Article

Clinical and radiological characteristics of methotrexate-induced acute encephalopathy in pediatric patients with cancer.

Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA.
Annals of Oncology (impact factor: 6.43). 02/2008; 19(1):178-84. DOI:10.1093/annonc/mdm466 pp.178-84
Source: PubMed

ABSTRACT Little information is available about the diagnosis and management of acute methotrexate (MTX)-induced encephalopathy.
We reviewed clinical and magnetic resonance imaging (MRI) [including diffusion-weighted imaging (DWI)] characteristics of this complication in pediatric cancer patients treated from 2000 to 2006.
Six of 754 (0.8%) patients with leukemia or lymphoma and 2 of 44 (4.5%) with bone sarcoma experienced acute encephalopathy within 2 weeks (median, 7.5 days) after receiving high-dose i.v. and/or intrathecal MTX. The signs and symptoms varied at presentation and during episodes: hemiparesis (eight patients, alternating from side to side in four), dysphasia (six), confusion/emotionality (six), headache (three), choreoathetosis (two), and seizure (two). All patients recovered after 1-7 days (median, 5.5 days). DWI revealed restricted diffusion in anatomic brain regions associated with the symptoms; changes on T2-weighted and fluid-attenuated inversion recovery (FLAIR) imaging were consistently less marked. After recovery, DWI findings were normal but T2 and/or FLAIR imaging usually showed residual abnormalities.
Acute MTX toxicity often manifests as fluctuating neurologic symptoms with alternating hemispheric involvement. Restricted diffusion on DWI is a reliable early sign of acute MTX encephalopathy and resolves as clinical status improves, despite the persistence of subtle abnormalities on MRI.

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Keywords

acute encephalopathy
 
acute methotrexate
 
acute MTX encephalopathy
 
alternating hemispheric involvement
 
anatomic brain regions
 
choreoathetosis
 
clinical status
 
DWI findings
 
DWI)] characteristics
 
FLAIR
 
FLAIR imaging
 
fluctuating neurologic symptoms
 
fluid-attenuated inversion recovery
 
hemiparesis
 
high-dose i.v
 
magnetic resonance imaging
 
pediatric cancer patients
 
residual abnormalities
 
subtle abnormalities
 
symptoms varied
 

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