Neurologic emergency

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Neurologic emergency

• 28 JUNE 2005
• Jin-Hee Ahn, M.D.
• Division of Oncology, Asan Medical Center

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Classification of oncologic emergencies

• 1. Structural-obstructive oncologic emergencies
• 2. Metabolic emergencies
• 3. Treatment-related emergencies

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Structural-Obstructive emergencies

• Spinal cord compression
• Increased intracranial pressure
• SVC syndrome
• Pericardial effusion/ tamponade
• Intestinal obstruction
• Malignant biliary obstruction

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Metabolic emergencies

• Hypercalcemia
• Hyponatremia of malignancy
• Lactic acidosis
• Hypoglycemia
• Adrenal insufficiency

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Treatment-related emergencies
Neutropenia and infection Tumor-lysis
syndrome Hemolytic-uremic syndrome Pulmonary
infiltrates Hemorrhagic cystitis DIC
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Neurologic emergencystructural-obstructive
oncologic emergency
- Spinal cord compression - Brain
metastasis - Leptomeningeal seeding
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Neurologic emergencystructural-obstructive
oncologic emergency
- Spinal cord compression - Brain
metastasis - Leptomeningeal seeding
8
? ?

• Chief complaint both lower extremity weakness
  onset) 1 week ago
• ?/55      - 2 ? ? ????? ?? ?? ?????? ??
  (MRM, modified radical mastectomy)
• (?? pT2N1M0, ER(-)/PR(-)) ? ?? ? ?? ?????? 4?
  ??
• - 6 ?? ? ? ??? ??? ???? ?????? ?? ?? ??
• - ??? ??? ?? ????? ?? ??? ??? ?? ???? ????
• ?? ?? ??? ?? ?? ??? ???? ??? ??

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• Physical examination
• Vital sign 120/80mmHg 20/min 80/min 36.5 ?C
• General chronic ill-looking
• alert mentality, intact orientation
• HEENT pinkish conjunctiva
• clear sclera
• No palpable neck lymphadenopathy
• Respiratory clear breathing sound without
  crackle
• regular heart beat without murmur
• Abdomen soft and flat
• normoactive bowel sound
• no palpable organomegaly
• Back Ext CVA tenderness (-)
• no palpable inguinal LN
• Lower back pain with tenderness

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? ? (1)

• Neurologic examination
• Sensory
• numbness (-) / paresthesia (-)
• Motor power
• both upper extremity normal (grade V)
• both lower extremity decreased motor power
  (grade I)
• Autonomic function
• anal sphincter tone intact

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• ? ???? ??? ???? ? ??? ?? ??? ?????

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Spine MRI

Steroid Tx
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• ?/44
• - ???? ???? ??
• - ?? ?? ??? ??, 5???? ???? ?? ???? ???? ?????
  ??? ??

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Posterolateral fixation at L1-L4
Breast cancer
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Epidemiology
? ? (1)

• ????? ???? ?? ???? ???
• ?? ?? ?? ? ??? 5-10
• ????? ??? ??? 20
• ?? ?? ??, ???, ????, ??????
• ???? ??? ???? ?? ?? ?? 10
• ???? ?? ??? ???? ?? ??

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? ? (1)
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1. Intramedullary
2. Leptomeningeal
3. Epidural ant. aspect of spinal canal
4. Epidural paravertebral tumors invading
   vertebral foramina
5. Metastasis arising in the epidural space itself

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Pathophysiology
? ? (1)
hypoxia
Capillary blood flow ?
27
?? ??
Multiple gt 50
Most mechanically prone to compression because
of natural kyphosis and because it occupies
most of the intrathecal cross section
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PAIN (??)

• 83 95 of patients (median of 8 weeks)
• Local pain
• Exacerbated after a period of lying down
  because of distension of the epidural venous
  plexus (often worse in supine position at night)
• Radicular pain
• Usually associated with local back pain
  caused
• by compression of nerve root
• Thoracic epidural lesions can lead to
  bilateral,
• gripping girdle discomfort

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MOTOR DEFICITS

• 6085 of patients have weakness at diagnosis
• Two-thirds of patients are non-ambulatory when
  diagnosed.
• Weakness is most severe with thoracic epidural
  spinal cord compression
• Pretreatment neurologic status is by far the most
  important
• predictor of function after treatment

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SENSORY DEFICITS

• Less common than weakness
• 4090 of patients have sensory deficits at
  diagnosis
• Radicular sensory loss or loss of reflex is a
  more reliable localiser
• Lhermittes sign (electric-shock-like sensations
  in the back and extremities with neck flexion)
  can be seen with cervical or thoracic epidural
  spinal cord compression

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BOWEL AND BLADDER DYSFUNCTION

• Autonomic dysfunction
• - Usually occurs late in course
• - ?Anal tone, ?Perineal sensibility, Distended
  bladder
• - Loss of bladder or bowel control
• - Unfavorable Px. factor

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Clinical presentation of spinal cord compression
34
??

• Clinically suspected epidural spinal cord
  compression must be confirmed by imaging not only
  to define the diagnosis, but also to make
  informed decisions about surgery, radiotherapy,
  chemotherapy, or supportive care and palliation
• CT and MRI remain the two most useful diagnostic
  and management tools in metastatic spinal cord
  compression

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MRI

• - Diagnostic procedure of choice
• - Sensitivity 93, specificity 97
• - Can distinguish between benign metastatic
  causes
• of vertebral body collapse
• - Ability to distinguish spinal cord from other
  soft tissues
• in spinal canal
• - The full-length image of cord provided by MRI
  is useful

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?? ??

• Diagnosis of spinal cord compression requires
  emergent Tx.
• Patients with gradual rather than rapid onset of
  pretreatment paresis ? better motor function and
  ambulation
• ?? ??
• - ?? ??
• - ?? ?? ?? ? ??
• - ?? ??? ??

