•Nausea and vomiting:

–Often in relation to headache

–Nighttime vomiting

•Visual disturbances (mostly abducens palsy):

–Diplopia

–Strabismus

–Visual loss and/or visual field loss

–Head turns to one side

•Change of personality: Lethargy, apathy, irritability, somnolence

•Head enlargement in infants and young children (less than 2 years of age)

9.6.2Focal Neurological Failures

•Dependent on locations

•Epileptic convulsions

•Ataxia

•Visual loss and/or visual field loss

•Cranial nerve palsy

•Peripheral neurological disturbances (see “Special Tumor Types”)

9.6.3Tumor Types and Symptoms According to Intracranial Location

9.6.3.1 Cerebral Hemisphere

Most frequent tumor types

•Astrocytoma

•Ependymoma

•Oligodendroglioma

•Meningioma

•Main symptoms: focal cerebral dysfunction and/or epilepsy in cortical tumors; hemiplegia and visual field defects in subcortical tumors

•Frontal: anterior frontal globe:

–Few clinical signs until a large tumor evokes pressure; personality and emotional changes: blandness and indifference to surroundings

–Gyrus precentralis to capsula interna: contralateral weakness of the face; of the extremities, change in handedness as early sign; disturbance of fluent speech but intact comprehension (Broca aphasia). Seizure type: adverse turning of the eyes and head toward the opposite side, focal tonic or clonic convulsion of the contralateral extremity

•Temporoparietal

–Focal seizure, with secondary generalization of seizure

–Postictal, transient neurological deficit

Common tumor types

•Pinealoblastoma

•Teratoma

•Germinoma

•Astrocytoma of the corpus callosum or thalamus

•Nongerminomatous germ cell tumor

•Early symptoms: brain pressure caused by obstruction of cerebral fluid

•Parinaud syndrome

–Paralysis of conjugate upward gaze

–Disturbed pupillary light reflex

•Extension of tumor to midbrain

–Disturbed ocular motor nerve function and extension with nystagmus, anisocoria, and paralysis of convergence ability

–Caudal extension: tinnitus and bilateral deafness

–In forward extension, eyelid retraction

•Association with hypogonadism and precocious puberty

9.6.3.4 Posterior Fossa Tumors

Common tumor types

•Cystic astrocytoma

•Solid astrocytoma

•Hemangioblastoma (with erythrocytosis and high serum level of erythropoietin in 50% of patients)

•Symptoms

–Ipsilateral cerebral dysfunction of the extremities: with tremor, dysmetria, rebound phenomenon, dysdiadochokinesia

–Extension in the direction of fourth ventricle: signs of hydrocephalus (central nervous system (CNS)-mediated hypertension)

–With extension to foramen magnum (herniation): neck pain, opisthotonus, paresthesiae of the upper extremities, high blood pressure with bradycardia, changes in vision, fever, bulbar signs (dysphagia, dysarthria)

9.6.3.5 Vermis Cerebelli

Tumor type

•Often medulloblastoma with infiltration of the fourth ventricle

•Symptoms

–Symmetrical ataxia of the trunk

–Signs of high intracranial pressure and cerebellar tonsillar herniation

9.6.3.6 Fourth Ventricle

Tumor types

•Choroid plexus carcinoma

•Dermoid tumor or teratoma in infants

•Symptom: high intracranial pressure

9.6.3.7 Brain Stem

Tumor type

•Astrocytoma, WHO grade I–IV: infiltration into the brain stem

•Symptoms:

–Unilateral paralysis of cranial nerves VI and VII

–Contralateral hemiparesis of the extremities with hyperreflexia, spasticity, positive Babinski sign, vertical nystagmus

–Occasionally high intracranial pressure

–Invasion of brain areas controlling vital functions result in a high death rate

•Differential diagnosis

–Tumors arising from external structures such as rhabdomyosarcoma, nonHodgkin lymphoma, neuroblastoma, or from primary brain tumors such as medulloblastoma

9.6.3.8 Cerebellopontine Angle Tumors

Tumor type

•Acoustic neuroma

•Symptoms and signs

–Dysfunction of the auditory and vestibular nerves

–Ipsilateral corneal reflex palsy or absence

9.6.3.9 Spinal Cord

Tumor types

•Intramedullary

–Astrocytoma

–Oligodendroglioma

–Ependymoma, often with cysts (differential diagnosis: syringomyelia)

•Extramedullary and intradural tumors

–Neurofibroma

–Meningioma

–Dermoid tumor

–Teratoma