SMART syndrome is a rare complication of brain radiotherapy. This is the first described presentation of SMART syndrome with metamorphopsia, which responded to aspirin, verapamil, and high-dose L-arginine therapy.A 43-year-old man presented with 3 weeks of migraine headaches with metamorphopsia and complex visual hallucinations affecting the left lower quadrant of both visual fields. This occurred on a background of high-dose radiotherapy for right cerebellar astrocytoma 32 years ago. MRI brain demonstrated unilateral gyriform enhancement and FLAIR hyperintense cortical swelling in the right occipital lobe consistent with SMART syndrome.Unusual presentations of SMART syndrome exist and require consideration in all patients with focal neurological deficit post-brain radiotherapy. Validated diagnostic and treatment modalities for SMART syndrome are urgently required.