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Brain Tumors Emergencies

Brain Tumors Emergencies. Daniela Bota, MD PhD Neuro-oncologist UC Irvine. Low-Grade WHO grade I: low proliferative potential frequently discrete nature possibility of cure after surgical resection alone WHO grade II: generally infiltrating and low in mitotic activity frequently recur

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Brain Tumors Emergencies

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  1. Brain Tumors Emergencies Daniela Bota, MD PhD Neuro-oncologist UC Irvine

  2. Low-Grade WHO grade I: low proliferative potential frequently discrete nature possibility of cure after surgical resection alone WHO grade II: generally infiltrating and low in mitotic activity frequently recur some types tend to progress to higher grades. High Grade WHO grade III: histologic evidence of malignancy mitotic activity clearly expressed infiltrative capabilities anaplasia. WHO grade IV: mitotically active necrosis-prone associated with a rapid preoperative and postoperative evolution of disease. Classification of Brain Tumors: - high grade vs. low grade and primary vs. secondary - Kleihues P and Cavenee WK 2000, Kleihues et al. 2002

  3. Primary CNS Tumors: Malignant Gliomas • the most common primary neoplasms of the brain • affects approximately 10,000 people every year in the United States • very aggressive tumors with a historical survival of less the one year, which has changed little over the last two decades • high heterogeneity in pts response to treatment, disease free survival, and overall survival (OS), which cannot be accurately predicted at the time of diagnosis

  4. Glioblastoma Multiforme (WHO Grade IV) Anaplastic Astrocytoma (WHO Grade III) • 18,000 cases primary CNS tumors/year • 15,000 deaths/year • 2nd leading cancer death in young adults • Overall 5th and 6th leading causes of cancer death in men and women respectively • Uniformly fatal tumors

  5. Secondary Neoplasms of the Central Nervous System • 100,000-170,000 cases in the United States every year • Median survival rates between 2.9 and 3.4 months • Most common primary tumors are: • Lung carcinoma (27%) • Melanoma (22%) • Breast Carcinoma (15%) • Location: • Cerebrum (80%) • Cerebellum (16%) • Brainstem (3%)

  6. Brain Tumor Diagnosis • Initial Presentation: • Headache: most common • Mental Status Changes • “Acute tumor attack” 5-10% of the patients: seizures, stroke- like symptoms • Imaging: MRI is superior to the CT • More accurate detection of multiple lesions • Better diagnosis of smaller lesions (under 2 cm) • No bone artifacts Surgery is required for diagnostic, followed by combined treatment modalities (radiation, chemotherapy).

  7. Brain Tumors – Acute Presentation • General impairment of cerebral function, headaches, seizures • Increased intracranial pressure • Specific localizing syndromes

  8. Neurologic Manifestations of Brain Tumors Primary effects • Direct effects • Compression of adjacent structures Secondary effects • Edema • Hydrocephalus • Increased intracranial pressure • Paraneoplastic syndromes

  9. Neurologic Manifestations of Brain Tumors • Positive symptoms seizures, headaches • Negative symptoms sensory loss aphasia hemiparesis

  10. Headache • First symptom in 35% of the patients with brain tumors • Eventually present in 70% of the patients

  11. Headache Characteristics in BT • Morning headaches or those that awaken patient from sleep • Headaches that increase in frequency or severity over weeks or months • Headaches that differ from patient’s usual chronic headaches • Headaches associated with papilledema or focal signs

  12. Pain - distortion of intracranial pain sensitive structures • dura • venous sinuses • cerebral arteries • cranial nerves It usually responds to neuropathic pain medication (such as Gabapentin), or to opioids- but the cause needs to be identified.

  13. Headache Location • Frontal – supratentorial • Nuchal and occipital - posterior fossa

  14. Nausea and Vomiting • Increased intracranial pressure or hydrocephalus • When projectile, involvement of chemoreceptor trigger zone in medulla • Always consider the possibilities of tumor growth (progression) vs. intracranial bleeding (bleeding in the tumor) vs chemotherapy side-effects • Always obtain a head CT without contrast in a patient with HA’s and a known brain tumor

  15. Facial Pain secondary to Brain Tumors • Distribution of trigeminal nerve • Common for the tumors at base of skull or nasopharynx

  16. Facial Pain with BT compression vs. Trigeminal Neuralgia • Longer lasting • Less likely to be lancinating • May have sensory loss (facial numbness)

  17. Temporal or Auricular Pain • If cancer-related, is most commonly due to thoracic malignancies • referred pain from irritation of vagus nerve in the chest

