Diagnostic Considerations

New signs or symptoms (particularly when multifocal) may represent progression of leptomeningeal metastases (LM) but may need to be distinguished from parenchymal disease (primarily brain) and or epidural metastases. Of patients with LM, 30–40% will also have brain metastases.

LM may also coexist with paraneoplastic syndromes or the adverse effects of chemotherapy or radiation. Signs of meningeal irritation may also be caused by infection. LM can be difficult to distinguish from subacute or chronic meningoencephalitis caused by tuberculosis or fungus. In these diseases, CSF findings may also show moderate mononuclear pleocytosis, elevated protein and decreased glucose (as described below). However, patients with LM usually are afebrile, and their neurologic symptoms appear earlier in the disease course with a preserved level of consciousness, rather than later with depressed mental status as in tubercular or fungal meningoencephalitis.

Intradural extramedullary spinal metastases (IESM) may be a separate phenomenon from LM. Proposed diagnostic criteria for IESM include: solid tumors located within the intradural extramedullary space, the absence of other leptomeningeal lesions seen on full-spine injected magnetic resonance imaging, and the absence of malignant cells in CSF. According to one study, the median overall survival was significantly higher for IESM patients (732 days) than for patients with LM (53 days).^[15]

Differential Diagnoses

Brain Metastasis
Epidural spinal cord compression
Fungal Meningitis
Meningococcal Meningitis
Paraneoplastic Syndromes
Sarcoidosis
Spinal Metastasis
Toxic/metabolic encephalopathy
Tuberculous Meningitis

Workup

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Author

Herbert H Engelhard, III, MD, PhD, FACS, FAANS Affiliated Professor of Bioengineering, University of Illinois at Chicago

Herbert H Engelhard, III, MD, PhD, FACS, FAANS is a member of the following medical societies: American Association for Cancer Research, American Association of Neurological Surgeons, American College of Surgeons, American Medical Association, Congress of Neurological Surgeons, Illinois State Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jorge C Kattah, MD Head, Associate Program Director, Professor, Department of Neurology, University of Illinois College of Medicine at Peoria

Jorge C Kattah, MD is a member of the following medical societies: American Academy of Neurology, American Neurological Association, New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

Stephen A Berman, MD, PhD, MBA Professor of Neurology, University of Central Florida College of Medicine

Stephen A Berman, MD, PhD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Michael J Schneck, MD, MBA Vice Chair and Professor, Departments of Neurology and Neurosurgery, Loyola University, Chicago Stritch School of Medicine; Associate Director, Stroke Program, Director, Neurology Intensive Care Program, Medical Director, Neurosciences ICU, Loyola University Medical Center

Michael J Schneck, MD, MBA is a member of the following medical societies: American Academy of Neurology, American Society of Neuroimaging, Neurocritical Care Society, Stroke Council of the American Heart Association

Disclosure: Nothing to disclose.

Frederick M Vincent, Sr, MD Clinical Professor, Department of Neurology and Ophthalmology, Michigan State University Colleges of Human and Osteopathic Medicine

Frederick M Vincent, Sr, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Forensic Examiners Institute, American College of Legal Medicine, American College of Physicians

Disclosure: Nothing to disclose.

Acknowledgements

Lawrence D Recht, MD Professor of Neurology and Neurosurgery, Department of Neurology and Clinical Neurosciences, Stanford University Medical School

Lawrence D Recht, MD is a member of the following medical societies: American Academy of Neurology, American Association for Cancer Research, American Neurological Association, and Society for Neuroscience

Disclosure: Nothing to disclose.

R Andrew Sewell, MD Associate Research Scientist in Psychiatry and Mental Illness Research, Education,Veterans Affairs Connecticut Health Care System, Yale University School of Medicine

R Andrew Sewell, MD is a member of the following medical societies: American Academy of Neurology, American Headache Society, American Pain Society, and American Psychiatric Association

Disclosure: Nothing to disclose.