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Radiology of Infectious Diseases and Their Potential Mimics in the Critical Care Unit
Published in Cheston B. Cunha, Burke A. Cunha, Infectious Diseases and Antimicrobial Stewardship in Critical Care Medicine, 2020
Jocelyn A. Luongo, Boris Shapiro, Orlando A. Ortiz, Douglas S. Katz
Carcinomatous meningitis occurs from both secondary and primary brain tumors. The most common distant primary tumors include breast and lung cancer. Glioblastoma multiforme, pineal tumors, and choroid plexus tumors can also extend along the leptomeninges. The enhancement pattern of carcinomatous meningitis is often thicker and irregular compared with the one that is seen with infectious meningitis, although thin and linear enhancement can also occur. In such patients, clinical information, including the presence of a primary malignancy, and CSF analysis may be needed to definitively differentiate between the two entities [62,64].
CNS tumours
Published in Peter Hoskin, Peter Ostler, Clinical Oncology, 2020
Tumour spread to the CNS can manifest as diffuse involvement of the meninges around the brain (Figure 12.14) and/or spinal cord. This is particularly seen in haematological malignancies (e.g. non-Hodgkin lymphoma), breast cancer, lung cancer and melanoma. It can present with non-specific symptoms such as headache, vomiting, meningism, lethargy, confusion or more focal neurological deficit, typically cranial nerve palsies. Such patients might have disease that extends along the optic nerves to involve the optic disc (Figure 12.15) or peripheral retina (Figure 12.16). Its onset and presentation is insidious, and it is easy to mistake some of the symptoms for other conditions, e.g. opiate toxicity. Diagnosis can be made from typical appearances on a contrast-enhanced MRI, although lumbar puncture is often necessary to obtain CSF for cytology and confirm the diagnosis. The diagnosis can sometimes remain elusive with negative imaging and CSF cytology, in which case further cytological sampling of CSF is indicated. Treatment options include intrathecal instillation of chemotherapy agents, such as methotrexate, at twice weekly intervals via lumbar puncture or an Ommaya intraventricular catheter and/or cranial/craniospinal radiotherapy. The outlook for solid tumour carcinomatous meningitis is extremely poor, many patients dying within weeks of their diagnosis.
Current management of central nervous system metastasis from cholangiocarcinoma: the neurosurgical perspective. Literature review
Published in British Journal of Neurosurgery, 2020
Federica Novegno, Giuseppe Umana, Pierluigi Granaroli, Filippo Borri, Augusto Orlandi, Pierpaolo Lunardi
In general, the diagnosis of carcinomatous meningitis may be difficult due to subtle clinical manifestations: it generally begins with progressive multiple neurologic symptoms for the involvement of different levels of the neuroaxis, most commonly spinal roots.9 Therefore, the clinical picture may vary from changes of mental status and confusion to diffuse lower extremities weakness; focal neurological signs are described when focal brain metastasis are associated.
