{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,3]],"date-time":"2026-02-03T10:36:57Z","timestamp":1770115017447,"version":"3.49.0"},"reference-count":40,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"21","license":[{"start":{"date-parts":[[2025,5,26]],"date-time":"2025-05-26T00:00:00Z","timestamp":1748217600000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J Cosmet Laser Ther"],"published-print":{"date-parts":[[2025,5,26]]},"abstract":"\n BACKGROUND<\/jats:title>\n Stroke-like migraine attack after radiation therapy (SMART) syndrome is a rare, episodic neurological condition characterized by headache and unilateral cortical deficits following remote cranial radiation therapy. It is more frequently reported in adults, while pediatric cases remain exceedingly rare due to the latency period between radiation therapy and onset, which can span years to decades. Diagnosis is challenging due to overlapping symptoms with conditions like ventriculoperitoneal shunt (VPS) malfunction.<\/jats:p>\n <\/jats:sec>\n \n OBSERVATIONS<\/jats:title>\n The authors report the case of an 11-year-old boy with SMART syndrome following radiation treatment for a resected pineal region nongerminomatous germ cell tumor and VPS placement. The patient presented with headache, vomiting, lethargy, and seizures, raising initial concern for shunt malfunction. MRI revealed left occipital and posterior temporal cortical FLAIR hyperintensity and abnormal leptomeningeal enhancement, consistent with SMART syndrome. Multidisciplinary evaluation ruled out shunt failure and tumor recurrence. A course of corticosteroids led to symptom resolution. A review of 15 pediatric cases highlights variability in latency, symptoms, and treatment, with most patients responding favorably.<\/jats:p>\n <\/jats:sec>\n \n LESSONS<\/jats:title>\n SMART syndrome, although rare, should be considered in pediatric patients with postradiation episodic neurological symptoms to avoid unnecessary interventions. Multidisciplinary collaboration is essential. Further studies are needed to establish standardized diagnostic and treatment protocols.<\/jats:p>\n \n https:\/\/thejns.org\/doi\/10.3171\/CASE25189<\/jats:ext-link>\n <\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/case25189","type":"journal-article","created":{"date-parts":[[2025,5,26]],"date-time":"2025-05-26T20:17:49Z","timestamp":1748290669000},"source":"Crossref","is-referenced-by-count":1,"title":["Stroke-like migraine attack after radiation therapy (SMART) syndrome in a pediatric patient with a ventriculoperitoneal shunt: illustrative case"],"prefix":"10.3171","volume":"9","author":[{"given":"Christopher S.","family":"Lozano","sequence":"first","affiliation":[{"name":"Division of Neurosurgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2249-5054","authenticated-orcid":true,"given":"Cody L.","family":"Nesvick","sequence":"additional","affiliation":[{"name":"Division of Neurosurgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alexandra De","family":"Sequeira","sequence":"additional","affiliation":[{"name":"School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4878-8517","authenticated-orcid":true,"given":"Lindsey M.","family":"Vogt","sequence":"additional","affiliation":[{"name":"Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Suzane","family":"Laughlin","sequence":"additional","affiliation":[{"name":"Division of Neuroradiology, Department of Diagnostic and Interventional Radiology, The Hospital for Sick Children, Toronto, Ontario, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6009-0859","authenticated-orcid":true,"given":"Puneet","family":"Jain","sequence":"additional","affiliation":[{"name":"Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Abhaya V.","family":"Kulkarni","sequence":"additional","affiliation":[{"name":"Division of Neurosurgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"James