Brain Tumours mimicking Stroke

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Learning objectives

  • Understand the different forms - primary and secondary
  • Know some important risk factors
  • Be able to recognise the clinical presentation
  • Discuss diagnostics and treatment strategies

Introduction

It is not uncommon for us to diagnose brain tumours either in the TIA clinic or the Emergency Department. The usual presentation is usually of progressive symptoms and development of weakness which is not completely de novo. If there is a history and imaging corresponding to that suggesting a tumour thrombolysis must be avoided. Occasionally tumours present with haemorrhage within or around the tumour and then it can be difficult to differentiate from a haemorrhagic stroke but in most cases, acute or delayed imaging will help with the diagnosis. Meningiomas are tumours that arise outside the brain "extra-axial" but can cause localised pressure with oedema affects the underlying. There are two main types of tumour. Those that arise from the brain itself called primary tumours. The most common are usually from glial cells and known as gliomas. Secondary tumours are those that spread to the brain from elsewhere. For a single lesion, it can be primary or secondary. If there are multiple lesions they are usually from elsewhere.

Different types

  • Secondary: Commonest. Often Lung 45%, Breast 10%, Kidney 7%, Gastrointestinal 6%, Melanoma 5%. Can often resemble abscess.
  • Primary brain annual incidence 10 per 100,000: Glial cells - Gliomas : Milder Astrocytomas to aggressive Glioblastoma multiforme, Meningioma. Oligodendroglioma. Risks include immune suppression, whole brain irradiation. Clinical features over weeks and months.
  • HIV related: non-Hodgkin's lymphomas of B-cell type
<img src="patient120.jpg" width=300><img src="patient121.jpg" width=300>

Clinical

  • Symptoms due to local effects and general rise in ICP
  • Childhood tumours are mainly posterior fossa which present with hydrocephalus
  • Headache - worse in morning and on stopping/straining
  • Changed personality, Seizures
  • Stroke like episodes when tumour bleeds or causes focal seizure activity
  • Coma due to Raised ICP/Hydrocephalus or Seizure or haemorrhage

Investigations

  • Bloods: FBC, U&E, LFTs, CRP. HIV test may be indicated.
  • CXR: exclude lung cancer
  • CT with and without contrast:There is the breakdown of the blood-brain barrier such that tumours enhance with contrast called ring enhancing. This often shows up with a surrounding area of oedema.
  • MRI with gadolinium: There is the breakdown of the blood-brain barrier such that tumours enhance with gadolinium. This often shows up with a surrounding area of oedema.
  • CT Chest Abdomen and pelvis: to look for a primary lesion and for staging
  • Mammography: for breast cancer and skin examination for melanoma.
  • Tumour markers: CEA for colon, CA125 for ovarian, CA 19-9 for pancreatic, PSA for prostate
  • Brain biopsy: may be required when the diagnosis is unclear.

Management

Usually initiate imaging and referral to local neuro-oncology services. Oncology can discuss with Neurosurgeons whether to biopsy or resect lesion. Much of this focuses on performance status and fitness for surgery, co-morbidities and physiological age and whether an eloquent area of the brain is involved and the scope for resection and patient choice.

  • Whole brain radiation: usually for multiple usually metastases in what is felt to be a radiosensitive tumour e.g. small cell lung cancer and lymphoma and least helpful for melanoma.
  • Chemotherapy would need to cross the blood-brain barrier and so has a reserved role. Sometimes can be inserted directly into the brain perioperatively.
  • Start anticonvulsants, e.g. Keppra is often preferred to Phenytoin nowadays with one seizure as high risk of recurrence with a focal lesion.
  • Hydrocephalus is an emergency that requires transfer to the Neurosurgeons for shunting
  • Start Dexamethasone 4-8 mg BD which can be increased to reduce oedema
  • For many palliation is the correct course when there is a poor outcome.