Case of the Week
Section Editors: Matylda Machnowska1 and Anvita Pauranik2
1University of Toronto, Toronto, Ontario, Canada
2BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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October 14, 2013
Methotrexate-Induced Neurotoxicity
- Oral, IV, or intrathecal (IT) methotrexate (MTX) is used widely to treat cancer. MTX can be associated with acute, subacute, and chronic neurotoxicities ranging from asymptomatic white matter changes to severe CNS demyelination.
- Subacute neurotoxicity usually develops 5–14 days after administering IT or high-dose IV-MTX, and manifests as headache, altered mental status, aphasia, weakness, hemiparesis, or seizures.
- Key Diagnostic Features: DWI has been useful to diagnose subacute neurotoxicity by detecting areas of cytotoxic and intramyelinic edema before such lesions become more conspicuous with conventional MRI sequences. Thus, DWI appears to be the most sensitive imaging modality at the onset of subacute MTX neurotoxicity.
- DDx: Ischemic stroke
- Rx: Most clinical symptoms and imaging abnormalities of MTX subacute neurotoxicity are transient. In our patient, imaging done 3 weeks later showed nearly complete resolution of lesion.
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