Leptomeningeal metastases

Last revised by Dr Bahman Rasuli on 19 Apr 2021

Leptomeningeal metastases, also known as carcinomatous meningitis, refers to the spread of malignant cells through the CSF space. These cells can originate from primary CNS tumors (e.g. drop metastases), as well as from distant tumors that have metastasized via hematogenous spread.

This article has a focus on subarachnoid space involvement. Refer to intradural extramedullary metastases for a discussion of leptomeningeal metastases in the spine. For other intracranial metastatic locations, please refer to the main article on intracranial metastases

The demographics follow those of the underlying malignancy.

Clinical presentation is varied, but most commonly includes a headache, spine or radicular limb pain or sensory abnormalities, nausea and vomiting, and focal neurological deficits 3. Meningism is only present in a minority of patients (13% 3).

The primary intracerebral malignancies that may cause metastases to the subarachnoid space are:

The vast majority of leptomeningeal metastases occur in the context of widespread metastatic disease, likely by hematogenous spread. Over 50% of cases have concurrent brain (parenchymal) metastases 13.  The most common primary sites are: 

Less common, but reported primary sites include:

  • T1: usually normal
  • T1 C+ (Gd): leptomeningeal enhancement is the primary mode of diagnosis, often scattered over the brain in a 'sugar coated' manner
  • T2: usually normal
    • abnormally elevated signal within sulci 2
    • can be performed both non-contrast and post-contrast, but is slightly less specific if performed post-contrast 1

Leptomeningeal metastases have a poor prognosis with patients usually succumbing within a few months (median overall survival 2.4 months 13).  With treatment, that time may be extended up to 6-10 months 2,3. Treatment can consist of 3:

  • intrathecal chemotherapy
  • radiotherapy

Resection is usually inappropriate due to the presence of widespread metastases.

  • leptomeningeal inflammation: leptomeningitis
  • slow flow in vessels
  • propofol, high oxygen tension, and subarachnoid blood can all elevate sulcal FLAIR signal

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Cases and figures

  • Case 1: from esophageal cancer
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  • Case 2: with background NHL
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  • Case 3: from breast cancer - over cerebellar folia
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  • Case 4: from breast cancer
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  • Case 5
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  • Case 6
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  • Case 7: from breast cancer
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  • Case 8
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  • Case 9: with choroid plexus metastases
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  • Case 10
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  • Case 11
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