Presentation
Found unconscious. High anion gap metabolic acidosis. Past history of substance abuse.
Patient Data
Bilateral symmetrical hypodensities in caudate and putamen, extending to the subcortical white matter in insular regions bilaterally. At the level of basal ganglia, multiple foci of hyperdensities can be noted, indicating small acute hemorrhages - the largest one is located in the left lentiform area.
Pronounced bilateral, symmetrical high T2/FLAIR signal in caudate nucleus and putamen, along with nearby subcortical white matter of insular regions, external and extreme capsules. Additionally, high signal in FLAIR and DWI sequences are demonstrate within the subcortical white matter and overlying cortex diffusely in parts of the frontal, parietal, and temporal lobes, occipital lobes bilaterally. SWI reveals small hemorrhages within the left putamen, as well as focal hematomas in the anteromedial aspect of the left temporal lobe and frontobasal area.
Case Discussion
Methanol is a highly toxic substance, and a component of many household, industrial, and recreational use. Methanol toxicity is achieved by it's metabolism and eventual accumulation of formic acid. Neurological disability and prognosis of sequelae is often poor, and usually correlates with extent of structural brain involvement.
In this case, extensive signal abnormalities can be appreciated, consistent with reported widespread injury secondary to methanol intoxication, in the typical historical and clinical manifestations. This case presented emphasizes early radiographic changes indicating necrotic hemorrhagic complications of methanol ingestion.
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