SMART Attacks – have you heard of them?
SMART attacks or SMART Syndrome is a rarer Neurological condition and occurs after someone has undergone radiation therapy to the brain. It sometimes presents many years after the radiation treatment. In keeping with the cause, SMART stands for Stroke-like Migraine After Radiation Therapy. While the presentation of SMART attacks can mimic Stroke symptoms this is not the cause, and SMART attacks are normally transient but may lead to long-term issues.
The Causes of SMART Syndrome Expanded
Several contributing factors have been identified for SMART attacks. As known, symptoms follow radiation treatment for brain tumours and cancer of the head/neck. The radiation treatment can affect the lining of the blood vessels, lead to chronic inflammation within the brain, change the autoregulation of the brain's blood flow, and cause structural changes in the brain. These can lead to Stroke-like or Migraine-like symptoms, and those with a prior history of Migraines have a greater likelihood of developing SMART attacks.
How do SMART Attacks Present?

As SMART attacks mimic Strokes and Migraines, their diagnosis can be complex, the symptoms can last from hours to days, and recur again in the future.
There are several symptoms which can present. A person may show a weakness or paralysis on one side of the body and/or numbness/ tingling. There can be problems with speech, where someone may struggle with their words or understanding what is being said. Vision can be affected, where things appear blurred, part of the visual field is not seen or hallucinations can be experienced. Sometimes patients can also show seizure activity. Other symptoms include headaches which may start before the onset of neurological presentations or at the same time, and finally, someone may struggle with cognitive issues including difficulty with concentration and memory.
How are SMART Attacks Diagnosed?
While a clinical history that includes treatment using radiation is necessary for the diagnosis of SMART attacks, other alternative causes for symptoms must also be ruled out. This can involve the use of diagnostic imaging and tools.

How are SMART Attacks Managed?

Some types of medication could be prescribed to help, and the type of medication may depend on whether the person is going through an acute attack or not. Steroid tablets can be prescribed to help with inflammation in an acute episode. Other medications that may be given are preventative, including anti-epileptics to help manage seizures, medication to manage vascular risk factors, and medications that manage Migraine-like attacks.
Self-management strategies include the identification of any triggers, for example, bright lights may be something that specifically affects you. However, some triggers may be more generic including lack of sleep. From clinical practice, I have seen when someone has had an unrelated viral bug, any long-standing residual symptoms are worsened, and endurance in undertaking exercises is compromised. The other factor I have seen adversely affect someone is when the weather is significantly warmer than usual. Of note, high temperatures can cause fatigue in other neurological conditions and are not specific to SMART attacks. In these situations, management needs to be mindful to pace activity accordingly as a person may seem strong initially but fatigue quite quickly.

Physiotherapy can help with the longer-term management of SMART attacks and focuses on approaches that ultimately promote function. As SMART attacks can happen periodically, the approach would sometimes need to be modified to accommodate any episodes of increased weakness/fatigue.
One of the key pillars of Physiotherapy practice is exercise. While a Physiotherapist would first undertake an initial assessment and tailor treatment to the individual, exercises undertaken would typically focus on improving motor control (the ability of the brain and nerves to regulate and co-ordinate muscles and movement of the limbs) and work to build muscle strength from deconditioning (which may have occurred secondary to a SMART attack). Additionally, specific exercises would be undertaken to promote typical daily activities like walking and transferring e.g. sit-to-stand. If a person is experiencing issues with numbness and tingling, some sensory techniques can promote recovery from this. Occasionally, a person may be experiencing pain – the reasons can be varied however, examples include shoulder pain after a prolonged period of arm weakness or reliance on weight bearing through the upper limb when using a walking aid. While SMART attacks can have a more neurological-type presentation manual therapy is sometimes indicated to help with pain management or even a support sleeve/brace may be indicated. As part of an assessment and ongoing review, a Physiotherapist would advise on expected outcomes and be able to show home exercises that could be done by the patient. Finally, while cognitive rehabilitation is not typically seen as a core part of Physiotherapy, there are games on electronic devices, for example, PlayBall and GripAble (mentioned in the Technology for Neurological Rehabilitation blog post) which have exercise games that target memory, concentration, and problem-solving skills.
Though rare, SMART attacks can significantly impact an individual's quality of life. They need early recognition and appropriate management which can involve a variety of Physiotherapy approaches.
References
· Fadul, C. E., Wood, J., Thaler, H. T., Galetta, S. L., & Posner, J. B. (1999). Cerebrovascular complications of radiation therapy for head and neck malignancies: A review. Neurology, 53(5), 818-825.
· Marks, J. E., & Baglan, R. J. (1978). Cerebral complications of radiation therapy: A review. Cancer, 41(3), 1117-1124.
· Stupp, R., Hegi, M. E., Mason, W. P., van den Bent, M. J., Taphoorn, M. J., & Janzer, R. C. (2005). Effects of radiotherapy with concomitant and adjuvant temozolomide versus radiotherapy alone on survival in glioblastoma. The New England Journal of Medicine, 352(10), 987-996.
· Shah, A. K., Young, A. B., & Lee, R. R. (2013). SMART syndrome: Stroke-like migraine attacks after radiation therapy. Journal of Clinical Neuroscience, 20(8), 1130-1135.
· Oberndorfer, S., Marosi, C., & Grisold, W. (2007). Radiation-induced changes in the central nervous system: Effects on brain function, imaging, and neuropathology. Current Opinion in Oncology, 19(6), 543-549.
· Tinkle, C. L., & Haas-Kogan, D. A. (2015). Late complications of radiation therapy for pediatric brain tumors. Pediatric Blood & Cancer, 62(3), 394-401.
· Hadsall, R. L., Mu, K. P., & Maurer, M. J. (2016). Physiotherapy and functional recovery in neurological conditions: A case study in SMART syndrome. NeuroRehabilitation, 39(2), 281-289.
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