 All right, thank you, Evan. Our last final presenter this morning is Atman Shah. He's a first-year neurosurgery resident. And he'll tell us about neuro-ophthalmological complications of neoplastic leptomeningial disease. So thanks for having me. I just completed my month on the service. And so this presentation will be about leptomeningial carcinomatosis. Our story starts off with patient SK. So this is a patient I saw with anesthesia as well as Dr. Warner. This is a 38-year-old female with this new complaint of bilateral vision loss. She was rather somnolent, so all the information that was taken during the exam was taken from the mother. So she has a history of ER negative, PR negative of her two new breast cancer. Her last cycle of chemotherapy was in December of 2015. So in September 2016, she developed these severe headaches and a change in behavior, including excessive profanity. So from a neurosurgical perspective, anytime you see change in behavior, that dramatic, you think something in the frontal lobe. So the MRI brain confirmed this, demonstrated a right frontal lobe metastasis. In September 23rd, that lesion was resected with Dr. Jensen here at the U. And then on October 8th, she endorsed visual changes and headache. And the MRI demonstrated new cerebellar lesion and leptomeningial enhancement. Just to complete the picture, past medical history, depression, diabetes, and of course, breast cancer. Family history, she has an extensive family history of cancer in her family, colon and breast cancer. In medication, she's on decadron for inflammation and swelling, capra for seizure prophylaxis, and oxycodone for pain. So on physical exam, her visual acuity, she was only able to see hand motion, and there was no nystagmus. Pupils were equally run reactive, no afferent pupillary defect, intraocular pressures are listed, external anterior segments were normal. The other salient finding was on dilated funnous exam. We saw optic nerve swelling with several flame hemorrhages. So to look at some of the imaging, just to orient you guys, this is an axial T1 post-contrast image. So right here we see this is the fourth ventricle, cerebellum, this is the CPA or the cerebellum, plantain angle. These are the internal auditory canals. The noses up here, eyes are here. And so what we see first and foremost is the enhancement of the internal auditory canal, which is indicative of leptomine and geocarsinomatosis. We also see this pretty big goomba here on the right cerebellar hemisphere, in which is basically an additional met from her breast cancer. And a lumbar puncture was performed and cytology was positive for malignant cells. So a little bit of background, what is leptomine and geodisease? Well, to understand that, first we have to understand what's on the surface of the brain. So we have the Pia-moder, the arachnoid and then the Duramoder. So leptomine and geodisease are basically when neoplastic cells disseminate through the cerebrospinal fluid. And so it involves a Pia and the arachnoid membranes. So as far as breast cancer goes, any breast cancers that are ER negative tend to have a higher risk for developing LD. Other cancers, melanoma, lung, gastrointestinal tumors also can have a proclivity for developing leptomine and geodisease. The overall incidence is dependent on the primary tumor, but on average ranges three to five percent of patients with systemic cancer. As far as diagnostics, CSF is a gold standard. Next also would be neuroimaging. And lastly I'll present some more novel approaches to diagnosing, but ideally you would wanna get about 10.5 cc's of fluid. Oftentimes if the initial lumbar punctures are negative but there's a high suspicion, you should repeat it. And some of the findings you would find are non-specific pleocytosis, hyperprotonemia and an elevated opening pressure. There are false positives known to occur with traumatic taps. And the CSF cytology has pretty good specificity but the sensitivity is only 50%. And even on some patients, 10% of patients will have negative findings even with repeated lumbar punctures. For diagnostics, T1 with contrast is the ideal imaging modality. The sensitivity ranges about 60 to 70% and specificity is around 77. I thought this would be kind of neat to add. There's still a lot of work that needs to be done. So basically NIAC has published on this rare cell capture technology. They essentially use antibodies covered with ferrous particles to identify some of these glycoproteins found on the surface of carcinomas. And so the one they look at mainly is EPCAM. And so they're only an N of 15 in the study they published so there's a lot more work that needs to be done. But in the 15, the sensitivity was about 100%. Other things CSF biomarkers such as VEGF and anti-tissue type plasminogen activator also have pretty high sensitivity and specificity compared to current methods of diagnosis. So why does this relate to ophthalmology? Well, if you look at the most frequent signs and symptoms headaches, double vision and back pain are the most frequent symptoms. Most frequent signs are alter mental status, ocular motor precess and leg weakness. But double vision and ocular motor precess are two of the most common symptoms and signs. So the ophthalmology exam is incredibly important if there is high suspicion. The most common cranial nerve symptom is diplopia. Visual losses are reported in roughly 3% to 10% of patients. And loss of acuity is roughly in around 2% to 20% of patients. So to talk about the pathophysiology, why do patients with leptomeningial disease, why do they develop visual loss? Well, there's two papers. I don't believe this person is not the same doctor of cats that works in the department. But cats at all, they did some pathology reports on patients who had leptomeningial disease. And they found that these cancer cells can invade these virtual Robinson spaces in the perivascular areas around the optic nerve. And they lead to demyelination and axonal degeneration. So McFadzian et al. sort of corroborated this, but then went once up further and did xenon studies to look at cerebral blood flow. And they found that 88% of patients with leptomeningial disease tend to have reduced cerebral blood flow. So the model they've put forth is that ischemia and impairment metabolism probably contribute somewhat to the visual loss. To talk a little bit about prognosis, it has a very poor prognosis, unfortunately. Untreated patients die usually within one to nine weeks. And so basically early diagnosis is essential. And so patients who present with fewer neurological deficits generally have improved survival. Couple conclusions that can be drawn is that just from the presentations, breast cancers that have negative ER and PR receptors are considered to be at higher risk for developing leptomeningial disease. Diagnosis through CSF neuroimaging findings are the main ways we go about it now. However, there are other ways that show promise. Visual loss likely occurs to demyelination and axonal degeneration. And the neuroophthalo exam is incredibly important as these can be some of the initial presenting symptoms. And just to wrap up the story, just to tell a little bit about what's going on with her right now. She had an omia reservoir placed by Dr. Jensen. She's had intrathecal trastuzumab and methotrexate starting in the middle of October. She unfortunately was intubated for respiratory distress. She has recovered somewhat. And she has received trastuzumab and pertuzumab on the 15th extratherapy to the medistinum. And she started her second cycle in the beginning of November. And she still continues to fight the disease. Revision. Revision, I don't believe so. So you say increased survival. If non-treated at 1-9 weeks, how much better is treated? All right. I believe it's up to 20 weeks at this point. But I'll have to go back and I remember reading it. But I don't think I can say for sure. But some of the foam runs, the chances of getting more and more treatable is really amazing. There are so much more to see. It's certainly not, I would say that it's not appropriate to tell a patient, oh, gosh, do that. The whole thing, that's it. I think that a third order consultation with the Cancer Institute like enhancement is in order. Because if there's something that can be done or might be done, then they'll know that. Thank you, Dr. Schade. Is there any other questions? I think that both of you have used a multiple frame on errors or individual. That's a good question, Dr. Ward. It's just like any other. It could be single or multiple. I think that one of the things that's surprising is often how few definitions a patient may have based on how bad they're seeing a situation is. But it can be wonderful to see. I don't think that if the only one is reassuring. Thanks very much.