14.8 (14.1) neurological problems in advanced cancer Flashcards
List SEVEN features of intracranial pressure waves (aka inc ICP).
◆ altered state of consciousness, agitation, delirium
◆ focal/generalized seizures
◆ cerebellar fits (opisthotonus - WP: think tetanus posture)
◆ decortication or decerebration posture
◆ amaurosis (transcient vision loss), anisocoria (unequal pupil size)
◆ II, IV, VI nerve paralysis, conj. eye deviation (WP: conj. = both)
◆ nystagmus, tinnitus
◆ myoclonus of face and limb
◆ dysarthria, dysphagia
◆ headache, neck pain
◆ pyramidal signs, paraesthesiae
◆ CV/Resp disturbances, yawning, hiccup
◆ hyperthermia, face cyanosis, flushing, pallor, sweating
◆ nausea, vomiting, sialorrhoea, diarrhea, incontinence
List FOUR features of a HA that would make you concerned about increased ICP
◆ Progressive, severe, diffuse
◆ More intense in the supine position*
◆ Worse in AM immediately after awakening *
◆ Worsen w/ head movement, cough, Valsalva*
◆ Accompanying N/V*
- projectile vomiting in children -> post fossa lesions
FS:
- morning headache
- worse supine + valsalva (2)
- comes with N/V
List four types of brain edema that can cause increased ICP and their mechanisms. Which is the most common type in advanced cancer?
Vasogenic edema - increase of extracellular fluid caused by increased capillary permeability (due to lesions that damages the blood brain barrier)
osmotic edema - increase of extracellular fluid caused by plasma hypoosmolarity (ie. SiADH)
Interstitial edema - increase of extracellular fluid caused by blockade of csf resorption at any level
cytoxic edema - increase in intracellular fluid due failure of intracellular ion pump ( caused by ischemic or hypoxic cellular damage)
*vasogenic edema most common in advanced cancer
FS: VOIC
List three interventions for reducing ICP and maintaining cerebral perfusion pressure
Positioning - neutral head position at least 30 degrees above heart
Infusion of hypertonic solutions (mannitol, hypertonic saline) - works only if blood brain barrier intact
Corticosteroids
List 8 side effects of corticosteroids (box 14.1.2 + 14.8.3)
◆ BRAINZ
- pseudotumor cerebri
◆ Cutaneous
- delay in wound healing
- thinning of skin
- easy bruising
- epidural lipomyotosis
◆ Endo
- hyperglycemia
- adrenal suppression
- immunosuppression
◆ GI
- PUD
- perineal burning sensation
◆ Muscular
- myopathy
(impacts pelvic girdle, head flexors & shoulder)
◆ Bone
- osteoporosis
- aseptic necrosis of the fem head
◆ Psych
- dysphoria
- aggressiveness/irritability
- psychosis/hallucination/delirium
◆ Ocular
- glaucoma
- cataract
FS:
Insomnia
Delirium
Agitation
PUD
GI bleed
Hyperglycaemia
Adrenal insufficiency
Hypogonadism
Proximal muscle weakness
Osteoporosis
Skin changes (easy bruising)
What is the role of seizure prophylaxis in patients with brain mets (no seizure hx)
Not utilized
List three antiseizure meds that induce CYP 3A4
Antiepileptic agents that can induce CYP3A4 are carbamazepine, phenobarbital, phenytoin, and primidone
List 2 features of status epilepticus
≥5 minutes of continuous seizures
≥2 discrete seizures between which there is incomplete recovery of consciousness
WP: used Uptodate def because 5th/6th answers suck
You are on the PCU when a patient develops status epilepticus. The patient has no IV access. List three medications and their routes that can be used to a treat a seizure
Phenobarbital - subcutaneous
midazolam - subcutaneous
lorazepam - subcutaneous, sublingual
List the three most common cancers associated with brain mets
Lung
breast
melanoma
List 3 ways by which brain mets cause symptoms
Local destruction compression brain edema bleeding irritation of surrounding brain tissue
How do corticosteroids reduce edema from brain mets
reduction in peritumoral edema due to partial restoration of the blood brain barrier
What 3 factors determine the functional outcome of a patient with epidural spinal cord compression
degree of neurlogical impairment at diagnosis
promptness of treatment
response to treatment
List 4 features of pain that suggests spinal cord compression
crescendo pattern
worse with cough or valsalva
pain lying down
longstanding pain that changes characteristics
radicular pain
+ Lhermitte’s (barber’s chair sign)
FS:
L - radicular pain
O - Acute worse I g
P - valsalva, lying down
Q - sharp stabbing
R - radicular
S
T - crescendo pain
List 3 treatments for underlying epidural spinal cord compression
surgery
radiation
steroids
List four indications for surgery in the setting of spinal cord compression
site of primary tumor unknown
spinal instability or vertebral displacement*
plegia of rapid onset*
neurological symptoms progress during radiotherapy*
relapse after xrt
tumor not likely radiosensitive*
Leptomeningeal disease represents dissemination of tumour cells in what space
subarachnoid space
Leptomeningeal disease is most commonly seen in what four cancers
Lung* Breast * Melanoma * lymphoma leukemia
List four common symptoms of leptomeningeal disease
Headache* change in mental status* Seizure radicular type pain* Cauda equina cranial nerve involvement polyradiculopathy *most common
List four findings of leptomeningeal disease in csf
high opening pressure high protein content increased white cell count low glucose \+/- malignant cells
List three treatments for leptomeningeal disease
corticosteroids
radiotherapy
intrathecal or intraventricular chemo
systemic chemo
A patient develops numbness in the chin but no pain. What nerve is likely involved?
