Morning Headache and Vomiting in a Melanoma Survivor
Morning Headache and Vomiting in a Melanoma Survivor - Oncology clinical simulation case. A 54-year-old woman, status post adjuvant pembrolizumab for...
A 54-year-old woman, status post adjuvant pembrolizumab for stage IIIB melanoma, presenting with one week of progressive morning headaches, two days of projectile vomiting, and a witnessed generalized tonic-clonic seizure with transient post-ictal right-sided weakness. Stage IIIB cutaneous melanoma survivor, completed adjuvant pembrolizumab 4 months ago
Acute Resuscitation Milestones & Priorities
Clinical phases and key interventions encountered in this emergency module:
In immunocompromised cancer patients, levetiracetam is the AED of choice due to minimal drug-drug interactions with chemotherapy and immunotherapy.
Dexamethasone is the cornerstone of vasogenic edema management in brain metastases and should not be withheld for fear of immunosuppression when herniation risk is imminent.
Solitary brain metastases >3 cm with mass effect and edema benefit from surgical resection first (Patchell trial), followed by stereotactic radiosurgery to the resection cavity rather than whole-brain radiotherapy.
Melanoma brain metastases are pathognomonic on MRI: T1 hyperintensity (due to melanin and hemorrhage) and ring enhancement; up to 30% harbor extracranial skip lesions requiring full staging.
Multidisciplinary sequencing of surgery, SRS, and systemic therapy (BRAF/MEK inhibitors or immunotherapy) is essential; premature immunotherapy rechallenge perioperatively amplifies CNS toxicity.
Abrupt steroid cessation after weeks of therapy risks adrenal crisis and rebound cerebral edema; taper over 1-2 weeks.
Test Your Clinical Reasoning in Real Time
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