T.","family":"Rutka","sequence":"additional","affiliation":[{"name":"Division of Neurosurgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"George M.","family":"Ibrahim","sequence":"additional","affiliation":[{"name":"Division of Neurosurgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"James","family":"Drake","sequence":"additional","affiliation":[{"name":"Division of Neurosurgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"issue":"4","key":"bib1","series-title":"Neuroradiology","first-page":"471","article-title":"Intracranial long-term complications of radiation therapy: an image-based review","volume":"63","author":"Carr","year":"2021","unstructured":"Carr CMBenson JCDeLone DRIntracranial long-term complications of radiation therapy: an image-based review. Neuroradiology. 2021;63(4):471-482."},{"issue":"6","key":"bib2","series-title":"AJNR Am J Neuroradiol","first-page":"626","article-title":"Comprehensive update and review of clinical and imaging features of SMART syndrome","volume":"44","author":"Ota","year":"2023","unstructured":"Ota YLiao EShah GSrinivasan ACapizzano AA.Comprehensive update and review of clinical and imaging features of SMART syndrome. AJNR Am J Neuroradiol. 2023;44(6):626-633."},{"issue":"1","key":"bib3","series-title":"Neurol Sci","first-page":"157","article-title":"SMART (stroke-like migraine attack after radiation therapy) syndrome: a case report with review of the literature","volume":"37","author":"Rigamonti","year":"2016","unstructured":"Rigamonti ALauria GMantero VFilizzolo MSalmaggi A.SMART (stroke-like migraine attack after radiation therapy) syndrome: a case report with review of the literature. Neurol Sci. 2016;37(1):157-161."},{"issue":"12","key":"bib4","series-title":"AJNR Am J Neuroradiol","first-page":"2298","article-title":"Stroke-like migraine attacks after radiation therapy (SMART) syndrome is not always completely reversible: a case series","volume":"34","author":"Black","year":"2013","unstructured":"Black DFMorris JMLindell EPStroke-like migraine attacks after radiation therapy (SMART) syndrome is not always completely reversible: a case series. AJNR Am J Neuroradiol. 2013;34(12):2298-2303."},{"issue":"10","key":"bib5","series-title":"Neurology","first-page":"1837","article-title":"\u201cComplicated migraine-like episodes\u201d in children following cranial irradiation and chemotherapy","volume":"45","author":"Shuper","year":"1995","unstructured":"Shuper APacker RJVezina LGNicholson HSLafond D.\u201cComplicated migraine-like episodes\u201d in children following cranial irradiation and chemotherapy. Neurology. 1995;45(10):1837-1840."},{"issue":"3","key":"bib6","series-title":"J Child Neurol","first-page":"336","article-title":"SMART syndrome (stroke-like migraine attacks after radiation therapy) in adult and pediatric patients","volume":"29","author":"Armstrong","year":"2014","unstructured":"Armstrong AEGillan EDimario FJ.SMART syndrome (stroke-like migraine attacks after radiation therapy) in adult and pediatric patients. J Child Neurol. 2014;29(3):336-341."},{"issue":"9","key":"bib7","series-title":"Cephalalgia","first-page":"1137","article-title":"SMART: stroke-like migraine attacks after radiation therapy","volume":"26","author":"Black","year":"2006","unstructured":"Black DFBartleson JDBell MLLachance DH.SMART: stroke-like migraine attacks after radiation therapy. Cephalalgia. 2006;26(9):1137-1142."},{"issue":"7","key":"bib8","series-title":"Am J Med","first-page":"863","article-title":"An intelligent diagnosis: SMART syndrome","volume":"134","author":"Branfield Day","year":"2021","unstructured":"Branfield Day LRajendram PKalia LVGold WL.An intelligent diagnosis: SMART syndrome. Am J Med. 2021;134(7):863-865."