Neoplastic meningitis

Background

• Also known as Leptomeningeal Carcinomatosis or leptomeningeal metastasis (LM)
• Uncommon and late complication of solid tumors and hematological cancers, approximately 5-8% and 5-15% respectively
• Most common primary tumors associated with LM are breast, lung, and melanoma
• Commonly misdiagnosed due to symptoms mimicking infectious meningitis and chronic headache

Pathophysiology

• Multiple routes tumor cells can gain access to CSF
• Most commonly thought to be through hematogenous spread via arachnoid vessels or direct extension from brain parenchyma

Clinical Features

• Chronic headache
• Nausea and vomiting
• Fever
• Nuchal rigidity
• Altered mental status
• Seizure
• Spinal cord compression (non-traumatic)
  • Limb weakness
  • Dermatomal sensory loss
  • Radicular pain
  • Bladder and bowel dysfunction
• Cranial nerve abnormalities
  • Diplopia
  • Facial weakness
  • Hearing loss
  • Ataxia

Differential Diagnosis

Headache

Common

• Migraine headache
• Tension headache
• Cluster headache

Killers

• Meningitis/encephalitis
  • Neoplastic meningitis
• Myocardial ischemia
• Retropharyngeal abscess
• Intracranial Hemorrhage (ICH)
  • SAH / sentinel bleed
• Acute obstructive hydrocephalus
• Space occupying lesions
• CVA
• Carbon monoxide poisoning
• Basilar artery dissection
• Preeclampsia
• Cerebral venous thrombosis
• Hypertensive emergency
• Depression

Maimers

• Giant cell arteritis of temporal artery (temporal arteritis)
• Idiopathic intracranial hypertension (Pseudotumor Cerebri)
• Acute Glaucoma
• Acute sinusitis
• Cavernous sinus thrombosis or cerebral sinus thrombosis
• Carotid artery dissection

Others

• Mild traumatic brain injury
• Trigeminal neuralgia
• TMJ pain
• Post-lumbar puncture headache
• Dehydration
• Analgesia abuse
• Various ocular and dental problems
• Herpes zoster ophthalmicus
• Herpes zoster oticus
• Cryptococcosis
• Febrile headache (e.g. pyelonephritis, nonspecific viral infection)
• Ophthalmoplegic migraine
• Superior Vena Cava Syndrome

Aseptic Meningitis

• Viral
  • Varicella
  • Herpes
  • Enterovirus
  • West Nile
• Tuberculosis
• Lyme disease
• Syphilis
• Leptospirosis
• Fungal (AIDS, transplant, chemotherapy, chronic steroid use)
• Noninfectious
  • Sarcoidosis
  • Vasculitis
  • Connective tissue disease
  • Drug induced aseptic meningitis

Evaluation

Meningeal carcinomatosis on contrast-enhanced axial T1-weighted MRI.

Workup

• CT brain is not sensitive or specific, may show intracranial mass
• MRI brain and spine with contrast preferred (70% sensitivity, 77-100% specificity)
  • Leptomeningeal enhancement
  • Hydrocephalus
  • Subependymal nodules or deposits
• Lumbar Puncture-mainly to rule out infectious etiology in ED
  • Elevated opening pressure
  • Glucose, protein, cell count and cytology can be abnormal
  • Malignant cells on CSF smear

Diagnosis

• Leptomeningeal enhancement or lesions on MRI
• Malignant cells on CSF smear

Management

• Control seizures
  • Benzodiazepines
  • Antiepileptics
  • Intubation if status epilepticus
• Pain management if headache, radicular pain
• Steroids may be indicated depending on severity of symptoms

Disposition

• Admit

References

• Shin Ahn, Kyung Soo Lim, "Three Cases of Neoplastic Meningitis Initially Diagnosed with Infectious Meningitis in Emergency Department", Case Reports in Emergency Medicine, vol. 2013, Article ID 561475, 4 pages, 2013.
• Batool A, Kasi A. Leptomeningeal Carcinomatosis. [Updated 2020 Apr 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499862/
• Cooney DR, Cooney NL. Meningeal carcinomatosis diagnosed during stroke evaluation in the emergency department. Int J Emerg Med. 2011;4:52. Published 2011 Aug 9. doi:10.1186/1865-1380-4-52