Cefalea e deficit neurologici dopo radioterapia: pensa alla sindrome SMART

Stroke-like Migraine Attacks after Radiation Therapy (SMART) syndrome is a rare delayed complication of cranial irradiation characterised by headache, seizures, focal neurological deficits and distinctive MRI findings. A 14-year-old boy with a history of medulloblastoma treated with surgery, chemotherapy and cranial radiotherapy presented with acute visual symptoms, severe headache and progressive focal neurological deficits. Brain CT excluded hydrocephalus and ventriculoperitoneal shunt malfunction, while MRI revealed a right parieto-occipital cortical lesion with subsequent gyriform enhancement. Clinical deterioration with focal status epilepticus initially suggested encephalitis. However, the history of cranial irradiation, the characteristic clinical presentation and MRI evolution supported the diagnosis of SMART syndrome. Corticosteroid therapy led to a rapid and complete clinical recovery. SMART syndrome should be included in the differential diagnosis of acute neurological deficits in patients with previous cranial irradiation. Early recognition may avoid unnecessary invasive investigations and allow prompt corticosteroid treatment to be started.