Case Report: SMART syndrome mimicking Todd's paralysis after meningioma irradiation

Stroke-like Migraine Attacks after Radiation Therapy (SMART) syndrome is a rare, delayed complication of cerebral irradiation characterized by stroke-like symptoms, seizures, and/or headaches, with mean latency period of 11.2 years. It is most associated with gliomas and medulloblastomas and diagnosis is challenging due to symptom overlap with recurrent neurologic deficits. We present a 59-year-old male with history of right frontal convexity anaplastic meningioma complicated by seizure disorder and Todd's paralysis, status post tumor resection, adjuvant radiation to 6000cGy, craniotomy and cranioplasty complicated by subdural abscess/empyema. Four years later, he presented with an epileptic seizure followed by progressive left facial and hand numbness with facial droop over 24 hours. Vitals, blood work, lumbar puncture and head computed tomography (CT) were unremarkable. CT angiography demonstrated asymmetric gyral enhancement and sulcal effacement within the right frontal lobe. Brain magnetic resonance imaging (MRI) demonstrated right hemispheric sulcal enhancement within the prior radiation field with cortical/leptomeningeal FLAIR hyperintensity and subtle diffusion restriction Electroencephalography revealed nonspecific right temporal and paracentral lateralized rhythmic discharges. Following multidisciplinary evaluation, the patient required a prolonged dexamethasone taper due to failed initial steroid taper and was initiated on amlodipine with continuation of levetiracetam, zonisamide, and clobazam. MRI at three months showed enhancement resolution with clinical improvement and no recurrent seizures. This case highlights SMART syndrome as a diagnosis of exclusion, notable for its shortened latency in comparison to the reported mean and rare association with meningioma, emphasizing the need for heightened clinical suspicion in patients with prior cerebral irradiation presenting with progressive neurologic deficits.