Brain Neoplasms Clinical Presentation

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

History

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, which may comprise any of the following:

  • Increased intracranial pressure (ICP)
  • Direct compression of essential gray or white matter
  • Shifting of intracranial contents
  • Secondary cerebral ischemia

Symptoms may be nonspecific and include any of the following:

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

Central nervous system (CNS) neoplasms also may manifest as follows:

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

Onset of symptoms usually is insidious. However, an acute episode may occur with bleeding into the tumor, or when an intraventricular tumor suddenly occludes the third ventricle.

In a United Kingdom study of 139 children with brain tumors, the median time from symptom onset to diagnosis of a brain tumor was 3.3 months. Head tilt, cranial nerve palsies, endocrine and growth abnormalities, and reduced visual acuity were associated with a longer delay in diagnosis. Headache was the most common initial manifestation, occurring in 55 patients (40%). By the time of diagnosis, patients had a median of six signs and/or symptoms. [14]

In a study from the United States, the mean time to diagnosis in the emergency department from onset of any symptom was 86.3 days, and 104.5 days for headache. Approximately 91% of cases were diagnosed by computed tomography scan, with 48% of tumors located in the posterior fossa. Headache, nausea/vomitting, and gait disturbance were the most common presenting symptoms. [15]

Although headache is the symptom customarily associated with an intracranial neoplasm, it often is a late complaint. In addition, headache usually is not an isolated finding, and headache is the worst symptom in only one half of patients.

Other features of headache from brain tumors are as follows:

  • Most headaches in patients with brain tumors are nonspecific and resemble tension-type headaches [1, 2, 3]
  • In patients with a history of headache, a change in the 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 portrayals of tumor headache that are in fact inaccurate include the following:

  • Pain that is worst in the early morning
  • Vomiting (with or without nausea)
  • Exacerbation with Valsalva maneuvers, bending over, or rising from a recumbent position

Manifestations of brain tumor may reflect the tumor site, as follows:

  • 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 two 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-secreting 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.
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Physical

No physical finding or pattern of findings unmistakably identifies a patient with a CNS neoplasm. Findings in these patients may include the following:

  • 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 (see the image below) may produce homonymous hemianopia or partial visual field deficits.
    Neoplasms, brain. Occipital lobe glioblastoma with 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.
  • Tumors in the region of the cerebellopontine angle may impair the functions of the three cranial nerves that traverse this region: facial, cochlear, and vestibular. Acoustic neuromas most commonly originate from the vestibular nerve (part of cranial nerve VIII).
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Causes

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

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