# Stroke Mimic in a Cancer Survivor: A Rare Case of SMART (Stroke-Like Migraine Attacks After Radiation Therapy) Syndrome

## TL;DR

A cancer survivor experienced stroke-like symptoms years after radiation therapy, diagnosed as SMART syndrome, which can be mistaken for other neurological conditions.

## Contribution

This case report highlights the importance of considering SMART syndrome in patients with a history of cranial irradiation and transient neurological symptoms.

## Key findings

- SMART syndrome can manifest up to 10 years after cranial irradiation with stroke-like symptoms.
- Diagnosis relies on ruling out other acute neurological conditions and recognizing the patient's radiation history.
- Treatment with migraine prophylaxis like verapamil showed gradual improvement in the patient's condition.

## Abstract

Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare and delayed side effect of cranial irradiation. It can appear after many years following radiation therapy and is characterised by temporary, stroke-like neurological deficits such as hemiparesis, seizures, aphasia, sensory abnormalities, and headaches. Although the condition is self-limiting, it can pose a difficulty in diagnosis due to its symptoms coinciding with other neurological disorders.

We report a case of a 63-year-old male with a diagnosis of oligodendroglioma for which he had previously received cranial irradiation in 2015. He presented to the emergency room in 2025, 10 years later, with an abrupt-onset weakness in his left upper and lower limbs. Acute causes like infection, stroke, and seizures were ruled out through investigations. The patient’s history, clinical presentation, and radiological exclusion of other pathologies led to the diagnosis of SMART syndrome. Verapamil was prescribed as migraine prophylaxis, and neurology follow-up was part of the treatment plan. At the subsequent follow-up, it was reported that the clinical condition was showing gradual improvement.

Patients with a history of cranial irradiation and temporary focal neurological symptoms should be evaluated for SMART syndrome, especially when other acute pathologies are excluded, as early detection can help avoid needless interventions and guide appropriate management.