Brain Neoplasms Clinical Presentation

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: an increase in ICP, direct compression of essential gray or white matter, shifting of intracranial contents, or secondary cerebral ischemia.

Symptoms may be nonspecific and include headache, altered mental status, ataxia, nausea, vomiting, weakness, and gait disturbance. CNS neoplasms also may manifest as focal seizures, fixed visual changes, speech deficits, or focal sensory abnormalities. The onset of symptoms usually is insidious, but an acute episode may occur with bleeding into the tumor, or when an intraventricular tumor suddenly occludes the third ventricle.

In one study of children with brain tumors, time from symptom onset to diagnosis of a brain tumor was found to be 3.3 months. Head tilt, cranial nerve palsies, endocrine and growth abnormalities and reduced visual acuity were associated with a longer symptom interval. Headache was the number one symptom experienced in more than half of patients.^[10]

• Although headache is the symptom customarily associated with an intracranial neoplasm, it often is a late complaint. Usually, headache is not an isolated finding.

  • Headache is the worst symptom in only one half of patients.
  • Most headaches in patients with brain tumors are nonspecific and resemble tension-type headaches.^{[8, 11, 12]}
  • A change in any patient's 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 inaccurate portrayals of a tumor headache include pain that is worse in the early morning than at other times; vomiting (with or without nausea); and exacerbation with Valsalva maneuvers, bending over, or rising from a recumbent position.
• 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 2 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 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.

No physical finding or pattern of findings unmistakably identifies a patient with a CNS neoplasm.

• 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 may produce homonymous hemianopia or partial visual field deficits.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.

  • Three cranial nerves run through the cerebellopontine angle: facial, cochlear, and vestibular. Masses in these regions may impair the functions of these nerves.
  • Acoustic neuromas most commonly originate from the vestibular nerve (part of cranial nerve VIII).

Although few factors are unequivocally associated with an increased risk of brain cancer, some 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.