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Abstract Details

Leptomeningeal Carcinomatosis Mimicking Reversible Cerebral Vasoconstriction Syndrome
Cerebrovascular Disease and Interventional Neurology
Cerebrovascular Disease and Interventional Neurology Posters (7:00 AM-5:00 PM)
231
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Leptomeningeal carcinomatosis is the result of metastatic infiltration of the leptomeninges by malignant cells originating from an extra meningeal primary tumor site. Breast cancer followed by lung cancer and melanoma are the most common causes of solid-tumor-related leptomeningeal carcinomatosis. We describe a patient with active breast cancer who presented with thunderclap headaches and imaging showing multi-segment irregular arterial narrowing of intracranial vasculature.
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A 58-year-old Caucasian woman with active stage IV estrogen receptor-positive breast adenocarcinoma and migraine presented with thunderclap headache (TH). Computed tomography and brain magnetic resonance (MR) imaging without contrast were unremarkable. Over a period of one week she had recurrent THs; interval vessel imaging showed multi-segment irregular arterial narrowing. Treatment with verapamil was initiated for suspected reversible cerebral vasoconstriction syndrome (RCVS). She subsequently had two discrete episodes of confusion with aphasia and left upper extremity numbness. Repeat gadolinium enhanced MR imaging showed nodular leptomeningeal enhancement. Lumbar puncture revealed malignant cells in the cerebrospinal fluid consistent with leptomeningeal carcinomatosis. Complete resolution of headaches occurred within 3 weeks and follow up vessel imaging at week 5 showed interval resolution of the arterial irregularity. She subsequently underwent whole brain radiation treatment and intrathecal chemotherapy and had no further episodes of TH.
Our case emphasizes the importance of considering leptomeningeal carcinomatosis in the differential diagnosis of thunderclap headaches and reversible cerebral vasculopathy, especially in patients with known underlying active cancer. We hypothesize that this rarely seen phenomenon results from breakdown of the blood brain barrier due to the development of tumoral angiogenesis or invasion of tumor in the Virchow-Robin spaces that could lead to segmental arterial narrowing and reversible vasculopathy mimicking RCVS. The illustration also proves the importance of a complete work-up in patients with known malignancy in the setting of suspected RCVS.
Authors/Disclosures
Parneet K. Grewal, MD
PRESENTER 		The institution of Dr. Grewal has received research support from Bristol Myer Squibb Foundation. The institution of Dr. Grewal has received research support from IPSEN Global.
Julianne Hall, MD Dr. Hall has nothing to disclose.
No disclosure on file
Rima Dafer, MD (Rush University Medical Center) Dr. Dafer has received personal compensation in the range of $10,000-$49,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Eli Lilly. Dr. Dafer has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Eli Lilly. Dr. Dafer has received personal compensation in the range of $500-$4,999 for serving as an Expert Witness for Anderson, Rasor, and partners.