Mesial temporal sclerosis as a complication of hematologic cancer

Abstract

Seizures may occur in patients with hematological malignancies usually associated with central nervous system (CNS) metastasis or treatment toxicity [1]. However, development of temporal epilepsy due to mesial temporal sclerosis (MTS) in patients with leukemia or lymphoma is extremely rare. Here we report two patients who developed MTS after treatment for hematologic cancer.Patient 1 A previously healthy 59-year-old man was admitted for treatment of newly diagnosed acute promyelocytic leukemia. Induction chemotherapy included transretinoic acid and idarubicin. Two weeks after admission he developed pneumonia, sepsis and acute renal failure. After stabilization, and under treatment for severe hypertension, he had a 5-min generalized tonic-clonic seizure. Magnetic resonance image (MRI) showed bilateral occipital abnormalities consistent with posterior reversible encephalopathy syndrome (PRES). Mild hyperintensity of the left hypocampus in T2-weighted FLAIR images was observed, with normal volume of both hippocampi (Fig. 1a, b). The patient was started on levetiracetam that was discontinued after two seizure-free weeks. After discharge, he received trans-retinoic acid, idarubicin and mitoxantrone. Two months later, the patient developed seizures consisting of a rising epigastric sensation followed by right hemicorporal tingling. Control MRI showed left hipocampal sclerosis (Fig. 1c, d). Levetiracetam was reintroduced and at 1-year follow-up seizure control was good.Patient 2 A 21-year-old woman was referred for evaluation of intractable partial epilepsy. She had been well until 13 years of age when she was diagnosed of nonHodgkin lymphoblastic lymphoma. Chemotherapy included vincristine, daunorubicin, prednisone, L-asparaginase, cyclophosfamide and intrathecal methotrexate, cytarabine and hydrocortisone. No immediate complications were recorded. One year later, shortly after finishing chemotherapy, she started with paroxysmal episodes consisting of epigastric rising sensation followed by a short period of disconnection. A brain MRI performed in other center was reported as normal. Treatment with carbamacepine was started, with acceptable seizure control until the age of 20, when she developed very frequent seizures unresponsive to several antiepileptic drugs, and was referred to our epilepsy unit. Comprehensive re-evaluation was performed, including a MRI that showed right MTS (Fig. 2). We reviewed the previous MRI that showed mild right hippocampus atrophy. Prolonged video-EEG monitoring showed a right temporal theta activity at seizure onset. Serum onconeural antibody analysis was negative. Surgical excision of the right anterior temporal pole, hippocampus and amygdala was performed. The pathological findings were consistent with MTS. Two years later the patient remains seizure free. DiscussionMTS often develops when an initial precipitant injury (IPI) produces a primary hipocampal lesion in a genetically predisposed patient [2]. Most frequent IPIs are

Temporal Lobe Epilepsy With Hippocampal Sclerosis in Acute Lymphoblastic Leukemia

“…5 Thus far, only 8 cases of children with MTLE-HS in hematologic cancers have been reported. [6][7][8][9][10] We experienced 2 such cases at our institute and believe that MTLE-HS is probably not as rare as generally deemed. This is the first report to our knowledge that describes the clinical course of patients who were longitudinally followed throughout the latent period until the manifestation of MTLE-HS by EEG and MRI.…”

“…[12][13][14] Recently, cases of very rare MTLE-HS associated with hematologic malignancies have been reported, [6][7][8][9][10] wherein seizures induced by chemotherapy or cranial irradiation were suspected as IPIs.…”

“…In this case, the IPI might have been the antileukemia chemotherapy itself, similar to a case reported by Goyal et al 6 The current literature describes only 10 patients, including the present cases, with MTLE-HS after treatment of hematologic cancer. [6][7][8][9][10] EEG during the latent period, which may have emerged from the subcortical thalamus induced by secondary bilateral synchrony. We believe that interictal EEGs in cases of mesial temporal lobe epilepsy are likely to show diffuse epileptic discharges in the latent period during infancy, becoming localized to anterior-temporal spikes with age.…”

Drug resistant epilepsy with mesial temporal sclerosis as possible late neurological complication in two AML survivors after stem cell transplantation

“…Table C.1 summarises the demographics, diagnosis, use of intrathecal chemotherapy and application of cranial irradiation in the patients. Table C.2 summarises the features of epilepsy including seizure types, use of anti-seizure medications and neurological outcomes [2] , [3] , [4] , [5] , [6] , [7] .…”

“…Drug resistant epilepsy with mesial temporal sclerosis (MTS) has previously been reported as a late complication of hematological malignancies, mainly acute lymphoblastic leukaemia (ALL) and lymphoma with or without stem cell transplantation (SCT) [1] , [2] . Most cases had no prior central nervous system inflammation or infection.…”