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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February 23, 2015
Acute Toxic Leukoencephalopathy
- Acute toxic leukoencephalopathy is a rare complication of chemotherapy, and has been described for various agents such as methotrexate, 5-FU, fludarabine, tacrolimus, and cyclosporine. The more common neuropathologic findings include gliosis, macrophage infiltrate, and demyelinization of white matter.
- Clinical Presentation: Change in mental status, seizures, nistagmus, and less frequently, focal neurological deficits
- Key Diagnostic Features Diffuse bilateral symmetrical areas of diffusion restriction in subcortical and deep white matter and corpus callosum. There is sparing of cortex and the U-fibers white matter as well as basal ganglia. Following discontinuation of therapy, reversal of findings may occur.
- DDx:
- PRESS: Signal abnormalities are more commonly posterior, in watershed areas and involve also the cortex and U fibers. ADC values are positive in DWI ("vasogenic" edema)
- Encephalitis: More commonly asymmetric with cortical involvement
- Radiation-induced leukoencephalopathy: Clinical history is the key as they have the same pathological findings and can be indistinguishable on imaging alone
- Drug abuse (toluene, ethanol, cocaine, methamphetamine, and heroin) and toxic agents (carbon monoxide, arsenic, and CCl)
- Rx: Discontinuation of treatment
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