A diagnosis of stroke-like migraine attacks after radiation therapy (SMART) as severe headache with stroke-like presentation

A 52-year-old woman presented to the emergency department with gradual onset headache and expressive dysphasia. She had a left-sided facial droop and an unsteady gait on examination. An immediate non-contrast brain computed tomography (CT) was performed demonstrating evidence of prior right-sided neurosurgical intervention but no acute abnormality to account for her clinical findings (Figure 1). Further enquiry revealed a history of right parietal meningioma resection eleven years earlier followed by adjuvant cranial radiotherapy. A subsequent brain magnetic resonance imaging (MRI) demonstrated cortical thickening and a gyriform pattern of enhancement at the site of previous resection, with no convincing area of abnormal diffusion restriction (Figure 2, A-C). The patient’s symptoms gradually resolved over the course of few months and a repeat MRI brain revealed complete resolution of the previously demonstrated acute findings (Figure 2, D and E).