The prognosis of LM is poor and survival is typically
less than 6 months. However, a small subset of patients with LM (including those with breast cancer) may
experience prolonged survival of 1 year or greater.
Treatment options for patients with LM are pallia-
tive and include intrathecal chemotherapy, sys-
temic chemotherapy, and radiotherapy.
Intra-CSF chemotherapy can be delivered via lum-
bar puncture (intrathecal) or via a ventricular catheter
connected to a reservoir placed under the scalp
(Ommaya reservoir). While complications are pos-
sible from an Ommaya reservoir, it offers a means
of delivering intra-CSF chemotherapy as well as
obtaining CSF sampling with greater convenience
than serial lumbar puncture. A radionucleotide CSF
flow study (cisternogram) may be performed prior
to delivering intrathecal chemotherapy to identify
any sites of obstruction to CSF flow; these areas
may be treated with focal radiotherapy to restore
normal flow patterns.80 Agents which may be ad-
ministered into CSF for LM are listed in Table 7.
Arachnoiditis, a common acute complication of intra-
CSF chemotherapy, may present within 72 hours of
drug administration as headache, nausea, and vomit-
ing, and is treated with systemic cortico-steroids.
Systemic chemotherapy may play a role in treating LM as well as managing the extracranial malignancy (Table 8).81 Supportive care for patients
with LM includes CSF shunting,82 corticosteroids,
Radiation therapy can also be used to palliate
LM. The extent of the central nervous system
Table 5. Malignancies Associated with Leptomeningeal
Non-CNS solid tumors
Head and neck 1
Primary CNS tumors
CNS = central nervous system; SCLC = small cell lung cancer; NSCLC =
non-small-cell lung cancer; PCNSL = primary CNS lymphoma.
Adapted from Kesari S, Batchelor TT. Leptomeningeal metastases.
Neurol Clin 2003;21:27
Table 6. Magnetic Resonance Imaging Findings in
Parenchymal volume loss 93
Sulcal (pial) enhancement 57
Enhancing nodules 36
Ependymal enhancement 21
Communicating hydrocephalus 7
Cauda equina nerve root thickening 20
Lineal pial enhancement 32
Enhancing subarachnoid nodules Not reported
Adapted from Chamberlain MC, Sandy AD, Press GA. Leptomeningeal
metastasis: a comparison of gadolinium-enhanced MR and contrast-enhanced CT of the brain. Neurology 1990;40( 3 Pt 1):435–8; and Collie DA, Brush JP, Lammie GA, et al. Imaging features of leptomeningeal
metastases. Clin Radiol 1999;54:765–71.