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About the Brain
Know About the Brain Tumor

Brain tumors can be most dreaded disease to come across. Brain tumors occur in approximately 6 persons per lakh per year. There is a saying “You don’t see what your don’t know or you have not read”. The idea of this article is to give an insight into the symptoms of presentation of a brain tumor and how they are dealt with by Neurosurgeons of the present era.
Introduction
Historical aspect of brain tumor can be traced to 17th century. When the first brain tumor was reported by Curvehelier , but the patient died. Safe intracranial surgery for the tumors became possible only the 19th century due to pioneering work by Stalwarts like W.W. Keene, William Maceven , Sir Victor Horsley and Harvey Cushing.

Brain tumors are a diverse group of neoplasms arising from different cells within the central nervous system (CNS) or from systemic tumors that have metastasized to the CNS. Brain tumors can produce symptoms and signs by local brain invasion, compression of adjacent structures, and increased intracranial pressure (ICP). In addition to the histology of the tumor, the clinical manifestations are determined by the function of the involved areas of the brain. The proper evaluation of the patient with a suspected brain tumor requires a detailed history, comprehensive neurologic examination, and appropriate diagnostic neuroimaging studies.
Types of Brain Tumors

These tumors can be of two types - Benign and Malignant (Cancerous).

Malignant tumors can be Primary or Secondary. Common Primary tumors are Gliomas, Meningiomas, Schwannomas, Pituitary Adenomas etc .

Secondary tumors also known as metastatic tumors spread to the brain from the primary locations, that is lung , breast, kidney etc.

Clinical Manifestations

Patients with primary or metastatic brain tumors may present with either generalized or focal signs and/or symptoms.

GENERALISED

Headaches:
Headache is a common manifestation of brain tumors and is the worst symptom in about one-half of patients. The headaches are usually dull and constant, occasionally early morning headache and occasionally throbbing. Severe headaches are infrequent.
Features suggestive of a brain tumor in a patient complaining of headaches include nausea and vomiting (present in about 40 percent), a change in prior headache pattern, and an abnormal neurologic examination.

Seizures:
Seizures(fits) are among the most common symptoms of gliomas and cerebral metastases. .Seizures may be the presenting symptom or develop subsequently. Although seizures can be either generalized or focal, any seizure focus can cause a generalized seizure. In patients who have focal seizures, the clinical presentation is dependent upon the tumor location. As an example, frontal lobe tumors may cause focal tonic-clonic movements involving one extremity, while seizures originating within the occipital lobe may cause visual disturbances. Temporal lobe seizures are the most difficult to diagnose and localize. In this setting, abrupt sudden behavioral changes may occur with or without typical pre-seizure auras, such as abnormal smell, taste, or gastrointestinal symptoms.

Nausea and Vomiting:
Brain tumors can cause nausea and/or vomiting by increasing the ICP . Several characteristics suggest the possibility of tumor-associated emesis, such as triggering emesis by an abrupt change in body position. More importantly, neurogenic nausea and vomiting usually occur in the context of other neurologic symptoms such as headache or focal neurologic deficit; these signs and symptoms may be subtle.

Syncope:
A significant rise in ICP can temporarily cut off cerebral perfusion, leading to loss of consciousness.

Cognitive Dysfunction:
Cognitive dysfunction, which includes memory problems and mood or personality change, is common among patients with intracranial malignancy. Most of the neurocognitive deficits associated with brain tumors are subtle. Patients often complain of having low energy, fatigue, an urge to sleep, and loss of interest in everyday activities.

Focal

Weakness:
Muscle weakness is a common complaint in patients with brain tumors. The manifestations may be subtle, particularly in the early stages.

Sensory Loss:
Cortical sensory deficits (e.g., graphesthesia or abnormalities in stereo gnosis) can develop in patients whose tumors invade the primary sensory cortex. These sensory deficits usually do not respect a dermatomal or peripheral nerve distribution.

Aphasia:
Aphasia is a disorder of language function. It is a specific sign of a lesion in the dominant hemisphere (usually left frontal or parietal).

