SHM Converge Scientific Abstract ePoster Gallery-Morbid Complications: Intrathecal Methotrexate-Induced Bilateral Subdural Hygromas With Transtentorial Herniation

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This poster describes a rare, severe complication of intrathecal methotrexate (IT MTX) in a 64-year-old man with Burkitt’s lymphoma and CNS involvement. After diagnosis, he received DA-R-EPOCH chemotherapy and planned biweekly IT MTX. Over the hospital course, he also experienced major complications including diffuse alveolar hemorrhage, invasive pulmonary aspergillosis, and stroke.<br /><br />After multiple lumbar punctures for IT MTX, he developed diplopia, sensory changes, and later severe headaches. Brain MRI initially showed trace bilateral subdural collections, consistent with early subdural hygromas. By hospital day 42, he became obtunded with a fixed gaze, and repeat MRI demonstrated markedly enlarged bilateral subdural hygromas with descending midline herniation and brainstem compression. Clinicians suspected intracranial hypotension caused by cerebrospinal fluid leakage from repeated lumbar punctures, worsened by the subdural hygromas.<br /><br />Neurosurgery and neurology were consulted. No surgical intervention was recommended, and an epidural blood patch was considered to address the suspected CSF leak, but interventional neuroradiology felt the benefit was unclear. The patient later developed acute hypoxic respiratory failure, and his family chose comfort care because no intervention was likely to improve his quality of life. He subsequently died on comfort care.<br /><br />The poster emphasizes that subdural hygromas are a rare complication of intrathecal chemotherapy, occurring in about 1–2% of patients. It also highlights the potentially life-threatening risk of transtentorial herniation when recurrent lumbar punctures lead to CSF leak and intracranial hypotension. Early recognition of subdural hygroma and consideration of epidural blood patch may help prevent catastrophic neurologic decline.

Asset Subtitle

Shervin Zoghi

Meta Tag

Author List Nina Modanlo, Shervin Zoghi, Su Htet Htet Naing, Theresa Duong, Yaseen M. Hakim

Category Clinical Vignettes

Concept Subdural Hygroma

Concept Spontaneous Intracranial Hypotension

Concept Brain Herniation

Concept Brainstem Compression

Concept Spinal CSF Leak

Distinguished Non-Finalist

Presenter Organization University of California, Davis School of Medicine

Presenting Author Shervin Zoghi

Track Adult

Keywords

intrathecal methotrexate

subdural hygroma

intracranial hypotension

lumbar puncture

cerebrospinal fluid leak

transtentorial herniation

Burkitt lymphoma

brainstem compression

epidural blood patch

central nervous system involvement

Subdural Hygroma

Spontaneous Intracranial Hypotension

Brain Herniation

Brainstem Compression

Spinal CSF Leak