eMedicine Specialties > Neurology > Neuro-oncology

Brainstem Gliomas: Differential Diagnoses & Workup

Author: Joseph Landolfi, DO, Director of Neuro-oncology, New Jersey Neuroscience Institute Brain Tumor Center; Medical Director, Gamma Knife Program, JFK Medical Center; Associate Professor of Neurology, Seton Hall University School of Graduate Medical Education
Coauthor(s): Anita Venkataramana, MBBS, Clinical Instructor, Department of Neurology, Division of Neuroimmunology/HIV, Johns Hopkins University
Contributor Information and Disclosures

Updated: Jun 30, 2009

Differential Diagnoses

Arteriovenous Malformations
Meningioma
Ependymoma
Metastatic Disease to the Brain
Glioblastoma Multiforme
Neurosarcoidosis
Low-Grade Astrocytoma
Tolosa-Hunt Syndrome
Medulloblastoma

Other Problems to Be Considered

Hemangioblastoma

Workup

Laboratory Studies

  • Lab studies of blood chemistry and related body fluids are not helpful as a rule, though cerebrospinal fluid (CSF) examination is often important for differential diagnosis. The protein content of CSF may be elevated. Because of the risk of increased intracranial pressure due to obstructive hydrocephalus, caution in clinical and imaging assessment prior to lumbar puncture is stressed.
  • Tissue confirmation is frequently not feasible with infiltrating, expansile tumors unless an exophytic component exists, and even then, biopsy cannot always be obtained.

Imaging Studies

MRI

  • MRI of the head is the diagnostic test of choice. MRI can differentiate vascular malformations and other processes that can be misdiagnosed as a brainstem glioma on CT scan.3
  • The typical MRI appearance of a brainstem glioma is an expansile, infiltrative process with low-to-normal signal intensity on T1-weighted images and heterogeneous high-signal intensity on T2-weighted images, with or without contrast enhancement (see Media files 1-2).

    T2-weighted image of a diffuse intrinsic pontine ...

    T2-weighted image of a diffuse intrinsic pontine glioma.

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    T2-weighted image of a diffuse intrinsic pontine ...

    T2-weighted image of a diffuse intrinsic pontine glioma.



    T2-weighted image of a right tectal glioma.

    T2-weighted image of a right tectal glioma.

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    T2-weighted image of a right tectal glioma.

    T2-weighted image of a right tectal glioma.

  • MR spectroscopy has been used to help distinguish between tumor and nontumor lesions in the brain. An elevated choline peak suggests neoplasm.
  • MRI can delineate the extent of infiltration of the leptomeninges and the surrounding structures.
  • High midbrain tumors, especially those arising in the tectum, are typically low-grade lesions by histologic criteria. They commonly appear hypointense on T1 and hyperintense on T2 images even without contrast enhancement.
  • The occurrence of contrast enhancement in a tectal lesion should raise suspicion of a metastatic lesion, especially in an adult, with or without a known history of cancer.

CT scan

  • Although CT imaging is an appropriate choice when MRI is not available, the appearance of brainstem gliomas is variable on CT scan, and the sensitivity of and characterization of tumors by CT are poorer.
  • CT identifies calcifications, cystic changes, and displacement of the ventricular system; however, lower brainstem lesions are often not apparent on CT scan.

Other Tests

Arteriography occasionally is useful in differentiating vascular lesions, including tumors, from gliomas.

Procedures

  • Patients with hydrocephalus may require ventriculostomy or ventriculoperitoneal shunting for symptomatic relief.
  • Patients with difficulties in swallowing and diminished gag reflex may need feeding by gastrostomy such as the percutaneous esophagogastrostomy (PEG).
  • Those patients who have had multiple upper respiratory infections, pneumonia, or altered voice may need postoperative ventilatory assistance.

Histologic Findings

The histopathology is variable; most gliomas in the brain stem are fibrillary, pilocytic astrocytomas, or the more malignant glioblastoma multiforme. Hemorrhage and necrosis are associated with the more malignant forms. Cysts may be seen with either the high- or low-grade forms.

More on Brainstem Gliomas

Overview: Brainstem Gliomas
Differential Diagnoses & Workup: Brainstem Gliomas
Treatment & Medication: Brainstem Gliomas
Follow-up: Brainstem Gliomas
Multimedia: Brainstem Gliomas
References
Further Reading
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References

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  2. Ueoka DI, Nogueira J, Campos JC, Maranhão Filho P, Ferman S, Lima MA. Brainstem gliomas--retrospective analysis of 86 patients. J Neurol Sci. Jun 15 2009;281(1-2):20-3. [Medline].

  3. Grau SJ, Rachinger W, Holtmannspoetter M, Herms J, Tonn JC, Kreth FW. Serial Stereotactic Biopsy of Brainstem Lesions in Adults Improves Diagnostic Accuracy Compared to MRI Only. J Neurol Neurosurg Psychiatry. Jun 10 2009;[Medline].

  4. Frappaz D, Schell M, Thiesse P et al. Preradiation chemotherapy may improve survival in pediatric diffuse intrinsic pontine gliomas: Final results of BSG 98 prospective trial. Neuro Oncol. Aug/2008;10(4):599-607. [Medline].

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Keywords

brainstem tumors, pontine lesions, tectal lesions, hydrocephalus, cervicomedullary lesions, neurofibromatosis, intrinsic pontine gliomas, tectal gliomas, cervicomedullary gliomas, intracranial tumors

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Contributor Information and Disclosures

Author

Joseph Landolfi, DO, Director of Neuro-oncology, New Jersey Neuroscience Institute Brain Tumor Center; Medical Director, Gamma Knife Program, JFK Medical Center; Associate Professor of Neurology, Seton Hall University School of Graduate Medical Education
Joseph Landolfi, DO is a member of the following medical societies: Alpha Omega Alpha
Disclosure: Schering-Plough Honoraria Speaking and teaching; Genetech Honoraria Speaking and teaching

Coauthor(s)

Anita Venkataramana, MBBS, Clinical Instructor, Department of Neurology, Division of Neuroimmunology/HIV, Johns Hopkins University
Disclosure: Nothing to disclose.

Medical Editor

Edward L Hogan, MD, Professor, Department of Neurology, Medical College of Georgia; Emeritus Professor and Chair, Department of Neurology, Medical University of South Carolina
Edward L Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Neurological Association, American Society for Biochemistry and Molecular Biology, Phi Beta Kappa, Sigma Xi, Society for Neuroscience, and Southern Clinical Neurological Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Jorge Kattah, MD, Head, Program Director, Professor, Department of Neurology, University of Illinois College of Medicine at Peoria
Jorge Kattah, MD is a member of the following medical societies: American Academy of Neurology, American Neurological Association, and New York Academy of Sciences
Disclosure: Biogen Honoraria Consulting; Bayer Corporation Honoraria Consulting

CME Editor

Matthew J Baker, MD, Consulting Staff, Collier Neurologic Specialists, Naples Community Hospital
Matthew J Baker, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Chief Editor

Tarakad S Ramachandran, MBBS, FRCP(C), FACP, Professor of Neurology, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Chair, Department of Neurology, Crouse Irving Memorial Hospital
Tarakad S Ramachandran, MBBS, FRCP(C), FACP is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American College of Forensic Examiners, American College of International Physicians, American College of Managed Care Medicine, American College of Physicians, American Heart Association, American Stroke Association, Royal College of Physicians, Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of England, and Royal Society of Medicine
Disclosure: Abbott Labs  Honoraria Consulting; Teva Marion Honoraria Consulting; Boeringer-Ingelheim Honoraria Speaking and teaching

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