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Brain Neoplasms Clinical Presentation

  • Author: Bruce M Lo, MD, CPE, RDMS, FACEP, FAAEM, FACHE; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
 
Updated: Nov 09, 2015
 

History

Presenting complaints of patients with an intracranial neoplasm tend to be similar for primary brain tumors and intracranial metastases. Manifestations depend on the cause of the symptoms, which may comprise any of the following:

  • Increased intracranial pressure (ICP)
  • Direct compression of essential gray or white matter
  • Shifting of intracranial contents
  • Secondary cerebral ischemia

Symptoms may be nonspecific and include any of the following:

  • Headache
  • Altered mental status
  • Ataxia
  • Nausea
  • Vomiting
  • Weakness
  • Gait disturbance

Central nervous system (CNS) neoplasms also may manifest as follows:

  • Focal seizures
  • Fixed visual changes
  • Speech deficits
  • Focal sensory abnormalities

Onset of symptoms usually is insidious. However, an acute episode may occur with bleeding into the tumor, or when an intraventricular tumor suddenly occludes the third ventricle.

In a United Kingdom study of 139 children with brain tumors, the median time from symptom onset to diagnosis of a brain tumor was 3.3 months. Head tilt, cranial nerve palsies, endocrine and growth abnormalities, and reduced visual acuity were associated with a longer delay in diagnosis. Headache was the most common initial manifestation, occurring in 55 patients (40%). By the time of diagnosis, patients had a median of six signs and/or symptoms.[14]

In a study from the United States, the mean time to diagnosis in the emergency department from onset of any symptom was 86.3 days, and 104.5 days for headache. Approximately 91% of cases were diagnosed by computed tomography scan, with 48% of tumors located in the posterior fossa. Headache, nausea/vomitting, and gait disturbance were the most common presenting symptoms.[15]

Although headache is the symptom customarily associated with an intracranial neoplasm, it often is a late complaint. In addition, headache usually is not an isolated finding, and headache is the worst symptom in only one half of patients.

Other features of headache from brain tumors are as follows:

  • Most headaches in patients with brain tumors are nonspecific and resemble tension-type headaches [1, 2, 3]
  • In patients with a history of headache, a change in the headache pattern may be cause for concern
  • New onset of headaches in middle-aged or older patients is worrisome
  • The location of the headache reliably indicates the side of the head affected, but it does not indicate the precise site of the tumor.
  • Headaches are more common with posterior fossa tumors
  • Headache is a more frequent symptom of intracranial tumor in pediatric patients

Prevailing portrayals of tumor headache that are in fact inaccurate include the following:

  • Pain that is worst in the early morning
  • Vomiting (with or without nausea)
  • Exacerbation with Valsalva maneuvers, bending over, or rising from a recumbent position

Manifestations of brain tumor may reflect the tumor site, as follows:

  • Mental status changes, especially memory loss and decreased alertness, may be subtle clues of a frontal lobe tumor. Complaints may be as mundane as sleeping longer, appearing preoccupied while awake, and apathy.
  • Temporal lobe neoplasms may lead to depersonalization, emotional changes, and behavioral disturbances.
  • Vision, smell, and other sensory disturbances may be caused by a brain tumor.
  • An acoustic neuroma may present as intermittent (then progressive) hearing loss, disequilibrium, and tinnitus.
  • Symptoms of pediatric posterior fossa tumors include increased irritability, unsteadiness, ataxia, headache, vomiting, and progressive obtundation.
  • Supratentorial tumors in children are more commonly associated with seizures, hemiparesis, visual field cuts, speech difficulties, and intellectual disturbance.

Pituitary adenomas may be divided into two broad categories: nonfunctional and hypersecretory. Nonfunctional pituitary adenomas remain asymptomatic until they are large enough to encroach the optic chiasm and disturb normal vision. Most hypersecretory pituitary adenomas secrete prolactin, with affected women noting an amenorrhea-galactorrhea syndrome. Men with prolactin-secreting pituitary adenomas more commonly complain of headache, visual problems, and impotence.

Seizures, focal or generalized, may be the earliest expression of a brain tumor.

