Cortical blindness during chemotherapy: clinical, CT, and MR correlations

Two patients treated by chemotherapy for a non-Hodgkin malignant lymphoma developed focal neurological symptoms including disorientation, hemoplegia, and cortical blindness 5 and 15 days after the end of a polychemotherapy course, including methotrexate and vindesine. In both patients ECG and blood pressure were normal. Case 1 had a slight increase of protein level without cells on CSF examination and presented with a paralytic ileus. Case 2 developed an inappropriate antidiuretic hormone secretion (IADHS) syndrome. In both cases, noncontrast CT scans showed bilateral, symmetrical low density areas within the temporooccipital regions. Postcontrast CT images stressed major cortical and subcortical enhancement predominantly over the gray matter. In Case 2 the lesions also affected the right parietal lobe. Magnetic resonance scans 2-3 weeks after the onset of neurological symptoms demonstrated low intensity signal lesions on T1-weighted images and bright signal on T2-weighted images. In Case 1 the visual deficit failed to regress and in Case 2 the patient died 2 months later because of the natural evolution of her lymphoma. The clinical and radiological data suggested that a vascular ischemic process was responsible for the cerebral lesions in these two patients. As Vinca alkaloids and not methotrexate have been implicated as a cause of cortical blindness, and as our two patients presented signs of overdose of vindesine (paralytic ileus and IADHS), we suggest that the neurological and radiological abnormalities in our patients may have been due to neurotoxicity of vindesine.