Sonia Jaraba1, Oriol Puig2, Júlia Miró3, Roser Velasco4, Sara Castañer5, Laura Rodríguez6, Cristina Izquierdo4, Marta Simó4, Misericordia Veciana7, Mercè Falip3. 1. Neurology Department, Epilepsy Unit, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Neurology Department, Hospital de Viladecans, Viladecans, Barcelona, Spain. Electronic address: soniajaraba@gmail.com. 2. Nuclear Medicine Department, SPECT Unit, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain. 3. Neurology Department, Epilepsy Unit, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain. 4. Neurology Department, Neuro-Oncology Unit, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain. 5. Image Diagnostic Institute, Radiology Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain. 6. Image Diagnostic Institute, Nuclear Medicine Department, PET Unit, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain. 7. Neurophysiology Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
Abstract
INTRODUCTION: Stroke-like migraine attacks after radiation therapy (SMART) is a late-onset complication of brain irradiation of unknown physiopathology. Our aim was to present three patients with SMART syndrome who had clinical and neuroimage studies suggestive of status epilepticus. PATIENTS: Patient 1. A 69-year-old woman, who was treated with radiation therapy 14 years before her first admission to the Neurology Department, presented with several episodes of headache, speech disturbances, and weakness of left limbs with altered awareness. Patient 2. A 49-year-old man, who was treated with whole brain radiation 20 years before the onset of symptoms, developed some episodes consisting of headache and numbness of the right side of face and right arm; the latest episodes were accompanied by visual disturbances followed by generalized tonic-clonic seizures. Patient 3. A 40-year-old man, who received cranial irradiation 20 years before, suffered three episodes of behavioral disturbance, aphasia, headache, and visual aura followed by left homonymous hemianopia. RESULTS: All three patients suffered seizures mostly with visual aura. Electroencephalography showed interictal epileptiform discharges or focal slowing. Brain magnetic resonance image (MRI), positron emission tomography (PET), or ictal-single-photon emission computed tomography (SPECT) showed focal cortical hyperperfusion. Focal diffusion restriction and focal gadolinium-enhancement were observed on MRI. All patients were treated with antiepileptic drugs, being effective in one of them. One patient needed anesthesic coma, and the other patient responded to therapy with corticosteroids. CONCLUSIONS: Taking into account clinical evolution and ictal neuroimaging studies, status epilepticus could explain the origin of these episodes in SMART syndrome. Although most patients have reversible symptoms, in some cases, aggressive treatment to avoid sequelae is needed. This article is part of a Special Issue entitled "Status Epilepticus".
INTRODUCTION:Stroke-like migraine attacks after radiation therapy (SMART) is a late-onset complication of brain irradiation of unknown physiopathology. Our aim was to present three patients with SMART syndrome who had clinical and neuroimage studies suggestive of status epilepticus. PATIENTS: Patient 1. A 69-year-old woman, who was treated with radiation therapy 14 years before her first admission to the Neurology Department, presented with several episodes of headache, speech disturbances, and weakness of left limbs with altered awareness. Patient 2. A 49-year-old man, who was treated with whole brain radiation 20 years before the onset of symptoms, developed some episodes consisting of headache and numbness of the right side of face and right arm; the latest episodes were accompanied by visual disturbances followed by generalized tonic-clonic seizures. Patient 3. A 40-year-old man, who received cranial irradiation 20 years before, suffered three episodes of behavioral disturbance, aphasia, headache, and visual aura followed by left homonymous hemianopia. RESULTS: All three patients suffered seizures mostly with visual aura. Electroencephalography showed interictal epileptiform discharges or focal slowing. Brain magnetic resonance image (MRI), positron emission tomography (PET), or ictal-single-photon emission computed tomography (SPECT) showed focal cortical hyperperfusion. Focal diffusion restriction and focal gadolinium-enhancement were observed on MRI. All patients were treated with antiepileptic drugs, being effective in one of them. One patient needed anesthesic coma, and the other patient responded to therapy with corticosteroids. CONCLUSIONS: Taking into account clinical evolution and ictal neuroimaging studies, status epilepticus could explain the origin of these episodes in SMART syndrome. Although most patients have reversible symptoms, in some cases, aggressive treatment to avoid sequelae is needed. This article is part of a Special Issue entitled "Status Epilepticus".