Mental nerve
A patient has pain in the neck and throat which radiates to the ear. Pain is aggravated by swallowing.
What nerve is likely involved?
Severe pain may be associated with what other cardiac feature?
glossopharyngeal nerve
syncope
A patient with breast ca develops pain in the shoulder, elbow, hand and 4th & 5th fingers.
What complication is occurring?
Which malig is it common in?
◆ brachial plexopathy
◆ breast, lung, lymphoma
List 4 reasons a patient with cancer may develop a peripheral neuropathy or polyneuropathy
◆ myeloma associated neuropathies
◆ paraneoplastic sensory neuropathy
◆ sensory motor peripheral neuropathy
◆ nutritional factors (cachexia-ass neuromyopathy)
◆ vitamin deficiency (B12, folate)
◆ cancer related metabolic dysfunction (hepatic, renal)
◆ direct infiltration of peripheral nerves (lymphoma, leukemias)
◆ vascular nerve injury (hemorrhagic or ischemic)
◆ cytotoxic treatments
~~~
FS:
Ca -> Infiltration of peripheral nerve
Ca -> vascular nerve injury
Ca -> Paraneoplastic neuropathy
Ca -> metabolic dysfunction
Chemo
List FOUR chemo drugs that cause peripheral neuropathy.
Each one must be from a different class.
◆ Sensory or sensory/motor or autonomic
- Vinca alkaloids (vincristine)
- Taxanes (paclitaxel)
- Platinum-derivate agents (oxaliplatin)
- Antibodies (trastuzumab)
- Immunomodulatory drugs (thalidomide)
- Proteasome inhibitor (bortezomib)
- Rarely: anti-metabolites (5-FU)
- Rarely: immune checkpoint inhibitors (pembrolizumab)
◆ Guillain-Barre
- Immune checkpoint inhibitors (pembrolizumab)
- Tyrosine kinase inhibitors (imatinib)
- Antibodies (rituximab)
◆ Myasthenia gravis
- Immune checkpoint inhibitors (pembrolizumab)
Box 14.8.6
FS:
COP - TV
What are the two most common paraneoplastic neurological syndromes? What cancers are they associated with?
Lambert eaton myasthenic syndromes -> SCLC
Myasthenia gravis -> thymoma
List FOUR features of ICP in children
◆ Non-specific findings
◆ irritability
◆ labile mood*
◆ negativity
◆ aggressive or hostile behaviour*
◆ sunset sign
- downward ocular deviation, eyelids retract due to compression of quadrigeminal plate*
◆ projectile vomiting w/ post fossa lesions
List FIVE signs of central herniation syndrome*
◆ starts with:
- dec LOC
- Cheyne-Stokes resp
- miotic but light reactive pupils
- “doll’s eyes” phenomenon/oculovestibular caloric response (warm/cold water in ext ear canal) preserved
- paratonic rigidity
- pyramidal signs
◆ progresses to:
- coma
- resp rhythm changes
- fixed pupils
- oculovestibular abnormalities
- decerebrate rigidity
- limb flaccidity
- loss of brainstem reflexes
List FIVE signs of uncal herniation*
◆ starts with:
- ipsilateral pupil to lesion mydriatic + non-reactive to light
- sometimes contralateral pupil changes (w/ brainstem displacement)
- ipsilateral to lesion visual field defects
◆ progress to:
- dec LOC
- Cheyne-Stokes resp
- oculomotor paralysis
- oculovestibular abnormalities
List THREE signs of cerebellar herniation*
◆ starts with:
- occipital/frontal headache
- hiccups
- vomiting
◆ progress to:
- dec LOC
- abnormal breathing
- “cerebellar fits” - opisthotonus + decerebration
Dex dosing suggestion in 6th Ed for inc ICP*
dexamethasone 96 mg IV (!!) immediately then 24 mg IV q6hr
Suggested lorazepam + midaz dosing in status epilepticus
◆ Loraz
- Adult: 4-8 mg IV/IM/SC
- Children: 0.1 mg/kg IV/IM/SC
◆ Midaz
- 0.2 mg/kg initial dose then 0.05-0.5 mg/kg/h IV infusion
- no specification child vs adult
- initial dose 0.05 mg/kg if frail, concurrent opioids/other benzos
Suggested TWO alternatives to benzos to seizures management
◆ sodium valproate
◆ levetiracetam
◆ lacosamide
Name THREE common side effects of sodium valproate*
◆ tremors
◆ sedation
◆ ataxia
◆ GI sym
◆ thrombocytopenia
◆ severe liver tox (rare; in children under 3 yo on other anticonvulsants)
Name TWO common side effects of levetiracetam
◆ somnolence
◆ asthenia (abN weakness)
◆ dizziness
Peds dosing dex in brain mets
initial dose of 1 mg/kg
then 0.4-1 mg/kg in one or more dose
Name SIX cancers associated with lumbosacral plexopathy
◆ colorectal
◆ breast
◆ lung
◆ cervical
◆ melanoma
◆ pelvic
- bladder
- uterus
- prostate
◆ retroperitoneal
- sarcoma
- met nodal tumours
- sarcoma
- lymphoma
Name THREE symptoms of lumbosacral plexopathy
◆ pain (can precede other sym by weeks/months)
◆ numbness
◆ paraesthesia
◆ weakness
◆ leg edema
Name THREE symptoms and therapies that cause posterior reversible encephalopathy syndrome (PRES)*
◆ Symptoms
- headache
- confusion
- visual disturbances
- seizures
◆ Therapies
- sunitinib
- sorafenib
- pembrolizumab
- bevacizumab