  18. Brain Tumors and Plateau waves • Abrupt elevation of the intracranial pressure by as much as 100 mm Hg (normal 20 mm Hg) • May be sustained for minutes or hours • Clinical manifestation include: • Headache • Nausea • Vomiting • Leg weakness • Symptoms of incipient herniation

  19. Plateau Wave Triggers • Infections • Anesthetics • REM sleep • common factor - cerebral vasodilatation by events that lower arterial blood pressure

  20. Cushing Reflex - severe increased ICP • Rising blood pressure • Bradycardia • Immediately consider means to lower ICP medically and call neurosurgery stat

  21. Seizures and Brain Tumors • First symptom in 30% of the patients with brain tumors (every new seizure patient needs to have a brain MRI with contrast) • Present at some time in 70% of the diagnosed patients (consider tumor progression, intracranial bleeding secondary to chemotherapy such as Avastin, medication interaction with chemotherapy and non-compliance) • 5% of patients with first time- seizure are diagnosed with brain tumors • Age increase the risk of epilepsy being caused by a tumor, especially over 45 years of age

  22. The causes of a first seizure in adults 15 years of age and older Cause Number of patients (%) Idiopathic 27 (27.6) Cerebral infarction 23 (23.5) Alcohol withdrawal 11 (11.2) CNS infection 9 (9.2) Tumor 8 (8.2) Vascular malformation 6 (6.1) Trauma 4 (4.1) Drug toxicity 3 (3.1) Subdural hematoma 2 (2.0) Hyperglycemia 2 (2.0) Uremia 1 (1.0) Hyponatremia 1 (1.0) Cerebral malformation 1 (1.0) Adapted from Brain Tumors: an Encyclopedic Approach. Eds. Kaye AH, Laws E. 2nd edition. 2003

  23. The causes of a first seizure based upon age distribution Cause Number of patients (%) <45 yrs >45 yrs Idiopathic 18 (45) 9 (15.5) Cerebral infarction 1 (2.5) 22 (37.9) Alcohol related 6 (15.0) 5 (8.6) CNS infection 7 (17.5) 2 (3.4) Tumor 1 (2.5) 7 (12.0) Vascular malformation 3 (7.5) 3 (5.2) Trauma 3 (7.5) 1 (1.7) Drug toxicity 0 (0) 3 (5.2) Subdural hematoma 0 (0) 2 (3.4) Hyperglycemia 0 (0) 2 (3.4) Uremia 0 (0) 1 (1.7) Hyponatremia 1 (2.5) 0 (0) Cerebral malformation 0 (0) 1 (1.7) Adapted from Brain Tumors: an Encyclopedic Approach. Eds. Kaye AH, Laws E. 2nd edition. 2003

  24. Type of Tumor and Seizures • Seizures are more common with relatively slow-growing tumors (low-grade glioma are twice more frequent associated with seizures then glioblastoma) • Gangliogliomas, dysembrioplastic neuroepithelial tumors and hamartomas commonly present with epilepsy • Tumors originating from the meninges and vascular structures may also cause seizures, at a rate less then gliomas

  25. Seizure Type and Location Temporal Lobe • Simple olfactory hallucinations • Feelings of fear (anxiety attacks) • Complex partial seizures Occipital Lobe • Occasionally visual seizures

  26. Symptomatic Anticonvulsivant Therapy • Prophylactic AED treatment is not recommended • Symptomatic treatment is often difficult, with low rate of seizure-free patients • The AED’s proposed mechanisms of action cover only a few of the mechanisms involved in BT related seizures. • The morphologic changes, altered receptor distribution, changes in the cytokines expression cannot be altered by the current AED

  27. AED’s, Brain Tumors and Multidrug Resistance • AEDs levels are hard to maintain in patients with BT due to the interactions with current medication (chemotherapy) and patient compliance issues • The multidrug resistance protein, glycoprotein P (P-gp) in increased in the brain of pt with neoplasms, as well as with intractable epilepsy, and is associated with the exotransport (elimination) of AED and chemotherapy drugs • Consider AED drugs that are not eliminated through the liver (such as Keppra and Topamax).

  28. Thromboembolisms: DVT and PE • Patients with brain tumors develop much more common then the general population thromboembolic complications such as deep venous thrombosis and pulmonary embolisms • Newly-developed chemotherapy (anti-angiogenesis agents-Avastin) increases the risk of thrombosis • Work-up of the brain tumor patients presenting to the ER with leg pain or SOA should always include an US of the lower extremities and a spiral chest CT • Before starting the heparin/lovenox- a head CT needs to be obtained to r/o bleeding.

  29. Conclusions • Most acute BT patient presentations are potentially life-threatening • Good medical management and prompt call to neurosurgical services when in doubt can save lifes • As our patients prognosis improve, more long-term complications are seen

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