Leptomeningeal and brain parenchymal metastases

Case contributed by Dr Francis Deng

Presentation

Generalized weakness, fatigue, poor oral intake, and 2 near-syncopal episodes, progressive over the past 2 weeks. History of triple negative breast cancer, stage IIIC, treated with multimodal therapy.

Patient Data

Age: 50 years
Gender: Female

Multiple hyperdense intraparenchymal lesions (at least in the left frontal and right parietal lobes), likely representing metastatic disease. Further evaluation with brain MRI with contrast is recommended.
Ventriculomegaly likely representing communicating hydrocephalus. Thickening of cisternal segments of multiple cranial nerves. Evaluation for leptomeningeal disease is recommended.

4 brain parenchymal metastases, in the left frontal lobe, right insula, and 2 in the right parietal lobe. The largest, in the left frontal lobe, measures 3.6 cm and has significant surrounding vasogenic edema.

Leptomeningeal metastases, as evidenced by contrast enhancement coating multiple sulci, fissures, basal cisterns, and ventricles. These deposits indent the medulla oblongata, coat cisternal segments of the cranial nerves, and fill the internal auditory canals. Enhancement extends to the upper cervical cord surface.

Communicating hydrocephalus with transependymal edema.

Case Discussion

The findings were consistent with brain parenchymal and diffuse leptomeningeal metastatic disease, which is associated with a poor prognosis. Noncontrast head CT is insensitive for the detection of intracranial metastases but this case demonstrates the subtle findings that can be detected early on during this rapidly evolving course of illness to place the patient on the right management pathway and provide anticipatory guidance.

The patient was admitted to the medical oncology service and initially managed with steroids (dexamethasone), seizure prophylaxis (levetiracetam), and acetazolamide. Lumbar puncture was performed. Opening pressure was 24 cm H2O.

  • Appearance: clear, yellow
  • Glucose: 2 mg/dL (reference range: 50-75)
  • Protein: 828 mg/dL (reference range: 15-45)
  • White blood cell count: 161 / cu mm (reference range: 0-5)
  • Bacterial culture: no growth
  • Cytopathology: metastatic carcinoma consistent with known breast primary

Neurosurgery, radiation oncology, neuro-oncology, and palliative care opinions were solicited. The patient's level of consciousness progressively declined and, upon discussion with family, the patient was transitioned to hospice.

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