Management of Brain Tumors: Key Considerations
Prednisone is important in the management of brain tumors due to its critical role in controlling cerebral edema, which is essential for reducing intracranial pressure and improving neurological symptoms. 1
Diagnostic Approach
- MRI is the gold standard for brain tumor diagnosis, not CT, due to its higher resolution and sensitivity in detecting multiple lesions when CT might only identify a single tumor 1
- MRI can identify single brain metastases in approximately one-fourth to one-third of patients with brain metastases 1
- T2-weighted or fluid-attenuated inversion recovery MR images are best for visualizing cerebral edema associated with brain tumors 1
Role of Corticosteroids in Management
Mechanism and Importance
- Perilesional vasogenic edema commonly associated with brain tumors responds well to oral glucocorticoid steroids 1
- Corticosteroids rapidly reduce cerebral edema, preventing neurologic deterioration and potentially life-threatening brain herniation 1
Dosing Considerations
- Recommended dosages of dexamethasone vary significantly; European Federation of Neurological Sciences (EFNS) recommends starting dosages between 4-8 mg/day 1
- For patients with more acute neurologic issues, higher dosages approaching 100 mg/day in divided doses may be considered 1
- Steroid dose should be tapered as quickly as clinically possible due to toxicity associated with long-term use (>3 weeks) 1
Adverse Effects of Prolonged Use
- Long-term steroid use can cause personality changes, suppressed immunity, metabolic derangements, insomnia, and impaired wound healing 1
- H2-receptor blockers or proton pump inhibitors should be used to prevent gastrointestinal complications in patients receiving high doses of corticosteroids 1
Other Management Considerations
Seizure Management
- 15-20% of patients with brain metastases present with seizures 1
- Anticonvulsants should be administered only to patients at risk for seizure, not prophylactically 1
- Common first-line agents include phenytoin, carbamazepine, levetiracetam, and valproic acid 1
- Non-enzyme-inducing agents are preferred to avoid interactions with chemotherapy and steroids 1
Surgical Considerations
- Surgical resection is indicated for diagnostic uncertainty, symptoms refractory to steroids, bulky metastases (>3-4 cm), or solitary brain metastases 1
- Factors favoring craniotomy include: surgically accessible tumors, size >3 cm, need for tissue diagnosis, obstructive hydrocephalus, midline shift, and mass effect 1
- Factors favoring stereotactic radiosurgery include: deep location, tumor size <3 cm, known diagnosis, and minimal mass effect 1
Radiation Therapy
- Radiation therapy options include brachytherapy, stereotactic fractionated RT, and stereotactic radiosurgery (SRS) 1
- Whole-brain RT (WBRT) and SRS are used primarily for brain metastases 1
Common Misconceptions
- Brain CT is not the gold standard investigation; MRI provides superior resolution and sensitivity 1
- There is no consistent evidence that prognosis is better in females than males for brain tumors
- Both size AND site affect symptoms in brain tumors - location in eloquent areas can cause significant symptoms even with small tumors 1
Pitfalls to Avoid
- Failing to taper steroids appropriately, leading to unnecessary long-term side effects 1
- Using prophylactic anticonvulsants in patients without seizure history 1
- Delaying steroid administration in patients with significant cerebral edema 1
- Overlooking the need for gastric protection in patients on high-dose steroids 1