Patient Evaluation

Pre-operative evaluation of patients with possible brain lesions requires a careful history and physical examination (including an accurate assessment of the patient's KPS) followed by radiological evaluation. The duration of pre-operative symptoms varies greatly, because some patients have harbored lower grade gliomas that have undergone malignant transformation, leading to longer histories than those with HGGs that arise de novo. Patients with HGG often present with headache (approx-imately35%), new-onset seizures (approximately 20%), altered mental status (approximately 15%), or focal neurological signs and symptoms. Headaches associated with brain tumors vary in severity, location and quality. However, these headaches are usually different from previous headaches that the patient may have had, and because they may be secondary to elevated intracranial pressure (ICP), they are often associated with nausea and vomiting, and exacerbated by exercise and postural changes. Although drugs, alcohol and metabolic derangement may lead to seizures, new-seizure onset in adults is often associated with structural brain lesions, mandating a brain imaging study. Neurological signs and symptoms vary depending on tumor location and size. While large tumors in the frontal lobes may impart only subtle personality changes, small tumors in the brainstem or eloquent cortical regions may cause significant focal deficits. Patients with HGG rarely present with significant weight loss or pain (other than headache). These problems more often accompany systemic malignancies, which raises the diagnostic probability that the brain lesion may be metastatic or infectious.

Prior to contemplating any form of surgical intervention, the patient's overall medical status must be evaluated. Age, cardiopulmonary status, and medications that hamper coagulation (non-steroidal anti-inflammatory drugs, heparin, coumadin, etc.) may greatly impact the surgical strategy. Elderly patients, those with other life-shortening medical problems, and those with very low KPS may benefit more from biopsy than from an aggressive cytoreduc-tive procedure.

The role of anti-epileptic drugs (AEDs) in patients with gliomas remains somewhat controversial. For those patients who have had seizures, it is clear that AEDs are indicated. Likewise, for patients who are to undergo cortical stimulation mapping during surgery, AEDs offer some protection from iatrogenic seizures. For patients who have never had seizures, the routine use of AEDs is arguable.

Corticosteroids are routinely administered to patients with HGG. Dexamethasone has become the steroid of choice owing to its high glucocorticoid effect and minimal mineralocorticoid effect. Steroids reduce peritumoral edema, often lowering ICP and reducing symptoms. These drugs may also impart some protection from surgical trauma when given prior to surgery. In contradistinction, steroids given following brain trauma do not improve neurological outcome and may increase infectious complications and peptic ulceration. It must be remembered that the normal daily steroid production is less than 1 mg of dexamethasone. Therefore, slow tapers of this medication, while indicated for persistent edema or evolution of neurological deficits, are not rational for hypothalamic-pituitary axis reasons. For HGG patients who are debilitated or elderly or have been on steroids for prolonged periods, dexamethasone should be replaced by prednisone and tapered carefully.

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