Brain tumors: going over the basics

Recently I have seen many patients with brain tumors in my office and that shall be the focus of my post.  Brain tumors are tumors (cancers) that arise in the brain or spread to the brain. We call these primary brain tumors (tumors arising in the brain itself) or metastatic tumors to the brain (the primary tumor/ cancer is somewhere else for example in the lung or breast but then spreads to the brain).

Let us now spend a moment to talk about how brain tumors present clinically. Many of you shall be surprised to learn that the brain itself is insensitive to pain (meaning if I was to put a knife through your brain tissue, you shall feel no pain!!!).  So a small brain tumor may be silent, causing no pain or discomfort. It is usually when the brain tumor increases in size and starts involving (stretching the blood vessels in the brain) or the covering of the brain (meninges) that the patient may complain of headache. Blood vessels and covering of the brain (meninges) are richly supplied by nerves and hence are exquisitely pain sensitive.  So first and foremost not all brain tumors present with headache. The corollary to that is that not all headaches are due to brain tumors. Most of the times when patients present to a doctor for evaluation of headache, a “benign” cause such as migraine or tension headache is found and not a brain tumor.

If I am examining a patient with headache, there are certain red-flags in the history and the examination which shall make me think about a possible brain tumor.

Laterality of the headache:  Headaches associated with brain tumors are usually holocranial (the whole head hurts). Remember migraines are typically hemicranial (patient complains of a throbbing headache on one side of the head). This though is not a hard and fast rule and I would not base my opinion on the laterality of the headache.

Is the headache associated with projectile vomiting: Because a large brain tumor  shall lead to an increase in the intracranial pressure (pressure inside the brain),  patients with brain tumors may have projectile vomiting. This again is not a hard and fast rule as patients with migraines are frequently nauseated and may throw up.

Does the headache awaken the patient at night from sleep? Headache associated with brain tumor may awaken the patient from sleep. Classically the headache is worst when lying down and abates in the morning when the patient gets up and starts to move around. Migraines usually do not awaken a patient from sleep, infact sleep frequently helps to abort a mgraine attack. Again a weak point and I would not base my opinion on this alone.

History! History! History!: 

Let us compare two different histories in two patients:

Patient number 1 (age=53 years male)

“Dr Sethi, I have never had a headache in my life, never had a headache in my adolescence but recently I am waking up with a severe headache.”–THE THOUGHT OF BRAIN TUMOR DOES CROSS MY MIND WHEN I HEAR THIS

Compare this to:

Patient number 2 (age 26 years female)

“Dr Sethi, I have headaches since my college days. Frequently I shall get a throbbing headache on one side of my head and at that time bright lights shall bother me. I used to feel nauseated when I had my headaches and at times threw up. My headaches went away in my 30s but now I am again having bad headaches” –MIGRAINE IS THE FIRST THOUGHT THAT CROSSES MY HEAD AND NOT BRAIN TUMOR.

Other presentations of brain tumors: brain tumors at times may present more dramatically. Patients may present with a generalized convulsion. When these patients are imaged (via a CT scan or a MRI brain scan) the brain tumor may be detected. At times patients present with progressive neurological deficits. The type of neurological deficit depends frequently on the location of the brain tumor. Let me explain this further. Let us assume the brain tumor is pressing on the optic nerve or other nerves which control eye-movements: patients may present with visual problems (such as blurring of vision, double vision or diplopia, cuts in their visual fields and so forth). If the tumor presses on the motor or sensory system: patients may present with weakness or numbness on the contralateral side of the body. If the tumor is in the cerebellum, they shall complain of balance problems or lack of coordination. If the tumor involves the auditory nerve, their presenting complaint shall be of hearing loss (usually though unilateral hearing loss may not be appreciated by the patient).

Finally the neurological examination is of great help. Patients with migraines, tension type headaches and other “benign” headaches have a normal (we call this non-focal) neurological examination. On the other patients with brain tumors may have some subtle and other more prominent neurological findings. Thus your doctor shall examine you: check your cranial nerves (does the patient have a symmetrical smile, are eye-movements intact, is the visual field intact, do thay have any sign of increased pressure inside the brain (this is determined by looking into the eye to visualize the optic nerve head), is motor strength and sensory system intact,  are there any signs of cerebellar dysfunction (incoordination, ataxia–balance is off and so forth).

