59 y.o . f who presented with bilateral lower extremity weakness
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: 59 y.o . F who presented with bilateral lower extremity weakness](https://reader035.vdocument.in/reader035/viewer/2022062521/568167a0550346895ddce9cb/html5/thumbnails/1.jpg)
59 y.o. F who presented with bilateral lower extremity weakness
![Page 2: 59 y.o . F who presented with bilateral lower extremity weakness](https://reader035.vdocument.in/reader035/viewer/2022062521/568167a0550346895ddce9cb/html5/thumbnails/2.jpg)
![Page 3: 59 y.o . F who presented with bilateral lower extremity weakness](https://reader035.vdocument.in/reader035/viewer/2022062521/568167a0550346895ddce9cb/html5/thumbnails/3.jpg)
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
![Page 4: 59 y.o . F who presented with bilateral lower extremity weakness](https://reader035.vdocument.in/reader035/viewer/2022062521/568167a0550346895ddce9cb/html5/thumbnails/4.jpg)
![Page 5: 59 y.o . F who presented with bilateral lower extremity weakness](https://reader035.vdocument.in/reader035/viewer/2022062521/568167a0550346895ddce9cb/html5/thumbnails/5.jpg)
Examination
Diffuse bilateral lower extremity weakness at 4/5
![Page 6: 59 y.o . F who presented with bilateral lower extremity weakness](https://reader035.vdocument.in/reader035/viewer/2022062521/568167a0550346895ddce9cb/html5/thumbnails/6.jpg)
![Page 7: 59 y.o . F who presented with bilateral lower extremity weakness](https://reader035.vdocument.in/reader035/viewer/2022062521/568167a0550346895ddce9cb/html5/thumbnails/7.jpg)
Imaging
![Page 8: 59 y.o . F who presented with bilateral lower extremity weakness](https://reader035.vdocument.in/reader035/viewer/2022062521/568167a0550346895ddce9cb/html5/thumbnails/8.jpg)
![Page 9: 59 y.o . F who presented with bilateral lower extremity weakness](https://reader035.vdocument.in/reader035/viewer/2022062521/568167a0550346895ddce9cb/html5/thumbnails/9.jpg)
![Page 10: 59 y.o . F who presented with bilateral lower extremity weakness](https://reader035.vdocument.in/reader035/viewer/2022062521/568167a0550346895ddce9cb/html5/thumbnails/10.jpg)
![Page 11: 59 y.o . F who presented with bilateral lower extremity weakness](https://reader035.vdocument.in/reader035/viewer/2022062521/568167a0550346895ddce9cb/html5/thumbnails/11.jpg)
![Page 12: 59 y.o . F who presented with bilateral lower extremity weakness](https://reader035.vdocument.in/reader035/viewer/2022062521/568167a0550346895ddce9cb/html5/thumbnails/12.jpg)
![Page 13: 59 y.o . F who presented with bilateral lower extremity weakness](https://reader035.vdocument.in/reader035/viewer/2022062521/568167a0550346895ddce9cb/html5/thumbnails/13.jpg)
![Page 14: 59 y.o . F who presented with bilateral lower extremity weakness](https://reader035.vdocument.in/reader035/viewer/2022062521/568167a0550346895ddce9cb/html5/thumbnails/14.jpg)
![Page 15: 59 y.o . F who presented with bilateral lower extremity weakness](https://reader035.vdocument.in/reader035/viewer/2022062521/568167a0550346895ddce9cb/html5/thumbnails/15.jpg)
![Page 16: 59 y.o . F who presented with bilateral lower extremity weakness](https://reader035.vdocument.in/reader035/viewer/2022062521/568167a0550346895ddce9cb/html5/thumbnails/16.jpg)
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)
![Page 17: 59 y.o . F who presented with bilateral lower extremity weakness](https://reader035.vdocument.in/reader035/viewer/2022062521/568167a0550346895ddce9cb/html5/thumbnails/17.jpg)
Staging for breast cancer
Stage 0: carcinoma in situ: 99% 5 year survivalStage 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%
![Page 18: 59 y.o . F who presented with bilateral lower extremity weakness](https://reader035.vdocument.in/reader035/viewer/2022062521/568167a0550346895ddce9cb/html5/thumbnails/18.jpg)
RPA classification
![Page 19: 59 y.o . F who presented with bilateral lower extremity weakness](https://reader035.vdocument.in/reader035/viewer/2022062521/568167a0550346895ddce9cb/html5/thumbnails/19.jpg)
Surgical approach
Anatomic considerations• Motor strip• Cortical veins• ACA• Extent of retraction• Air embolus
Anesthesia considerations• Brain relaxation• Precordial doppler• Centeral line
Pre-operative assessment• Oncologic history• IVC, discontinue filter
![Page 20: 59 y.o . F who presented with bilateral lower extremity weakness](https://reader035.vdocument.in/reader035/viewer/2022062521/568167a0550346895ddce9cb/html5/thumbnails/20.jpg)
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
![Page 21: 59 y.o . F who presented with bilateral lower extremity weakness](https://reader035.vdocument.in/reader035/viewer/2022062521/568167a0550346895ddce9cb/html5/thumbnails/21.jpg)
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.