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Abstract Details

Underlying Infection is Probably Linked to an Increased Risk of Intrathecal Methotrexate Induced Leukoencephalopathy Mimicking Ischemic Stroke: A Case Series
Cerebrovascular Disease and Interventional Neurology
P10 - Poster Session 10 (5:30 PM-6:30 PM)
4-009
To explore potential risk factors in patients diagnosed with methotrexate induced leukoencephalopathy mimicking ischemic stroke.
Methotrexate (MTX) induced leukoencephalopathy mimicking ischemic stroke is a rare condition that occurs in less than 2% of patients with hematological malignancies on MTX (1). It manifests as an acute onset of hemiparesis, aphasia or hemisensory loss within 14 days of intrathecal (IT) MTX administration, and poses diagnostic challenge, as clinical syndrome, and imaging findings resemble an acute vascular process (2-5). Only polymorphisms in genes related to neurogenesis were identified as a potential contributor to MTX-related neurotoxicity (5). However, since MTX is a very commonly used drug, it is important to identify risk factors that predispose patients to adverse events including stroke-like symptoms.

We retrospectively reviewed records of four patients with acute lymphoblastic leukemia (ALL) on IT MTX, evaluated at our institutions for acute onset of stroke-like symptoms, and were diagnosed with IT MTX induced leukoencephalopathy mimicking ischemic stroke.

Study included three women and one man with the median age of 20 (range, 14-35) with ALL, presented with sudden onset of hemiparesis and paresthesia, prompting evaluation for acute stroke. Brain MRI revealed demarcated lesions with restricted diffusion in the subcortical white matter associated with apparent diffusion coefficient maps, which mimicked acute infarcts.  However, the treatment history [patients received IT MTX 2-14 days before the presentation] and careful image evaluation supported MTX leukoencephalopathy. Interestingly, all patients had an underlying infectious process at the time of the diagnosis: chronic sinusitis, Mycobacterium avium complex (MAC) infection, cellulitis, Aspergillosis pneumonia, and sepsis of unclear etiology.
Methotrexate induced leukoencephalopathy mimicking acute strokes is a very rare diagnosis with no clear identified risk factors. Our review highlights the possibility that underlying infectious process could predispose patients who received IT MTX to neurotoxicities. Further evaluation of available data is warranted.
Authors/Disclosures
Maya Hrachova, DO (Home)
PRESENTER 		Dr. Hrachova has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for SpringWorks Therapeutics.
David J. Adams, MD (CHOC Neurology) Dr. Adams has nothing to disclose.
Xiao-Tang Kong, MD, PhD (UC Irvine) Dr. Kong has nothing to disclose.