Intracarotid BCNU leukoencephalopathy

Intracarotid 1,3‐bis(2‐chloroethyl)‐1‐nitrosurea (BCNU) is now a frequently used chemotherapeutic agent for high‐grade glial neoplasms. The toxicity from such therapy has not been well‐documented. A 50‐year‐old man with a left frontoparietal grade 4 astrocytoma received three injections of intracarotid BCNU400 mg eachover a 2‐month period. No radiation or other chemotherapy was ever given. He tolerated the BCNU injections wellwith some reduction of tumor bulkuntil the third dose. After his last injectionhis condition gradually deteriorated; he became obtundedand died 5 weeks later. At autopsythe brain showed extensive cavitation and coagulative necrosisfibrinoid vascular necrosisedemaswollen axonsand bizarre cellular morphologic features confined to the BCNU perfusion territory. Grade 4 astrocytoma remained in the right hemisphere and in the left occipital lobesites outside the area of BCNU perfusion. Intracarotid BCNU can result in a severe leukoencephalopathy similar to that seen with methotrexate or delayed radionecrosis.