Childs Nervous System

, Volume 6, Issue 4, pp 231–235 | Cite as

Transient focal leukoencephalopathy following intraventricular methotrexate and cytarabine

A complication of the Ommaya reservoir: case report and review of the literature
  • V. Colamaria
  • R. Caraballo
  • C. Borgna-Pignatti
  • P. Marradi
  • R. Balter
  • C. Mazza
  • C. Procacci
  • B. Dalla Bernardina


A 14-year-old boy, suffering from acute lymphoblastic leukemia with meningeal involvement, was treated with intraventricular methotrexate and cytosine arabinoside, administered via an Ommaya reservoir (OR). Three months later, right occipital headache, vomiting, and lethargy appeared. Cerebrospinal fluid specimens showed increased proteins and a right frontal slow-wave focus was evident on the EEG recording. The computed tomography scan revealed white matter hypodensity within the right frontal and rolandic regions. After injection of medium contrast, an abscesslike hyperdensity appeared, surrounding both a well-placed cannula tip and the right frontal horn of the lateral ventricle. Brain swelling and shift signs were also evident. Nine cases of focal methotrexate leukoencephalopathy have been previously reported, and in six of these there was a misplaced OR cannula tip. The focal meihotrexate leukoencephalopathy seems to be related to the neurotoxicity of the drugs administered, and may also exist with a well-placed OR cannula tip. Immediate removal of the catheter may be associated with a benign evolution.

Key words

Methotrexate leukoencephalopathy Ommaya reservoir Computed tomography Magnetic resonance imaging Meningeal leukemia 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Bjorgen JE, Gold LHA (1977) Computed tomographic appearance of methotrexate-induced necrotizing leukoencephalopathy. Radiology 122:377–378PubMedGoogle Scholar
  2. 2.
    Bleyer WA (1988) Central nervous system leukemia. Pediatr Clin North Am 35:789–814PubMedGoogle Scholar
  3. 3.
    Bleyer WA, Griffin TW (1980) White matter necrosis; mineralizing microangiopathy, and intellectual abilities in survivors of childhood leukemia: associations with central nervous system irradiation and methotrexate therapy. In: Gilbert HA, Kagan AR (eds) Radiation damage to the nervous system. Raven Press, New York, pp 155–174Google Scholar
  4. 4.
    Bleyer WA, Pizzo PA, Spence AM, Platt WD, Benjamin DR, Kolins J, Poplack DG (1978) The Ommaya reservoir. Newly recognized complications and recommendations for insertion and use. Cancer 41:2431–2437CrossRefPubMedGoogle Scholar
  5. 5.
    Callaghan JT, Ausman JI, Clubb R (1981) CSF perfusion to treat intraventricular penicillin toxicity. Arch Neurol 38: 390–391PubMedGoogle Scholar
  6. 6.
    Diamond RD, Bennett JE (1973) A subcutaneous reservoir for intrathecal therapy of fungal meningitis. N Engl J Med 288:186–188CrossRefPubMedGoogle Scholar
  7. 7.
    Duffner PK, Cohen ME, Brecher ML, Berger P, Parthasarathy KL, Bakshi S, Ettinger LJ, Freeman A (1984) CT abnormalities and altered methotrexate clearance in children with CNS leukemia. Neurology (Cleveland) 34:229–233Google Scholar
  8. 8.
    Kay HEM, Knapton PJ, O'Sullivan JP, Wells DG, Harris RF, Innes EM, Stuart J, Schwartz FCM, Thompson EN (1972) Encephalopathy in acute leukaemia associated with methotrexate therapy. Arch Dis Child 47:344–354CrossRefPubMedGoogle Scholar
  9. 9.
    Obbens EAMT, Leavens ME, Beal JW, Lee YY (1985) Ommaya reservoirs in 387 cancer patients: a 15-year experience. Neurology 35:1274–1278PubMedGoogle Scholar
  10. 10.
    Ommaya AK, Oxon MA, Punjab MB (1963) Subcutaneous reservoir and pump for sterile access to ventricular cerebrospinal fluid. Lancet 11:983–984CrossRefGoogle Scholar
  11. 11.
    Packer RJ, Zimmerman RA, Rosenstock J, Rorke LB, Norris DG, Berman PH (1981) Focal encephalopathy following methotrexate therapy administration via a misplaced intraventricular catheter. Arch Neurol 38:450–452PubMedGoogle Scholar
  12. 12.
    Peylan-Ramu N, Poplack DG, Blei CL, Herdt JR, Vermess M, Di Chiro G (1977) Computer assisted tomography in methotrexate encephal opathy. J Comput Assist Tomogr 1:216–221CrossRefPubMedGoogle Scholar
  13. 13.
    Poskitt KJ, Steinbok P, Flodmark O (1988) Methotrexate leukoencephalopathy mimicking cerebral abscess on CT brain scan. Child's Nerv Syst 4:119–121Google Scholar
  14. 14.
    Price RA, Jamieson PA (1975) The central nervous system in childhood leukemia. 11. Subacute leukoencephalopathy. Cancer 35:306–318CrossRefPubMedGoogle Scholar
  15. 15.
    Rubin RC, Ommaya AK, Henderson ES, Bering EA, Rall DP (1966) Cerebrospinal fluid perfusion for central nervous system neoplasm. Neurology (Minneap) 16:680–692Google Scholar
  16. 16.
    Rubinstein LJ, Herman MM, Long TF, Wilbur JR (1975) Disseminated necrotizing leukoencephalopathy: a complication of treated central nervous system leukemia and lymphoma. Cancer 35:291–305CrossRefPubMedGoogle Scholar
  17. 17.
    Shapiro WR, Chernik NL, Posner JB (1973) Necrotizing encephalopathy following intraventricular instillation of methotrexate. Arch Neurol 28:96–102PubMedGoogle Scholar
  18. 18.
    Spiers ASD, Booth AE (1973) Reservoirs for intraventricular chemotherapy. Lancet 1:1263CrossRefPubMedGoogle Scholar
  19. 19.
    Wendling LR, Bleyer WA, DiChiro G, McIlvanie SK (1978) Transient, severe periventricular hypodensity after leukemic prophylaxis with cranial irradiation and intrathecal methotrexate. J Comput Assist Tomogr 2:502–505CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 1990

Authors and Affiliations

  • V. Colamaria
    • 1
  • R. Caraballo
    • 2
  • C. Borgna-Pignatti
    • 1
  • P. Marradi
    • 1
  • R. Balter
    • 1
  • C. Mazza
    • 4
  • C. Procacci
    • 3
  • B. Dalla Bernardina
    • 2
  1. 1.Department of PediatricsVerona UniversityPoliclinico di Borgo Roma
  2. 2.Child Neuropsychiatry Verona UniversityPoliclinico di Borgo Roma
  3. 3.Institute of RadiologyVerona UniversityPoliclinico di Borgo Roma
  4. 4.Department of NeurosurgeryOspedale di Borgo TrentoVeronaItaly

Personalised recommendations