Case: 32-year-old-Woman with Bradyphrenia

00:01 In this lecture, we're going to talk about brain metastases.

00:03 Tumors that develop in the systemic circulation and travel to the brain.

00:09 Let's start with a case.

00:10 A 32-year-old woman who presents with Bradyphrenia or slowed thinking.

00:15 32-year-old woman with estrogen, progesterone, and HER2 positive breast cancer, that's a very common type of breast cancer, presents with who has metastases to the bones and liver, and presents with a first-time seizure.

00:30 She previously underwent mastectomy with axillary lymph node dissection, chemotherapy, and radiation, which are standard treatments for breast cancer to the left chest wall and axilla, which she completed about four years ago.

00:42 Further history reveals that she elected to stop hormone therapy with tamoxifen, that's a hormonal active agent, about two years ago, and has been pursuing naturopathic remedies for her treatment.

00:53 So she's been off standard treatment for about two years.

00:57 About four months ago, she began to develop confusion, slowed thinking, which we call bradyphrenia, and occasional paroxysmal episodes of left-sided tingling and weakness that started in the hand and progressed into her arm and face evolving like a seizure.

01:14 Exam shows that she's returned to baseline but it's bradyphrenic with slowed responses and endorses constant headache with gait dysfunction.

01:22 What's the diagnosis? Well, let's start with some of the features of the case.

01:26 First of all, she has breast cancer with metastasis to the bones and the liver.

01:31 This indicates that this is a cancer that has already metastasized to common areas.

01:36 And she's out far enough after her diagnosis that we can start to see brain metastasis.

01:42 She presents with a focal neurologic deficit or a focal neurologic sign being this evolving seizure.

01:49 And that should indicate that we need to look for that area of focus why this focal event occurred? And she needs imaging.

01:58 So what's the diagnosis? Well, pituitary adenoma, doesn't seem like a likely etiology here.

02:04 She may have a pituitary adenoma.

02:06 They're very common incidental findings, but they don't commonly present with seizure or confusion.

02:11 So that's an unlikely diagnosis for this patient.

02:14 Vestibular schwannoma.

02:16 Those are tumors that arise on the vestibulocochlear nerve and present with hearing loss. None of which this patient has.

02:22 Meningiomas are tumors that occur in the brain and are very common, but uncommon in a patient with metastatic breast cancer to present with first-time seizure.

02:32 Gliomas are common tumors arising from the brain, but this patient's history of breast cancer really pushes us to favor a diagnosis of brain metastasis.

02:41 And a new onset seizure, and a patient with metastatic cancer should raise primary suspicion for brain metastasis.

02:47 This is a classic case, for breast cancer, brain metastasis.

02:52 This patient underwent imaging. This is an MRI of the brain and we see her MRI here.

02:58 This is a T1 post-contrast.

03:01 So gadolinium enhanced, Contrast-enhanced image.

03:03 And we see innumerable mini-contrast enhancing lesions throughout the brain.

03:08 In the front part of the brain, the back part of the brain, the left, the right, really throughout the brain parenchyma.

03:14 When we look at these lesions, it looks like there's just a lot of lesions.

03:18 But we're really seeing two things.

03:20 The first is some of these lesions are buried at the Grey-white junction, the border between the cortical gray matter, and the subcortical white matter and that's a common location for brain metastasis to occur.

03:32 And that should tip us off to consider brain metastasis.

03:35 Other lesions are out near the cortical surface in the area where the CSF flows and suggests that this patient may also be suffering Leptomeningeal metastases.

03:44 An important case that underscores our need to understand how to diagnose and treat brain metastasis.