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Neurology Case Presentation. Rawan Albadareen, MD PGY-3 5/17/2013. Clinical presentation. A 58 YO female with pre-B cell acute lymphoblastic leukemia (Philadelphia chromosome positive) w CNS involvement. She was undergoing CTX high dose MTX- Ara -C .

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Neurology Case Presentation

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Neurology case presentation

Neurology Case Presentation

Rawan Albadareen, MD



Clinical presentation

Clinical presentation

  • A 58 YO female with pre-B cell acute lymphoblastic leukemia (Philadelphia chromosome positive) w CNS involvement.

  • She was undergoing CTX high dose MTX-Ara-C .

  • Three days after last IT MTX, she complained of dysarthria and Lt sided weakness that fluctuated over the course of the day, started at 3 am that morning and by the time of evaluation around 3 pm was almost back to base line.

  • Worth mentioning this had happened three times in the past and was associated with CTX. The first time this happened the episode was associated with confusion and picture of encephalopathy.

  • Pt as well has tremors and distal numbness along with dryness of mouth and eyes

Neurology case presentation

  • PMHx,

    • HTN

    • HLP

    • GERD

    • ALL

    • Hypothyroidism

  • PSHx,

    • Cholecystectomy

  • FHx

    • Non contributory

  • SHx,

    • Nonsmoker

    • Nonalcoholic

    • married

Physical exam

Physical exam

Mental status:alert, oriented to person/place/time

Neurology case presentation

  • Motor:

    5-/5 on the Lt side compared to 5/5 on the Rt (improved strength)

  • Sensory;

    Intact to LT, glove and stocking distribution to pin prick

  • Reflexes:

  • Coordination:

    normal FTN, HTS, rapid alternating (resolved ataxia)

Neurology case presentation

  • Where ?

  • What?

Diagnostic studies

Diagnostic studies..

  • CSF cytology: -ve for malignant cells,

    0 WBC/RBC, Normal Glucose/protein

  • Infectious w/u: negative cultures and titers.

  • MRI Brain 7/2/12 (at the time of initial diagnosis):

  • Essentially unremarkable

Mri brain 12 6 12 time of presentation

MRI Brain 12/6/12 (time of presentation)

  • Development of patchy and confluent areas of FLAIR hyperintinsity predominantly involving the deep bifrontal hemispheric white matter consistent with moderate nonspecific white matter disease.

    • Leading diagnostic consideration include ADEM, chemotherapy induced necrotizing leukoencephalopathy or viral encephalitis. PML is an additional less likely consideration

  • No acute or recent infarct.

  • Neurological complications of it mtx

    Neurological complications of IT MTX

    • IT MTX is commonly associated with aseptic meningitis

    • In addition, IT administration is rarely associated with:

      • posterior reversible leukoencephalopathy syndrome,

      • seizures

      • subacute focal neurologic deficits

      • lumbosacral polyradiculopathy

      • noncardiogenic pulmonary edema

      • pneumonitis and sudden death



    • Leukoencephalopathy is a delayed complication of IT MTX, usually occurring after six months of therapy and when the cumulative IT dose of MTX exceeds 140 mg

    • It is more likely in patients who receive concurrent whole brain radiotherapy or have previously received chemotherapy with intravenous MTX

    Transient leukoencephalopathy after it mtx mimicking stroke

    Transient leukoencephalopathy after it mtx mimicking stroke.

    • Acute neurotoxicity with confusion, disorientation, seizures, and focal deficits may also be seen.

    • This can clinically mimic stroke with restricted diffusion on MRI.

    • However, unlike stroke, there is resolution of clinical and imaging findings within 1-4 weeks.

    • Lesions exceeded the confines of adjacent vascular territories

    • DWI findings seem to reflect cytotoxic edema within cerebral white matter suggesting a reversible metabolic derangement, rather than ischemia, as the basis for this syndrome.

    Dwi changes adc matching

    DWI changes.. ADC matching..

    Stroke or not a Stroke…

    That is the question??