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?? ??

• Corticosteroids
• RT
• Surgery
• Chemotherapy

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Corticosteroid

• Mechanism
• - Reduce edema
• - Inhibit inflammatory response
• - Stabilise vascular membranes
• - Delay the onset of neurological deficit in
  spinal cord compression
• Optimal dose schedule not proven
• - High vs. Low-dose dexamethasone
• - Any dose of 16100 mg dexamethasone per day is
  appropriate
• Routine use in patients with asymptomatic early
  cord compression in not necessary

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Radiation therapy

• Pain reduction in 70 of patients
• Motor function improvement in 4560
• Reverses paraplegia up to 1121
• Early Dx. of SCC is the most significant factor
  in Tx. outcome
• By convention, 200300cGy per fraction to total
  dose not exceeding 30004000cGy to spinal cord
  in 24 weeks
• Radiosurgery single high dose of radiation
  delivered by use of stereotactic guidance ? still
  unproven

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Surgery

• Indication
• (1) Unknown diagnosis
• (2) Spinal instability or compression by bone
• (3) Failure to respond to RT
• (4) Maximal allowable RT dose already
  administered
• to spinal cord

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Surgery anterior and posterior surgery and
fixation
T1-weighted image
T2-weighted image
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CONCLUSIONS

• When feasible, surgical management should be
  offered to patients with malignant spinal cord
  compression.
• Radiotherapy is an excellent adjuvant to surgery
  and may be used as the only management in
  patients who are unsuitable for surgery or when
  palliation is the aim

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Neurologic emergencystructural-obstructive
oncologic emergency
- Spinal cord compression - Brain
metastasis - Leptomeningeal seeding
44
? ?

• M/52
• ?? 4??? ????? ??(Non-small cell lung cancer)?
  ???(stage IV)? ????, ??? ????? ????? ??? ?? 1??
  ??? ??? ?? ? ?? ??? ?? ??? ??? ??? (Gait ataxia)
  ???? ??

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Brain CT
? ? (2)
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? ?
? ? (2)

• ?/ 37
• - 5?? ????? ???? ?? (MRM) ??
• - ?? ??? ????? 5??? ??? ?? ? ? ?? ?? ??? ??? ???
  ?? ? 2???? ??? ?? ??? ????? ? ?? ??? ???? ??? ??
  ??? ??? ??.

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Brain MRI
? ? (2)
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? ?
? ? (2)

• ?/ 60
• - 1?? ????(renal cell carcinoma)?? ???? ????
  (radical nephrectomy) ??? ???? ??? ?????? ?????
  ????? ? ??? ??? ?? ?? ?? ?? ??? ??? ???.
• - ?? 2? ??? ??? ?????, ?? ?? ?? ? ?? ??? ???
  ???? ??.

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Brain CT
50
?? ?? (???Brain metastasis)

• ?? ??
• ???, ?? ??? ???
• ??, ????, ?????, ????
• ????
• ??, ??, ??, ?? ??, ??, ???? ??
• if ???? ?? (??? ???? ? ????)
• ? ?? ??
• ?? ?? ??? ??
• - ????
• - Brain MRI, or Brain CT

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?? ? ?? ? ??
Maximal medical management

• 1. Hyperventilation ? pCO2 ??, ??? ??
• 2. Mannitol (1-1.5 g/kg q6h)
• - blood brain ?? osmotic gradient ??
• - water from the brain ? higher osmolarity in
  the blood
• 3. Dexamethasone ? edema control
• Whole brain RT
• Surgical excision
• ????? (gamma-knife)

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Neurologic emergencystructural-obstructive
oncologic emergency
- Spinal cord compression - Brain
metastasis - Leptomeningeal seeding
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Leptomeningeal Seeding

• ??
• Metastasis from solid tumors that seed the
  leptomeninges
• ??
• ??? 510 (solid tumor) / 19 (autopsy)
• ??? adenocarcinoma (m/c)
• ???? breast gt lung gt melanoma
• In Korea stomach gt breast gt lung
• ( Park et al, 2001)
• ??? ??? ?? 3375
• ???? ????, ????? ???? ??? ?? ?? ??, ??? ???.

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????

• Symptoms
• ??
• ????? ??
• ??? ?? ??(ptosis,EOM??, dysarthria, facial
  weakness)
• ??, ?????(radicular pain)
• ??, ????
• ????
• ??? ????
• Signs
• ?? ???? ???? ???? ??? ????
• ? ?? ??? ??? ?? ?? multiple level? ???? ?? ???
  ?? ? ??? ??? ?!!!

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??

• Spinal tapping cytology
• Radiologic imaging brain MRI

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?? ??? ??? ? ????

• ???? ???? ???? ??
• ????? ???? ???? ??
• ??? ?? ?? ??? ??? ???? ????? ???? ??? ?? ??
• ( ???? ??? ???? ????)

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?? ??

• Intrathecal chemotherapy
• ????
• Intermittent spinal tapping
• Subcutaneous reseroir and ventricular catheter
• ( Ommaya reservoir )
• ????
• Methotrexate / Thiotepa / Ara-C
• Radiation therapy (whole brain / spinal cord)
• Symptomatic area
• CSF flow obstruction by tumor mass

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??

• Improvement of neurologic status
• Improvement 38
• Continue stable status 23
• ( Park et al, J Korea Cancer Assoc 2001)
• Prolongation of survival
• No treatment 4-6 weeks
• Treatment and responsive 6 months

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Neurologic emergency

• Prompt diagnosis can lead to early
  intervention
• It can often be life saving..
• or improve quality of life

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?????.

• 2005/06/28 ? ? ?