1404 - A Comprehensive Rehabilitation Approach in Managing SMART Syndrome: Case Report

Case Diagnosis: A Comprehensive Rehabilitation Approach in Managing SMART Syndrome:

Case Description: A 38-year-old man with a complex medical history, including diabetes, hypothyroidism, prior medulloblastoma treated with chemoradiation complicated by panhypopituitarism, papillary thyroid carcinoma, Addison’s disease presented with worsening headache and visual disturbance during viral gastroenteritis. He was treated with acyclovir, cefepime, and vancomycin. Neurology addressed altered mental status and seizures with levetiracetam and topiramate. CSF results shown. He was transferred to acute rehabilitation for deconditioning, achieving functional gains, with outpatient neuropsychological follow-up arranged.

Discussions:

SMART syndrome (Stroke-like Migraine Attacks after Radiation Therapy) is a rare complication of cranial irradiation, typically presenting years after treatment for brain tumors. First described in 1995, it manifests with transient neurological deficits resembling stroke, often accompanied by severe migraine-like headaches and seizures. The latency period varies widely, ranging from 1 to 30 years. The pathophysiology is incompletely understood but is thought to involve radiation-induced endothelial injury, blood–brain barrier disruption, cortical spreading depression, and impaired autoregulation leading to transient cortical dysfunction.

Neuroimaging is central to diagnosis, with MRI commonly showing unilateral cortical T2/FLAIR hyperintensity and gyriform enhancement in irradiated regions, usually without restricted diffusion, which helps distinguish it from ischemic stroke. Symptoms generally resolve over days to weeks, and MRI abnormalities regress within months. Management is supportive, including antiepileptics, corticosteroids, and migraine-directed therapy. While prognosis is often favorable, recurrences and persistent cognitive deficits are possible, underscoring the need for awareness.

Conclusions: This case illustrates the complexity of managing viral encephalopathy in a patient with multiple endocrine and oncologic comorbidities. Successful recovery required a multidisciplinary approach addressing infectious, metabolic, neurologic, and rehabilitative domains.