PassFinals
Neurology

Brain tumours

Brain tumours are primary or metastatic intracranial neoplasms that can present through seizures, progressive focal dysfunction or raised intracranial pressure; diagnosis and treatment depend on imaging, tissue, molecular profile, site and performance status.

In a nutshell

Brain tumours present through progressive focal dysfunction, seizures, cognitive change or raised intracranial pressure. MRI with contrast is central, and tissue plus molecular classification determines treatment. Refer early to a specialist MDT, use steroids only for symptomatic oedema, treat seizures without routine primary prophylaxis, and separate glioma, meningioma and metastasis pathways.

Classic presentation

An adult develops a progressive focal deficit, behavioural change or first seizure with MRI evidence of an intracranial mass; urgent neuro-oncology assessment and tissue or systemic staging determine the pathway.

Key points

  • Progressive focal neurology or a new seizure needs urgent brain imaging; headache alone is non-specific.
  • MRI structural imaging with contrast is the initial test for suspected glioma; CT is used urgently when MRI is unavailable or contraindicated.
  • Glioma reporting uses WHO CNS classification and molecular markers; high-grade specimens need MGMT promoter methylation testing.
  • Dexamethasone reduces symptomatic peritumoural oedema but does not treat the tumour.
  • Do not prescribe routine primary anticonvulsant prophylaxis in someone with a brain tumour who has never had a seizure.
  • Brain metastasis treatment depends on number, volume, site, extracranial disease, primary tumour, performance status and preference.
  • Active monitoring can be appropriate for selected low-grade tumours or meningiomas; benign does not mean no follow-up.
  • Rehabilitation, palliative care, cognitive support and driving advice are part of the treatment pathway.

First-line investigation

Urgent structural MRI with contrast and full neurological assessment, followed by tissue or systemic staging through the specialist MDT.

Management

Triage pressure, seizure and focal deterioration

  • Escalate reduced consciousness, herniation features, hydrocephalus, status epilepticus, new deficit or major mass effect urgently and avoid lumbar puncture.1,3,2

Image and refer to the specialist MDT

  • Use structural MRI with contrast for suspected glioma, CT when necessary, and refer at first radiological diagnosis to the specialist multidisciplinary team.1,6

Control oedema and seizures safely

  • Use dexamethasone for symptomatic oedema or mass effect and antiseizure treatment after a seizure; routine primary anticonvulsant prophylaxis is not recommended.1,4

Preserve function and shared decision-making

  • Include cognition, communication, rehabilitation, endocrine and psychological support, palliative care, carer support and the person's goals from diagnosis onward.1,5

Treat by tumour type and molecular risk

  • Use tissue and molecular results to guide maximal safe surgery, radiotherapy, chemotherapy, active monitoring or supportive care for glioma and meningioma, and use number, volume, primary cancer and performance status for metastases.1,4

Monitor recurrence, late effects and driving

  • Arrange tumour-specific imaging and clinical review, safety-net neurological deterioration and treatment toxicity, and give current DVLA advice.1,7

Exam traps

  • Do not call every ring-enhancing lesion a tumour; abscess and other mimics need consideration.
  • Do not perform lumbar puncture when mass effect or raised intracranial pressure is possible.
  • Steroids treat vasogenic oedema and can complicate diagnosis or treatment; they are not antitumour therapy.
  • A first seizure needs urgent imaging, but not every first seizure is caused by a brain tumour.
  • NICE treatment choices for glioma and metastases depend on performance status, molecular profile, age, number and volume of lesions and preferences.

Illustrations

Glioblastoma on sagittal contrast MRISagittal post-contrast T1 MRI showing an irregular ring-enhancing frontal mass with central necrosis and surrounding oedema. Explain that this pattern needs differential diagnosis and tissue or specialist interpretation.Christaras A, Wikimedia Commons · CC-BY-2.5
Severe papilloedema on fundoscopyFundus photograph showing a swollen hyperaemic optic disc with obscured margins and venous congestion. Use it to illustrate raised intracranial pressure and urgent escalation, while noting that its absence does not exclude a tumour.Jonathan Trobe, M.D., Wikimedia Commons · CC-BY-3.0

Key sources

  1. NICE NG99, Brain tumours (primary) and brain metastases in over 16s (NICE guideline published 11 July 2018 and last updated 29 January 2021; includes MRI, molecular classification, glioma, meningioma, metastasis, supportive care and follow-up recommendations)Updated 29 Jan 2021
  2. NHS, Brain tumours (NHS symptoms and broad treatment information for brain tumours)
  3. NICE NG12, Suspected cancer: recognition and referral (Current NICE suspected-cancer pathway including urgent direct-access MRI or CT for progressive subacute loss of central neurological function in adults)
  4. BNF, current prescribing information for brain-tumour symptom treatment (Current UK prescribing source for dexamethasone, antiseizure medicines, gastric protection and treatment-interaction checks; direct access was restricted and the browser session was unavailable, so unsupported doses were omitted)
  5. NHS, Malignant brain tumour: treatment (NHS treatment and supportive-care information for malignant brain tumours)
  6. NICE CSG10, Improving outcomes for people with brain and other central nervous system tumours (NICE cancer-service guidance supporting specialist multidisciplinary brain-tumour services)
  7. GOV.UK, Assessing fitness to drive: brain tumours (DVLA medical standards updated January 2024; driving depends on tumour type, treatment, neurological impairment and seizure risk)Updated 15 Jan 2024

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.