Patients with headaches who have an abnormal neurological examination should be imaged. Your doctor may then recommend either a CT scan of the head or a MRI scan. Frequently this is done with and without contrast. I shall dwell into different types of brain tumors and their management in my next post.

Nitin Sethi, MD

Persistent vegetative state or Minimally conscious state: a question and an answer

Dear Dr. SethiI am really confused and I would be very grateful if you could help me. My 40 years old brother had a car accident six months ago and suffered a diffuse axonal injury. He was a university teacher, very intelligent. He is slowly improving and his evolution is very similar to what you described in your first post. Now he looks to where we ask him to look but he does not respond to other verbal commands. The doctors sent him home 2 weeks ago and did not say if he is PVS or MCS. We do not have good care centers in the city and the neurologists said there is nothing we can do to help him. We should just feed him and avoid infections. He is getting good physical therapy, now. We talk to him a lot, he watches TV and listens to music. We even give him small quantities of sauces and juices to stimulate his taste. We believe that our love will help him more than being away from his family in a rehab center. But we are afraid of doing less than we should. Are the neurologists right? Is it possible to provide enough stimulation at home? Is there any literature to guide us on this path? Thank you very much for your attention. By the way, we live in Brazil and I apologize for the bad english. c

braindiseases

Dear C, thank you for writing in to me. I apologize for the delay in my reply. As I stated in my posts, it is at times indeed difficult to prognosticate about patients who have suffered a traumatic brain injury. You say your brother’s neuroimaging studies showed diffuse axonal injury (DAI). I shall not use words like PVS or MCS. I shall try to explain a few things with examples. So here goes and I speak from your perspective.1. Just what is the level of my brother’s consciousness. Is he fully consciousness or is he not. There are different grades of consciousness–people use words like comatosed, semi-comatosed, drowsy, somolent, sleepy) 2. He may be conscious but not aware ( consciousness is intact but there is no awareness. By awareness I mean to one’s own need like hunger, a full bladder and so forth. Is he aware he is hungry? Is he aware he has a full bladder and needs to void? Awareness about surroundings. Who is that person standing next to me? Is that my sister?) 3. He is conscious with limited awareness. There are days or moments in a day when he seems more aware. He smiled at you when you came to see him today. He said or attempted to say something. He squeezed your hand. So as you can see these disorders of consciousness are very fluid conditions. The brain is not static. There are patients who may be in one stage and may progress or deteriorate into another state. As neurologists we are now acutely aware of how limited our understanding is of these disorders of consciousness. So this is what I advise: 1. Firstly you are dealing with an extremely tough condition. One that unfortunately has no good treatment or possibly outcome. So hang in there and have faith. 2. He should be assessed by his neurologist at some future date. Remember what I said above. Patients evolve and their neurological examination changes. 3. Stimulation cannot hurt him and so interacting with your brother is good. 4. Infections like pneumonia (patients usually have a weak cough reflex and may aspirate their food leading to a lung infection), bed sores and urinary tract infection are the main things you need to watch out for. These frequently lead to poor outcomes and hence should be aggressively identified and treated. 5. Good physical therapy forms the cornerstone of any treatment regime. I would encourage that. Maybe he can go for physical therapy once or twice a week. Rest of the days, it can be done at home. 6. There is hope on the way. New research is been done. There are recent reports of improved outcome/ dramatic improvement in patients in MCS who underwent neurostimulation. I hope I have been of help to you. Personal Regards, Nitin Sethi, MD

Infantile spasms: a few questions and answers

 

Dear Dr,
My son is diagnosed with hypsarhythmia and he is 18 months. As of now we do not see notice any delay in his development.Is there a chance for developmental delay?? He is on ACTH treatment. His symptoms are Head Dropping.

