Diffuse leptomeningeal gliomatosis associated with multifocal CNS infarcts

Cancer-associated spinal cord infarction: A systematic review and analysis of survival predictors

OBJECTIVE

The association between spinal cord infarction (SCI) and cancer is an infrequent condition but requires an accurate diagnosis to establish the appropriate treatment. Clinical features and prognosis of cancer-associated SCI have never been assessed. The aim of this systematic review is to describe the characteristics and outcomes of patients with cancer-associated SCI. Illustratively, a case of ovarian cancer-related SCI is presented.

MATERIAL AND METHODS

Two authors independently analysed three different bibliographic databases looking for cancer-associated SCI case reports and case series. Data regarding age, sex, cardiovascular risk factors (CVRF), history of known cancer, infarction localization, spinal cord syndrome, Zalewski criteria classification, mechanism of ischemia, diagnostic tests, treatment and functional outcome were registered. A statistical analysis was carried out to identify factors related to mortality and survival time.

RESULTS

A total of 48 articles met the inclusion criteria and 52 patients were identified. The median age was 62 years. The most frequent neoplasm was intravascular large B-cell lymphoma. The median survival time was 17.4 weeks and the cumulative probability of survival at 12 months was 16.3%. In the group of deceased patients there was a higher proportion of malignant neoplasms than in those who survived (94.7% vs. 5.3%, p < 0.01). There were no statistically significant differences in terms of mortality or survival time depending on age, previously known cancer or CVRF.

CONCLUSION

Cancer-associated SCI entails a poor outcome. Mortality is increased in patients with malignant neoplasm. No other prognosis factors could be identified.

Glioblastoma evolving within 10 days following unremarkable computer tomography of the brain: a case report

Glioblastoma multiforme might develop radiologically within a few days following unremarkable CT scan of the brain. Glioblastoma multiforme is the most frequent primary brain tumor. Initial presentations are diverse, including headache, seizures and transient or persistent neurological deficits. Cerebral imaging followed by histological examination of a tissue specimen is the mainstay of diagnosis. We report the case of a 79-year-old female patient whose computer tomography (CT) of the brain was unremarkable at first clinical presentation with a transient hemiparesis of the right side, but revealed a cerebral space-occupying lesion ultimately diagnosed as glioblastoma only 10 days later. According to our case presentation glioblastoma might develop radiologically within a few days following unremarkable CT scan of the brain. Since clinical manifestation with a transient ischemic attack (TIA)-like episode was preceding CT manifestation, this case indicates, that a magnetic resonance imaging (MRI) should be routinely performed in all patients presenting with TIA.

Primary diffuse leptomeningeal oligodendrogliomatosis with an isolated 1p deletion

We report a case of primary diffuse leptomeningeal oligodendrogliomatosis with an isolated 1p deletion confirmed by fluorescent in situ hybridization (FISH) analysis in 52 year-old man. The MRI scan in a patient presenting with progressive headache, nausea and diplopia revealed diffuse leptomeningeal thickening and enhancement without definitive evidence of an intraparenchymal lesion. Biopsy of thickened, enhancing meninges within the left sylvian fissure revealed subarachnoid proliferation of oligodendroglial cells with varying degrees of de-differentiation and sparing of the underlying cortex. An isolated 1p deletion was confirmed by FISH analysis. This is the first reported adult case of a 1p deletion in primary diffuse leptomeningeal oligodendrogliomatosis.

Convergence-Retraction Nystagmus in a Dog With Presumptive Ischemic Encephalopathy Following Acute Cervicothoracic Myelopathy

A 6.5-year-old male neutered Trailhound was admitted for hyperacute, nonprogressive, left-sided hemiparesis. Physical and neurologic examination revealed nonpainful, left-sided poorly ambulatory hemiparesis, decreased left-sided postural reactions and thoracic limbs hyporeflexia. Neuroanatomic localisation was consistent with a left-sided C6-T2 myelopathy. Haematology and biochemistry revealed nonspecific abnormalities. Magnetic resonance imaging of the neck revealed a focal intramedullary lesion at the level of C6-C7 vertebrae compatible with acute hydrated noncompressive nucleus pulposus extrusion or ischemic myelopathy. During the second day of hospitalization, the dog developed convergence-retraction nystagmus, up-gaze palsy and eyelid retraction (Collier's sign) compatible with dorsal midbrain syndrome. Magnetic resonance imaging of the brain revealed a focal lesion compatible with dorsal midbrain ischemic infarct. Further clinicopathologic testing, thoracic and abdominal imaging were unremarkable. Ischemic encephalopathy of unknown etiology was additionally diagnosed. Physiotherapy was performed therapeutically. At 1-year follow-up the dog was normal. This is an unusual report of a dog with myelopathy followed by ischemic encephalopathy with manifestation of convergence-retraction nystagmus in the absence of vestibular signs. This saccadic intrusion is a characteristic clinical manifestation of a dorsal midbrain syndrome localization. The importance of a complete differential diagnoses list formation in a dog with ischemic encephalopathy which leads to a thorough diagnostic investigation plan is highlighted. Moreover, this report contributes to the enrichment of the clinical reasoning veterinary literature on convergence-retraction nystagmus. To the authors' knowledge, this is the second case report (fourth dog) to describe convergence-retraction nystagmus in dogs as a manifestation of dorsal midbrain syndrome.

