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Brain metastases
Signs and Symptoms
Neurological deficits
Seizures
Giddiness/Headache
Confusion, drowsiness
Change in Mentation
Gradual onset vs stroke sudden
Brain metastases
Differential Diagnosis
Intracranial events
Sepsis
Metabolic
Drugs (e.g. morphine)
Mdm CMK
32 chinese female
Previously diagnosed with L breast Ca (T1b N1 M0 ) after
she self palpated breast lump
- WEAC done 2006
- histo 10 mm , 1/10 LN positive , SBR Grade 3 , extensive
LVSI , margins -ve
- ER /PR -ve Her2Neu -ve ie triple negative
- s/p AC #4 then RT
Currently admitted from clinic May 2010 for
headache last 3 months
Any further history you would like to take?
Mdm CMK
32 chinese female
Previously diagnosed with L breast Ca (T1b N1 M0 ) after she self palpated
breast lump
- WEAC done 2006
- histo 10 mm , 1/10 LN positive , SBR Grade 3 , extensive LVSI , margins ve
- ER /PR -ve Her2Neu -ve ie triple negative
- s/p AC #4 then RT
Patient alert
Afebrile
VS stable
H S1S2
L clear
A soft NT no HPM
moving all 4 limbs
no sensory deficit
Left dysmetria
Hypocount
Baseline CLC
CT
MRI
If plan for op preop bloods
Septic workup if infection is a differential
CT Brain
MRI brain
Case 2
Metastatic colon Ca dx August 2009.
OGD: normal; colonoscope 12/8/09: sigmoid Ca (malignant
stricture); CEA 12/08/09: 28.1
- underwent left hemicolectomy on 24/8/09.
Histo: Moderately differentiated adenocarcinoma reaching
pericolonic fat ( pT3). 16 benign lymph nodes.
- Post-operatively Xelox #2, underwent liver resection ( left
hemihepatectomy and segment VI resection 3/12/2009) then Xelox
x 6 cycles
Histo: Metastatic adenocarcinoma.
- noted lung nodules Sep 2010 s/p #4 Xeliri
-PD at anastomotic site, s/p extended AR in April 2011 subsequently
declined further chemo
MRI Brain
Brain metastases
Management
IV Steroids - reduces oedema & provides symptomatic relief
Consider iv Mannitol effective within min; last several
hours
Whole brain RT (whether or not op done)
Refer Neurosurgery for decompression/ VP shunt if:
Solitary brain met
Large brain metastasis
Posterior fossa lesion
Hydrocephalus
Management of fits
Ensure respiratory and circulatory status ( and supportive
therapy eg mechanical ventilation given as needed)
Blood sugar level ensure fits not due to hypoglycemia
Benzodiazepines eg diazepam 0.1 0.3 mg/kg ( stat dose
either IV or rectal suppository) for rapid control
Phenytoin ( given up to 20mg/kg)
Increased risk of hypotension and cardiac arrthymias with faster
infusion rates
Cardiac monitoring required
Pericardial Tamponade
Pericardial Tamponade
Signs and Symptoms
Breathlessness, chest pain, orthopnoea, lethargy
Becks Triad tamponade
Raised JVP
Muffled heart sounds
Hypotension
Pulsus Paradoxus
Pericardial Tamponade
Diagnosis
CXR:
borders
ECG small voltages
Small bilateral pleural effusions
Pericardial Tamponade
Confirmatory Diagnosis
2DE separation of pericardial layers can be detected
when fluid exceeds 1535 ml; early diastolic collapse of
RV wall (tamponade)
CT Chest
Pericardial Tamponade
Management
IV Drip to maintain intravascular volume
Avoid diuretics
Refer to CVM and CTS
Pericardial window
In the meantime - pericardiocentesis
Non-malignant
Long-term central venous catheters, thrombosis
Cough 24%
Arm swelling 18%
Chest pain 15%
Dysphagia 9%
Signs
Neck veins distended
66%
Venous distension of
oedema
Cyanosis 20%
Facial plethora 19%
CT Chest
cause
ABCs of resuscitation
Oxygen
Nurse at 45
Diuretics (iv lasix 40mg) if SBP >100mmHg
IV dexamethasone 8mg tds (withhold in patients
thrombolysis
Surgery (rare)
lymphoma, germ cell tumours- all are chemosensitive tumors and potentially curable chemo
will be primary treatment
- malignant lymphoma
- small cell lung carcinoma
Nursing care
Assessment of worsening neurological,
pulmonary and cardiac function
Elevation of HOB, oxygen and allaying anxiety
Decrease exertion
Fluid balance