Much of this change in behavior is accepted by the patient with forbearance; if any complaint is made, it is of being weak, tired, or dizzy (nonvertiginous). Within a few weeks or months, these symptoms become more prominent. When the patient is questioned, a long pause precedes each reply (abulia); at times the patient may not respond at all. Or, at the moment the examiner decides that the patient has not heard the question and prepares to repeat it, an appropriate answer is given, usually in few words. Moreover, the responses are often more intelligent than one would expect, considering the patient’s torpid mental state. Many of these features will be recognized as components of a frontal lobe syndrome, but the tumor is often situated elsewhere, or is diffusely infiltrative. There are, in addition, patients who are overtly confused or demented. If the condition remains untreated, dullness and somnolence increase gradually and, finally, as increased intracranial pressure supervenes, the patient progresses to stupor or coma.
Headaches (See Also “Headaches of Brain Tumor” in Chap. 9)
These are an early symptom in far fewer than 25 percent of patients with brain tumor and the nature of cranial discomfort is variable in nature. In some, the pain is slight, dull, and episodic; in others, it is severe and either dull or sharp but also intermittent. If there are any characteristic features of the headache, they would be its nocturnal occurrence or presence on first awakening and perhaps its deep, nonpulsatile quality. However, these are not specific attributes, as migraine and hypertensive vascular headaches may also begin in the early morning hours or upon awakening. But if vomiting occurs at the peak of the head pain, tumor is more likely, as noted later. Occipitonuchal headache with vomiting is indicative of a tumor in or near the cerebellum and foramen magnum and is one typical presentation of brain tumors in children.
Patients with brain tumors do not always complain of head pain even when it is present, but they may betray its existence by placing their hands to their heads and looking distressed. When headache appears in the course of the psychomotor asthenia syndrome, it serves to clarify the diagnosis, but not nearly as much as does the occurrence of a seizure (see in the following text).
The mechanism of the headache is not fully understood and there may be more than one pathophysiology. In the majority of instances, the CSF pressure is normal during the first weeks when the headache is present, and one can attribute it only to local swelling of tissues and to distortion of blood vessels in the dura overlying the tumor. Later, the headache may be related to increases in intracranial pressure, thus the early morning occurrence after recumbency and vomiting, as discussed in Chap. 9. Tumors above the tentorium cause headache on the side of the tumor and in its vicinity, in the orbitofrontal, temporal, or parietal region; tumors in the posterior fossa usually cause ipsilateral retroauricular or occipital headache. With elevated intracranial pressure, bifrontal or bioccipital headache is the rule regardless of the location of the tumor.
Vomiting appears in a relatively small number of patients with a tumor syndrome and usually accompanies the headache when the latter is severe. It is more frequent with tumors of the posterior fossa. The most persistent vomiting (lasting several weeks) that we have observed has been in patients with low brainstem gliomas, fourth ventricular ependymomas, and subtentorial meningiomas. Some patients may vomit unexpectedly and forcibly without preceding nausea (“projectile vomiting”), a sign that is fairly specific to tumor in children, but others suffer nausea and severe discomfort. Usually the vomiting is not related to the ingestion of food, and, often, it occurs before breakfast.