History

Fact Explanation
Presence of risk factors ( genetic conditions/ exposure to ionizing radiation/ white race/ age between 69 -5 years) Presence of neurofibromatosis 1 is a known risk factor for astrocytomas [1]. High-dose ionizing radiation is the only proven environmental risk factor for primary brain tumors [2]. Whites have twice a risk of getting glioblastoma (astrocytoma grade IV) [WHO] than black people. Highest number of brain tumors were detected between 69 -5 years of age [1].
Focal symptoms Patient complaint of focal symptoms at the early stages, when the tumor is localized. The nature of the symptoms characterizes the site of the tumor, as the impairment is caused by the loss of function of the particular part of the brain. Frontal lobe : impairment of memory with change in personality revealed by the patient himself or by the family members / difficulty in walking/ difficulty in speech/ fits Parietal lobe : visual impairment/ loss of sensation/ difficulty in speech Temporal lobe : visual & memory impairment/ fits/ change in behavior revealed by the family members Occipital lobe : visual impairment Thalamus : loss of sensation in one side of the body/ change in behavior revealed by the family members / difficulty in speech & language Cerebellum : imbalance in walking Brain stem : difficulty in walking/ symptoms related to cranial nerve dysfunction/ weakness of a side/ limb Headache : This is the most common symptom. Warning signs are positional worsening, change in headache pattern, association with vomiting & seizures [1].
Generalized symptoms These occur as the tumor enlarges and includes headache, nausea, vomiting, seizures, and altered mental functions. Seizures can be accompanied by aura and post-ictal symptoms [1].
References
  1. CHANDANA SR, MOVVA S, ARORA M, SINGH T. Primary brain tumors in adults. Am Fam Physician [online] 2008 May 15, 77(10):1423-30 [viewed 25 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18533376
  2. FISHER JL, SCHWARTZBAUM JA, WRENSCH M, BERGER MS. Evaluation of epidemiologic evidence for primary adult brain tumor risk factors using evidence-based medicine. Prog Neurol Surg [online] 2006:54-79 [viewed 25 August 2014] Available from: doi:10.1159/000095179

Examination

Fact Explanation
Memory impairment with cognitive dysfunction This can be detected by mini mental state examination. This is usually associated with tumors in the frontal lobe & the temporal lobe [1-chart]. Cognitive dysfunction is appeared to be associated with the tumors of the dominant hemisphere and can be the initial clinical feature in brain tumors [1].
Speech & language deficit Expressive aphasia is detected with frontal lobe tumor while receptive aphasia detected with parietal lobe tumor. Language problems may be detected with thalamic tumors [1]. Cerebellar tumors can also cause slurring of speech.
Motor deficit Detected with tumors of the brain stem & the frontal lobe [1].
Sensory deficit Detected in tumors of the parietal lobe and thalamus. Thalamic tumors cause a contralateral sensory loss [1].
Visual impairment Contralateral hemianopia is detected with occipital lobe tumors, while hemianopia & quadrantonopia is detected with parietal & temporal lobe tumors respectively [1].
Cranial nerve dysfunction Impaired function of cranial nerves in the cranial nerve examination helps to identify the tumor location in the brainstem [1].
Cerebellar dysfunction Ataxia, dysmetria and nystagmus are the common signs of cerebellar tumors [1].
Pupillary abnormalities Seen in tumors of the brain stem [1].
Papilledema This is a rare symptom of brain tumors [1] and indicates increased intracranial pressure.
References
  1. CHANDANA SR, MOVVA S, ARORA M, SINGH T. Primary brain tumors in adults. Am Fam Physician [online] 2008 May 15, 77(10):1423-30 [viewed 25 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18533376

