Brain Neoplasms Follow-up

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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Follow-up

Further Outpatient Care

See the list below:

  • The patient's primary physician best manages coordination of consultants, but the responsible neurosurgeon should direct the treatment of specific postoperative complications or care.
  • A common problem confronting the ED physician is a patient with a known brain neoplasm complaining of a headache or worsening other symptoms. This scenario always raises the possibility of tumor recurrence or worsening cerebral edema. Obtain a CT scan or MRI to rule out life-threatening events, such as hemorrhage or herniation.
  • Radiation therapy for gliomas usually is performed on an outpatient basis.
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Further Inpatient Care

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  • Further inpatient care is complex and may involve multiple consultants, depending on the tumor type and overall prognosis.
  • Definitive diagnosis requires tissue biopsy performed by a qualified neurosurgeon.
  • Additional neurosurgical options include resection or debulking and placement of a ventricular shunt with obstructive hydrocephalus.
  • The admitting physician should coordinate oncologic or radiation oncology consultations.
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Transfer

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  • New occurrence of CNS tumor may require transfer to a facility with appropriate neurosurgical staff.
  • Speak directly to the consultant prior to transfer to address initiation of steroid or anticonvulsant treatment.
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Complications

Acute symptoms in a patient with a brain tumor, particularly when signs and symptoms resemble stroke, suggest the possibility of acute hemorrhage into a tumor. Brain neoplasms predisposed to hemorrhage include lung cancer, melanoma, and choriocarcinoma.

Lesions near the third ventricle can cause paroxysmal symptoms of headache, syncope, or mental status change. Additionally, vomiting, ataxia, memory changes, visual disturbances, or personality changes may occur.

Episodic increases in ICP secondary to pressure arising from blockage of cerebrospinal fluid outflow cause transient symptoms. Sudden death is a reported complication from obstruction of outflow drainage from the third ventricle. Sudden increases in ICP may lead to life-threatening brain herniation, which shifts the brain parenchyma in the direction of least resistance: caudally through the foramen magnum (posterior fossa tumors) or transtentorial apertures.

Some pituitary tumors are hormonally active and capable of producing acromegaly or galactorrhea. Pituitary apoplexy, an unusual complication arising from pituitary adenomas, describes hemorrhage into the tumor, leading to headache, deterioration of vision, oculomotor palsies, and shock secondary to acute adrenal insufficiency.

Although radiation therapy rarely causes acute toxicity with modern dosing schedules and concomitant use of steroids, subacute or chronic effects may occur, as follows:

  • Subacute encephalopathy occurs 6-16 weeks after radiation therapy and is characterized by somnolence and headaches
  • Chronic effects of prolonged radiation treatment tend to be more serious and range from impairment of intellectual capacity to complete incapacity
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Prognosis

Prognostic features include the following:

  • Tumor resectability, tumor location, age of the patient, and tumor histology are the primary determinants of survival.
  • Without radiation therapy, the mean life expectancy of a patient with brain metastases is 1 month. Radiation therapy may extend survival to 4-6 months.
  • Patients with seizures secondary to a brain tumor generally experience obvious neurologic deterioration over a 6-month course.
  • Most patients with brain metastases die from progression of their primary malignancy rather than from brain damage.

In a study of 69 pediatric brain tumor survivors, the patients showed deficits in executive function, memory, and attention. Whole-brain radiation therapy, tumor size, young age at diagnosis, and male gender were risk factors for late cognitive sequelae. [18] Adult survivors of pediatric brain tumors have an increased risk of psychiatric illnesses, including depression, anxiety, suicidal ideation, schizophrenia and related psychoses, and behavioral problems. [19]

 

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Patient Education

For patient education resources, see the Cancer Center, as well as Brain Cancer.

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