In summary, you have a 40 year old woman presenting with neuro complaint and a scary looking head CT scan. Click HERE for the original post.
What is your diagnosis and management?Her history of “breast surgery” and mastectomy scars give a clue to her medical history of breast cancer. Given that, metastatic breast cancer to the brain is pretty high on the differential. The head CT also shows some vasogenic edema surrounding the mass.
As EM docs, our first priority is stabilize, stabilize, stabilize, so ABCs, IV, O2, monitor should be the first step in management. Afterwards, you can call your consults and admit the patient for further testing. Brain metastases with perilesional edema respond well to glucocorticoids, so consider giving dexamethasone. Dosing recommendations vary significantly depending on who you ask. Although these patients have an increased risk of seizures, prophylactic AEDs have not shown to reduce the risk of a first seizure.
If this patient presented with a submassive PE, what would be your management?Intracranial neoplasm is an absolute contraindication to TPA. However, these patients can be fully anticoagulated. In a study published by
Blood in May 2015, therapeutic anticoagulation did not increase the risk of ICH in patients with brain metastases and blood clots.
References Ewend, M. G., Morris, D. E., Carey, L. A., Ladha, A. M., & Brem, S. (2008). Guidelines for the Initial Management of Metastatic Brain Tumors: Initial Medical Stabilization: Control of Seizures and Cerebral Edema. Retrieved from http://www.medscape.org/viewarticle/574607_2
Jessica Donato, Federico Campigotto, Erik J. Uhlmann, ErikaColetti, Donna Neuberg, Griffin M. Weber, Jeffrey I. Zwicker. Intracranial hemorrhage in patients with brain metastases treated with therapeutic enoxaparin: a matched cohort study. Blood Jan 2015, DOI: 10.1182/blood-2015-02-626788
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EM/IM Resident at Kings County/SUNY Downstate
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