We report a case of methotrexate (MTX)-induced stroke-like encephalopathy in an 18-year-old woman, with acute lymphoblastic leukemia, who developed a sudden neurological deficit mimicking a cerebrovascular event. Bain MRI showed hyperintensities on diffusion-weighted-imaging (DWI) with matching apparent diffusion coefficient hypointensities, which also represent the commonest MRI findings in acute cerebral infarction. DWI changes spared the cerebral cortex and did not respect vascular territories, supporting a non-vascular mechanism. MRI plays a crucial role in the diagnostic workup and is essential to avoid unnecessary intervention such as thrombolytic therapy.Teaching Point: Methotrexate-induced stroke like neurotoxicity should be considered in patients treated with methotrexate and presenting with a stroke-like clinical picture and radiological findings consistent with acute cerebral infarction.

Copper deficiency is an acquired condition that can lead to neurologic dysfunctions, such as myelopathy, motor neuron impairment, polyneuropathy, cognitive impairment, and optic nerve neuropathy. Associated biological findings are low serum copper and ceruloplasmin levels with low copper urinary excretion. We report the case of a previously healthy 59-year-old man who presented a complex neurological picture starting with symptoms and radiological signs consistent with degenerative myelopathy in the presence of persisting low serum copper and ceruloplasmin despite oral and intravenous copper supplementation. Over time, his symptoms evolved into a motor neuron disease evocating an amyotrophic lateral sclerosis (ALS) phenotype. The potential role of copper deficiency is discussed, together with the difficulties in biomonitoring copper supplementation.

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