Brain Neoplasms Treatment & Management

Updated: Dec 14, 2018
  • Author: Bruce M Lo, MD, MBA, CPE, RDMS, FACEP, FAAEM, FACHE; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Treatment

Approach Considerations

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. The patient's primary physician best manages coordination of consultants, but the responsible neurosurgeon should direct the treatment of specific postoperative complications or care. New occurrence of CNS tumor may require transfer to a facility with appropriate neurosurgical staff. 

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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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 intracranial pressure (ICP), and notable impairment of consciousness may necessitate definitive airway control with endotracheal intubation and, possibly, hyperventilation.

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Emergency Department Care

Emergency department (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.

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.

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 (ICP), 10 mg IV [12] 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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Medical Care

Further inpatient care is complex and may involve multiple consultants, depending on the tumor type and overall prognosis. The admitting physician should coordinate oncologic or radiation oncology consultations. Radiation therapy for gliomas usually is performed on an outpatient basis.

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Surgical Care

Definitive diagnosis requires tissue biopsy performed by a qualified neurosurgeon. Neurosurgical options include resection or debulking and placement of a ventricular shunt with obstructive hydrocephalus.

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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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