  • A Jacksonian pattern (ie, one in which a focal seizure begins in one extremity and then progresses until it becomes generalized) is distinctive in suggesting a focal structural lesion of the cortex.
  • Depending on the rate of growth of the tumor, seizures may be present for months to years before a brain tumor is diagnosed.
  • Any middle-aged or elderly patients presenting with a first seizure should have CNS tumor high in the differential diagnosis.
  • Patients with a brain tumor may present with acute neurologic changes mimicking those associated with stroke.
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Physical

No physical finding or pattern of findings unmistakably identifies a patient with a CNS neoplasm. Findings in these patients may include the following:

  • Based on their location, intracranial tumors may produce a focal or generalized deficit, but signs may be lacking (especially if the tumor is confined to the frontal lobe) or even falsely localizing.
  • Papilledema, which is more prevalent with pediatric brain tumors, reflects an increase in ICP of several days or longer. Papilledema usually does not cause visual loss. Not all patients with CNS tumors develop papilledema.
  • Diplopia may result from displacement or compression of the sixth cranial nerve at the base of the brain.
  • Impaired upward gaze, called Parinaud syndrome, may occur with pineal tumors.
  • Tumors of the occipital lobe specifically (see the image below) may produce homonymous hemianopia or partial visual field deficits.
    Neoplasms, brain. Occipital lobe glioblastoma with Neoplasms, brain. Occipital lobe glioblastoma with surrounding edema.
  • Anosmia may occur with frontal lobe tumors.
  • Brainstem and cerebellar tumors induce cranial nerve palsies, ataxia, incoordination, nystagmus, pyramidal signs, and sensory deficits on one or both sides of the body.
  • Tumors in the region of the cerebellopontine angle may impair the functions of the three cranial nerves that traverse this region: facial, cochlear, and vestibular. Acoustic neuromas most commonly originate from the vestibular nerve (part of cranial nerve VIII).
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Causes

Although few factors are unequivocally associated with an increased risk of brain cancer, the following are consequential:

  • Most CNS neoplasms are thought to arise from individual cell mutations.
  • A prior history of irradiation to the head for reasons other than treatment of the present tumor may increase the chance of primary brain tumor.
  • A few inherited diseases, such as neurofibromatosis, tuberous sclerosis, multiple endocrine neoplasia (type 1), and retinoblastoma, increase the predilection to develop CNS tumors.
  • The most common tumors originating from the cerebellopontine angle are acoustic neuroma and meningioma.
  • Primary CNS lymphoma is a relatively frequent occurrence in HIV patients.
  • Metastatic tumors reach the brain via hematogenous dissemination through the arterial system.

Lung cancer is by far the most common solid tumor disseminating to the brain, followed by breast, melanoma, and colon cancer. Less common sources of metastasis are malignant melanoma, testicular cancer, and renal cell cancer. Prostate, uterine, and ovarian cancers are unlikely sources of brain metastasis.

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Contributor Information and Disclosures
Author

Bruce M Lo, MD, CPE, RDMS, FACEP, FAAEM, FACHE Medical Director, Department of Emergency Medicine, Sentara Norfolk General Hospital; Associate Professor, Assistant Program Director, Core Academic Faculty, Department of Emergency Medicine, Eastern Virginia Medical School

Bruce M Lo, MD, CPE, RDMS, FACEP, FAAEM, FACHE is a member of the following medical societies: American Academy of Emergency Medicine, American Association for Physician Leadership, American College of Emergency Physicians, American College of Healthcare Executives, American Institute of Ultrasound in Medicine, Emergency Nurses Association, Medical Society of Virginia, Norfolk Academy of Medicine, Society for Academic Emergency Medicine

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.

Jeffrey L Arnold, MD, FACEP Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center

Jeffrey L Arnold, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Edmond A Hooker, II, MD, DrPH, FAAEM Associate Professor, Department of Health Services Administration, Xavier University, Cincinnati, Ohio; Assistant Professor, Department of Emergency Medicine, University of Cincinnati College of Medicine

Edmond A Hooker, II, MD, DrPH, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Public Health Association, Society for Academic Emergency Medicine, Southern Medical Association

Disclosure: Nothing to disclose.

J Stephen Huff, MD, FACEP Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD, FACEP is a member of the following medical societies: American Academy of Neurology, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References
  1. Forsyth PA, Posner JB. Headaches in patients with brain tumors: a study of 111 patients. Neurology. 1993 Sep. 43(9):1678-83. [Medline].

