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59 y.o . F who presented with bilateral lower extremity weakness

59 y.o . F who presented with bilateral lower extremity weakness. PMH: widely metastatic breast CA diagnosed in 2009 (Her2-, ER+, PR+) s/p paclitaxel , bevacizumab , and letrozole recurred in 2010, s/p gemcitabine disease progression, s/p capecitabine + zometa

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59 y.o . F who presented with bilateral lower extremity weakness

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  1. 59 y.o. F who presented with bilateral lower extremity weakness

  2. PMH: • widely metastatic breast CA diagnosed in 2009 (Her2-, ER+, PR+) • s/p paclitaxel, bevacizumab, and letrozole • recurred in 2010, s/p gemcitabine • disease progression, s/p capecitabine+ zometa • disease progression, s/p radiation to lumbar spine and hip • PE in 2011 on lovenox • Meds: • Zometa, Lovenox, Xeloda

  3. Examination • Diffuse bilateral lower extremity weakness at 4/5

  4. Imaging

  5. Differential for lower extremity weakness • cerebral (compression of bilateral ACA) • Spinal • Metabolic (B12, lipomatosis) • Vascular (hematoma, AVM) • Infectious(abscess, AIDs, TB, syphilis) • Trauma • Congenital (ALS, GBS, CIDP, myopathyies, ATM, MS)

  6. Staging for breast cancer Stage 0: carcinoma in situ: 99% 5 year survival Stage 1: < 2 cm carcinoma: 92% Stage 2: > 2 cm carcinoma, no nodal involvement: 60-80% Stage 3: nodal involvement or large tumor: 40-60% Stage 4: distal metastasis: 14%

  7. RPA classification

  8. Surgical approach • Anatomic considerations • Motor strip • Cortical veins • ACA • Extent of retraction • Air embolus • Anesthesia considerations • Brain relaxation • Precordialdoppler • Centeral line • Pre-operative assessment • Oncologic history • IVC, discontinue filter

  9. Air embolus • Tachycardia • Drop in end title CO2 • Hypotension Maneuver • Flood the field, drop the head, jugular compression, terminate surgery • Stop nitrous oxide, ventilate with 100% O2 • Central line suction, left side down

  10. Cerebral swelling • Identify source • Position: head up, release neck strain • ICP maneuvers: hyperventilate, mannitol, lasix, EVD • Craniectomy • Lobectomy • Pentobarb coma (10 mg/kg over 30 minutes, 5 mg/kg q 1 hr x 3 hrs, 1 mg/kg/hr), titrate <5 mg% or EEG flattening.

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