Toxic and metabolic leukoencephalopathies in emergency department patients: a primer for the radiologist

One of the most common chief complaints in the emergency department (ED) is altered mental status (AMS). Imaging plays a critical role in triaging patients and identifying the etiology of AMS. Toxic and metabolic etiologies are one of the primary differential categories for AMS, leading to toxic leukoencephalopathies. Toxic leukoencephalopathies are white matter disorders that result from either exogenous or endogenous sources. Common exogeneous causes of toxic leukoencephalopathy include drugs of abuse (heroin and cocaine), alcohol, inhaled gases (carbon monoxide), industrial agents (pesticides, toluene, ethylene glycol), and neurotoxic medications (methotrexate, metronidazole, vigabatrine, etc.); endogenous causes include hyper- and hypoglycemia, hyperammonemia, hyponatremia, and uremia. The imaging findings of toxic leukoencephalopathies manifest through a combination of vasogenic and cytotoxic edema, resulting in white matter patterns. These white matter patterns have been found to be pathognomonic. In the ED setting, it is imperative to develop a diagnosis based off of the imaging due to the lack of history and context that is typically provided with a chief complaint of altered mental status (AMS). To offer expeditious and accurate diagnosis, we present the classic imaging features of toxic leukoencephalopathies and correlate these imaging findings with pathophysiology.