1301 - Why Patient Advocacy Matters: Changing the Trajectory of Patient Care with a Second Opinion on a Palliative Shunt

Case Diagnosis: Non-Small Cell Lung Cancer with leptomeningeal disease and obstructive hydrocephalus

Case Description: A 66-year-old male with non-small cell lung cancer (NSCLC) and leptomeningeal disease was hospitalized after developing obstructive hydrocephalus. Neurosurgery performed a palliative shunt trial without benefit. He was no longer ambulatory and required heavy caregiver assistance for activities of daily living, therefore a rehabilitation hospital admission was pursued for caregiver training. His functional progress was limited due to impaired consciousness and severity of functional deficits; however, family was able to complete caregiver training for a planned home disposition. Prior to discharge, he developed acute cognitive decline prompting repeat neuroimaging which revealed worsened hydrocephalus. Physiatry reconsulted neurosurgery to advocate for a palliative shunt which was performed. The next morning the patient was more alert, communicative, and his humorous personality returned. Due to his improvement, physiatry secured a one-week inpatient extension. By discharge, he was walking almost 300 feet with a rolling walker and required less caregiver assistance than upon rehab admission.

Discussions: Patients with brain metastasis typically have an unfavorable prognosis, with a median life expectancy of two to four months despite aggressive treatment. About 14% of lung cancer metastasizes to the brain and often results in obstructive hydrocephalus. Many patients who undergo palliative shunt placement in this setting experience cognitive improvement. Palliative shunt placement should therefore be considered in patients with considerable disease-related symptom burden and those with a high prior level of function.

Conclusions: Neurosurgery can offer palliative shunting for symptomatic hydrocephalus to enhance the quality of life for patients with advanced metastatic cancer. Physiatry emphasizes the importance of maximizing functional gains and advocating for all reasonable therapeutic modalities throughout care plans. They play a pivotal role in coordinating multispecialty care while achieving patient-centered goals.