Primary diffuse leptomeningeal glioneuronal tumors

Diffuse leptomeningeal disseminated glioneuronal tumor (DL-GNT) is a rare brain tumor that presents as a plaque-like subarachnoid tumor, commonly involving the basal cisterns and interhemispheric fissure of children but lacking intraparenchymal tumor. Histologically, the tumors are composed of sheets of monotonous rounded cells. Here, we report three cases of DL-GNTs, focusing on clinicopathologic features. Two patients were adult male, but one patient was child. The patients presented with seizures (n = 1) or headaches (n = 2). In all patients, radiography revealed characteristic leptomeningeal thickening and enhancement with minor superficial parenchymal lesions. All three cases were diffusely positive for both GFAP and synaptophysin, and scattered positive for OLIG2 and NeuN, but negative for IDH-1 (H09). Electron microscopic examination showed astrocytic and neuronal differentiation. The patient with the anaplastic tumor died due to aggressive progression of the tumor, but the remaining two patients were stable without tumor recurrence for 23 and 37 months. Thus, these findings suggest that DL-GNT can occur in both children and adult and both supra- and infra-tentorial leptomeninges. It has unique radiological and histopathological features and biological behavior. Further clinicopathological data with molecular genetic study are required for establishing DL-GNT as a unique entity.

Long survival of primary diffuse leptomeningeal gliomatosis following radiotherapy and temozolomide: case report and literature review

Objective

Primary diffuse leptomeningeal gliomatosis (PDLG) is a rare neoplasm with a short survival time of a few months. there is currently no standardized therapeutic approach for PDLG.

Materials and methods

We report on a 53-year-old male patient who presented with epileptic seizures, gait disturbance, paraparesis and sensory deficits in the dermatomes T8-10.

Results

Magnetic resonance imaging (MRI) revealing numerous spinal and cranial gadolinium-enhancing nodules in the meninges and histopathology led us to diagnose primary diffuse leptomeningeal gliomatosis with WHO grade III astrocytic cells. Consecutively, the patient underwent craniospinal radiotherapy (30 Gy) and 11 sequential cycles of temozolomide. This regimen led to partial tumor regression. Thirteen months later, spinal MRI revealed tumor progression. Second-line chemotherapy with 5 cycles of irinotecan and bevacizumab did not prevent further clinical deterioration. The patient died twenty-two months after diagnosis, being the longest survival time described thus far with respect to PDLG consisting of astrocytic tumor cells.

Conclusions

Radiochemotherapy including temozolomide, as established standard therapy for brain malignant astrocytomas, might be valid as a basic therapeutic strategy for this PDLG subtype.

Leptomeningeal gliomatosis as the initial presentation of gliomatosis cerebri

Leptomeningeal gliomatosis is a known, yet uncommon, complication of malignant gliomas. In rare instances it can present with non-specific symptoms prior to the development of detectable intraparenchymal lesions, posing a diagnostic challenge. Gliomatosis cerebri is also a rare disease, characterized by extensive diffuse infiltration of neoplastic glial cells. For both entities, limited data exist to guide treatment and prognosis is poor. We describe the case of a patient who presented with symptoms of increased intracranial pressure and diffuse leptomeningeal enhancement in the brain and spinal cord on MRI. After a period of surveillance, intraparenchymal lesions developed in association with widespread diffuse infiltration. The diagnosis of gliomatosis cerebri with diffuse leptomeningeal gliomatosis was established in hindsight. Initial treatment consisted of six cycles of temozolomide chemotherapy. Following radiological progression, the patient received craniospinal radiotherapy. Four months later the patient's symptoms had resolved and MRI demonstrated near complete response of leptomeningeal enhancement and intraparenchymal lesions. Six months after radiotherapy, the patient remains clinically well without radiographic recurrence.

A case report and review of the literature

Primary diffuse leptomeningeal gliomatosis (PDLG) is a rare central nervous system neoplasm in which gliomatous tissue is diffusely identified in the subarachnoid space with no evidence of a primary intraparenchymal tumor. A 52-year-old man presented low back pain followed by sudden unconsciousness and had also cognitive dysfunction and meningeal sign. Examinations of cerebrospinal fluid (CSF) did not show malignant cells but increased protein and pleocytosis. Magnetic resonance (MR) imaging demonstrated diffuse leptomeningeal enhancement without any source of intraparenchymal lesion. Fluid-attenuated inversion recovery (FLAIR) also demonstrated individual diffuse high intensity area in the subarachnoid space. A biopsy disclosed wide spreading of anaplastic glial cells within the leptomeninges. He died 3 months later because of disease progression despite both radiotherapy and chemotherapy. Post-mortem examination identified PDLG and several neuropathological features of glioblastoma as well. Reviewing previous cases of PDLG instructs that this entity is rare, resembles meningitis in clinical pictures, usually occurs in a relatively younger population and has more progressive clinical course than the ordinary form of malignant gliomas.

