Varialibility of Neurological Complications in the Treatment of Acute Lymphoblastic Leukemia:Experience of a Single Pediatric Institution

Intensive chemotherapy significantly improves the outcome of pediatric acute lymphoblastic leukemia (ALL) but unfortunately increases the incidence and severity of acute adverse events. The current study analyses the incidence of central nervous system (CNS) complications during ALL treatment in a single pediatric institution. CNS leukemic infiltration at diagnosis, therapy-related peripheral neuropathy and leukoencephalopathy and neurocognitive defects after treatment were excluded by the study. From September 2000 to July 2008, two hundred and forty ALL patients (pts) were treated in our Institution according to BFM-AIEOP ALL 2000 protocol. Twenty-four out of 240 patients (10 %) (15 females and 9 males, median age at the event 7.7 years, range 2–16 years) developed CNS complications during treatment. Thirteen presented tonic-clonic seizures, four showed dyskinesia and dyslalia, one presented visual impairment and enuresis, and six had loss of consciousness. In 18 pts a rapid resolution of the event was obtained by administration of benzodiazepines or barbiturates; 6 pts required admission in intensive care unit, instead. Only two out of twenty-four patients presented neurological sequelae (one pts with recurrent seizures and one pts with right limb disability). Co-morbidity at the time of neurological accident included: blood pressure increase (6 pts), electrolytes imbalance (4 pts), LDH increase (4 pts), coagulation disorders (6 pts), hepatic enzyme increase (2 pts), severe anemia (1 pts), severe thrombocytopenia (4 pts), renal failure (1 pts), and Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) (1 pts). Radiological scanning (either CT or MRI) and electroencephalography (EEG) performed within 48 hr from the onset of the clinical symptoms revealed different etiologies: 8 posterior reversible leukoencephalopathies (PRES), 3 cerebral bleedings, 2 ischemic cerebral diseases, 2 methotrexate toxicity, 1 SIADH, 2 temporal lobe epilepsy and 6 unidentified problems. In conclusion this retrospective study on CNS complications during ALL treatment shows that the most frequent neurological accident (33%) is the PRES.