Brain Neoplasms Treatment & Management

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

Prehospital Care

Prehospital care is supportive and directed to the presenting symptom complex. For example, treat seizures in the usual manner. Airway disturbance, breathing difficulty, signs of pronounced elevation in ICP, and notable impairment of consciousness may necessitate definitive airway control with endotracheal intubation and, possibly, hyperventilation.

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Emergency Department Care

ED treatment of the patient with an intracerebral neoplasm depends on both the nature of the tumor and the general condition of the patient. Decisions regarding surgical resection, initiation of radiation treatment, and chemotherapy are beyond the scope of practice of the ED physician.

  • Corticosteroids may dramatically reduce signs and symptoms related to cerebral edema. Affected patients may experience relief within the first few hours of steroid therapy.
    • Dexamethasone is the agent of choice because of its minimal salt-retaining properties. Recommended doses generally range from 4-24 mg daily. For patients with impaired consciousness or signs of increased intracranial pressure, 10 mg IV[4] or 10-24 mg IV are recommended as the first dose. Side effects, notably proximal muscle weakness, are dose-dependent. Often, corticosteroids can be tapered or discontinued after definitive therapy. The final dose of steroids should be the lowest necessary to control the patient's neurologic symptoms.
  • For patients with signs or symptoms of impending herniation and airway compromise, consider use of adjunctive medications for rapid sequence intubation. These might include lidocaine and medication for rapid-onset neuromuscular blockade, with precautions to diminish fasciculations. Induction agents, such as thiopental, may be used.
  • After definitive control of the airway, consider gentle hyperventilation.
  • Discuss the use of mannitol with the appropriate consultant. Although mannitol may reduce transiently lower ICP, concern about rebound increases in ICP makes its use problematic.
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Consultations

Local practice patterns govern requests for consultations.

  • 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.
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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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