    Hyperperfusion on mri in acute chemotherapy related leukoencephalopathy

    Hyperperfusion on MRI in acute chemotherapy-related leukoencephalopathy

    • Magnetic resonance perfusion revealed mildly increased perfusion, a finding inconsistent with ischemic stroke.

    • Magnetic resonance perfusion imaging proved valuable to rapidly distinguish acute chemotherapy-related leukoencephalopathy from ischemia.

      • El-HakamLM, Ramocki MB, RivielloJJ,Illner A.

        Baylor College of Medicine

    Is it preventable

    Is it preventable?

    • Prevention of neurotoxicity by high-dose folinic acid rescue after high-dose methotrexate and intrathecal methotrexate without compromising cure in spite of previous transient leukoencephalopathy after intrathecal methotrexate.

      • HamidahA, Raja Lope RJ, Abdul Latiff Z, Anuar ZM, Jamal R.

        • Ann Acad Med Singapore. 2009 Aug;38(8):743-4.

    Cytarabine ara c

    Cytarabine (Ara-c)

    • High doses of Ara-C can cause an acute cerebellar syndrome in 10 to 25% of patients

    • The pathogenesis of this syndrome is unknown, but there is widespread loss of Purkinje cells in the cerebellum.

    • Symptoms range in severity from mild ataxia to an inability to sit or walk unassisted. Rarely, seizures develop.

    • Less frequent complications

      • peripheral neuropathies,

      • brachial plexopathy,

      • encephalopathy,

      • lateral rectus palsy,

      • optic neuropathy

      • extrapyramidal syndrome

    Thank you

    Thank You!!

    Mechanism of action

    Mechanism of action

    • Interference with folate metabolism

    • Several key enzymes of these synthetic pathways are targets of MTX:

      • Dihydrofolatereductase (DHFR)

      • Thymidylatesynthetase (TS) uses a methyl group from the reduced folate (dUMP) to (dTMP).

    • MTX is considered an S-phase specific cytotoxic drug.

    • The level of DHFR in any given cell is in great excess of what is needed to provide normal levels of reduced folates

    • 95% DHFR needs to be blocked, reason behind the need for HDMTX

    Importance of polyglutamation

    Importance of polyglutamation

    • Increases the intracellular pool of folates, (not easily transported out of the cell because of their size and charge -continual cellular uptake of folates)

    • The accumulation of PGMTX metabolites serves to further amplify and prolong the antiproliferative effects of MTX:

      • Intracellular accumulation and decreased efflux of PGMTX enhances and prolongs inhibition of DHFR, since PGMTX is less readily dissociable from the enzyme than is free MTX

      • Polyglutamated forms of MTX also bind to other enzymes involved in DNA synthesis such as TS, AICARFT, and GARFT; this further depletes intracellular thymidine and inhibits purine synthesis

    Rationale for leucovorin rescue

    Rationale for leucovorin rescue

    • MTX has little selectivity for tumor cells, and its effectiveness is limited by toxicity to normal tissue.

    • Reduced folate to bypass the metabolic block induced by MTX within 24 to 36 hours.

    • Folatetransport is deficient in the malignant cells.

    • In contrast to tumor cells, comparatively little PGMTX synthesis occurs in normal gut epithelium and bone marrow precursors under similar conditions

    Resistance to mtx

    Resistance to MTX

    • Innate resistance (AML ;no polyglutamination)

    • Acquired resistance:

      • Decreased drug transport due to gene mutations or a change in the rate of transcription of the folate carrier

      • Increased DHFR activity, typically due to gene amplification

      • Mutations in the DHFR protein, which decrease its affinity for MTX

      • Decreased cellular polyglutamation of MTX due to increased folylpolyglutamate hydrolase activity or decreased FPGS activity

      • Decreased TS activity or affinity for the folate antagonists

    • MTX is not typically used as a single agent for treatment of aggressive malignancy with some exceptions (primary CNS lymphoma, head and neck cancer, and malignant GTD).

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