26th June 2023

Features of Brain and Spinal Tumours

Common symptomatology of brain tumours 

The symptoms of brain tumours are usually progressive, and you may meet a patient at the start of their journey or when their tumour has progressed to an advanced stage. Therefore, it is important to understand the red flag symptoms that may be associated with a potential brain tumour diagnosis and have a low threshold for investigation as the symptomatology may be subtle.

As with all pathologies involving a high metabolic activity, lethargy and weight loss can be a common feature due to the increased energy expenditure by the growing lesion. Social withdrawal, poor sleep and behavioural changes can be some of the subtle changes reported by the patient or their loved ones.

Raised intracranial pressure (ICP) associated with a space-occupying lesion in the brain can cause a variety of symptoms. Headaches are a commonly reported symptom; classically, the headache is worse in positions of increased ICP, such as when straining, lying down, or in the early morning. Nausea and vomiting are other common symptoms caused by raised ICP. Papilloedema may be seen on fundoscopy (see image below) and is another sign of increased ICP. This can be experienced as blurred or double vision; a bulged optic disc, blurring of disc margins and microhaemorrhages may be seen on fundoscopy.

Depending on the location of the lesion, focal neurological deficits in an upper motor neuron pattern may be seen, including numbness, weakness, spasticity, and hyperreflexia. Vertigo or gait disturbance may occur due to pressure on, or involvement of, the cerebellum. Visual loss can be experienced if the optic nerve is compressed by the tumour, or due to surrounding oedema.

Seizures are experienced in up to 80% of patients with brain tumours due to disruption of the normal impulses of the neurons in and around the tumour, and the compression of surrounding structures.

Retinal image showing evidence of papilloedema

Image Source: Wikimedia Commons (2011). Papilledema, Licensed under a creative commons licence. Available for free at: https://commons.wikimedia.org/wiki/File:Papilledema.jpg (Accessed on: 30 January 2023).

Localising the lesion 

Symptoms can vary depending on the location of the brain lesion; commonly in MRCP, clues are given within the patient history to help to localise the lesion. Understanding the different functions of the lobes of the brain can help to identify the area likely affected prior to imaging. This is covered in more detail in the ‘Basic Neuroanatomy’ section.

Frontal lobe

The frontal lobe controls personality, speech fluency (via Broca’s area) and the coordination of movement (via the primary motor cortex). A lesion here may therefore cause motor weakness, changes in personality and problem solving, loss of smell or speech changes.

Parietal lobe

The parietal lobe is involved with coordination of sensory and spatial stimuli. It is the part of the brain that allows us to recognise faces and stores the memory for reading and writing. A lesion here may cause difficulty with spatial awareness, weakness or sensory changes, or astereognosis (inability to recognise objects by touch).

Temporal lobe

The temporal lobe is involved in speech comprehension (Wernicke’s area) and processing of sounds and memories. A tumour in this region can cause short term memory loss or language and speech difficulties.

Occipital lobe

The occipital lobe is involved in visual perception. A tumour located in this area may cause changes in vision, such as size, shape, visual deficits, and colour identification.

Cerebellum

The cerebellum controls balance, coordination, and posture. A tumour in this area may cause dizziness, ataxia, nystagmus, and nausea.

Brain stem

The brain stem controls important body functions such as breathing, swallowing, sneezing, and coughing.

Lobes of the brain.

Image Source: Wikimedia Commons (2016). 1306 Lobes of Cerebral CortexN, Licensed under a creative commons licence. Available for free at: https://commons.wikimedia.org/wiki/File:1306_Lobes_of_Cerebral_CortexN.jpg (Accessed on: 30 January 2023).

Common symptomatology of spinal tumours 

Spinal tumours (both primary and secondary) can give rise to back pain, which may be associated with tenderness to palpation at a specific vertebral level. Numbness and neuropathic pain can arise from compression of nerves by the tumour or surrounding oedema. Compression below the level of the termination of the spinal cord in adults at L1-L2 may result in cauda equina syndrome, which may present with bladder and bowel dysfunction, saddle anaesthesia, and sensory or motor changes in the lower limbs. This is an oncological emergency due to the risk of permanent neurological deficit. As with all cancers, symptoms such as weight loss, fatigue and night sweats may also be reported.

There are some background diagnoses, albeit rare, that can predispose to spinal tumours. Neurofibromatosis type 1 (NF1) is an autosomal dominant condition associated with the development of nerve sheath tumours, which are mostly benign neurofibromas, however, there is a small risk of malignant transformation. Other signs of NF1 include axillary freckling, café-au-lait spots, Lisch nodules of the iris, and optic gliomas. Neurofibromatosis type 2 (NF2) is associated with benign vestibular schwannomas, meningiomas and ependymomas. NF2 can be associated with sensorineural hearing loss due to the development of vestibular schwannomas (acoustic neuromas) around cranial nerve VIII. NF2 is more associated with symptomatic spinal tumours than NF1.

Von Hippel-Lindau syndrome (VHL) is another autosomal dominant hereditary condition associated with the development of tumours and cysts in multiple parts of the body. Haemangioblastomas are one of the types of tumours associated with VHL; these are benign tumours arising from the blood vessels of the brain, spinal canal, and retinas. VHL is also associated with the development of some cancerous tumours, especially of the kidneys, phaeochromocytomas and endolymphatic sac tumours.