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Brain Neoplasms

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

Practice Essentials

Brain tumors may originate from neural elements within the brain, or they may represent spread of distant cancers. Gliomas, metastases, meningiomas, pituitary adenomas, and acoustic neuromas account for 95% of all brain tumors. See the image below.

Neoplasms, brain. CT images of several tumor types Neoplasms, brain. CT images of several tumor types. Slide courtesy of UMASS Continuing Education Office.

Signs and Symptoms

Presenting complaints of patients with an intracranial neoplasm tend to be similar for primary brain tumors and intracranial metastases. 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.

Manifestations may be nonspecific and include the following:

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

CNS neoplasms also may manifest as follows:

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

Headache associated with intracranial neoplasms have the following characteristics:

  • Often is a late complaint
  • Usually not an isolated finding
  • The worst symptom in only one half of patients
  • Usually nonspecific and resembles tension-type headaches [1, 2, 3]
  • In patients with established headache, may manifest as a change in the headache pattern
  • 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 the following:

  • Pain that is worse in the early morning than at other times
  • Accompanying vomiting (with or without nausea)
  • Exacerbation with Valsalva maneuvers, bending over, or rising from a recumbent position

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. Findings may include the following:

  • Papilledema, which is more prevalent with pediatric brain tumors, reflects an increase in intracranial pressure (ICP) of several days or longer
  • 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
  • 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

See Clinical Presentation for more detail.

Diagnosis

With clinical suspicion of cancer, obtain routine laboratory studies on admission, including the following:

  • Complete blood cell count (CBC)
  • Coagulation studies
  • Electrolyte levels
  • Comprehensive metabolic panel

Obtain neuroimaging studies in patients with symptoms suggestive of an intracranial neoplasm, such as the following:

  • Acute mental status changes
  • New-onset seizures
  • Focal motor or sensory deficits, including gait disturbance
  • Suspicious headache
  • Signs of elevated ICP (eg, papilledema)
  • Generally, CT is the imaging modality of choice for the ED physician.

Although some tumors exhibit a characteristic appearance, do not make an unequivocal diagnosis based solely on radiologic findings. Generally, computed tomography (CT) is the imaging modality of choice for the emergency department physician. CT findings are as follows:

  • Most tumors demonstrate enhancement with contrast material administration
  • Tumors may appear hypodense, isodense, or hyperdense or have mixed density
  • Metastases to the brain tend to be multiple, but certain tumors (eg, renal cell carcinomas) tend to produce solitary metastatic brain lesions

As magnetic resonance imaging (MRI) becomes increasingly available, it may supplant CT as the imaging procedure of choice. Features of MRI for imaging intracranial neoplasms are as follows:

  • MRI is most helpful for identifying tumors in the posterior fossa (including acoustic neuromas) and hemorrhagic lesions
  • MRI is useful in patients with an allergy to iodinated contrast material or renal insufficiency
  • Drawbacks to MRI include incompatibility with certain medical equipment, longer imaging times (increased risk of motion artifact), and poor visualization of the subarachnoid space
  • Neither CT nor MRI can be used to differentiate tumor recurrence from radionecrosis

See Workup for more detail.

Management

Acute treatment for cerebral edema from intracranial neoplasms is as follows:

  • Corticosteroids may dramatically reduce signs and symptoms, bringing relief within a few hours
  • Dexamethasone is the agent of choice
  • Recommended doses generally range from 4-24 mg daily

Definitive treatment is as follows:

  • Generally, care of patients with a brain tumor is multidisciplinary, requiring assistance from a neurosurgeon, an oncologist, a radiologist, and an expert in radiation therapy
  • Management varies greatly depending on tumor location, tissue type, and comorbid conditions
  • Surgical treatment options may include tumor removal or debulking, installation of a ventricular shunt, and placement of radioactive implants

See Treatment and Medication for more detail.

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Background

Brain tumors may originate from neural elements within the brain, or they may represent spread of distant cancers. Primary brain tumors arise from CNS tissue and account for roughly half of all cases of intracranial neoplasms. The remainder of brain neoplasms are caused by metastatic lesions. In adults, two thirds of primary brain tumors arise from structures above the tentorium (supratentorial), whereas in children, two thirds of brain tumors arise from structures below the tentorium (infratentorial). Gliomas, metastases, meningiomas, pituitary adenomas, and acoustic neuromas account for 95% of all brain tumors. Classification by tumor cell type is irrelevant to the emergency physician because emergent treatment is the same regardless of the tumor type.

