A 60-year-old right-handed woman with a history of breast cancer with known spine metastasis comes to the emergency department because of headaches and mild left arm weakness. The headaches started 1 month ago and have progressively gotten worse. They occur in the right orbitofrontal region, are sharp in quality, fluctuate in intensity, and have recently been waking her from sleep. She noticed 2 weeks ago that her left arm was weaker than usual. She has taken ibuprofen, with only slight improvement of the headaches.
Her temperature is 37°C (98.6°F), blood pressure is 130/80 mm Hg, and pulse is 90/min. Neurologic examination shows a slight left lower facial palsy and a pronator drift in the left upper extremity. Reflexes are 3+ on the left side of the body, with an ipsilateral Babinski sign. The rest of the neurologic examination shows no abnormalities.
Basic blood work is normal. An MRI of the brain with and without gadolinium shows a single ring-enhancing lesion with mild surrounding vasogenic edema and mass effect at the grey-white junction in the right frontal lobe that is diffusion-restriction negative.
Which of the following is the most appropriate next step in the management of this patient?

Question

A 60-year-old right-handed woman with a history of breast cancer with known spine metastasis comes to the emergency department because of headaches and mild left arm weakness.  The headaches started 1 month ago and have progressively gotten worse.  They occur in the right orbitofrontal region, are sharp in quality, fluctuate in intensity, and have recently been waking her from sleep.  She noticed 2 weeks ago that her left arm was weaker than usual.  She has taken ibuprofen, with only slight improvement of the headaches.  
Her temperature is 37°C (98.6°F), blood pressure is 130/80 mm Hg, and pulse is 90/min.  Neurologic examination shows a slight left lower facial palsy and a pronator drift in the left upper extremity.  Reflexes are 3+ on the left side of the body, with an ipsilateral Babinski sign.  The rest of the neurologic examination shows no abnormalities.
Basic blood work is normal.  An MRI of the brain with and without gadolinium shows a single ring-enhancing lesion with mild surrounding vasogenic edema and mass effect at the grey-white junction in the right frontal lobe that is diffusion-restriction negative.
Which of the following is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

In the setting of metastatic breast cancer, a new-onset headache with focal neurologic deficits should prompt a workup for cerebral metastatic disease. On brain MRI with and without gadolinium, metastasis appears as a ring-enhancing lesion with significant reactive vasogenic edema with or without local mass effect. Radiographically, metastasis can mimic an infectious process (e.g., abscess). However, metastasis does not cause restricted diffusion on diffusion-weighted MR sequences, whereas an abscess causes homogeneous restricted diffusion. Also, a cerebral abscess causes fever and peripheral leukocytosis. This patient most likely has a solitary cerebral metastasis and needs to be urgently started on intravenous steroids (e.g., methylprednisolone or dexamethasone) to reduce the surrounding vasogenic edema and mass effect. Reducing the edema might improve the patient's neurologic deficits. (Choice A) Craniotomy with excisional biopsy of the right frontal lesion is appropriate to confirm the diagnosis of metastatic breast cancer. However, the next step in the management of this patient is to reduce the vasogenic edema and mass effect by starting intravenous steroids. (Choice C) Current studies show prophylactic anticonvulsant medications are mainly beneficial in patients with newly diagnosed brain tumors who present with a seizure. Prophylactic anticonvulsants (for 1 week with taper afterwards) are also indicated in patients who have had a craniotomy for brain tumor resection, brain MRI showing acute hemorrhage within the tumor, or significant mass effect/edema in the vicinity of the cortex. Steroids can acutely reduce the edema and greatly reduce the risk of seizure in this patient. (Choice D) A lumbar puncture is contraindicated in the setting of a space-occupying lesion with mass effect and/or midline shift, due to risk of herniation. In addition, this patient's clinical history, brain imaging, and blood work are not suggestive of an infectious process. (Choice E) Whole-brain radiation therapy is indicated in patients with multifocal brain metastases. For solitary metastasis, the treatment of choice is surgical resection. Educational objective: Patients presenting with new-onset headache with focal neurologic deficits in the setting of cerebral metastatic disease should be started on intravenous steroids (e.g., methylprednisolone or dexamethasone) to reduce vasogenic edema and mass effect. __________ References: The role of steroids in the management of brain metastases: a systematic review and evidence-based clinical practice guideline (http://www.ncbi.nlm.nih.gov/pubmed/19957014) Medical management of cerebral metastases (http://www.ncbi.nlm.nih.gov/pubmed/8823773)

A 60-Year-Old Right-Handed Woman with a History of Breast Cancer