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Provocative Hyperventilation in a Patient With Stroke-Like Migraine Attacks After Radiation Therapy

Educational Objective
To identify the key insights or developments described in this article

1 Credit CME

JAMA Neurology

Published Online: March 21, 2022

Images in Neurology

Article Information and Disclosures

Yonatan Serlin, MD¹;

Mohammed Alshahrani, MD¹;

Birgit Frauscher, MD, PhD²

Author Affiliations

¹Electroencephalography/Epilepsy Fellowship Training Program, McGill University, Montreal, Quebec, Canada
²Analytical Neurophysiology Lab, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada

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A 65-year-old woman with a remote history of right frontal low-grade astrocytoma resection and adjuvant radiotherapy (RT) at the age of 15 years underwent routine electroencephalography (EEG). She had experienced RT-induced infratentorial and supratentorial cavernomas and right occipital angiomatous meningioma. The patient reported a 5-year history of episodic right frontal migraine-type headaches, paroxysmal flashes of light in the left visual field, and transient left arm paresthesia. She had visited the emergency department twice for transient left hemibody weakness, attributed to a possible right transient ischemic attack (TIA). Contrast-enhanced T1 magnetic resonance imaging of the brain revealed cortical edema, T2-weighted fluid-attenuated inversion recovery hyperintensity, and gyriform enhancement (Figure 1), along with hyperperfusion in the right temporoparietooccipital and posterior frontal lobes. The clinical and imaging features were compatible with stroke-like migraine attacks after radiation therapy (SMART) syndrome.

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Article Information

Corresponding Author: Birgit Frauscher, MD, PhD, Montreal Neurological Institute and Hospital, McGill University, 3801 University St, Montreal, QC H3A 2B4, Canada (birgit.frauscher@mcgill.ca).

Published Online: March 21, 2022. doi:10.1001/jamaneurol.2022.0182

Conflict of Interest Disclosures: Dr Frauscher is supported by a salary award (Chercheur-boursier clinicien Senior) from Fonds de Recherche du Québec-Santé during the conduct of the study as well as personal fees and grants from Eisai and personal fees from UCB outside the submitted work. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References

Singh TD , Hajeb M , Rabinstein AA , et al. SMART syndrome: retrospective review of a rare delayed complication of radiation. Eur J Neurol. 2021;28(4):1316-1323. doi:10.1111/ene.14632 PubMed Google Scholar Crossref

Fan EP , Heiber G , Gerard EE , Schuele S . Stroke-like migraine attacks after radiation therapy: a misnomer? Epilepsia. 2018;59(1):259-268. doi:10.1111/epi.13963 PubMed Google Scholar Crossref

Sinha SR , Sullivan L , Sabau D , et al. American clinical neurophysiology society guideline 1: minimum technical requirements for performing clinical electroencephalography. J Clin Neurophysiol. 2016;33(4):303-307. doi:10.1097/WNP.0000000000000308 PubMed Google Scholar Crossref

Holmes MD , Dewaraja AS , Vanhatalo S . Does hyperventilation elicit epileptic seizures? Epilepsia. 2004;45(6):618-620. doi:10.1111/j.0013-9580.2004.63803.x PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.