Brain Neoplasms 

  • Author: J Stephen Huff, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP   more...
 
Updated: Jan 25, 2012
 

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 typesNeoplasms, 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.[1, 2, 3, 4, 5, 6, 7, 8, 9]

Glioma has recently been in the news with the diagnosis of this malignant brain tumor in May 2008 in Senator Edward M. Kennedy and his death August 25, 2009. For more information on this, see the Medscape Medical News article and the WebMD Health News article.

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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 ventriNeoplasms, 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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Epidemiology

Frequency

United States

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. An increase in the prevalence of HIV infection corresponds to an increase in the occurrence of primary CNS lymphoma. 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 incidence is not known, but it is thought to parallel that of the United States.

Mortality/Morbidity

  • In the United States in 1999, primary cancers of the central nervous system were the cause of death in approximately 13,100 people.
  • 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

  • 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

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

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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

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, and Southern Medical Association

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

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 and American College of Physicians

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP  Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, 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 Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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

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

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

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

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

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

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

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

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

  10. 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. Jan 2012;171(1):87-93. [Medline].

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

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

  13. [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. May 23 2000;54(10):1886-93. [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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