Visual Symptoms:
The visual pathway courses through the brain from the retina and optic chiasm to the occipital poles of the cerebral cortex. Because of its long course through the brain, the visual pathway can be affected by brain tumors that involve any of these areas.

Investigations

Neuroradiologic imaging is the major diagnostic modality in the evaluation of brain tumors. These studies are critical for preoperative planning, and they often provide information about the type of a mass lesion.

Computed tomography:
CT-scan has been imaging modality of choice for brain tumors .It remains the most cost effective investigation for screening.

Magnetic resonance imaging:
Gadolinium-enhanced magnetic resonance imaging (MRI) is the most important test needed to suggest a brain tumor. MRI may also provide information that indicates the specific tumor type.

Magnetic resonance spectroscopy:
Magnetic resonance spectroscopy (MRS) is increasingly being utilized as a diagnostic technique in patients with suspected brain tumors. This technique may improve the differentiation of locally infiltrative brain tumors from other types of well-circumscribed intracranial lesions by analyzing the chemical composition in an area of interest selected by the radiologist. The three important spectroscopic signals are N-acetylaspartate, choline, and lactate.

Functional MRI:
When a region of the brain is activated (e.g., the language center during talking or the motor cortex when moving a limb), blood flow to that region increases.
Functional MRI (also known as echo planar MRI) permits the measurement of differences in blood flow though particular regions of the brain, and has several advantages in patients with brain tumors.

These investigations give the exact location of tumor, size, extent of damage of brain tissue. Overall , this information helps in surgical planning and execution of surgical procedure. Angiography and CSF examination along with tumor markers and others haematological and radiological investigations are complimentory to come to conclusion regarding tumor diagnosis.

Treatment

Preoperative assessment:
If any aspect of the clinical , haematological or neurodiagnostic evaluation suggests that a brain tumor is a metastatic rather than a primary lesion, systemic evaluation, particularly of the thorax, abdomen etc should be carried out.

Surgical treatment:
Patients of brain tumor are treated medically with steroids, and anti-edema drugs to reduce brain swelling and anticonvulsants to prevent fits (Seizures). Surgical excision of tumor is done by performing, a craniotomy (removing a piece of skull) to approach the tumor. Few tumors like tumors of Pituitary gland can be excised through nasal route, which is less traumatic and less morbid. Endoscopic surgeries are also performed, which are minimally invasive in certain tumor cases. Occasionally stereotactic biopsies are done to attain histopathological diagnosis when total excision of tumor is not possible. Patients with malignant tumors are subjected to radiotherapy or chemotherapy which acts like an adjunctive mode of treatment.
Prognosis i.e. life expectancy and functional outcome depends on whether the tumour is benign or malignant and whether complete tumour excision was possible or not. Benign tumours like meningioma's with complete excision have excellent outcome. Malignant tumors like gliomas or metastasis, have a compromised outcome depending on the grade of tumors.

Neuropathology:
Histology examination of the biopsy specimen remains the most important component of the diagnostic evaluation of brain tumors. A smear or frozen section can be performed in the operating room for a preliminary interpretation of the histology subtype. With this information, the neurosurgeon can make a decision whether or not to proceed with a more extensive resection. Grading of tumor gives a decent idea about the prognosis.

Treatment, as it Stands Today!

Brain tumor management has undergone drastic changes due to advancement in radiology, anesthesia, micro surgical techniques and equipment (Microscope, CUSA, USG). The outcome has started becoming favorable and predictable. Radio surgery or Gamma-knife is a latest tools to deal with lesions in un-approachable areas of brain with safety.

Technical advances have improved the safety of both surgical resection and stereotactic biopsy. Improved diagnostic neuroimaging permits better preoperative localization of the lesion and separation of the lesion from adjacent normal brain tissue, particularly in eloquent areas of the brain. Techniques such as Neuronavigation and intraoperative MRI (Brain Suite) facilitate improved surgical navigation for lesion biopsy and resection.

Gene therapy which is now at an experimental level, but had generated considerable research interest, carries future potential. All these developments give the present generation a sense of optimism while dealing with dreaded disease of brain tumor.