  2. Purdy RA, Kirby S. Headaches and brain tumors. Neurol Clin. 2004 Feb. 22(1):39-53. [Medline].

  3. Forsyth PA, Posner JB. Headaches in patients with brain tumors: a study of 111 patients. Neurology. 1993 Sep. 43(9):1678-83. [Medline].

  4. McKinney PA. Brain tumours: incidence, survival, and aetiology. J Neurol Neurosurg Psychiatry. 2004 Jun. 75 Suppl 2:ii12-7. [Medline].

  5. DeAngelis LM. Brain tumors. N Engl J Med. 2001 Jan 11. 344(2):114-23. [Medline].

  6. Lassman AB, DeAngelis LM. Brain metastases. Neurol Clin. 2003 Feb. 21(1):1-23, vii. [Medline].

  7. Kaal EC, Vecht CJ. The management of brain edema in brain tumors. Curr Opin Oncol. 2004 Nov. 16(6):593-600. [Medline].

  8. Damek DM. Cerebral edema, altered mental status, seizures, acute stroke, leptomeningeal metastases, and paraneoplastic syndrome. Emerg Med Clin North Am. 2009 May. 27(2):209-29. [Medline].

  9. Giglio P, Gilbert MR. Neurologic complications of cancer and its treatment. Curr Oncol Rep. 2010 Jan. 12(1):50-9. [Medline].

  10. Collins VP. Brain tumours: classification and genes. J Neurol Neurosurg Psychiatry. 2004 Jun. 75 Suppl 2:ii2-11. [Medline].

  11. Grant R. Overview: Brain tumour diagnosis and management/Royal College of Physicians guidelines. J Neurol Neurosurg Psychiatry. 2004 Jun. 75 Suppl 2:ii18-23. [Medline].

  12. Cancer Facts & Figures 2015. American Cancer Society. Available at http://www.cancer.org/acs/groups/content/@editorial/documents/document/acspc-044552.pdf. Accessed: August 19, 2015.

  13. GLOBOCAN 2012: Estimated Cancer Incidence, Mortality and Prevalence Worldwide in 2012. International Agency for Research on Cancer. Available at http://globocan.iarc.fr/Pages/fact_sheets_population.aspx. Accessed: August 10, 2015.

  14. Wilne S, Collier J, Kennedy C, Jenkins A, Grout J, Mackie S, et al. Progression from first symptom to diagnosis in childhood brain tumours. Eur J Pediatr. 2012 Jan. 171(1):87-93. [Medline].

  15. Lanphear J, Sarnaik S. Presenting symptoms of pediatric brain tumors diagnosed in the emergency department. Pediatr Emerg Care. 2014 Feb. 30 (2):77-80. [Medline].

  16. US Food and Drug Administration. FDA approves Dotarem, a new magnetic resonance imaging agent. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm344758.htm. Accessed: August 20, 2015.

  17. [Guideline] Glantz MJ, Cole BF, Forsyth PA, Recht LD, Wen PY, Chamberlain MC, et al. Practice parameter: anticonvulsant prophylaxis in patients with newly diagnosed brain tumors. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000 May 23. 54(10):1886-93. [Medline].

  18. Tonning Olsson I, Perrin S, Lundgren J, Hjorth L, Johanson A. Long-term cognitive sequelae after pediatric brain tumor related to medical risk factors, age, and sex. Pediatr Neurol. 2014 Oct. 51 (4):515-21. [Medline].

  19. Shah SS, Dellarole A, Peterson EC, Bregy A, Komotar R, Harvey PD, et al. Long-term psychiatric outcomes in pediatric brain tumor survivors. Childs Nerv Syst. 2015 May. 31 (5):653-63. [Medline].

 
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Neoplasms, brain. CT images of several tumor types. Slide courtesy of UMASS Continuing Education Office.
Neoplasms, brain. Colloid cyst of the third ventricle with obstructive hydrocephalus. Image courtesy of Peter Ferrera, MD.
Neoplasms, brain. Occipital lobe glioblastoma with surrounding edema.
Neoplasms, brain. Noncontrast CT scan of a tumor in the region of the posterior corpus callosum.
Neoplasms, brain. Contrast CT scan of the same patient as in media file4. Notice that contrast enhancement brings out detail.
 
 
 
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