Abstract
Case A 76 years old female presents with acute aphasia, headache and agitation. Aphasia spontaneously resolved within 24 hours, followed by prolonged period of altered level of consciousness, positional headache and persistent postural hypotension in spite of volume replacement. Her neurological exam was significant for symmetrical ataxia.
EEG revealed moderate diffuse encephalopathy, in addition to electrographic seizures arising from right central region (F4-C4). MRI revealed a small right cerebellar stroke (Image 1). MRI of spine showed diffuse prominently smooth leptomeningeal enhancement, extending from cervical spinal cord to the proximal cauda equina. Axial T2 weighted sequences showed central foci of increased T2 signal from C5 to C7. Cerebrospinal fluid was significantly abnormal with decreased glucose 1.6 mmol/L, raised protein 2100 mg/L and leukocytes 10x10^6/L with lymphocyte predominance, opening pressure was 14cmH2O. Repeat CSF demonstrated protein 1400 mg/L, glucose 1.9 mmol/L and leukocytes 23x10^6/L, again with lymphocytic predominance. Workup for stroke including 7 day telemetry, CT neck angiography and transthoracic echocardiography did not reveal additional findings. CT chest, abdomen and pelvis did not reveal lesions suspicious of malignancy.
She received 3 days of intravenous methylprednisolone, followed by weaning regime of oral Prednisolone. She received anti-seizure medications. She deteriorated with clinical status epilepticus requiring intubation and was palliated as per family’s wishes. This occurred prior to completion of PET-CT and transoesophageal echocardiography. Autopsy consented by family. Neuropathological findings describes a diffuse leptomeningeal glioma.
Conclusion Meningeal carcinomatosis can occur secondary to primary intracranial malignancies or occur in the setting of widespread metastatic disease.
