Abstract Details

Title Methotrexate Induced CNS Neurotoxicity: Is It Always Leukoencephalopathy?

Topic Neuro-oncology

Presentation(s) P16 - Poster Session 16 (8:00 AM-9:00 AM)

Poster/Presentation
Number 4-004

Objective We report an atypical presentation of methotrexate toxicity predominantly involving gray matter and mimicking an acute ischemic stroke.

Background Methotrexate (MTX) is a folic acid antagonist used for multiple oncological and inflammatory disorders. Methotrexate related neurotoxicity may affect the peripheral as well as central nervous system. Previous studies have reported methotrexate induced posterior reversible encephalopathy syndrome, leukoencephalopathy, and seizures.

Design/Methods N/A

Results A 75 year old man with hypertension and B-cell lymphoma on CHOP therapy presented to the hospital with complaints of confusion, headache, and drowsiness ongoing for 3 days and generalized weakness resulting in a fall. He had received one dose of intra-thecal methotrexate 8 days prior to presentation. MRI brain with contrast revealed bilateral diffusion restriction of the basal ganglia with subtle patchy enhancement and a left parietal white matter punctate region of diffusion restriction. Vessel imaging, including CT venogram and angiography did not reveal any significant vascular pathology. Serum homocysteine and methotrexate levels were normal. He was started on daily folate, aminophylline 5mg/kg q6hr, and intravenous leucovorin 5mg/m2 for seven days. During the hospital stay, his neurological exam showed a fluctuating course with eventual resolution of confusion and improvement in ambulation. Repeat MRI brain at 7 days showed partial resolution of the restriction diffusion on the right and stability of the lesion on the left basal ganglia. The patient was eventually discharged home.

Conclusions Methotrexate induced CNS neurotoxicity usually presents days after intra-thecal treatment and may mimic an acute ischemic stroke. Clinical features often include a subacute encephalopathy with a fluctuating course followed by frequent improvement of symptoms. While MTX neurotoxicity commonly affects the white matter, symmetrical involvement of the basal ganglia may also occur. Treatment of MTX toxicity remains unclear, but leucovorin rescue with aminophylline is typically well tolerated and may be considered.

Authors/Disclosures
PRESENTER	No disclosure on file
Muhammad Taqi, MD	No disclosure on file
Hisham Salahuddin, MD	Dr. Salahuddin has nothing to disclose.

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