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Leptomeningeal carcinomatosis — SCE Neurology MCQ

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HardNeuro-oncologyLeptomeningeal carcinomatosisSCE Neurology

A 48-year-old man presented with headache, multifocal cranial neuropathies and radicular pain in breast cancer. On examination, there was diplopia, hearing loss and reduced leg reflexes. Initial investigations showed: MRI showed leptomeningeal enhancement; CSF cytology showed malignant cells. What is the most appropriate investigation?

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Correct answer: B — MRI brain with gadolinium

MRI brain with gadolinium is the best answer because the vignette describes Leptomeningeal carcinomatosis: multifocal neuraxis symptoms with malignant CSF indicates leptomeningeal disease. MRI brain with diffusion-weighted imaging is plausible in a neighbouring presentation, but the chronology, examination or investigation pattern does not match the key discriminator here. Video-EEG telemetry and Carotid duplex ultrasound are less appropriate because they would require different localisation, timing or test findings; Serum and CSF autoimmune antibody panel would fit a different syndrome. Clinical pearl: paraneoplastic syndrome rarely causes malignant cells in CSF.

Reference: NICE NG99; EANO guidance; ABN paraneoplastic guidance