Medical management of patients with brain tumors.

OPINION STATEMENT: Patients with brain tumors require meticulous attention to medical issues resulting from their disease or its therapy. The following specific issues are the ones most frequently arising in the purview of neurologists: (1) Vasogenic edema: Corticosteroids should be used in divided doses in the minimum amount required to control symptoms and should be tapered as quickly as possible. Some patients may require long-term steroid supplementation, and symptoms of adrenal insufficiency should be investigated with 8 AM: cortisol measurement and treated with appropriate repletion. (2) Seizures: Patients with brain tumors should receive antiepileptic drugs only if they have had seizures, and the drugs should be chosen to minimize cognitive effects and interactions with concurrently administered chemotherapy. Levetiracetam is an excellent choice for patients with partial seizures and is available both orally and parenterally. Lamotrigine is another reasonable choice but requires slow titration. (3) Venous thromboembolism: All brain tumor patients should receive perioperative venous thrombosis prophylaxis with compression boots and enoxaparin or dalteparin. Lifelong treatment with low molecular weight heparinoids or warfarin is required for those developing venous thromboembolism. (4) Other problems: Long-term survivors of brain tumors should be monitored indefinitely for cognitive problems, endocrine dysfunction, and development of secondary neoplasms. Modafinil can improve mood and attention impairments.