Brain Neoplasms Workup

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

Laboratory Studies

  • Patients with cancer are predisposed to medical complications, including bleeding disturbances (hyperviscosity), metabolic disorders (hypercalcemia), and production of excessive hormones (syndrome of inappropriate antidiuretic hormone secretion).
  • With clinical suspicion of cancer, obtain routine laboratory studies on admission, including a CBC, coagulation studies, and analysis of electrolytes and comprehensive metabolic panel.
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Imaging Studies

  • Obtain neuroimaging studies in patients with symptoms suggestive of an intracranial neoplasm (eg, acute mental status changes; new-onset seizures; focal, motor, or sensory deficits, including gait disturbance; suspicious headache; signs of elevated ICP, such as papilledema).
  • Although some tumors exhibit a characteristic appearance, do not make an unequivocal diagnosis based solely on radiologic findings.
  • Generally, CT is the imaging modality of choice for the ED physician.
    • Intravenous contrast material assists in tumor identification. Most tumors demonstrate enhancement with contrast material administration.
    • Tumors may appear hypodense, isodense, or hyperdense, or they may have mixed density.
    • Metastases to the brain tend to be multiple, but certain tumors, such as renal cell carcinomas, tend to be solitary metastatic brain lesions.
  • With increasing availability, MRIs may supplant CTs as the imaging procedures of choice.
    • An MRI is most helpful for identifying tumors in the posterior fossa (including acoustic neuromas), hemorrhagic lesions. It 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.
  • On plain skull radiographs, large pituitary adenomas are associated with a large sella turcica.
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Procedures

  • Lumbar puncture is not indicated in the ED in the patient with suspected CNS neoplasms.
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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

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  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].

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  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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