Brain Neoplasms Workup

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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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). Therefore, with clinical suspicion of cancer, obtain routine laboratory studies on admission, including the following:

  • Complete blood cell count (CBC)
  • Coagulation studies
  • Electrolyte levels
  • Comprehensive metabolic panel

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, computed tomography (CT) is the imaging modality of choice for the emergency physician. On CT scans with contrast, brain 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 cause solitary metastatic brain lesions.

As magnetic resonance imaging (MRI) becomes increasingly available, MRIs may supplant CT as the imaging procedures of choice. An MRI is most helpful for identifying tumors in the posterior fossa (including acoustic neuromas) and hemorrhagic lesions. MRI is also useful in patients with an allergy to iodinated contrast material or renal insufficiency. The US Food and Drug Administration (FDA) has approved gadolinium-based contrast agents for use in MRIs of the brain, spine, and associated tissues, to improve detection and analysis of CNS lesions. [16]

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.



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