Abstract Details

Title A rare mechanism of Acute Ischemic Stroke following Intrathecal Methotrexate

Topic Neuro Trauma and Critical Care

Presentation(s) P8 - Poster Session 8 (11:45 AM-12:45 PM)

Poster/Presentation
Number 1-001

Objective NA

Background Cerebral edema is a rare and poorly understood complication of Intrathecal (IT) Methotrexate ( MTX ) that can lead to neurological complications including seizures, coma, and death. Mass effect from edema can cause compression of intracranial vasculature, leading to ischemic strokes.

Design/Methods

Case presentation

We report a case of a 28-year-old with nodular sclerosing Hodgkin's lymphoma on chemotherapy with ABVD and IT Methotrexate, who presented with intractable severe headaches. His mental status rapidly declined after being initially alert and oriented in the emergency department. He had a witnessed episode of seizure and became unresponsive. CT head disclosed large bilateral subdural collections and diffuse cerebral edema. The patient was intubated and managed with hyperosmolar therapy and steroids. An EVD was placed for intracranial pressure (ICP) monitoring. MRI (Magnetic Resonance Imaging) of the brain revealed DWI (Diffusion-Weighted Imaging) infarctions in the right basal ganglia, pons, bilateral thalami, and bilateral occipital lobe. MRI spine showed no evidence of paraspinal fluid collection. The patient’s exam improved after aggressive hyperosmolar therapy and he was extubated and was discharged to a long-term facility.

Results NA

Conclusions Fulminant cerebral edema is a rare and morbid complication of IT chemotherapy. In this patient, the proposed mechanism of cerebral edema was likely due to either MTX itself or large subdural hygromas or both. The proposed mechanism of MTX toxicity in literature is tumor lysis causing cerebral edema. The mechanism of subdural hygroma is presumed to be secondary to transdural CSF leak, causing intracranial hypotension and sagging of brain structures. Large subdural hygromas can exert significant mass effect, causing local compression of intracranial vessels. Our case emphasizes a neurological manifestation that may occur following IT chemotherapy. Intractable headache following IT therapy is a warning sign to evaluate patients for such neurological complications for rapid diagnosis and aggressive treatment to prevent mortality.

Authors/Disclosures
Navreet Kaur, MBBS (Ascension Saint Agnes Neurology) PRESENTER	Dr. Kaur has nothing to disclose.
Christina Xia, MD	Dr. Xia has nothing to disclose.
Karan Philip, MBBS	Dr. Philip has nothing to disclose.
Hesham Masoud, MD (Department of Neurology)	Dr. Masoud has nothing to disclose.
Fadar O. Otite, MD (SUNY Upstate Medical University)	Dr. Otite has nothing to disclose.

��ɫ��

��ɫ��