Focal cerebral infarctions associated with perivascular tumor infiltrates in carcinomatous leptomeningeal metastases
P. Klein, E. C. Haley, G. F. Wooten and S. R. VandenBerg
Department of Neurology, University of Virginia School of Medicine, Charlottesville.
Diffuse carcinomatous leptomeningeal metastases "carcinomatous meningitis")
have the usual clinical course involving multifocal nerve root deficits and
a variable diffuse encephalopathy. In contrast, we describe a patient with
carcinomatous leptomeningeal metastases who presented with clinical signs
of meningitis and focal cerebral infarction. Over an 8-month period,
multiple cerebral infarctions and cranial neuropathies developed.
Postmortem examination of the patient's brain revealed diffuse
leptomeningeal infiltration by a signet-ring adenocarcinoma. The extensive
involvement of the subarachnoid space with tumor was associated with dense
neoplastic infiltration of the Virchow-Robin spaces. These perivascular
tumor infiltrates were accompanied by multifocal mural invasion and, less
frequently, by intravascular tumor cells obliterating the lumen. Focal
hemorrhagic infarcts in the cerebral cortex corresponded to areas of
microscopic vasculopathy. This case provides evidence that tumor-associated
vasculopathy with resultant ischemia plays a role in the pathogenesis of
focal cerebral infarctions in carcinomatous leptomeningeal metastases.