},{"issue":"6","key":"bib9","series-title":"An Pediatr (Engl Ed)","first-page":"311","article-title":"Clinical scale for the diagnosis of ventriculoperitoneal shunt malfunction in children in emergency department","volume":"84","author":"Mu\u00f1oz-Santanach","year":"2016","unstructured":"Mu\u00f1oz-Santanach DTrenchs Sainz de la Maza VCandela Canto SLuaces Cubells C.Clinical scale for the diagnosis of ventriculoperitoneal shunt malfunction in children in emergency department. 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Neurology. 2013;81(11):1014-1017."},{"issue":"3","key":"bib14","series-title":"J Pediatr Hematol Oncol","first-page":"248","article-title":"Early-onset SMART syndrome in an 11-year-old child with acute lymphoblastic leukemia","volume":"38","author":"Tsepis","year":"2016","unstructured":"Tsepis KTragiannidis AGombakis NHatzistilianou M.Early-onset SMART syndrome in an 11-year-old child with acute lymphoblastic leukemia. J Pediatr Hematol Oncol. 2016;38(3):248."},{"key":"bib15","series-title":"Semin Pediatr Neurol","first-page":"124","article-title":"A 15-year-old girl with sudden onsent reversible neurologic symptoms after cranial irradiation for medulloblastoma","volume":"26","author":"Duke","year":"2018","unstructured":"Duke EUllrich NJ.A 15-year-old girl with sudden onsent reversible neurologic symptoms after cranial irradiation for medulloblastoma. Semin Pediatr Neurol. 2018;26:124-127."},{"issue":"4","key":"bib16","series-title":"Neuropediatrics","first-page":"259","article-title":"Cerebral hyperperfusion in a child with stroke-like migraine attacks after radiation therapy syndrome","volume":"47","author":"Ardicli","year":"2016","unstructured":"Ardicli DGocmen ROguz KKVaran AYalnizoglu D.Cerebral hyperperfusion in a child with stroke-like migraine attacks after radiation therapy syndrome. Neuropediatrics. 2016;47(4):259-262."},{"issue":"4","key":"bib17","series-title":"J Pediatr Neurol","first-page":"304","article-title":"Stroke-like migraine after radiation treatment syndrome in children with cancer","volume":"20","author":"Ahmed","year":"2022","unstructured":"Ahmed QSSadighi ZSLucas JTKhan RB.Stroke-like migraine after radiation treatment syndrome in children with cancer. J Pediatr Neurol. 2022;20(4):304-308."},{"key":"bib18","series-title":"eNeurologicalSci","first-page":"1","article-title":"SMART (stroke-like migraine attacks after radiation therapy) syndrome responded to steroid pulse therapy: report of a case and review of the literature","volume":"12","author":"Jia","year":"2018","unstructured":"Jia WSaito RKanamori MIwabuchi NIwasaki MTominaga TSMART (stroke-like migraine attacks after radiation therapy) syndrome responded to steroid pulse therapy: report of a case and review of the literature. eNeurologicalSci. 2018;12:1-4."},{"issue":"3","key":"bib19","series-title":"AJNR Am J Neuroradiol","first-page":"396","article-title":"Prognostic factors of stroke-like migraine attacks after radiation therapy (SMART) syndrome","volume":"43","author":"Ota","year":"2022","unstructured":"Ota YLeung DLin EPrognostic factors of stroke-like migraine attacks after radiation therapy (SMART) syndrome. AJNR Am J Neuroradiol. 2022;43(3):396-401."},{"issue":"561","key":"bib20","series-title":"Surg Neurol Int","first-page":"561","article-title":"SMART syndrome (Stroke-like migraine attacks after radiation therapy): when to suspect it?","volume":"12","author":"Angelidis","year":"2021","unstructured":"Angelidis PSaleh CJaszczuk PSeyam MEbner KAHund-Georgiadis M.SMART syndrome (Stroke-like migraine attacks after radiation therapy): when to suspect it? Surg Neurol Int. 2021;12(561):561."},{"issue":"4","key":"bib1","series-title":"Neuroradiology","first-page":"471","article-title":"Intracranial long-term complications of radiation therapy: an image-based review","volume":"63","author":"Carr","year":"2021","unstructured":"Carr CMBenson JCDeLone DRIntracranial long-term complications of radiation therapy: an image-based review. Neuroradiology. 