Medical care of patients with brain tumors

Seizures, Edema, Thrombosis, and Hemorrhages: An Update Review on the Medical Management of Gliomas

Patients affected with gliomas develop a complex set of clinical manifestations that deeply impact on quality of life and overall survival. Brain tumor-related epilepsy is frequently the first manifestation of gliomas or may occur during the course of disease; the underlying mechanisms have not been fully explained and depend on both patient and tumor factors. Novel treatment options derive from the growing use of third-generation antiepileptic drugs. Vasogenic edema and elevated intracranial pressure cause a considerable burden of symptoms, especially in high-grade glioma, requiring an adequate use of corticosteroids. Patients with gliomas present with an elevated risk of tumor-associated venous thromboembolism whose prophylaxis and treatment are challenging, considering also the availability of new oral anticoagulant drugs. Moreover, intracerebral hemorrhages can complicate the course of the illness both due to tumor-specific characteristics, patient comorbidities, and side effects of antithrombotic and antitumoral therapies. This paper aims to review recent advances in these clinical issues, discussing the medical management of gliomas through an updated literature review.

Optimal Management of Corticosteroids in Patients with Intracranial Malignancies

OPINION STATEMENT

Corticosteroids have been essential in the management of brain tumor patients for decades, primarily for the treatment of peritumoral cerebral edema and its associated neurologic deficits. Dexamethasone is the drug of choice with standard practice being administration up to four times per day, however, because of its long biologic half-life and high potency, once or twice a day dosing is likely adequate in patients without elevated intracranial pressure. The length of corticosteroid treatment should be limited to the shortest period of time to minimize the risk of potential toxicities that can significantly affect quality of life, as well as to avoid a possible detrimental impact on survival in high-grade glioma patients and abrogation of the effect of immunotherapy. Agents such as bevacizumab should be considered in patients who are unable to wean completely off of steroids as well as those who have symptomatic edema and are on immunotherapy. Several other agents have been studied without much success. An increased understanding of the complex pathophysiology of peritumoral vasogenic edema is critically needed to discover new agents that are safer and more effective.

A critical balance: managing coagulation in patients with glioma

Cancer-associated thrombosis, including both arterial and venous thromboembolism (VTE), is a significant source of morbidity and mortality in patients with glioma. This risk is highest in the immediate postoperative period and is increased by chemotherapy, radiation, and corticosteroids. Systemic anticoagulation with low molecular weight heparin is the treatment of choice in both the therapeutic and prophylactic settings. However, these patients are also at risk of intracranial hemorrhage, a potentially catastrophic complication of anticoagulation, and this risk must be carefully balanced against the risk of VTE. In this review we outline the incidence, pathophysiology and management of thrombosis in patients with glioma, with a focus on clinical considerations including perioperative management, chemotherapy-induced thrombocytopenia, and end-of-life management.