First-time seizure, cont’d

Send a beta.  Cannonballs in the chest usually means choriocarcinoma, but many types of mets can look like this.  His beta was nearly 10k.

There are multiple hypodense lesions on the head ct, likely to be caused by masses and edema.  There is no herniation.
Although head CTs are commonly done in the ED for a first seizure, they are generally not needed.  Indications for head CT are debatable, and include focal seizure, patients with low CD4 counts, abnormal neuro exam, recent head trauma, anti-coagulation, and age < 6 months old (correction: 6 months, not 6 years).  I scan everyone with a history of lung or breast cancer, and all show metastatic cns disease.  “Cachexia” isn’t on anyone’s CT list, but it’s an obvious reason for concern.  Typically, the work-up will result in un-diagnosed cancer (or aids).
A first-time seizure does not require anti-seizure medication.  A first-time seizure due to cns brain lesions should get anti-seizure meds, because the seizures are likely to recur.  The benefits greatly outweigh the risks.
When we find a cns brain lesion causing edema and seizure, the patient is typically given steroids to reduce edema.  There’s nothing wrong with that, but the steroids may get you a few unkind words from the oncologist because steroids are contra-indicated in the face of primary cns lymphoma.  The concern is that cns lymphoma is sensitive to steroids and may alter diagnosis and treatment.  If you’re relatively sure that the cns lesions are metastatic disease, there’s no problem with steroids.
A patient with cns lesions and a first-time seizure should be admitted.
A chest CT is done on this patient.  How do you make the diagnosis?

 

chest ct

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