2021;63(4):471-482."},{"issue":"6","key":"bib2","series-title":"AJNR Am J Neuroradiol","first-page":"626","article-title":"Comprehensive update and review of clinical and imaging features of SMART syndrome","volume":"44","author":"Ota","year":"2023","unstructured":"Ota YLiao EShah GSrinivasan ACapizzano AA.Comprehensive update and review of clinical and imaging features of SMART syndrome. AJNR Am J Neuroradiol. 2023;44(6):626-633."},{"issue":"1","key":"bib3","series-title":"Neurol Sci","first-page":"157","article-title":"SMART (stroke-like migraine attack after radiation therapy) syndrome: a case report with review of the literature","volume":"37","author":"Rigamonti","year":"2016","unstructured":"Rigamonti ALauria GMantero VFilizzolo MSalmaggi A.SMART (stroke-like migraine attack after radiation therapy) syndrome: a case report with review of the literature. Neurol Sci. 2016;37(1):157-161."},{"issue":"12","key":"bib4","series-title":"AJNR Am J Neuroradiol","first-page":"2298","article-title":"Stroke-like migraine attacks after radiation therapy (SMART) syndrome is not always completely reversible: a case series","volume":"34","author":"Black","year":"2013","unstructured":"Black DFMorris JMLindell EPStroke-like migraine attacks after radiation therapy (SMART) syndrome is not always completely reversible: a case series. AJNR Am J Neuroradiol. 2013;34(12):2298-2303."},{"issue":"10","key":"bib5","series-title":"Neurology","first-page":"1837","article-title":"\u201cComplicated migraine-like episodes\u201d in children following cranial irradiation and chemotherapy","volume":"45","author":"Shuper","year":"1995","unstructured":"Shuper APacker RJVezina LGNicholson HSLafond D.\u201cComplicated migraine-like episodes\u201d in children following cranial irradiation and chemotherapy. Neurology. 1995;45(10):1837-1840."},{"issue":"3","key":"bib6","series-title":"J Child Neurol","first-page":"336","article-title":"SMART syndrome (stroke-like migraine attacks after radiation therapy) in adult and pediatric patients","volume":"29","author":"Armstrong","year":"2014","unstructured":"Armstrong AEGillan EDimario FJ.SMART syndrome (stroke-like migraine attacks after radiation therapy) in adult and pediatric patients. J Child Neurol. 2014;29(3):336-341."},{"issue":"9","key":"bib7","series-title":"Cephalalgia","first-page":"1137","article-title":"SMART: stroke-like migraine attacks after radiation therapy","volume":"26","author":"Black","year":"2006","unstructured":"Black DFBartleson JDBell MLLachance DH.SMART: stroke-like migraine attacks after radiation therapy. Cephalalgia. 2006;26(9):1137-1142."},{"issue":"7","key":"bib8","series-title":"Am J Med","first-page":"863","article-title":"An intelligent diagnosis: SMART syndrome","volume":"134","author":"Branfield Day","year":"2021","unstructured":"Branfield Day LRajendram PKalia LVGold WL.An intelligent diagnosis: SMART syndrome. Am J Med. 2021;134(7):863-865."},{"issue":"6","key":"bib9","series-title":"An Pediatr (Engl Ed)","first-page":"311","article-title":"Clinical scale for the diagnosis of ventriculoperitoneal shunt malfunction in children in emergency department","volume":"84","author":"Mu\u00f1oz-Santanach","year":"2016","unstructured":"Mu\u00f1oz-Santanach DTrenchs Sainz de la Maza VCandela Canto SLuaces Cubells C.Clinical scale for the diagnosis of ventriculoperitoneal shunt malfunction in children in emergency department. An Pediatr (Engl Ed). 2016;84(6):311-317."},{"key":"bib10","series-title":"Am J Emerg Med","first-page":"180","article-title":"Diagnostic modalities to determine ventriculoperitoneal shunt malfunction: a systematic review and meta-analysis","volume":"39","author":"Jayanth","year":"2021","unstructured":"Jayanth ABenabbas RChao JSinert R.Diagnostic modalities to determine ventriculoperitoneal shunt malfunction: a systematic review and meta-analysis. Am J Emerg Med. 2021;39:180-189."