This case of meningeal carcinomatosis is somewhat unique in its presentation. The patient was not known to have cancer at the time of her presentation, and her symptoms were focal and stroke-like. It is uncommon for MC to be diagnosed in patients without a previous diagnosis of cancer [3
]. In the review by Taillibert et al. facial weakness was an associated initial finding in only 25% of patients with MC, and seizure was only noted in 14% [2
]. The fact that the patient exhibited aphasia, extremity weakness, and facial droop is likely secondary to the patient's brain mass and edema.
Although MC is usually a secondary metastatic disease from solid tumors, like cancer of the breast or lung, direct spread from primary CNS tumors is possible [2
]. Focal findings with asymmetry are a poor prognostic sign, and MRI of the brain should be followed up with imaging of the entire neuroaxis. Lumbar puncture may also be considered and will likely yield abnormal opening pressure, cell counts, glucose, protein, or cytology. Cytology can be negative in up to 40-50% on initial lumbar puncture [2
]. Lumbar puncture should be performed only after MRI if possible to avoid false-positive enhancement at the site.
Computed tomography is 1.5-2 times less specific and sensitive than MRI. Contrast-enhanced MRI is preferred, and larger doses of gadolinium are thought to reduce the false-negative rate [2
]. Hydrocephalus and contrast enhancement of the meninges and sulci are common findings. Other testing, such as CSF flow studies and PET scans are not appropriate for the ED setting. Meningeal biopsy and non-specific biomarkers are sometimes obtained during the inpatient evaluation.
Emergency department management of seizure includes benzodiazepines and AEDs. However, AEDs are not thought to be needed on a prophylactic basis. Treatment of MC-associated headache, neck, and back pain should include analgesics, but may also include steroids. Alternatives to standard analgesics may be appropriate in patients who can be managed as an outpatient. Alternative pain management drugs like amitriptyline, gabapentin, carbamazepine, or benzodiazepines may be prescribed for chronic pain. Acute worsening of headache, neck pain, or back pain could be related to worsening complications, such as obstructive hydrocephalus, edema, or impingement of nerve roots or the spinal cord. Careful exam and history should be used to guide the clinician in determining the need for additional imaging or other diagnostics.
Despite intra-reservoir or intravenous chemotherapy, survival is merely 20-23 weeks [5
]. External beam radiation may be used to control tumor growth at areas of impingement or severe pain. Chemotherapy and radiotherapy for MC are considered palliative in most cases.