CASE 12889 Published on 19.07.2015

Leukaemic meningitis with multiple cranial nerve enhancement



Case Type

Clinical Cases


Anastasia Zikou1, Artemis Andrianopoulou1, Christos Gkizas1, Eleni Kapsali2, Vassilios Xydis1, Maria I. Argyropoulou1

1. Department of Clinical Radiology, Medical School of Ioannina, Greece.
2. Department of Haematology, Medical School of Ioannina, Greece.

57 years, female

Area of Interest Neuroradiology brain ; Imaging Technique MR
Clinical History
57-year-old woman with acute lymphoblastic leukaemia presented with diplopia. The ophthalmologic examination revealed papilloedema. A brain MRI was performed.
Imaging Findings
Brain-MRI reveals on T1- weighted images after contrast administration thickening and enhancement of perineural structures of the optic nerves (Fig. 1), the trigeminal nerves (Fig. 2), the complex of seventh and eighth cranial nerves (Fig. 3) as well as enhancement of the oculomotor nerves (Fig. 4 a, b) and nodular leptomeningeal enhancement (Fig. 4 c, d ). Cerebrospinal fluid cytologic examination confirmed the diagnosis of leukaemic meningitis.
Leukaemias are a heterogenous group of haematologic malignancies that result from neoplastic proliferation of immature haematopoietic cells that can infiltrate virtually any anatomic location, both by direct or haematogenous spread. The CNS complications of leukaemia include leptomeningeal, brain parenchyma, or cerebral vascular involvement. The most common pathology of the central nervous system (CNS) is leukaemic meningitis (33%), typically presented with signs and symptoms of increased intracranial pressure (headache, nausea, vomiting, irritability, lethargy, papilledema) or cranial nerve palsies [1]. Cerebrospinal fluid cytologic confirmation is necessary for the diagnosis, but there is a high frequency of false-negative results, especially in isolated nerve involvement. MR imaging can play an important role in the presence of papilledema or negative cytologic studies. In these cases, MRI demonstrates leptomeningeal disease, revealing abnormal, smooth or nodular, enhancement of the meninges and nerve roots after contrast administration. In some cases, abnormal cranial nerve enhancement on MRI may be the only clue to the underlying disease as a result of disruption of the blood–nerve barrier. When there is a disruption of the normal blood-nerve barrier, the contrast material enters the subarachnoid space and perineural enhancement is shown [2]. In rare cases, leukaemia may give rise to solid tumours consisting of myeloid leukaemic blasts called granulocytic sarcomas or chloromas. The term chloroma results from the greenish colour of these tumours caused by the presence of myeloperoxidase. Chloromas usually have a dural attachment, although parenchymal tumours have rarely been reported. These tumours are hypercellular and avidly enhance with either cranial MR or CT. Chloromas were detected in the orbit, the temporal bone, and the cerebellopontine angle [3]. In addition, leukaemic patients may develop disseminated intravascular coagulation with resulting hypofibrinogenaemia, and a pattern of multiple small haemorrhages in subcortical white matter. Bilateral subacute haematomas and multiple small intraparenchymal haemorrhages were also detected [4]. Ocular manifestations are present in 39–53% cases with retinal haemorrhage as the most frequent finding [5]. Apart from direct leukaemic involvement of CNS structures, there are other complications such as treatment-related neurotoxicity, drug-induced PRES, secondary brain tumours, infections, and cerebrovascular disorders [6-10]. In conclusion, neuroimaging is important to detect leukaemic involvement of CNS structures especially in presence of papilledema or a false-negative cytological study.
Differential Diagnosis List
Leukaemic meningitis with multiple cranial nerve enhancement.
Final Diagnosis
Leukaemic meningitis with multiple cranial nerve enhancement.
Case information
DOI: 10.1594/EURORAD/CASE.12889
ISSN: 1563-4086