Toxic leukoencephalopathy - methotrexate

Case contributed by A.Prof Frank Gaillard


Systemic malignancy

Patient Data

Age: Adult

Widespread involvement of the deep white matter (high T2 signal) without contrast enhancement or restricted diffusion. Note how the subcortical U-fibers are spared (best seen on FLAIR). 

Annotated image

Panda sign

Diffuse involvement of the white matter around the red-nuclei makes the red nuclei stand out mimicking a panda's face.  Superiorly, the subcortical U-fibers are spared (blue arrows).

Case Discussion

This patient received both intrathecal methotrexate and whole body (including cranial) irradiation. They then presented with gradual decrease in cognitive function.

Findings are thought to be consistent with a toxic leukoencephalopathy.

Intravenous methotrexate is associated with TL in 10% whereas it is seen in up to 40% of those who are treated by the intrathecal route.

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Case information

rID: 4438
Published: 25th Aug 2008
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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