Brain Metastasis Clinical Presentation

  • Author: Victor Tse, MD, PhD; Chief Editor: Nicholas Lorenzo, MD   more...
 
Updated: Oct 7, 2011
 

History

Approximately 60% of patients with brain metastases have subacute symptoms. Symptoms are usually related to the location of the tumor. About 85% of the lesions are in the cerebrum, 15% are in the cerebellum, and 5% are in the brainstem. Morning headache with nausea and vomiting together with papilledema are suggestive of intracranial hypertension. Features such as headache, nuchal rigidity and photophobia indicate meninges involvement. The timing of the onset of these symptoms is subacute rather than acute.

Acute onset of symptoms suggests vascular or electrical etiology such as bleeding or seizure. Dementia and cognitive deficits of a gradual onset most likely indicate a demyelination problem, radiation necrosis. Paraneoplastic syndromes include limbic encephalopathy and cerebellar degeneration. The latter is commonly associated with ovarian cancer. Progressive weight loss and general fatigue can be ominous and highly suggestive of recurrent systemic cancer. Similarly, neurologic problems such as polyneuropathy or myopathy can be sinister.

  • Headache (42%) and seizure (21%) are the 2 most common presenting symptoms.
  • New onset of seizures in a patient older than 35 years is highly suggestive of primary or metastatic disease.
  • In addition, 35% of patients have cognitive dysfunction, and 30% have motor dysfunction.
  • About 10% of patients present with hemorrhage. Metastases commonly derive from choriocarcinoma, melanoma, bronchogenic carcinoma, thyroid carcinoma, and renal carcinoma bleeding; most of these hemorrhages are intramural.
Next

Physical

Findings on the neurologic examination depend on the location of the metastatic lesions. Focal findings are common. Findings consistent with generalized CNS dysfunction also can occur secondary to the cumulative effects of multiple CNS lesions, edema associated with large single or multiple CNS lesions, and/or adverse effects of medications.

Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Victor Tse, MD, PhD  Associate Professor, Department of Neurosurgery, Stanford University Medical Center, Santa Clara Valley Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Amy A Pruitt, MD  Associate Professor of Neurology, University of Pennsylvania School of Medicine; Attending Neurologist, Hospital of the University of Pennsylvania

Amy A Pruitt, MD is a member of the following medical societies: American Academy of Neurology

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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, and New York Academy of Sciences

Disclosure: Biogen Honoraria Consulting; Bayer Corporation Honoraria Consulting

Selim R Benbadis, MD  Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association

Disclosure: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting; Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting; Pfizer Honoraria Speaking, consulting; Sleepmed/DigiTrace Honoraria Speaking, consulting

Chief Editor

Nicholas Lorenzo, MD  Consulting Staff, Neurology Specialists and Consultants

Nicholas Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, and American College of Physician Executives

Disclosure: Nothing to disclose.

References

  1. Nussbaum ES, Djalilian HR, Cho KH, Hall WA. Brain metastases. Histology, multiplicity, surgery, and survival. Cancer. Oct 15 1996;78(8):1781-8. [Medline].

  2. Santarelli JG, Sarkissian V, Hou LC, Veeravagu A, Tse V. Molecular events of brain metastasis. Neurosurg Focus. Mar 15 2007;22(3):E1. [Medline].

  3. Rusciano D, Burger MM. Mechanisms of Metastases. In: levine AJ, Schmidek HH (eds). In Molecular Genetics of Nervous System Tumors. New York: John Wiley & Son; 1993.

  4. Kaplan RN, Riba RD, Zacharoulis S, Bramley AH, Vincent L, Costa C. VEGFR1-positive haematopoietic bone marrow progenitors initiate the pre-metastatic niche. Nature. Dec 8 2005;438(7069):820-7. [Medline].

  5. Hanssens P, Karlsson B, Yeo TT, Chou N, Beute G. Detection of brain micrometastases by high-resolution stereotactic magnetic resonance imaging and its impact on the timing of and risk for distant recurrences. J Neurosurg. Sep 2011;115(3):499-504. [Medline].

  6. Tien RD, Felsberg GJ, Friedman H, Brown M, MacFall J. MR imaging of high-grade cerebral gliomas: value of diffusion-weighted echoplanar pulse sequences. AJR Am J Roentgenol. Mar 1994;162(3):671-7. [Medline].

  7. Galicich JH, French LA. Use of dexamethasone in the treatment of cerebral edema resulting from brain tumors and brain surgery. Am Pract Dig Treat. Mar 1961;12:169-74. [Medline].

  8. Debinski W, Tatter SB. Convection-enhanced delivery for the treatment of brain tumors. Expert Rev Neurother. Oct 2009;9(10):1519-27. [Medline].

  9. DeAngelis LM, Mandell LR, Thaler HT, et al. The role of postoperative radiotherapy after resection of single brain metastases. Neurosurgery. Jun 1989;24(6):798-805. [Medline].

  10. Jensen CA, Chan MD, McCoy TP, et al. Cavity-directed radiosurgery as adjuvant therapy after resection of a brain metastasis. J Neurosurg. Jun 2011;114(6):1585-91. [Medline].

  11. Kocher M, Soffietti R, Abacioglu U, et al. Adjuvant whole-brain radiotherapy versus observation after radiosurgery or surgical resection of one to three cerebral metastases: results of the EORTC 22952-26001 study. J Clin Oncol. Jan 10 2011;29(2):134-41. [Medline].

  12. Bindal RK, Sawaya R, Leavens ME, Lee JJ. Surgical treatment of multiple brain metastases. J Neurosurg. Aug 1993;79(2):210-6. [Medline].

  13. Bindal AK, Bindal RK, Hess KR, et al. Surgery versus radiosurgery in the treatment of brain metastasis. J Neurosurg. May 1996;84(5):748-54. [Medline].

  14. Cho KH, Hall WA, Lee AK. Stereotactic radiosurgery for patients with single brain metastasis. J Radiol. 1998;1:79-85.

  15. Auchter RM, Lamond JP, Alexander E, et al. A multiinstitutional outcome and prognostic factor analysis of radiosurgery for resectable single brain metastasis. Int J Radiat Oncol Biol Phys. Apr 1 1996;35(1):27-35. [Medline].

  16. Gaspar L, Scott C, Rotman M, Asbell S, Phillips T, Wasserman T, et al. Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy Oncology Group (RTOG) brain metastases trials. Int J Radiat Oncol Biol Phys. Mar 1 1997;37(4):745-51. [Medline].

  17. Rusciano D, Burger MM. Mechanisms of metastases. In: Levine AJ, Schmidek HH, eds. Molecular Genetics of Nervous System Tumors. New York, NY: Wiley-Liss; 1993.

 
Previous
Next
 
Management of recurrent metastasis.
Multiple brain metastasis in a patient with known non-small cell lung adenocarcinoma. There was also systemic disease in the liver.
Table 1. Sources of Primary Tumor in Brain Metastases
Primary Tumor SitePercentage (%)
Lung21
Breast9
Melanoma40
Lymphoma, mainly non-Hodgkin1
GI tract3
Genitourinary tract11
Osteosarcoma10
Head and neck6
Table 2. Overview of RPA Data from RTOG Studies[16]
GroupKarnofsky Performance StatusSystemic DiseaseMedian Survival (mo)
Age ≤ 65 y≥ 70Controlled primary disease, no extracranial metastases7.1; 13.5 for single metastasis, 6.0 for multiple metastases
Age ≥ 65 y≥ 70Controlled systemic disease, with extracranial metastasis4.2; 8.1 for single metastasis, 4.1 for multiple metastases
Any ageAnyAny2.3
Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.