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The neoplasms metastasizing most commonly to the leptomeninges are carcinoma of the breast, lymphomas, and leukemia Leptomeningeal metastases lead to multifocal neurologic deficits, which may be associated with infiltration of cranial and spinal nerve roots, direct invasion of the brain or spinal cord, obstructive hydrocephalus, or some combination of these factors

Tumors may lead to spinal cord dysfunction by direct compression, by ischemia secondary to arterial or venous obstruction, and, in the case of intramedullary lesions, by invasive infiltration

Symptoms and signs of expanding intracranial mass May be signs of primary infection or congenital heart disease Fever may be absent

Symptoms usually develop insidiously Pain is often conspicuous with extradural lesions; is characteristically aggravated by coughing or straining; may be radicular, localized to the back, or felt diffusely in an extremity; and may be accompanied by motor deficits, paresthesias, or numbness, especially in the legs When sphincter disturbances occur, they are usually particularly disabling Pain, however, often precedes specific neurologic symptoms from epidural metastases Examination may reveal localized spinal tenderness A segmental lower motor neuron deficit or dermatomal sensory changes (or both) are sometimes found at the level of the lesion, while an upper motor neuron deficit and sensory disturbance are found below it

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Brain abscess presents as an intracranial space-occupying lesion and arises as a sequela of disease of the ear or nose, may be a complication of infection elsewhere in the body, or may result from infection introduced intracranially by trauma or surgical procedures The most common infective organisms are streptococci, staphylococci, and anaerobes; mixed infections are not uncommon

Select Maintain Billing Plan Types for Periodic Billing In this view, seen in Figure 7-12, you assign values to a periodic billing plan type To create your own, simply copy the standard and name your copy ID with a prefix of Z

Findings on plain radiography of the spine may be normal but are commonly abnormal when there are metastatic deposits CT myelography or MRI may be necessary to identify and localize the site of cord compression The combination of known tumor elsewhere in the body, back pain, and either abnormal plain films of the spine or neurologic signs of cord compression is an indication to perform these studies on an urgent basis Some clinicians proceed to myelography based solely on new back pain in a cancer patient If a complete block is present at lumbar myelography, a cisternal myelogram is performed to determine the upper level of the block and to investigate the possibility of block higher in the cord

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

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

The cerebrospinal fluid removed at myelography is often xanthochromic and contains a greatly increased protein concentration with normal cell content and glucose concentration

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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