Multiple infarctions in a woman with carcinomatous meningitis infiltrating basal cerebral arteries

Case report: A 57-year-old woman developed cytologically proven carcinomatous meningitis due to cancer of unknown primary. Repeated cerebral CT and MRI scans with arterial angiography revealed contrast agent enhancement of the meninges and multiple cerebral infarctions, especially bilateral anterior cerebral artery infarcts. Spinal MRI indicated an involvement of the cauda and the spinal meninges as well. Transcranial contrast ultrasound revealed segmental flow acceleration in all basal cerebral arteries compatible with vasospasm or tumor cell infiltration/inflammation. Therapy with intrathecal methotrexate (MTX) was initiated. After 3 cycles of MTX accompanied by systemic as well as intrathecal corticosteroids, cerebral blood flow normalized and CSF cell count declined.

Discussion: In carcinomatous meningitis perivascular infiltration, accompanying inflammation and mural invasion of tumor cells can lead to a vasculopathy. Thus, cerebral infarctions can occur as rare complication in carcinomatous meningitis. For meningeal neoplasms intrathecal methorexate is a standard therapy. While other reports in similar cases can not exclude a possible adverse event of MTX therapy causing vasculopathy, we could demonstrate treatment-responsive neoplastic or inflammatory cerebral artery involvement in this case of carcinomatous meningitis.