Abstract Details

Title Migratory Focal Neurological Deficits due to Non-Ischemic Leukoencephalopathy: A Methotrickster of Stroke Mimics

Topic Neuro-oncology

Presentation(s) Neuro-oncology Posters (7:00 AM-5:00 PM)

Poster/Presentation
Number 019

Objective NA

Background 20 year old man with a history of Philadelphia Chromosome positive acute lymphocytic leukemia receiving intrathecal methotrexate presented following two episodes of unilateral weakness. Upon admission, he had left sided facial droop and left upper extremity weakness that resolved within 24 hours. Then he developed acute weakness in his right upper extremity, dysarthria, and expressive aphasia which again resolved within 12 hours. Intrathecal methotrexate with the most recent dose given 1 week prior to presentation.

Design/Methods NA

Results Initial differential included acute ischemic stroke, intracerebral hemorrhagic from thrombocytopenia, and postictal paresis. Initial examination showed left upper extremity weakness and left facial weakness. Acute MRI brain obtained while the patient was symptomatic showed bilateral, right greater than left, cerebral white matter signal abnormality. Patient’s deficits had resolved by the following morning. Shortly after awakening, the patient experienced new deficits of right upper extremity weakness, dysarthria, and aphasia. Repeat MRI brain obtained while the patient was symptomatic showed a mild interval increase in the territory of restricted diffusion involving the bilateral frontoparietal deep white matter with associated subtle T2/FLAIR hyperintensity. Symptoms had resolved by the following morning. Routine EEG was without abnormality.Hematology/oncology recommended to administer dextromethorphan and leucovorin with his methotrexate sessions.

Conclusions Methotrexate neurotoxicity may present with transient stroke-like symptoms, seizures, or encephalopathy. Transient focal neurologic deficits are a rare but known side effect. However there are limited reports with recurrent, different stroke-like presentations within a short time period, as most patients receive subsequent methotrexate without recurrence. Further research is warranted as it pertains to long-term management and pathogenesis of methotrexate neurotoxicity, however use of dextromethorphan and leucovorin has helped ameliorate symptoms in select cases. While standard-of-care management for acute neurologic deficits must still need to be followed, consideration of alternate etiologies of focal neurologic deficits is necessary in individuals receiving methotrexate.

Authors/Disclosures
Tu Nguyen, MD PRESENTER	Dr. Nguyen has nothing to disclose.
Micah Etter, MD (University of Arizona Neurology)	Dr. Etter has nothing to disclose.
Anna Kafka, DO (University of Arizona)	Dr. Kafka has nothing to disclose.
Imaad Nasir, MD	Dr. Nasir has nothing to disclose.
Geoffrey Ahern, MD, PhD (Univ Ariz Hlth Sci Ctr)	Dr. Ahern has nothing to disclose.
Mohammad H. El-Ghanem, MD (Neuroendovascular Surgery - Northwest Medical Center)	Dr. El-Ghanem has nothing to disclose.

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