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• disease progression, s/p radiation to lumbar

spine and hip• PE in 2011 on lovenox

Meds:• Zometa, Lovenox, Xeloda

Examination

Diffuse bilateral lower extremity weakness at 4/5

Imaging

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)

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%

RPA classification

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

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

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.