Malignant invasion of the cerebrospinal fluid in adult and paediatric patients with haematological and solid malignancies: a monocentric retrospective study
Published in Acta Clinica Belgica, 2022
Leonie Smets, Helena Claerhout, Christine Van Laer, Nancy Boeckx
Malignant invasion of the cerebrospinal fluid (CSF) or neoplastic meningitis can occur in patients with solid malignancies (carcinomatous meningitis) or haematological malignancies (leukaemic or lymphomatous meningitis). Neoplastic meningitis is caused by the migration of malignant cells to the leptomeninges and subarachnoid space, allowing malignant cells to disseminate through the CSF to all regions of the central nervous system (CNS). Leptomeningeal invasion can occur by haematogenous spread (arterial or venous), by endo- or perineural spread or by direct spread from nearby parenchymal brain or bone lesions [1–5]. Leptomeningeal metastasis occurs in 3–8% of patients with solid malignancies [3,4] and in approximately 5–15% of patients with haematological malignancies [3,4,6]. In patients with primary CNS tumours, neoplastic meningitis is observed in only 1–2% [7,8]. Autopsy reports of patients with systemic malignancies and neurological symptoms, however, suggest a much higher incidence [2,9]. In addition, last decades, the incidence of leptomeningeal invasion seems to be increasing due to better systemic cancer control and longer overall survival [4]. It is associated with a very poor prognosis with a median survival time of only weeks if untreated. Signs and symptoms of leptomeningeal invasion are often nonspecific and vary depending on the part of the neuroaxis involved and/or the presence of increased intracranial pressure [10]. Diagnosis of neoplastic meningitis is based on the detection of malignant cells in CSF sample (cytomorphological criteria) and/or on the presence of signs of leptomeningeal enhancement on magnetic resonance imaging (MRI) of brain and/or spinal cord (radiological criteria). Both methods are complementary and should be performed standardly when clinical suspicion is high [2,4]. Therapy is mainly aimed at improving the quality of life and prolonging life. Treatment options include radiotherapy (RT), intrathecal or systemic chemotherapy (CT) and novel, targeted therapies [3–5,7].
Episodic Oculomotor Nerve Palsy with Intracranial Hypertension and Carcinomatous Meningitis
Published in Neuro-Ophthalmology, 2020
Turgut Sahin, Zerin Ozaydın Aksun, Canan Togay Isikay, Ozden Sener
A 44-year-old woman presented with complaints of chronic fluctuating headache, nausea, and vomiting for five months. The patient also mentioned recurrent and short-lasting daily incidents of double vision. Before presentation, she had been diagnosed with lung cancer metastasised to the mediastinal lymph nodes two years ago and had been on a chemotherapy regimen. The physical examination was normal. Neurological examination (NE) was unremarkable except for grade II papilloedema. During her hospital stay, multiple episodes of unresponsiveness with subsequent near-total oculomotor paralysis, lasting a few minutes were observed. The NE during the attacks revealed complete unresponsiveness, upward deviation of the eyes, and moaning. Following the relief of her impaired consciousness, near-total oculomotor paralysis occurred on the left side (Figure 1a). Thereafter, the full recovery of the ocular findings was observed (Figure 1b). Those attacks persisted up to five minutes and ceased without any intervention. Emergency cerebral computerised tomography angiography was normal and therefore the possibility of an aneurysmal compression was excluded. Contrast-enhanced brain magnetic resonance imaging revealed leptomeningeal contrast enhancement, tetra-ventricular hydrocephalus and non-specific multiple millimetric hyperintense lesions in bilateral centrum semiovale on T2 and FLAIR sequences (Figure 2). A lumbar puncture revealed 46 cm of cerebrospinal fluid (CSF) opening pressure. Thirty millilitres of CSF was drained, resulting in an 18 cm CSF closing pressure. Fluid analysis revealed a cell count of 2/hpf, protein of 44 mg/dL, and glucose of 62 mg/dL (0.78 of the blood glucose measure). Real-time polymerase chain reaction analysis for common infectious agents of the central nervous system, as well as CSF bacterial, mycobacterial, and fungal cultures were negative excluding an infectious cause. The paraneoplastic anti-neuronal antibody panel of the CSF (including Anti-Hu) was negative. Cytopathological investigation of the CSF revealed malignant cells suggesting metastasis of adenocarcinoma. Impaired consciousness along with brief and stereotypical episodes hinted at an epileptic origin. However, an electroencephalogram (EEG) displayed generalised delta activity without any epileptic discharge. Moreover, antiepileptic treatment with levetiracetam and topiramate did not lead to resolution of the attacks. Eventually, the patient was diagnosed with carcinomatous meningitis and intracranial hypertension, and was referred to the oncology clinic. Acetazolamide and topiramate were initiated for symptomatic relief of her complaints. Three months after her discharge, she was on chemo- and radiotherapy and declared that the attacks were less severe and occurring twice per week.