Approach to the Patient: Tumors of the Nervous System

Clinical Presentation: Brain tumors of any type can present with general and/or focal symptoms and signs. General nonspecific symptoms include headache with or without nausea and vomiting, cognitive difficulties, personality change, and gait disorder. The classic headache associated with a brain tumor is most evident in the morning and improves during the day, but this pattern is actually seen in only a minority of pts. Papilledema may suggest elevated intracranial pressure. Focal symptoms and signs include hemiparesis, aphasia, or visual field deficit; these are typically subacute and progressive. Seizures are a common presentation, occurring in about 25% of pts with brain metastases or malignant glioma.

Evaluation: Primary brain tumors, unlike metastases, have no serologic features of malignancy such as an elevated ESR or tumor-specific antigens. Cranial MRI with contrast is the preferred diagnostic test for any pt suspected of having a brain tumor; CT should be reserved for pts unable to undergo MRI. Malignant brain tumors typically enhance with contrast and may have central areas of necrosis; they are characteristically surrounded by edema of the neighboring white matter. Low-grade gliomas typically do not enhance. Additional testing such as cerebral angiogram, EEG, or lumbar puncture is rarely indicated or helpful.

Treatment: Tumors of the Nervous System