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Low-Grade Astrocytoma Clinical Presentation

  • Author: George I Jallo, MD; Chief Editor: Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS  more...
 
Updated: Oct 27, 2014
 

History

No historical factors are pathognomonic for low-grade glioma. The history, however, should alert the clinician to the presence of a neurologic disorder and the need for an imaging study. Characteristically, low-grade gliomas present with headache and most notably seizures. The latter can be present in up to 80% of patients.[6] Other symptoms related to low-grade gliomas are those secondary to the mass effect of the lesion on the surrounding brain parenchyma (i.e hemiparesis, sensory deficits, alterations in speech or visual field defects).

A small percentage of low-grade astrocytomas present in the spinal cord of both children and adults. The history is characterized by a slow onset of back pain and neurologic deficits. The pain usually is localized over the region of the tumor, which is most common in the cervicothoracic area. Neurologic symptoms include paresthesias in the arms or legs. Weakness, objective numbness, and bowel or bladder symptoms also may be present.

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Physical

A comprehensive neurological exam must me done in any patient who is suspected of harboring an intracranial lesion. The level of conciousness must be assessed and recorded using the Glasgow Coma Scale which has been extensively validated as a reliable method to evaluate the neurological status of patients amongst the different members of the treating personnel (nurses, paramedics, physicians). Cranial nerve deficits are not pathognomonic of low-grade gliomas but the presence of multiple cranial neuropathies is common with brainstem lesions. The motor and sensory exam may disclose hemiparesis as well as hemisensory deficits, increased deep tendon reflexes and signs of corticospinal tract involvement (Babinski sign). In patients with posterior fossa lesions (which are more common in children), signs of cerebellar involvement like ataxia, intention tremor and dysdiadochokinesia are common.

Preoperative neuropsychological assessment may be indicated in patients with a lesion close to or in an eloquent region. Eloquent regions are brain regions that control speech, motor functions, visual perception, and higher cortical functions.

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Causes

The etiology of low-grade gliomas is poorly understood. There are numerous studies published throughout the literature that have attempted to link specific environmental factors with the subsequent development of brain tumors. Although many potential associations have derived from these studies the only clear predisposing factor is prior exposure to ionizing radiation. Other factors like socioeconomic status, occupational exposure and the ingestion of certain types of foods (those containing a high concentration of N- nitroso compounds) have not shown conclusively that they could be linked to an increase in the development of gliomas.[7]

Definitive genetic associations have been made between conditions like neurofibromatosis (NF-1 and NF-2), tuberous sclerosis, Li-Fraumeni syndrome and Turcot syndrome with the development of gliomas.

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Contributor Information and Disclosures
Author

George I Jallo, MD Professor of Neurosurgery, Pediatrics, and Oncology, Director, Clinical Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine

George I Jallo, MD is a member of the following medical societies: American Association of Neurological Surgeons, American Medical Association, American Society of Pediatric Neurosurgeons

Disclosure: Received grant/research funds from Codman (Johnson & Johnson) for consulting; Received grant/research funds from Medtronic for consulting.

Coauthor(s)

Eveline Teresa Hidalgo Staub, MD Neurosurgery Attending, Division of Neurosurgery, General and Pediatric Neurosurgery, Luzerner Kantonsspital

Eveline Teresa Hidalgo Staub, MD is a member of the following medical societies: Swiss Society of Neurosurgery, Swiss Young Neurosurgeons Society

Disclosure: Nothing to disclose.

David A Chesler, MD, PhD Clinical and Research Fellow, Division of Pediatric Neurosurgery, Johns Hopkins University School of Medicine

David A Chesler, MD, PhD is a member of the following medical societies: American Association of Neurological Surgeons, American Medical Association, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Rafael Uribe-Cardenas, MD Resident Physician in Neurosurgery, Department of Neuroscience, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Colombia

Rafael Uribe-Cardenas, MD is a member of the following medical societies: Colombian Association of Neurosurgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jorge C Kattah, MD Head, Associate Program Director, Professor, Department of Neurology, University of Illinois College of Medicine at Peoria

Jorge C Kattah, MD is a member of the following medical societies: American Academy of Neurology, American Neurological Association, New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS Professor Emeritus of Neurology and Psychiatry, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Neuroscience Director, Department of Neurology, Crouse Irving Memorial Hospital

Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS is a member of the following medical societies: American College of International Physicians, American Heart Association, American Stroke Association, American Academy of Neurology, American Academy of Pain Medicine, American College of Forensic Examiners Institute, National Association of Managed Care Physicians, American College of Physicians, Royal College of Physicians, Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of England, Royal Society of Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Rodrigo O Kuljis, MD Esther Lichtenstein Professor of Psychiatry and Neurology, Director, Division of Cognitive and Behavioral Neurology, Department of Neurology, University of Miami School of Medicine

Rodrigo O Kuljis, MD is a member of the following medical societies: American Academy of Neurology, Society for Neuroscience

Disclosure: Nothing to disclose.

Acknowledgements

Ethan A Benardete, MD, PhD Staff Physician, Department of Neurosurgery, New York University Medical Center

Disclosure: Nothing to disclose.

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A 28-year-old male taxi driver presented to the emergency department after having a seizure. Noncontrast head CT scan was obtained showing the typical appearance of a low-grade astrocytoma. The lesion in the mesial left frontal lobe was hypodense on CT scan.
Preoperative MRI of the brain of a 28-year-old male taxi driver who presented to the emergency department after having a seizure. On T1-weighted sequences, the tumor does not enhance and shows decreased signal intensity compared to normal brain. These findings are consistent with low-grade astrocytoma.
For tumors, MRI has the advantage of showing the lesion in multiple planes. This image, a T1-weighted sagittal image of the brain of a 28-year-old male taxi driver who presented to the emergency department after having a seizure, shows the tumor along the mesial aspect of the frontal lobe. Note that mass effect is minimal, typical of a low-grade lesion.
T2-weighted sequences of an MRI of the brain of a 28-year-old male taxi driver who presented to the emergency department after having a seizure show increased signal intensity compared with normal brain. The radiologic appearance is typical of low-grade astrocytoma.
A 9-year-old boy presented with headaches and gradual onset of right hemiparesis. MRI of the brain was obtained. The T2-weighted sequence in this MRI shows a tumor in the left thalamus, which is a typical location for a juvenile pilocytic astrocytoma. Note the relatively well-circumscribed nature of the lesion.
Coronal T1-weighted gadolinium-enhanced MRI of the brain shows the tumor of a 9-year-old boy who presented with headaches and gradual onset of a right hemiparesis. Note the heterogeneous enhancement of the tumor.
Sagittal T1-weighted MRI of the brain shows juvenile pilocytic astrocytoma of a 9-year-old boy who presented with headaches and gradual onset of right hemiparesis. Stereotactic surgery has made resection of these low-grade tumors in this deep location feasible.
A 3-year-old boy presented with speech regression. MRI of the brain revealed a tumor in the left mesial temporal lobe. This T1-weighted gadolinium-enhanced image shows an enhancing tumor involving the hippocampus, uncus, and amygdala. The surgical pathologic studies revealed a low-grade mixed tumor of astrocytes and atypical neurons, a ganglioglioma.
 
 
 
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