Brain metastases are most commonly discovered after a diagnosis of the primary tumor has been established; more than 80% of cerebral metastases present after discovery of the systemic source. Most appear at a late stage in the dissemination of the tumor. One exception is lung cancer, in which metastases often occur in the early stages of the disease and neurological symptoms secondary to metastases frequently antedate discovery of the primary tumor .
The clinical presentation of a metastasis reflects the location and size of the tumor . The most frequent presenting symptoms are headache, focal deficits and behavioral or cognitive changes (Table 16.3). Headache, although non-specific, is the most common single symptom. In a patient with known cancer, new onset of headaches, especially those occurring in the early morning, warrants radiologic investigation. Behavioral changes are more common with multiple than with single metastases. They may be as subtle and non-specific as mild confusion, memory loss, depression or emotional lability. Symptoms such as headache, behavioral change and focal deficits are usually subtle in onset and slowly progress as the mass effect from the tumor increases.
Seizures, hemorrhage and infarction bring a more acute presentation. Seizures, focal or
% of cases
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