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A Symptoms and Signs
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Headache, drowsiness, inattention, confusion, and seizures are early symptoms, followed by signs of increasing intracranial pressure and then a focal neurologic deficit There may be little or no systemic evidence of infection
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A CT scan of the head characteristically shows an area of contrast enhancement surrounding a low-density core Similar abnormalities may be found in patients with metastatic neoplasms MRI findings often permit earlier recognition of focal cerebritis or an abscess Arteriography indicates the presence of a space-occupying lesion, which appears as an avascular mass with displacement of normal cerebral vessels, but this procedure provides no clue to the nature of the lesion Examination of the cerebrospinal fluid does not help in diagnosis and may precipitate a herniation syndrome
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C Laboratory Findings
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The cerebrospinal fluid removed at myelography is often xanthochromic and contains a greatly increased protein concentration with normal cell content and glucose concentration
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Treatment consists of intravenous antibiotics, combined with surgical drainage (aspiration or excision) if necessary to reduce the mass effect, or sometimes to establish the diagnosis Abscesses smaller than 2 cm can often be cured medically Broad-spectrum antibiotics are used if the infecting organism is unknown A common regimen is penicillin G (2 million units every 2 hours intravenously) plus either chloramphenicol (1 2 g intravenously every 6 hours), metronidazole (750 mg intravenously every 6 hours), or both Nafcillin is added if Staphylococcus aureus infection is suspected Antimicrobial treatment is usually continued parenterally for 6 8 weeks, followed by orally for a further 2 3 weeks The patient should be monitored by serial CT scans or MRI every 2 weeks and at deterioration Dexamethasone (4 25 mg four times daily, depending on severity, followed by tapering of dose, depending on response) may reduce any associated edema, but intravenous mannitol is sometimes required
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Intramedullary tumors are treated by decompression and surgical excision (when feasible) and by irradiation The prognosis depends on the cause and severity of cord compression before it is relieved Treatment of epidural spinal metastases consists of irradiation, irrespective of cell type Dexamethasone is also given in a high dosage (eg, 25 mg four times daily for 3 days, followed by rapid tapering of the dosage, depending on response) to reduce cord swelling and relieve pain Surgical decompression is reserved for patients with tumors that are unresponsive to irradiation or have previously been irradiated and for cases in which there is some uncertainty about the diagnosis The long-term outlook is poor, but radiation treatment may at least delay the onset of major disability
Nervous System Disorders
Kastrup O et al Neuroimaging of infections NeuroRx 2005 Apr;2(2):324 32 [PMID: 15897953]
CMDT 2008
A variety of nonmetastatic neurologic complications of malignant disease (see Table 39 13) can be recognized Metabolic encephalopathy due to electrolyte abnormalities, infections, drug overdose, or the failure of some vital organ may be reflected by drowsiness, lethargy, restlessness, insomnia, agitation, confusion, stupor, or coma The mental changes are usually associated with tremor, asterixis, and multifocal myoclonus The electroencephalogram is generally diffusely slowed Laboratory studies are necessary to detect the cause of the encephalopathy, which must then be treated appropriately Immune suppression resulting from either the malignant disease or its treatment (eg, by chemotherapy) predisposes patients to brain abscess, progressive multifocal leukoencephalopathy, meningitis, herpes zoster infection, and other opportunistic infectious diseases Moreover, an overt or occult cerebrospinal fluid fistula, as occurs with some tumors, may also increase the risk of infection CT scanning aids in the early recognition of a brain abscess, but metastatic brain tumors may have a similar appearance Examination of the cerebrospinal fluid is essential in the evaluation of patients with meningitis but is of no help in the diagnosis of brain abscess Cerebrovascular disorders that cause neurologic complications in patients with systemic cancer include nonbacterial thrombotic endocarditis and septic embolization Cerebral, subarachnoid, or subdural hemorrhages may occur in patients with myelogenous leukemia and may be found in association with metastatic tumors, especially malignant melanoma Spinal subdural hemorrhage sometimes occurs after lumbar puncture in patients with marked thrombocytopenia Disseminated intravascular coagulation occurs most commonly in patients with acute promyelocytic leukemia or with some adenocarcinomas and is characterized by a fluctuating encephalopathy, often with associated seizures, that frequently progresses to coma or death There may be few accompanying neurologic signs Venous sinus thrombosis, which usually presents with convulsions and headaches, may also occur in patients with leukemia or lymphoma Examination commonly reveals papilledema and focal or diffuse neurologic signs Anticonvulsants, anticoagulants, and drugs to lower the intracranial pressure may be of value Paraneoplastic cerebellar degeneration occurs most commonly in association with carcinoma of the lung Symptoms may precede those due to the neoplasm itself, which may be undetected for several months or even longer Typically, there is a pancerebellar syndrome causing dysarthria, nystagmus, and ataxia of the trunk and limbs The disorder probably has an autoimmune basis Treatment is of the underlying malignant disease Encephalopathy, characterized by impaired recent memory, disturbed affect, hallucinations, and seizures, occurs in some patients with carcinomas The cerebrospinal fluid is often abnormal EEGs may show diffuse slow-wave activity, especially over the temporal regions Pathologic changes are
most marked in the inferomedian portions of the temporal lobes There is no specific treatment Malignant disease may be associated with sensorimotor polyneuropathy and less commonly with pure sensory neuropathy (ie, dorsal root ganglionitis) or autonomic neuropathy A subacute motor neuronopathy may be associated with lymphomas Dermatomyositis or a myasthenic syndrome may be seen in patients with underlying carcinoma (see 20) The myasthenic syndrome may have an autoimmune basis and differs clinically from myasthenia gravis
Darnell RB et al Paraneoplastic syndromes affecting the nervous system Semin Oncol 2006 Jun;33(3):270 98 [PMID: 16769417]
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