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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

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
1.
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.14632PubMedGoogle ScholarCrossref
2.
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.13963PubMedGoogle ScholarCrossref
3.
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.0000000000000308PubMedGoogle ScholarCrossref
4.
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.xPubMedGoogle ScholarCrossref
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