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MRI in methotrexate-related leukoencephalopathy: Disseminated necrotising leukoencephalopathy in comparison with mild
1Department of Radiology, Hokkaido Graduate University School of Medicine, 060-8638, Sapporo, Japan. okamasak@luke.or.jp
Abstract:
We report two fatal cases of methotrexate (MTX)-induced disseminated necrotising leukoencephalopathy (DNL) in which MRI was repeated from the onset. Initial T2-weighted images showed multiple areas of high signal, mainly in deep cerebral white matter, which on follow-up, spread and coalesced to involve the entire white matter. Small irregular low-signal foci on T2-weighted images were seen within the high-signal lesions. Multiple areas of contrast enhancement corresponded to these low-signal foci. The condition of both patients deteriorated and they died. We compared their MRI findings with those of seven patients with mild MTX-related leukoencephalopathy, six of whom were asymptomatic; one had transient neurological symptoms. They showed no contrast enhancement, but rather mild-to-moderate diffuse high signal in deep white matter, which later disappeared. These findings suggest that multiple low-signal foci on T2-weighted images with contrast enhancement may be characteristic of DNL, and that contrast-enhanced imaging is useful to differentiate this condition from mild leukoencephalopathy.
Insights
Methotrexate (MTX) induced disseminated necrotising leukoencephalopathy (DNL) shows characteristic MRI findings, including contrast enhancement. This helps differentiate severe DNL from milder MTX-related leukoencephalopathy.
Area of Science:
- Neurology
- Radiology
- Oncology
Background:
- Methotrexate (MTX) is a chemotherapy agent with known neurotoxicity.
- Leukoencephalopathy is a potential adverse effect of MTX treatment.
- Disseminated necrotising leukoencephalopathy (DNL) represents a severe form of MTX neurotoxicity.
Purpose of the Study:
- To characterize the MRI findings in fatal cases of MTX-induced DNL.
- To differentiate DNL from mild MTX-related leukoencephalopathy using MRI.
- To evaluate the utility of contrast-enhanced MRI in diagnosing DNL.
Main Methods:
- Retrospective analysis of serial MRI scans in two fatal DNL cases.
- Comparison of MRI findings with seven patients with mild MTX leukoencephalopathy.
- Detailed evaluation of T2-weighted and contrast-enhanced imaging features.
Main Results:
- Fatal DNL cases showed progressive, coalescing white matter lesions with T2 hypointense foci and contrast enhancement.
- Mild MTX leukoencephalopathy cases exhibited diffuse T2 hyperintensity without contrast enhancement.
- Contrast enhancement correlated with lesion severity and poor prognosis in DNL.
Conclusions:
- Multiple T2 hypointense foci with contrast enhancement are characteristic of MTX-induced DNL.
- Contrast-enhanced MRI is crucial for distinguishing DNL from milder MTX leukoencephalopathy.
- Early identification of DNL through characteristic MRI findings may aid in management decisions.