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Brain Tumors

Primary Intracranial Tumors

Gliomas are the most common intracranial neoplasm, accounting for half of all primary intracranial neoplasms. The remainder consist of meningiomas, pituitary adenomas, neurofibromas, and

Tumor Clinical Features Treatment and Prognosis

Glioblastoma Presents commonly with nonspecific Course is rapidly progressive, with

multiforme complaints and increased intracranial pressure. poor prognosis. Total surgical removal

As it grows, focal deficits develop. is usually not possible, and response

to radiation therapy is poor.

Astrocytoma Presentation similar to glioblastoma multiforme Prognosis is variable. By the time of

but course more protracted, often over several diagnosis, total excision is usually

years. Cerebellar astrocytoma, especially in impossible; tumor often is not

children, may have a more benign course. radiosensitive. In cerebellar

astrocytoma, total surgical removal is

often possible.

Medulloblastoma Seen most frequently in children. Generally Treatment consists of surgery combined

arises from roof of fourth ventricle and leads to with radiation therapy and

increased intracranial pressure accompanied by chemotherapy.

brain stem and cerebellar signs. May seed

subarachnoid space.

Ependymoma Glioma arising from the ependyma of a ventricle, Tumor is not radiosensitive and is best

especially the fourth ventricle; leads early to treated surgically if possible.

signs of increased intracranial pressure. Arises

also from central canal of cord.

Oligodendroglioma Slow-growing. Usually arises in cerebral Treatment is surgical and usually

hemisphere in adults. Calcification may be successful.

visible on skull x-ray.

Brain stem glioma Presents during childhood with cranial nerve Tumor is inoperable; treatment is by

palsies and then with long-tract signs in the irradiation and shunt for increased

limbs. Signs of increased intracranial pressure intracranial pressure.

occur late.

Cerebellar Presents with disequilibrium, ataxia of trunk Treatment is surgical.

hemangioblastoma or limbs, and signs of increased intracranial

pressure. Sometimes familial. May be associated with retinal and spinal vascular

lesions, polycythemia, and hypernephromas.

Pineal tumor Presents with increased intracranial pressure, Ventricular decompression by shunting

sometimes associated with impaired upward is followed by surgical approach to

gaze (Parinaud=s syndrome) and other deficits tumor; irradiation is indicated if tumor is

indicative of midbrain lesion. malignant. Prognosis depends on

histopathologic findings and extent of


Craniopharyngioma Originates from remnants of Rathke=s pouch Treatment is surgical, but total removal

above the sella, depressing the optic chiasm. may not be possible.

May present at any age but usually in childhood,

with endocrine dysfunction and bitemporal field defects.

Acoustic neurinoma Ipsilateral hearing loss is most common initial Treatment is excision by

symptom. Subsequent symptoms may include translabyrinthine surgery, craniectomy,

tinnitus, headache, vertigo, facial weakness or or a combined approach. Outcome is

numbness, and long-tract signs. (May be familial usually good.

and bilateral when related to neurofibromatosis.) Most sensitive screening tests are MRI and

brain stem auditory evoked potential.

Meningioma Originates from the dura mater or arachnoid; Treatment is surgical. Tumor may recur

compresses rather than invades adjacent neural if removal is incomplete.

structures. Increasingly common with advancing age. Tumor size varies greatly. Symptoms vary

with tumor siteCeg, unilateral exophthalmos (sphenoidal ridge); anosmia and optic nerve

compression (olfactory groove). Tumor is usually benign and readily detected by CT scanning

Primary cerebral Associated with AIDS and other Treatment is by whole-brain

lymphoma immunodeficient states. Presentation may be irradiation; chemotherapy may have an

with focal deficits or with disturbances of adjunctive role. Prognosis depends

cognition and consciousness. May be upon CD4 count at diagnosis.

indistinguishable from cerebral toxoplasmosis.

Clinical Findings

A. Symptoms and Signs: Intracranial tumors may lead to a generalized disturbance of


Treatment depends on the type and site of the tumor (Table 24B3) and the condition of the patient. Complete surgical removal may be possible if the tumor is extra-axial (eg, meningioma, acoustic neuroma) or is not in a critical or inaccessible region of the brain (eg, cerebellar hemangioblastoma). Surgery also permits the diagnosis to be verified and may be beneficial in reducing intracranial pressure and relieving symptoms even if the neoplasm cannot be completely removed. Clinical deficits are sometimes due in part to obstructive hydrocephalus, in which case simple surgical shunting procedures often

Metastatic Intracranial Tumors

Cerebral Metastases

Metastatic brain tumors present in the same way as other cerebral neoplasms, ie, with increased intracranial pressure, with focal or diffuse disturbance of cerebral function, or with both of these manifestations. Indeed, in patients with a single cerebral lesion, the metastatic nature of the lesion may only become evident on histopathologic examination. In other patients, there is evidence of widespread metastatic disease, or

Treatment is by irradiation to symptomatic areas, combined with intrathecal methotrexate. The long-term prognosis is poorConly about 10% of patients survive for 1 year.