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may cause sensory seizures, sensory loss or inattention, or some combination of these symptoms The sensory loss is cortical in type and involves postural sensibility and tactile discrimination, so that the appreciation of shape, size, weight, and texture is impaired Objects placed in the hand may not be recognized (astereognosis) Extensive parietal lobe lesions may produce contralateral hyperpathia and spontaneous pain (thalamic syndrome) Involvement of the optic radiation leads to a contralateral homonymous field defect that sometimes consists solely of lower quadrantanopia Lesions of the left angular gyrus cause Gerstmann s syndrome (a combination of alexia, agraphia, acalculia, right-left confusion, and finger agnosia), whereas involvement of the left submarginal gyrus causes ideational apraxia Anosognosia (the denial, neglect, or rejection of a paralyzed limb) is seen in patients with lesions of the nondominant (right) hemisphere Constructional apraxia and dressing apraxia may also occur with right-sided lesions 4 Occipital lobe lesions Tumors of the occipital lobe characteristically produce crossed homonymous hemianopia or a partial field defect With left-sided or bilateral lesions, there may be visual agnosia both for objects and for colors, while irritative lesions on either side can cause unformed visual hallucinations Bilateral occipital lobe involvement causes cortical blindness in which there is preservation of pupillary responses to light and lack of awareness of the defect by the patient There may also be loss of color perception, prosopagnosia (inability to identify a familiar face), simultagnosia (inability to integrate and interpret a composite scene as opposed to its individual elements), and Balint s syndrome (failure to turn the eyes to a particular point in space, despite preservation of spontaneous and reflex eye movements) The denial of blindness or a field defect constitutes Anton s syndrome 5 Brainstem and cerebellar lesions Brainstem lesions lead to cranial nerve palsies, ataxia, incoordination, nystagmus, and pyramidal and sensory deficits in the limbs on one or both sides Intrinsic brainstem tumors, such as gliomas, tend to produce an increase in intracranial pressure only late in their course Cerebellar tumors produce marked ataxia of the trunk if the vermis cerebelli is involved and ipsilateral appendicular deficits (ataxia, incoordination and hypotonia of the limbs) if the cerebellar hemispheres are affected 6 False localizing signs Tumors may lead to neurologic signs other than by direct compression or infiltration, thereby leading to errors of clinical localization These false localizing signs include third or sixth nerve palsy and bilateral extensor plantar responses produced by herniation syndromes, and an extensor plantar response occurring ipsilateral to a hemispheric tumor as a result of compression of the opposite cerebral peduncle against the tentorium.

The electroencephalogram provides supporting information concerning cerebral function and may show either a focal disturbance due to the neoplasm or a more diffuse change reflecting altered mental status Lumbar puncture is rarely necessary; the findings are seldom diagnostic, and the procedure carries the risk of causing a herniation syndrome

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Treatment depends on the type and site of the tumor (Table 24 5) and the condition of the patient Complete surgical removal may be possible if the tumor is extra-axial (eg, meningioma, acoustic neuroma) or is not in a critical or inaccessible region of the brain (eg, cerebellar hemangioblastoma) Surgery also permits the diagnosis to be verified and may be beneficial in reducing intracranial pressure and relieving symptoms even if the neoplasm cannot be completely removed Clinical deficits are sometimes due in part to obstructive hydrocephalus, in which case simple surgical shunting procedures often produce dramatic benefit In patients with malignant gliomas, radiation therapy increases median survival rates regardless of any preceding surgery, and its combination with chemotherapy provides additional benefit Indications for irradiation in the treatment of patients with other primary intracranial neoplasms depend on tumor type and accessibility and the feasibility of complete surgical removal Corticosteroids help reduce cerebral edema and are usually started before surgery Herniation is treated with intravenous dexamethasone (10 20 mg as a bolus, followed by 4 mg every 6 hours) and intravenous mannitol (20% solution given in a dose of 15 g/kg over about 30 minutes) Anticonvulsants are also commonly administered in standard doses (see Table 24 3) but are not indicated for prophylaxis in patients who have no history of seizures Long-term neurocognitive deficits may complicate radiation therapy For those patients whose disease deteriorates despite treatment, palliative care is important (see 5)

Byrne TN Cognitive sequelae of brain tumor treatment Curr Opin Neurol 2005 Dec;18(6):662 6 [PMID: 16280677] Gonzalez J et al Treatment of astrocytomas Curr Opin Neurol 2005 Dec;18(6):632 8 [PMID: 16280673] Henson JW Treatment of glioblastoma multiforme Arch Neurol 2006 Mar;63(3):337 41 [PMID: 16533960]

CT scanning or MRI with gadolinium enhancement may detect the lesion and may also define its location, shape, and size; the extent to which normal anatomy is distorted; and the degree of any associated cerebral edema or mass effect CT scanning is less helpful with tumors in the posterior fossa, but

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Taillibert S et al Palliative care in patients with primary brain tumors Curr Opin Oncol 2004 Nov;16(6):587 92 [PMID: 15627022] Tam Truong M Current role of radiation therapy in the management of malignant brain tumors Hematol Oncol Clin North Am 2006 Apr;20(2):431 53 [PMID: 16730301] Wen PY et al Malignant gliomas Curr Neurol Neurosci Rep 2004 May;4(3):218 27 [PMID: 15102348]

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