title: Refractory status epilepticus due to SMART syndrome.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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".
authors.affiliation: 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.
authors.forename: Sonia
authors.initials: S
authors.lastname: Jaraba
authors.affiliation: Nuclear Medicine Department, SPECT Unit, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
authors.forename: Oriol
authors.initials: O
authors.lastname: Puig
authors.affiliation: Neurology Department, Epilepsy Unit, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
authors.forename: Júlia
authors.initials: J
authors.lastname: Miró
authors.affiliation: Neurology Department, Neuro-Oncology Unit, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
authors.forename: Roser
authors.initials: R
authors.lastname: Velasco
authors.affiliation: Image Diagnostic Institute, Radiology Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
authors.forename: Sara
authors.initials: S
authors.lastname: Castañer
authors.affiliation: Image Diagnostic Institute, Nuclear Medicine Department, PET Unit, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
authors.forename: Laura
authors.initials: L
authors.lastname: Rodríguez
authors.affiliation: Neurology Department, Neuro-Oncology Unit, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
authors.forename: Cristina
authors.initials: C
authors.lastname: Izquierdo
authors.affiliation: Neurology Department, Neuro-Oncology Unit, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
authors.forename: Marta
authors.initials: M
authors.lastname: Simó
authors.affiliation: Neurophysiology Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
authors.forename: Misericordia
authors.initials: M
authors.lastname: Veciana
authors.affiliation: Neurology Department, Epilepsy Unit, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
authors.forename: Mercè
authors.initials: M
authors.lastname: Falip
mesh_terms: D000328:Adult; D000368:Aged; D000927:Anticonvulsants / Q000627:therapeutic use; D001932:Brain Neoplasms / Q000532:radiotherapy*; D016371:Cranial Irradiation / Q000009:adverse effects*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D008881:Migraine Disorders / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology*; D059906:Neuroimaging; D013226:Status Epilepticus / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology*; D013577:Syndrome
chemical_list: D000927:Anticonvulsants
keywords: Brain tumors; Radiation therapy; Reversible late effects; Seizures; Status epilepticus