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Intracranial tumors may lead to a generalized disturbance of cerebral function and to symptoms and signs of increased intracranial pressure In consequence, there may be personality changes, intellectual decline, emotional lability, seizures, headaches, nausea, and malaise If the pressure is increased in a particular cranial compartment, brain tissue may herniate into a compartment with lower pressure The most familiar syndrome is herniation of the temporal lobe uncus through the tentorial hiatus, which causes compression of the third cranial nerve, midbrain, and posterior cerebral artery The earliest sign of this is ipsilateral pupillary dilation, followed by stupor, coma, decerebrate posturing, and respiratory arrest Another important herniation syndrome consists of displacement of the cerebellar tonsils through the foramen magnum, which causes medullary compression leading to apnea, circulatory collapse, and death Other herniation syndromes are less common and of less clear clinical importance Intracranial tumors also lead to focal deficits depending on their location 1 Frontal lobe lesions Tumors of the frontal lobe often lead to progressive intellectual decline, slowing of mental activity, personality changes, and contralateral grasp reflexes They may lead to expressive aphasia if the posterior part of the left inferior frontal gyrus is involved Anosmia may also occur as a consequence of pressure on the olfactory nerve Precentral lesions may cause focal motor seizures or contralateral pyramidal deficits 2 Temporal lobe lesions Tumors of the uncinate region may be manifested by seizures with olfactory or gustatory hallucinations, motor phenomena such as licking or smacking of the lips, and some impairment of external awareness

Arteriovenous malformations of the cord are congenital lesions that present with spinal subarachnoid hemorrhage or myeloradiculopathy Since most of these malformations are located in the thoracolumbar region, they lead to motor and sensory disturbances in the legs and to sphincter disorders Pain in the legs or back is often severe Examination reveals an upper, lower, or mixed motor deficit in the legs; sensory deficits are also present and are usually extensive, although occasionally they are confined to radicular distribution Cervical arteriovenous malformations lead also to symptoms and signs in the arms Spinal MRI may not detect the arteriovenous malformation, and negative findings do not exclude the diagnosis In general, the diagnosis is suggested at myelography (performed with the patient prone and supine) when serpiginous filling defects due to enlarged vessels are found Selective spinal arteriography confirms the diagnosis Most lesions are extramedullary, are posterior to the cord (lying either intra- or extradurally), and can easily be treated by ligation of feeding vessels and excision of the fistulous anomaly or by embolization procedures Delay in treatment may lead to increased and irreversible disability or to death from recurrent subarachnoid hemorrhage

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Tumor Glioblastoma multiforme Clinical Features Presents commonly with nonspecific complaints and increased intracranial pressure As it grows, focal deficits develop Treatment and Prognosis Course is rapidly progressive, with poor prognosis Total surgical removal is usually not possible Radiation therapy and chemotherapy may prolong survival Prognosis is variable By the time of diagnosis, total excision is usually impossible; tumor may be radiosensitive and chemotherapy may also be helpful In cerebellar astrocytoma, total surgical removal is often possible Treatment consists of surgery combined with radiation therapy and chemotherapy Tumor is best treated surgically if possible Radiation therapy may be used for residual tumor Treatment is surgical and usually successful Radiation and chemotherapy may be used if tumor has malignant features Tumor is inoperable; treatment is by irradiation and shunt for increased intracranial pressure Treatment is surgical Radiation is used for residual tumor

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Presentation similar to glioblastoma multiforme but course more protracted, often over several years Cerebellar astrocytoma may have a more benign course

Seen most frequently in children Generally arises from roof of fourth ventricle and leads to increased intracranial pressure accompanied by brainstem and cerebellar signs May seed subarachnoid space Glioma arising from the ependyma of a ventricle, especially the fourth ventricle; leads to early signs of increased intracranial pressure Arises also from central canal of cord Slow-growing Usually arises in cerebral hemisphere in adults Calcification may be visible on skull x-ray Presents during childhood with cranial nerve palsies and then with long tract signs in the limbs Signs of increased intracranial pressure occur late Presents with disequilibrium, ataxia of trunk or limbs, and signs of increased intracranial pressure Sometimes familial May be associated with retinal and spinal vascular lesions, polycythemia, and renal cell carcinoma Presents with increased intracranial pressure, sometimes associated with impaired upward gaze (Parinaud s syndrome) and other deficits indicative of midbrain lesion

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