To describe an unusual case of recurrent stroke-like migraine attacks after radiation therapy (SMART) syndrome.

SMART, a rare syndrome of complex neurological manifestations, is a delayed complication of brain irradiation and has characteristic neuroimaging findings of unilateral T2 hyperintensity within temporal, parietal or occipital cortex and white matter sparing gyral cortical gray matter enhancement in a nonvascular distribution. Symptoms are usually reversible, however, in a recent review of 42 cases 16 showed incomplete recovery. Recurrence is rare and has been reported in only 11 cases. Role of steroid in the treatment is not established, however, some cases treated with steroid show benefit.

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66-year-old woman with right frontal lobe non-Hodgkin’s lymphoma, status-post complete excision and radiotherapy in 1997, developed simple focal sensory/motor epilepsy in 2011. She presented with 5-6 days of persistent left hemibody weakness and numbness in 2015. MRI showed right frontal encephalomalacia, mild leptomeningeal and extensive gyral enhancement affecting right temporal, frontal, insular and parietal cortices. She was diagnosed with SMART syndrome. REEG revealed rare right temporal slowing and spikes. Neurologic recovery occurred over the next 4 weeks. Minimal left extremity sensorimotor deficit persisted.  Enhancing lesions resolved on interval MRI. In 2018, she was readmitted with 2 days of left faciobrachial weakness and numbness. Long-term VEEG monitoring showed focal slowing. Brain MRI showed findings essentially similar to findings in 2015. She improved within 2 weeks and returned to baseline. Both the times, patient was treated conservatively.

Our patient expands the knowledge of clinical improvement in patients with rare recurrent SMART syndrome not treated by steroid. Partial recovery during the first attack and complete recovery during the second attack could possibly be related to the extent of neurologic deficit and duration of symptoms at the time of presentations.