Differential Diagnoses

Fact Explanation
Seizure disorder Family history of epilepsy favors the diagnosis. Electro encephalogram during the seizure and brain imaging may help in the diagnosis [1].
Infection of the central nervous system The patient will have rapidly progressive signs & symptoms that can be associated with fever, loss of appetite & malaise. Cerebro spinal fluid examination helps in making the diagnosis.
Stroke Ischaemia to a certain part of the brain can result in motor/ sensory deficit that can be mistaken with the clinical features of brain tumor. History of hypertension and diabetes and sudden onset of symptoms favor the diagnosis that can be confirmed by brain imaging [1].
Dementia due to other cause Cognitive dysfunction caused by dementia due to alzeimer’s disease/ vascular cause has a progressive course and the onset is at an advanced age. Brain imaging helps in excluding the possibility of a tumor [1].
References
  1. CHANDANA SR, MOVVA S, ARORA M, SINGH T. Primary brain tumors in adults. Am Fam Physician [online] 2008 May 15, 77(10):1423-30 [viewed 25 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18533376

Investigations - for Diagnosis

Fact Explanation
CT scan (computed tomography) Helps to localize the tumor and define the dimensions [1]
Magnetic resonance imaging (MRI) Gadolinium enhanced MRI is the preferred choice of investigation in evaluating the tumor dimensions. It is better than CT as the images are of higher resolution and tumors of the posterior fossa & spine can also be seen with MRI [1].
Positron emission tomography (PET) scan This also helps in making the diagnosis and tumor grading as it readily identifies highly metabolic areas of the tumor [2].
Magnetic resonance angiography Helps to look at the blood supply of the tumor and its anatomical relationship with the blood vessels [2].
Tumor biopsy Histology confirms the diagnosis. usually excisional biopsy is carried out during surgery [2].
References
  1. JACOBS AH, KRACHT LW, GOSSMANN A, RüGER MA, THOMAS AV, THIEL A, HERHOLZ K. Imaging in neurooncology. NeuroRx [online] 2005 Apr, 2(2):333-47 [viewed 25 August 2014] Available from: doi:10.1602/neurorx.2.2.333
  2. CHANDANA SR, MOVVA S, ARORA M, SINGH T. Primary brain tumors in adults. Am Fam Physician [online] 2008 May 15, 77(10):1423-30 [viewed 25 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18533376

Investigations - Followup

Fact Explanation
MRI brain Should be performed within 3 days following surgery to see the extent of tumor resection [1].
PET scan PET scan helps in the follow up as it aids in differentiating tumor recurrence from radiation necrosis []. It also helps to predict the response to chemotherapy compared to radio chemotherapy [1].
References
  1. CHANDANA SR, MOVVA S, ARORA M, SINGH T. Primary brain tumors in adults. Am Fam Physician [online] 2008 May 15, 77(10):1423-30 [viewed 25 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18533376

Investigations - Screening/Staging

Fact Explanation
Analysis of cerebro spinal fluid (CSF) There is no standard staging method and this aids in assessing the tumor spread to CSF [1].
References
  1. CHANDANA SR, MOVVA S, ARORA M, SINGH T. Primary brain tumors in adults. Am Fam Physician [online] 2008 May 15, 77(10):1423-30 [viewed 25 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18533376

Management - General Measures

Fact Explanation
Treatment of seizures This is important mainly in palliative care. Although anti-convulsants are used to treat the seizures, prophylactic use of them is nor currently recommended [1].
Treatment of venous thromboembolism (VTE) VTE is associated with glioblastoma multiforme and the recommended treatment is controlled anticoagulation with warfarin / low molecular weight heparin [2].
References
  1. SIRVEN JI, WINGERCHUK DM, DRAZKOWSKI JF, LYONS MK, ZIMMERMAN RS. Seizure prophylaxis in patients with brain tumors: a meta-analysis. Mayo Clin Proc [online] 2004 Dec, 79(12):1489-94 [viewed 25 August 2014] Available from: doi:10.4065/79.12.1489
  2. LEVIN JM, SCHIFF D, LOEFFLER JS, FINE HA, BLACK PM, WEN PY. Complications of therapy for venous thromboembolic disease in patients with brain tumors. Neurology [online] 1993 Jun, 43(6):1111-4 [viewed 25 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8170553

