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convexity of the skull are usually asymptomatic, but those at the base may implicate the cranial nerve roots or the pituitary body Bony metastases are readily recognized on bone and CT scans and most are evident in plain lms Occasionally, a carcinoma metastasizes to the subdural surface and compresses the brain, like a subdural hematoma Others, perhaps most, are asymptomatic Apart from the above, most carcinomas reach the brain by hematogenous spread Almost one-third of them originate in the lung and half this number in the breast; melanoma is the third most frequent source in most series, and the gastrointestinal tract (particularly the colon and rectum) and kidney are the next most common Carcinomas of the gallbladder, liver, thyroid, testicle, uterus, ovary, pancreas, etc, account for the remainder Tumors originating in the prostate, esophagus, oropharynx, and skin (except for melanoma) almost never metastasize to the substance of the brain From a somewhat different point of view, certain neoplasms are particularly prone to metastasize to the brain 75 percent of melanomas do so, 57 percent of testicular tumors, and 35 percent of bronchial carcinomas, of which 40 percent are small-cell tumors (Posner and Chernik) According to those authors, the cerebral metastasis is solitary in 47 percent of cases, a somewhat higher gure than that observed in our practice and reported by others (see Henson and Urich) The metastatic tumors most likely to be single come from kidney, breast, thyroid, and adenocarcinoma of the lung Small-cell carcinomas and melanomas tend to be multiple Generally the cerebral metastasis forms a circumscribed mass, usually solid but sometimes in the form of a ring (ie, cystic), that excites rather little glial reaction but much regional vasogenic edema Often edema alone is evident on imaging studies until the administration of contrast exposes small tumor nodules (Fig 3110) Metastases from melanoma and chorioepithelioma are often hemorrhagic, but some from the lung, thyroid, and kidney exhibit this characteristic as well In a number of these cases, one-quarter in some series, the rst manifestation of the metastasis is an intratumoral hemorrhage The relative frequency of lung cancer makes.

Figure 31-10 Contrast-enhanced CT scan showing multiple metastases from bronchogenic carcinoma Each lesion is surrounded by edema

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it the most common metastatic tumor to bleed, even though only a small proportion hemorrhage The usual clinical picture of metastatic carcinoma of the brain is much like that of glioblastoma multiforme Seizures, headache, focal weakness, mental and behavioral abnormalities, ataxia, aphasia, and signs of increased intracranial pressure all inexorably progressive over a few weeks or months are the common clinical manifestations Also, a number of unusual syndromes may occur One that presents particular dif culty in diagnosis is a diffuse cerebral disturbance with headache, nervousness, depressed mood, trembling, confusion, and forgetfulness, resembling a relatively rapid dementia from degenerative disease Cerebellar metastasis, with headache, dizziness, and ataxia (the latter being brought out only by having the patient walk) is another condition that may be dif cult to diagnose Brainstem metastases, most often originating in the lung, are rare but distinctive, giving rise to diplopia, imbalance, and facial palsy as in the characteristic case described by Weiss and Richardson Infrequently, the onset of symptoms from brain metastases is relatively abrupt or even stroke-like rather than insidious Some cases of sudden onset can be explained by bleeding into the tumor and others perhaps by tumor embolism, causing cerebral infarction with early regression of symptoms and later progression from the metastasis left in its wake In most cases, the explanation is not known Also, nonthrombolic (marantic) endocarditis with cerebral embolism must be suspected when a stroke-like event occurs in a tumor patient It is not unusual for one or other of these neurologic manifestations to precede those of the discovery of a pancreatic, bowel, gastric, breast, or lung carcinoma When any of the several clinical syndromes due to metastatic tumor is fully developed, diagnosis is relatively easy If only headache and vomiting are present, a common error is to attribute them to migraine or tension headache (page 158) One should invoke such explanations only if the patient has the standard symptoms of one of these conditions CT scanning, with and without contrast, will detect practically all sizable (1 cm) metastases In addition, MRI will expose associated leptomeningeal disease and is more sensitive to small cerebellar deposits Multiple nodular deposits of tumor in the brain on imaging studies most clearly distinguish metastatic cancer from other tumors but at the same time raise the possibility, on radiologic grounds, of brain abscesses Solitary metastatic disease rst must be distinguished from a primary tumor of the brain Also, metastases must not be confused with certain neurologic syndromes that sometimes accompany carcinoma but are not due to the invasion or compression of the nervous system by tumor The latter, referred to as paraneoplastic disorders, include polyneuropathy (especially with carcinoma of the lung), polymyositis, cerebellar degeneration (ovarian and other carcinomas and Hodgkin disease), necrotizing myelopathy (rare), and certain cerebral disorders (progressive multifocal leukoencephalopathy and limbic encephalitis ) These paraneoplastic syndromes are discussed further on, under Remote Effects of Neoplasia on the Nervous System In addition to the aforementioned conditions, there are many patients with cancer who exhibit symptoms of an altered mental state without evidence of metastases or a recognizable paraneoplastic disorder These mental symptoms usually arise on the basis of systemic metabolic disturbances (hypercalcemia in particular), drugs, and psychologic reactions, some of which have yet to be clearly delineated Problems of this type were noted in a high percentage of cancer patients seen in consultation at the Memorial.

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