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
Differential Diagnosis
Killers
- Meningitis/encephalitis
- 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
- 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
- Tuberculosis
- Lyme disease
- Syphilis
- Leptospirosis
- Fungal (AIDS, transplant, chemotherapy, chronic steroid use)
- Noninfectious
Evaluation
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
See Also
External Links
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
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