Blazek, Audrey

Abstract BACKGROUND Leptomeningeal carcinomatosis is commonly considered when patients present with meningeal enhancement on magnetic resonance imaging (MRI), even without a known primary malignancy. In practice, some clinicians advocate for early meningeal biopsy to expedite diagnosis, citing lack of specificity of other testing, such as cerebrospinal fluid (CSF) analysis. METHODS We identified a cohort of patients with meningeal enhancement that underwent biopsy for diagnostic purposes between 2010 and 2022. Presenting symptoms, physical exam, enhancement pattern on MRI, other imaging findings, CSF parameters, other laboratory results, final diagnosis, and recommended treatment were recorded when available. RESULTS Out of nearly 100 cases included, the majority were autoimmune or inflammatory in etiology. Only 13 patients were diagnosed with malignancy-related enhancement, and 10 of these cases were felt to be true carcinomatosis. Nine out of the 13 patients were diagnosed with lymphoma. Four of these lymphomas were diagnosed on systemic biopsy, with meningeal biopsies negative for malignant cells. The other malignancies included systemic adenocarcinoma, oligodendroglioma, and a rare hematologic cancer. Nearly all 13 patients had abnormal CSF parameters, notably pleocytosis, but none had malignant cells in the fluid. Most frequent presenting symptoms were encephalopathy, vision changes, and strength/sensory changes. MRI often showed cranial nerve or general cerebral and cerebellar involvement, and physical exam often showed cranial nerve, strength, and sensory deficits. All patients proceeded with chemotherapy after diagnosis. CONCLUSIONS When leptomeningeal carcinomatosis is considered based on MRI enhancement, the clinical approach should continue to revolve around indirect testing such as CSF analysis, serum studies, and other imaging techniques to consider alternative biopsy sites before pursuing direct sampling with meningeal biopsy. With this approach, many patients with suspected carcinomatosis can avoid undergoing meningeal biopsy and decrease the chance of treatment delay.

Objective: To evaluate the efficacy of adding large molecule anti-calcitonin gene-related peptide monoclonal antibodies (mAbs) to onabotulinumtoxinA (OBT-A) for chronic migraine prevention. Background: Chronic migraine (CM) is a highly prevalent, debilitating disorder that leads to personal, social, and economic burdens. Both OBT-A and mAbs are proven safe and effective in chronic migraine prevention. The use of combination therapy has not been formally studied but may prove more effective than either monotherapy alone in select patients. Methods: This is a retrospective chart review of patients with chronic migraine, treated with OBT-A, who received additional mAb preventative therapy. The primary endpoint was migraine headache days per month (MHD) after 3 months of combined therapy. Secondary endpoints included total headache days per month, headache intensity, disability level, and use of abortive medications. Results: Of 1503 patients reviewed, 133 met inclusion criteria. At 3 months of combined therapy, mean reduction of MHD from baseline was 6.2 (95% CI 4.91 to 7.49, p < 0.0001). Nearly 2/3rd of patients (60.9%) experienced ≥ 50% MHD reduction. Fewer patients reported high disability level (14.6% [17/126], compared to 29.4%) and high headache intensity (13.0% [16/119], compared to 51.3%) at 3 months (all p < 0.0001). A reduction in abortive medication doses needed and discontinuation of concomitant oral preventative medications was also noted in 15.8% and 6.8% of patients, respectively. Conclusions: Combined therapy with OBT-A and mAbs is well-tolerated, effective in further reducing migraine frequency, and may improve quality of life for patients with CM refractory to monotherapy.