Management - Specific Treatments

Fact Explanation
Surgery This is the treatment of choice for all types of astrocytomas [1]. Pilocytic astrocytoma is surgically curable whereas glioblastoma multiforme has very poor prognosis [2]. Complete resection of the tumor is the best treatment option. MRI brain should be performed within 3 days following surgery to see the extent of tumor resection [1]. Steroids are used to treat vasogenic edema that occurs following surgery. However, it should be used with caution while monitoring for side-effects such as hyperglycemia, myopathy, gastro-intestinal problems and opportunistic infections [1].
Radiotherapy Recommended for high grade & anaplastic astrocytomas following surgery. Stereostatic radio surgery which delivers high dose of radiation in one day is used as a boost after external beam radiation and as a palliative method to treat recurrent glioblastoma multiforme [1].
Chemotherapy Recommended in treatment of high-grade astrocytomas following surgery. Telozolomide is used commonly. Radiotherapy combined with chemotherapy has proven effective results than radiotherapy alone in the treatment of glioblastoma multiforme [3]. Suppressing the activity of methyl guanine & methyl transferase gene (MGMT) by chemotherapy in the treatment of glioblastoma multiforme has proven to have beneficial effect in increasing the survival [4].
References
  1. CHANDANA SR, MOVVA S, ARORA M, SINGH T. Primary brain tumors in adults. Am Fam Physician [online] 2008 May 15, 77(10):1423-30 [viewed 25 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18533376
  2. NABORS LB, AMMIRATI M, BIERMAN PJ, BREM H, BUTOWSKI N, CHAMBERLAIN MC, DEANGELIS LM, FENSTERMAKER RA, FRIEDMAN A, GILBERT MR, HESSER D, HOLDHOFF M, JUNCK L, LAWSON R, LOEFFLER JS, MAOR MH, MOOTS PL, MORRISON T, MRUGALA MM, NEWTON HB, PORTNOW J, RAIZER JJ, RECHT L, SHRIEVE DC, SILLS AK JR, TRAN D, TRAN N, VRIONIS FD, WEN PY, MCMILLIAN N, HO M. Central Nervous System Cancers: Clinical Practice Guidelines in Oncology J Natl Compr Canc Netw [online] 2013 Sep 1, 11(9):1114-1151 [viewed 25 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4124889
  3. STUPP ROGER, MASON WARREN P., VAN DEN BENT MARTIN J., WELLER MICHAEL, FISHER BARBARA, TAPHOORN MARTIN J.B., BELANGER KARL, BRANDES ALBA A., MAROSI CHRISTINE, BOGDAHN ULRICH, CURSCHMANN JüRGEN, JANZER ROBERT C., LUDWIN SAMUEL K., GORLIA THIERRY, ALLGEIER ANOUK, LACOMBE DENIS, CAIRNCROSS J. GREGORY, EISENHAUER ELIZABETH, MIRIMANOFF RENé O.. Radiotherapy plus Concomitant and Adjuvant Temozolomide for Glioblastoma. N Engl J Med [online] 2005 March, 352(10):987-996 [viewed 25 August 2014] Available from: doi:10.1056/NEJMoa043330
  4. HEGI MONIKA E., DISERENS ANNIE-CLAIRE, GORLIA THIERRY, HAMOU MARIE-FRANCE, DE TRIBOLET NICOLAS, WELLER MICHAEL, KROS JOHAN M., HAINFELLNER JOHANNES A., MASON WARREN, MARIANI LUIGI, BROMBERG JACOLINE E.C., HAU PETER, MIRIMANOFF RENé O., CAIRNCROSS J. GREGORY, JANZER ROBERT C., STUPP ROGER. Array. N Engl J Med [online] 2005 March, 352(10):997-1003 [viewed 25 August 2014] Available from: doi:10.1056/NEJMoa043331