development.
AB - Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare, delayed complication of cranial radiation therapy that consists of migraine-like headaches and focal neurologic deficits such as visual loss, aphasia, hemiparesis, hemisensory loss, and unconsciousness. SMART syndrome may be mistaken for tumor recurrence, radiation necrosis, and stroke. Timely recognition of SMART syndrome prevents unnecessary brain biopsies and enables appropriate anticipatory guidance. We present a 38 year-old right handed male with new headaches, vertigo, visual symptoms, and left-sided paresthesias. Neuroimaging revealed a heterogeneously enhancing mass with invasion into the transverse sinus, diagnosed as an epithelioid hemangioendothelioma by surgical pathology. After resection, the patient underwent proton beam radiation for maximal tissue-sparing. Six months later, he developed radiation necrosis. After another year, he developed recurrent headaches with transient language difficulties and blurry vision during each headache. Neuroimaging was consistent with SMART syndrome, and the patient was started on valproate. Verapamil was added after a second attack. The patient’s headaches improved, but he remains dyslexic. Subsequent imaging shows resolution of gyriform contrast enhancement and continued left temporo-occipital T2/FLAIR hyperintensity. We present a case of early SMART syndrome following proton beam radiotherapy, as well as the dual occurrence of radiation necrosis and SMART syndrome in this individual. Radiation necrosis and SMART syndrome are known complications of radiotherapy, with the latter less well-described. We discuss a possible shared pathophysiology involving endothelial cell dysfunction and impaired cerebrovascular autoregulation, and we question whether proton RT increases risk of early SMART syndrome development.
KW - case report
KW - epithelioid hemangioendothelioma
KW - magnetic resonance imaging
KW - migraine
KW - proton beam therapy
KW - radiation necrosis
KW - stroke-like migraine attacks after radiation therapy syndrome
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U2 - 10.1177/19418744221102290
DO - 10.1177/19418744221102290
M3 - Article
C2 - 35755215
AN - SCOPUS:85130584528
SN - 1941-8744
VL - 12
SP - 567
EP - 570
JO - Neurohospitalist
JF - Neurohospitalist
IS - 3
ER -