Primary diffuse multinodular leptomeningeal gliomatosis: case report and review of the literature

BACKGROUND

Primary diffuse leptomeningeal gliomatosis is an exceptional neoplasm, and only 30 cases have been reported in the literature. We report a recent case and compare data with previously published observations.

METHODS

A 50-year-old man was admitted to the neurosurgery department for a previous 4-month history of headache, associated with nonspecific neurological signs. Biologic data and cerebrospinal fluid examination suggested an inflammatory process. The patient was given an antituberculous therapy. Magnetic resonance imaging revealed a multinodular enhancement of spinal nerve roots. A biopsy of sacral rootlets was performed. Histological examination revealed an anaplastic astrocytoma. Patient's status worsened, and death occurred 7 months later.

RESULTS

Complete neuraxis postmortem examination revealed no intraparenchymatous glioma and was conclusive for the diagnosis of primary leptomeningeal gliomatosis (astrocytic, World Health Organization grade III), with a multinodular pattern in the spinal cord, the brainstem, and the brain base with diffuse extension into the cerebellar subarachnoid spaces.

CONCLUSIONS

Our case illustrates the diagnostic difficulties in making the premortem diagnosis. The review of the literature indicates that there are no specific clinical or biologic signs. Magnetic resonance imaging using T1-weighted images with gadolinium enhancement and biopsy material may be useful diagnostic tools. In most cases, autopsy evaluation alone permits definitive primary diffuse leptomeningeal gliomatosis diagnosis. Whatever the histological characteristics of proliferating cells are, the prognosis remains poor. No prognostic factors have been shown to be correlated with survival time. Unfortunately, no routine treatment has been yet proposed.

Leptomeningeal infiltration as the presenting manifestation of a malignant glioma

Infiltration of the leptomeninges by a malignant glioma typically occurs with recurrent supratentorial tumors, but patients may present with leptomeningeal gliomatosis before the primary tumor is diagnosed. This report describes two patients who presented with headache and signs of multifocal neurological disease. One of the patients had neurofibromatosis type I. In both patients the cerebrospinal fluid examination showed a mild pleocytosis, but malignant cells were not detected. The diagnosis of leptomeningeal gliomatosis was not confirmed until autopsy, but in retrospect imaging showed a small, asymptomatic primary tumor in both patients. Leptomeningeal gliomatosis should be considered in the differential diagnosis of chronic meningitis, if the patient is afebrile and if there are multifocal neurological signs, even when a primary tumor is not obvious.

Pilocytic astrocytoma presenting as primary diffuse leptomeningeal gliomatosis: report of a unique case and review of the literature

We describe a 25-year-old male patient with primary diffuse leptomeningeal gliomatosis (PDLG) presenting with gait ataxia, positive Lhermitte's sign, double vision, and right abducens nerve palsy. Spinal magnetic resonance imaging showed extended intradural, extramedullary, contrast-enhancing masses with compression of the myelon. Spinal leptomeningeal biopsy revealed a pilocytic astrocytoma WHO grade I. Despite chemotherapy with vincristin and carboplatin, the patient died 2 months after admission. A thorough autopsy showed no evidence for primary neoplasms in brain, spine and optic nerve. Sequence analysis of tumor protein 53 gene (TP53) revealed a missense mutation in exon 5, and expression of phosphatase and tensin homolog (mutated in multiple advanced cancers 1) (PTEN) protein was not detected, which may have contributed to astrocytoma development. To our knowledge, this is the first definitive case of pilocytic astrocytoma presenting as PDLG.

Pontine glioblastoma multiforme initially presenting with leptomeningeal gliomatosis

A 49-year-old female presented with diffuse leptomeningeal gliomatosis as the initial manifestation of pontine glioblastoma. Magnetic resonance imaging initially revealed diffuse leptomeningeal enhancement caused by metastatic deposits, predominantly along the basal cistern and bilateral sylvian fissures. The primary pontine lesion appeared as hypointense on T1-weighted imaging and hyperintense on T2-weighted imaging, but with no enhancement by gadolinium-diethylenetriaminepenta-acetic acid. There was no diffuse enlargement of the pons. The patient died 11 months after the initial presentation. The primary lesion in the pons was histologically confirmed at autopsy. Diffuse enhancement of leptomeningeal dissemination may occur as the initial manifestation of non-enhanced pontine glioblastoma.