IMAGES IN NEUROLOGY
|Year : 2017 | Volume
| Issue : 3 | Page : 320-321
Leptomeningeal carcinomatosis presenting as cauda equina syndrome
Bhagyadhan A Patel, Rahul T Chakor, Swaleha Nadaf, Kaumil V Kothari
Department of Neurology, T.N.M.C. and B.Y.L. Nair Ch. Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||10-Aug-2017|
Bhagyadhan A Patel
Ward No. 18, 7th Floor, Hospital OPD Building, T.N.M.C. and B.Y.L. Nair Ch. Hospital, Mumbai - 400 008, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Patel BA, Chakor RT, Nadaf S, Kothari KV. Leptomeningeal carcinomatosis presenting as cauda equina syndrome. Ann Indian Acad Neurol 2017;20:320-1
A 47-year-old female presented with subacute onset progressive backache, severe lancinating pain radiating to lower limbs, and bowel/bladder dysfunction over a period of 2 months duration. On examination, she had flaccid paraplegia, areflexia, and sensory loss in lower limbs. Diagnosis of severe cauda equina syndrome was considered. Magnetic resonance imaging (MRI) lumbosacral (LS) spine T2 sagittal images showed thickening and clumping of LS roots leading to the obliteration of cerebrospinal fluid (CSF) space. Contrast-enhanced MRI demonstrated intense enhancement of LS nerve roots and meninges [Figure 1]a and [Figure 1]b. Lumbar puncture resulted in dry tap due to LS root hypertrophy and CSF space obliteration. Positron emission tomography-computed tomography (PET-CT) showed linear hypermetabolic ill-defined soft tissue in spinal canal, raising suspicion of malignancy [Figure 1]c. Histopathology and immunohistochemistry of meningeal biopsy arachnoid matter were suggestive of undifferentiated carcinoma [Figure 2]. Diagnosis of leptomeningeal carcinomatosis was confirmed. However, the primary source of malignancy was not detected in this patient.
|Figure 1: (a) T2-weighted sagittal magnetic resonance imaging shows thickening and clumping of lumbosacral nerve roots leading to obliteration the cerebrospinal fluid space, (b) postcontrast T1-weighted sagittal magnetic resonance imaging shows thickening of lumbosacral nerve roots with intense post-contrast enhancement and (c) positron emission tomography-computed tomography shows linear ill-defined hypermetabolic soft tissue in spinal canal|
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|Figure 2: Histopathology showing large, anaplastic, round to oval cells with hyperchromatic nuclei and increased mitotic activity suggestive of malignancy|
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Diffuse cauda equina enhancement is seen in leptomeningeal carcinomatosis and lymphomatosis as well as many nonneoplastic disorders such as tubercular arachnoiditis, sarcoidosis, demyelinating, and hereditary neuropathies. There is overlap in imaging features of inflammatory and neoplastic processes affecting LS roots. The rapidity of progression, presence of pain, and associated bowel/bladder involvement may suggest neoplastic etiology. PET-CT and histopathology help to confirm etiology. It is important to highlight that carcinomatous infiltration of cauda equina can be the presenting feature of underlying neoplasm. Based on imaging and histopathological features, diagnosis of leptomeningeal carcinomatosis can be pursued even if the primary source of neoplasm remains undetected.,,,
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| References|| |
Khadilkar S, Patel B, Mansukhani KA, Jaggi S. Two cases of chronic immune sensorimotor polyradiculopathy: Expanding the spectrum of chronic immune polyradiculopathies. Muscle Nerve 2017;55:135-7.
Osborn AG. Diffuse cauda equine enhancement. In: Ross JS, Salzman KL, editors. Expert Ddx Brain and Spine. Toronto: Amirsys Publishing; 2009. p. II-6-2-5.
Bennett SJ, Katzman GL, Roos RP, Mehta AS, Ali S. Neoplastic cauda equina syndrome: A neuroimaging-based review. Pract Neurol 2016;16:35-41.
Tarulli AW. Disorders of the cauda equina. Continuum (Minneap Minn) 2015;21:146-58.
[Figure 1], [Figure 2]