Clinical Presentation (Continued)

Chapter 2 - Clinical Presentation, Differential Diagnosis and Response Assessment of Gliomas

If the liquor flow is compromised (obstructive hydrocephalus), a Valsalva manoeuvre, coughing and position change of the head may cause sudden short-term intensive headache associated with nausea and loss of consciousness.

Particular attention and early contact with neurosurgery is required in case of an expansive process in the posterior cranial fossa, due to the risk of herniation of the medulla oblongata.

Brain herniation, caused by a mass effect and increased intracranial pressure, occurs when a part of the brain is squeezed across structures, such as the falx cerebri, the tentorium cerebelli and through the foramen magnum.

The clinical history of patients with primary glioblastoma (90% of glioblastomas) is usually short, less than 3 months in half of patients. Secondary glioblastoma (usually younger patients) typically develops from lower grade gliomas and has a longer clinical history.

Rapidly growing high-grade glioma causes focal loss of function symptoms, rarely seen in low-grade glioma due to the plasticity of the brain, except in cases of bleeding in the tumour, when the onset is rapid, as in stroke.

Contrast agent will not leak into the brain unless the blood–brain barrier (BBB) is damaged. Enhancement is seen when a central nervous system (CNS) tumour destroys the BBB or when no BBB is present (meningioma, pituitary and pineal region).

A proper evaluation of a patient with a suspected brain tumour requires a detailed history, neurological examination, and appropriate diagnostic neuroimaging studies.

On suspicion of a brain tumour, magnetic resonance imaging (MRI) is the gold standard. If in need of urgent investigation, or if MRI is not available, computed tomography (CT) scan with and without contrast enhancement can be used.

If MRI/CT confirms the suspicion of brain tumour, the patient should be referred to a regional multidisciplinary therapy conference or to the neurosurgical clinic.

Revision Questions

  1. What is the risk of a glioma in the posterior fossa?
  2. When are focal loss of function symptoms seen?
  3. What is the gold standard when a brain tumour is suspected?

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Last update: 18 September 2017