},{"issue":"6","key":"bib11","series-title":"J Neurosurg Pediatr","first-page":"435","article-title":"Rethinking the indications for the ventriculoperitoneal shunt tap","volume":"1","author":"Miller","year":"2008","unstructured":"Miller JPFulop SCDashti SRRobinson SCohen AR.Rethinking the indications for the ventriculoperitoneal shunt tap. J Neurosurg Pediatr. 2008;1(6):435-438."},{"issue":"1","key":"bib12","series-title":"Neurology","first-page":"e210203","article-title":"Teaching NeuroImage: stroke-like migraine attacks after radiation therapy syndrome","volume":"104","author":"Lubotzky","year":"2025","unstructured":"Lubotzky APai VBranson HMChowdhury SSPulcine E.Teaching NeuroImage: stroke-like migraine attacks after radiation therapy syndrome. Neurology. 2025;104(1):e210203."},{"issue":"11","key":"bib13","series-title":"Neurology","first-page":"1014","article-title":"Acute late-onset encephalopathy after radiotherapy: an unusual life-threatening complication","volume":"81","author":"Di Stefano","year":"2013","unstructured":"Di Stefano ALBerzero GVitali PAcute late-onset encephalopathy after radiotherapy: an unusual life-threatening complication. Neurology. 2013;81(11):1014-1017."},{"issue":"3","key":"bib14","series-title":"J Pediatr Hematol Oncol","first-page":"248","article-title":"Early-onset SMART syndrome in an 11-year-old child with acute lymphoblastic leukemia","volume":"38","author":"Tsepis","year":"2016","unstructured":"Tsepis KTragiannidis AGombakis NHatzistilianou M.Early-onset SMART syndrome in an 11-year-old child with acute lymphoblastic leukemia. J Pediatr Hematol Oncol. 2016;38(3):248."},{"key":"bib15","series-title":"Semin Pediatr Neurol","first-page":"124","article-title":"A 15-year-old girl with sudden onsent reversible neurologic symptoms after cranial irradiation for medulloblastoma","volume":"26","author":"Duke","year":"2018","unstructured":"Duke EUllrich NJ.A 15-year-old girl with sudden onsent reversible neurologic symptoms after cranial irradiation for medulloblastoma. Semin Pediatr Neurol. 2018;26:124-127."},{"issue":"4","key":"bib16","series-title":"Neuropediatrics","first-page":"259","article-title":"Cerebral hyperperfusion in a child with stroke-like migraine attacks after radiation therapy syndrome","volume":"47","author":"Ardicli","year":"2016","unstructured":"Ardicli DGocmen ROguz KKVaran AYalnizoglu D.Cerebral hyperperfusion in a child with stroke-like migraine attacks after radiation therapy syndrome. Neuropediatrics. 2016;47(4):259-262."},{"issue":"4","key":"bib17","series-title":"J Pediatr Neurol","first-page":"304","article-title":"Stroke-like migraine after radiation treatment syndrome in children with cancer","volume":"20","author":"Ahmed","year":"2022","unstructured":"Ahmed QSSadighi ZSLucas JTKhan RB.Stroke-like migraine after radiation treatment syndrome in children with cancer. J Pediatr Neurol. 2022;20(4):304-308."},{"key":"bib18","series-title":"eNeurologicalSci","first-page":"1","article-title":"SMART (stroke-like migraine attacks after radiation therapy) syndrome responded to steroid pulse therapy: report of a case and review of the literature","volume":"12","author":"Jia","year":"2018","unstructured":"Jia WSaito RKanamori MIwabuchi NIwasaki MTominaga TSMART (stroke-like migraine attacks after radiation therapy) syndrome responded to steroid pulse therapy: report of a case and review of the literature. eNeurologicalSci. 2018;12:1-4."},{"issue":"3","key":"bib19","series-title":"AJNR Am J Neuroradiol","first-page":"396","article-title":"Prognostic factors of stroke-like migraine attacks after radiation therapy (SMART) syndrome","volume":"43","author":"Ota","year":"2022","unstructured":"Ota YLeung DLin EPrognostic factors of stroke-like migraine attacks after radiation therapy (SMART) syndrome. 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