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Earlier diagnosis of brain tumors by more appropriate testing
CORRESPONDENCE Opinions expressed in the Correspondence Section are those of the authors, and not necessarily of the Journal editors, ACEP, or UA/EM.
Table 1 TIME LAGS BETWEEN ONSET OF SYMPTOMS, PRESENTATION, AND DIAGNOSIS
Earlier Diagnosis of Brain Tumors By More Appropriate Testing (Editor's note: This manuscript was received January 28, 1980. Dr. Gingrass died in March, over three years after the diagnosis of his temporal lobe astrocytoma.) To the Editor: The frequently subtle development of neurological signs and symptoms in the patient with a brain tumor often delays patient presentation and early diagnosis. Inappropriate choice of tests may add to the delay in diagnosis and jeopardize the patient's chance for cure or prolonged survival. Astrocytomas are usually slow-growing lesions with gradual onset of symptoms, and accordingly were chosen for study. A retrospective review of 31 consecutive pathologically proven cases was carried out to evaluate the time between onset of symptoms and patient presentation, and between patient presentation and pathological diagnosis. The testing procedures used and their diagnostic value also were evaluated. The cases were obtained from the records of the Hennepin County Medical Center and the University of Minnesota between 1972 and 1979. The time lag between onset of symptoms and the patient's presentation varied between one and 24 months. Of more concern was the interval between the patient's first visit and the diagnosis. This varied from less than a month to 18 months. Averages and ranges for these two categories are shown (Table 1). The major diagnostic procedures performed also were reviewed. Of special significance is that all were not diagnostic in a significant percentage of cases except for CAT scanning and ipsilateral arteriography (Table 2). Physician awareness of neurological symptoms that may be caused by a slow-growing brain tumor is essential to early diagnosis and treatment. The symptom that resulted in the longest delay between patient presentation and diagnosis was a seizure (18 months average before diagnosis). A visual defect required 14.5 months on average before the diagnosis was made. A speech defect (4.5 months), sensory defect (3.3 months), or loss of coordination (3 months) followed in length of delay. Diagnosis was made in less than a month on average where the presenting symptom was headache or paresis. The diagnostic procedure of least value was a lumbar puncture. Radionucleotide scans and electroencephalograms followed and were not diagnostic in about two-thirds of the cases. Conversely, the CAT scan was diagnostic in all cases in which it was used. Physicians must be alert to the fact that a neurological complaint, however minor, may be caused by a
10:2 (February) 1981
Sign/Symptom Category No.* Seizure Incoordination Headaches Paresis Speech defect Visual defect Sensory defect
15 6 5 5 4 4 3
Avg time (and range) between Avg time presentation (and range) and before initial diagnosis presentation (months) 2.1 (0-18) 5.5 (0-18) 8.41 (0'-36) 1.0 (0-5) 2.5 (0-6) 9.8 (0-36) 24-- (0-72)
18 (0-120) 3 (0-6) <1 0.8 (0-3) 4.5 (0-14) 14.5 (0-54) 3.3 (0-10)
*The number of signs/symptoms is greater than 31 because some patients had several. The time before patient presentation is given for each of their signs/symptoms.
Table 2 DIAGNOSTIC PROCEDURES
Procedure Lumbar puncture Radionucleotide scan Electroencephalogram Pneumoencephalogram Arteriogram CAT scan
No. Done
No. Positive
11 24 22 6 16 12
2 8 8 3 14 12
brain tumor. Many neurological procedures were not diagnostic. However, the CAT scan was diagnostic in all cases in which it was used. One might suggest that a scan should be done for any patient who presents with one of the neurological signs or symptoms evaluated.
Peter J. Gingrass, MD Department of Emergency Medicine Hennepin County Medical Center Minneapolis, Minnesota
Radiation Accident Protocol To the Editor: I have received many favorable comments on the setup of the emergency department radiation accident
Ann Emerg Med
119/75
Table 1 TIME LAGS BETWEEN ONSET OF SYMPTOMS, PRESENTATION, AND DIAGNOSIS
Earlier Diagnosis of Brain Tumors By More Appropriate Testing (Editor's note: This manuscript was received January 28, 1980. Dr. Gingrass died in March, over three years after the diagnosis of his temporal lobe astrocytoma.) To the Editor: The frequently subtle development of neurological signs and symptoms in the patient with a brain tumor often delays patient presentation and early diagnosis. Inappropriate choice of tests may add to the delay in diagnosis and jeopardize the patient's chance for cure or prolonged survival. Astrocytomas are usually slow-growing lesions with gradual onset of symptoms, and accordingly were chosen for study. A retrospective review of 31 consecutive pathologically proven cases was carried out to evaluate the time between onset of symptoms and patient presentation, and between patient presentation and pathological diagnosis. The testing procedures used and their diagnostic value also were evaluated. The cases were obtained from the records of the Hennepin County Medical Center and the University of Minnesota between 1972 and 1979. The time lag between onset of symptoms and the patient's presentation varied between one and 24 months. Of more concern was the interval between the patient's first visit and the diagnosis. This varied from less than a month to 18 months. Averages and ranges for these two categories are shown (Table 1). The major diagnostic procedures performed also were reviewed. Of special significance is that all were not diagnostic in a significant percentage of cases except for CAT scanning and ipsilateral arteriography (Table 2). Physician awareness of neurological symptoms that may be caused by a slow-growing brain tumor is essential to early diagnosis and treatment. The symptom that resulted in the longest delay between patient presentation and diagnosis was a seizure (18 months average before diagnosis). A visual defect required 14.5 months on average before the diagnosis was made. A speech defect (4.5 months), sensory defect (3.3 months), or loss of coordination (3 months) followed in length of delay. Diagnosis was made in less than a month on average where the presenting symptom was headache or paresis. The diagnostic procedure of least value was a lumbar puncture. Radionucleotide scans and electroencephalograms followed and were not diagnostic in about two-thirds of the cases. Conversely, the CAT scan was diagnostic in all cases in which it was used. Physicians must be alert to the fact that a neurological complaint, however minor, may be caused by a
10:2 (February) 1981
Sign/Symptom Category No.* Seizure Incoordination Headaches Paresis Speech defect Visual defect Sensory defect
15 6 5 5 4 4 3
Avg time (and range) between Avg time presentation (and range) and before initial diagnosis presentation (months) 2.1 (0-18) 5.5 (0-18) 8.41 (0'-36) 1.0 (0-5) 2.5 (0-6) 9.8 (0-36) 24-- (0-72)
18 (0-120) 3 (0-6) <1 0.8 (0-3) 4.5 (0-14) 14.5 (0-54) 3.3 (0-10)
*The number of signs/symptoms is greater than 31 because some patients had several. The time before patient presentation is given for each of their signs/symptoms.
Table 2 DIAGNOSTIC PROCEDURES
Procedure Lumbar puncture Radionucleotide scan Electroencephalogram Pneumoencephalogram Arteriogram CAT scan
No. Done
No. Positive
11 24 22 6 16 12
2 8 8 3 14 12
brain tumor. Many neurological procedures were not diagnostic. However, the CAT scan was diagnostic in all cases in which it was used. One might suggest that a scan should be done for any patient who presents with one of the neurological signs or symptoms evaluated.
Peter J. Gingrass, MD Department of Emergency Medicine Hennepin County Medical Center Minneapolis, Minnesota
Radiation Accident Protocol To the Editor: I have received many favorable comments on the setup of the emergency department radiation accident
Ann Emerg Med
119/75