Neoplasms, brain. CT images of several tumor types Neoplasms, brain. CT images of several tumor types. Slide courtesy of UMASS Continuing Education Office.

Many review articles have been written on brain tumors, and this discussion at times draws from the consensus of these reviews.[4, 5, 6, 7, 8, 9, 10, 1, 11]

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Pathophysiology

Tumors of the brain produce neurologic manifestations through a number of mechanisms. Small, critically located tumors may damage specific neural pathways traversing the brain. Tumors can invade, infiltrate, or supplant normal parenchymal tissue, disrupting normal function. Because the brain dwells in the limited volume of the cranial vault, growth of intracranial tumors with accompanying edema may cause increased intracranial pressure. Tumors adjacent to the third and fourth ventricles may impede the flow of cerebrospinal fluid, leading to obstructive hydrocephalus. In addition, tumors generate new blood vessels (ie, angiogenesis), disrupting the normal blood-brain barrier and promoting edema.

Neoplasms, brain. Colloid cyst of the third ventri Neoplasms, brain. Colloid cyst of the third ventricle with obstructive hydrocephalus. Image courtesy of Peter Ferrera, MD.

The cumulative effects of tumor invasion, edema, and hydrocephalus may elevate the intracranial pressure (ICP) and impair cerebral perfusion. Intracranial compartmental rise in ICP may provoke shifting or herniation of tissue under the falx cerebri, through the tentorium cerebelli, or through the foramen magnum.

Slow-growing tumors, particularly tumors expanding in the so-called silent areas of the brain, such as the frontal lobe, may be associated with a more insidious clinical course. These tumors tend to be larger at detection.

Most primary brain tumors do not metastasize, but if they do metastasize, intracranial spread generally precedes distant dissemination.

Metastatic brain tumors from non-CNS primary tumors may be the first sign of malignancy, or they may herald a relapse. Nonetheless, the signs and symptoms of brain metastases simulate those of primary brain tumors.

Leptomeningeal infiltration may present with dysfunction of multiple cranial nerves.

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Frequency

United States

The American Cancer Society estimates that 22,850 brain and other nervous system cancers will be diagnosed in 2015.[12] Estimates of the annual incidence rate of primary brain tumors range from 7-19.1 cases per 100,000 population. Metastatic tumors to the brain are more common, with more than 200,000 patients per year in the United States with a new diagnosis of intracranial metastases. Pituitary adenomas are exceptionally common, and they are frequent incidental findings on autopsy. Autopsy series of patients with systemic cancer show that intracranial metastases are present in 18-24% of patients.

International

The International Agency for Research on Cancer of the World Health Organization estimates that in 2012, brain and nervous system cancers occurred in 139,608 men and 116,605 women worldwide.[13]

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Mortality/Morbidity

In the United States, brain and other nervous system cancers are expected to cause approximately 15,320 deaths in 2015.[12] Brain tumors are the second most common cancer in children, comprising 15-25% of all pediatric malignancies. Perhaps no other cancer is as feared as brain tumor, since severe disability, including paralysis, seizures, gait disturbances, and impairment of intellectual capacity may occur.

Race

Differences are seen between ethnic groups within the same country, and a 3-fold difference in incidence has been reported between countries worldwide. Developed countries appear to have the highest rates, but this may reflect better registration systems.

Sex

Meningiomas and pituitary adenomas are slightly more common in women than in men. Males are more likely to be diagnosed with brain tumors than females, with a male-to-female ratio of 1.5:1.

Age

Age-related variation is as follows:

  • Tumors in the posterior fossa predominate in preadolescent children, with the incidence of supratentorial tumors increasing from adolescence to adulthood.
  • Low-grade gliomas, such as astrocytomas, are more common in younger people than in older people. High-grade gliomas, such as anaplastic astrocytoma and glioblastoma multiforme, tend to originate in the fourth or fifth decade or beyond.
  • In children, brain tumors are the most prevalent solid tumor, second only to leukemia as a cause of pediatric cancer. The incidence rate of primary CNS neoplasms is 3.6 cases per 100,000 children each year.
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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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