N14) Headache, weakness, and unintentional weight loss

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

  1. Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with headache and vomiting.
  2. Review the DDx considerations in a patient with headache and vomiting.
  3. Identify the spectrum of imaging findings in appropriate modalities for evaluating patients with headache and vomiting.

History

Physical Exam

Labs

Provisional Diagnosis

Select the Dx you believe is most appropriate
This patient’s subacute onset of focal neurological deficits with headache is consistent with a brain malignancy. Considering the patient has a known, untreated metastatic melanoma, it is likely secondary to metastatic spread to the brain. Of note, a stroke may present with similar focal neurological deficits.
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Potential Acuity

What is your assessment of the likely acuity for this patient?

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This patient requires urgent workup.

First Imaging Study

What is the first imaging study you will order?

A CT of the brain with contrast is a good initial imaging modality to assess for an intracranial malignancy. The contrast pattern further helps evaluate for the presence and characteristics (enhancement pattern, calcifications) of a tumor.
View ACR Appropriateness Criteria
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Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

View Report

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Second Imaging Study

What is the next imaging study you will order?

While the diagnosis is made with the CT, the MRI with and without contrast may help further assess the edema and smaller metastases.
View ACR Appropriateness Criteria
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Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

View Report

Watch our video

View the full study if you'd like to like a look yourself

What is your Diagnosis now that you have seen the imaging results?

The patient’s prognosis is likely poor considering the number of lesions and presence of extracranial metastases (untreated lung cancer).

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

The patient requires urgent workup and management.

Assessment and Plan

Please provide your assessment and plan for this patient

This is a 55-year-old male presenting with hemorrhagic metastatic intracranial melanoma. Neurosurgery and neuro-oncology should be consulted to discuss treatment options with the patient. Seizure prophylaxis medication and glucocorticoids to manage symptomatic edema should be started. Considering the patient’s poor prognosis, he should undergo a discussion of goals of care, establish DNR/DNI status, and have a discussion with the palliative care team.

Lessons Learned:
- New onset seizures, headaches, and with systemic symptoms in in patients with hx of cancer is concerning for intracranial metastatic disease.
- Metastatic brain tumors are usually ring-enhancing, most often occur in the gray-white junction, and watershed regions. Metastatic melanomas often have intrinsic hemorrhage and therefore appear bright on CT without contrast.
- Surgical resection is the preferred approach for solitary, large tumors, or metastases leading to obstructive hydrocephalus. SRS is preferred when the tumor is small and inaccessible.
- Postoperative stereotactic radiation therapy (SRS) or fractionated radiation therapy to the tumor resection can reduce the risk of local recurrence. 
- SRS should be performed when several tumors are present.
- When innumerable tumors are present and systemic therapy is not an option, WBRT is the treatment of choice.
- In patients with a poor prognosis, like those with extracranial disease, the decision for treatment should be performed based on the patient’s preferences.

Socioeconomic Factors: In a patient with known metastatic melanoma, the diagnosis is certain with CT if it shows innumerable hemorrhagic and ring-enhancing metastases. Therefore, the added expense of an MRI is not necessary.

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