Thank You!
R

	braindiseases	Dear Mr.R , thank you for writing in to me. I am happy to learn that your son is doing so well and that you have not noticed any developmental delay or developmental regression. It suggests that his infantile spasms are well controlled. My advise would be to keep him under the close observation of his pediatrician and pediatric neurologist. At some point of time, they might like to repeat his EEG to assess seizure control. Sometimes a prolonged EEG study is very useful in this regard. Personal Regards, Nitin Sethi, MD
	K	Hi There, Our daughter is 18months, has had infantile spams since 2wks old. We have tried phenobarb, vigabatrin, nitrazepam, topirimate, b6, clobezam, epilim, lamotrigine & prednisolone. None have worked on our wee girl, her development is so far behind, she can sit & thats all, no reaching out, focusing etc. I am at my wits end with what to do next, Paeds dont seem to be really trying to get her sorted, Mri came back with no abnormalities, shes had bloods, urine & lumber puncture, all clear. Eegs show a lot of electrical activity. What do you think we should do? Im really wanting to get a second opinion & someone that will help us. Cheers
	braindiseases	Dear K, thank you for writing in to me. From what you tell me it seems your daughter’s seizures have proven to be refractory to multiple anticonvulsant drugs. Extensive investigative work-up revealed no cause for her infantile spasms. We call this condition cryptogenic or idiopathic infantile spasms (cryptogenic because a cause for infantile spasms is suspected but has not been identified). I can understand your frustration K. This is what I advise. It might be worth the time and effort to have her evaluated at a comprehensive epilepsy center. Special diets like the ketogenic diet at times work wonders. Also some new drugs are now available. Acthar (ACTH) gel at times works–though it is frightfully expensive and may not be covered by insurance. Neurostimulation devices like the vagus nerve stimulator (VNS) can be tried though to my knowledge there is little data on its efficacy in infantile spasms. Personal Regards, Nitin Sethi, MD

 

 

Seizures due to hypoglycemia–a couple of questions and answers.

I got a few insightful questions from my readers which I am sharing here. My reply to them follows.

K	Is it possible to have hypoglycemia and suffer with seizures without diabetes? My Blood sugar level after a seizure is high though quickly drops down (Shock?) Can Hypoglycemia be a random problem caused by diet at the time and stress etc?
	braindiseases	Dear K, thank you for writing in. You ask a good question. There can be many causes of hypoglycemia, diabetes mellitus is one of the more common causes. In diabetes mellitus hypoglycemia commonly occurs in the setting of a missed meal (by that I mean, a diabetic patient takes his anti-diabetic medication/ insulin but forgets to take his meal). Another setting may be if one has what is called brittle diabetes. This is a condition in which the blood sugar varies quite a lot. Such patients need fine control of their blood sugar level to prevent episodes of hypoglycemia or hyperglycemia. Seizures occur due to hypoglycemia per se (low blood sugar), not because of hypoglycemia due to diabetes. What I mean to say is that hypoglycemia due to any cause can cause a seizure provided the blood sugar falls below a critical level (usually less than 50 mg/dl). Personal Regards, Nitin Sethi, MD
	S	hi im not here to ask a question sorry, just to ponder your mind a little, ive had type 1 diabetes since the age of 4 (16 years) and i am now 20. when i was 7 i had my 1st seizure. time went on and since ive been 15 ive had around 20 + full on seizures ive had 2 in the street both ive recovered from, but the rest was in my sleep, with no warning atall. i go ridged and ALWAYS bite my tounge and injure myself, suck as banged my head off the cooker, the floor, raidiator etc. after this happens i get sugar rubbed in my gums by my family or friends till i come round, (no paramedic or hospital service involed) but the confusing thing was when i had them in the street and i came around WITHOUT sugar or anything. witch was also confusing for the hospital and my gp. witch also brings me to my next thing. ive been to my local gp and also im back attending the hospital on a weekly basis. as ive now been to see my gp today, and gave him details etc. of each seizure. hes now under the idea of sending me to a neurologist as he dosent beleive that my seizures are in anyway linked to my diabetes. also ive just had my insulin changed from human mixtard 30 (twice daily) to lantus(morning) & novo rapid(breakfast, lunch, dinner). what i was wondering was, what your thoughts would be on this ?
	braindiseases	Dear S, thank you for writing in. This is what I feel. I think it shall be worth your time to see a neurologist and get a thorough evaluation for your seizure disorder. Some of your seizures likely can be accounted for by hypoglycemia (the ones in which you make a rapid recovery when sugar is rubbed onto your gums). It is also possible that you have underlying epilepsy/ seizure disorder. This may result in convulsions which are unrelated to hypoglycemic episodes. Also why should you be having hypoglycemia induced seizures if your diabetes is well controlled? As you can understand there are bits in your history which do not “gel”. So I feel you need a good work-up. A neuroimaging study of the brain (ideally a MRI scan of the brain) and an electroencephalogram (EEG study) may be warranted. Your doctor may then decide to treat you with an anti-convulsant medication. Personal Regards, Nitin Sethi, MD