Brain metastases: Literature review | Revista Médica del Hospital General de México

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Dajer-Fadel, M.G. Pliego-Sánchez, E.M. Mejía-Melgar, D.P. Yépez-Ramos, C.A. Latorre-Davila, C.R. Tortolero-Sánchez, O. Flores-Calderón, S. Ramírez-Castañeda, O.F. López-Noria, R. Argüero-Sánchez" "autores" => array:10 [ 0 => array:2 [ "nombre" => "W.L." "apellidos" => "Dajer-Fadel" ] 1 => array:2 [ "nombre" => "M.G." "apellidos" => "Pliego-Sánchez" ] 2 => array:2 [ "nombre" => "E.M." "apellidos" => "Mejía-Melgar" ] 3 => array:2 [ "nombre" => "D.P." "apellidos" => "Yépez-Ramos" ] 4 => array:2 [ "nombre" => "C.A." "apellidos" => "Latorre-Davila" ] 5 => array:2 [ "nombre" => "C.R." "apellidos" => "Tortolero-Sánchez" ] 6 => array:2 [ "nombre" => "O." "apellidos" => "Flores-Calderón" ] 7 => array:2 [ "nombre" => "S." "apellidos" => "Ramírez-Castañeda" ] 8 => array:2 [ "nombre" => "O.F." "apellidos" => "López-Noria" ] 9 => array:2 [ "nombre" => "R." "apellidos" => "Argüero-Sánchez" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0185106316300683?idApp=UINPBA00004N" "url" => "/01851063/0000008000000001/v2_201702120003/S0185106316300683/v2_201702120003/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "Review article" "titulo" => "Brain metastases: Literature review" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "60" "paginaFinal" => "66" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J.L. Navarro-Olvera, E. Ariñez-Barahona, M.A. Esqueda-Liquidano, A. Muñoz-Cobos" "autores" => array:4 [ 0 => array:4 [ "nombre" => "J.L." "apellidos" => "Navarro-Olvera" "email" => array:1 [ 0 => "luiginavarro97@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "E." 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"apellidos" => "Muñoz-Cobos" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Neurology and Neurosurgery Service, Neurosurgery Department, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Enfermedad metastásica cerebral: revisión de la literatura" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 816 "Ancho" => 1501 "Tamanyo" => 133739 ] ] "descripcion" => array:1 [ "en" => "Axial cut of contrast MRI of the brain. On the left, T2-weighted image showing hyperintense left frontal region marked with arrows. On the right, T1-weighted image showing perilesional hypointensity and central hyperintensity of the left frontal region marked with arrows." ] ] ] "textoCompleto" => "IntroductionThe real incidence of metastatic brain tumours remains unknown,<a class="elsevierStyleCrossRefs" href="#bib0200">1,2</a> although some countries such as the United States of America report 17,000 cases annually,<a class="elsevierStyleCrossRef" href="#bib0200">1</a> and some authors consider brain metastases such as intracranial tumour to be more common.Brain metastases occur in 15–40% of patients with systemic cancer, which represents approximately 12 patients per 100,000 inhabitants per year.<a class="elsevierStyleCrossRefs" href="#bib0210">3–5</a>It is usually diagnosed between the 5th and 7th decade of life. This concurs with statistics from the American Cancer Society, which reveal that the probability of developing invasive cancer is high between 60 and 79 years of age.<a class="elsevierStyleCrossRef" href="#bib0225">6</a>Even after performing a thorough study to identify the primary tumour, it remains undetected in 15% of patients.<a class="elsevierStyleCrossRef" href="#bib0230">7</a>Certain types of cancers are more prone to spread to the central nervous system.<a class="elsevierStyleCrossRef" href="#bib0235">8</a> The most common, in order of frequency, are lung cancer, breast cancer, melanoma, colorectal and renal cancer, and less frequently thyroid cancer, gastrointestinal cancer and prostate cancer. Haematological neoplasms constitute only 10% of brain metastases and primarily affect the leptomeninges<a class="elsevierStyleCrossRefs" href="#bib0240">9–11</a> (see <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Clinical diagnosisMost patients’ initial manifestations are neurological, and therefore their first point of contact is commonly with a neurosurgeon or neurologist before they are referred to an oncologist.<a class="elsevierStyleCrossRef" href="#bib0255">12</a> It is considered that 15% of patients in whom the primary tumour has been identified at the time of diagnosis and 45% of these who moreover present neurological symptoms will be diagnosed with metastatic brain tumour.<a class="elsevierStyleCrossRefs" href="#bib0260">13,31</a>The most common symptoms include (see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>) headache, weakness, alterations of higher brain functions, focal neurological deficit and seizures, which are caused due to a local mass, cerebral oedema and increased intracranial pressure.<a class="elsevierStyleCrossRef" href="#bib0265">14</a><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Diagnostic imagingNuclear magnetic resonance imaging (MRI) of the brain is considered to be the exam of choice in patients with clinical suspicion of brain metastasis because it has a high sensitivity and specificity.<a class="elsevierStyleCrossRef" href="#bib0270">15</a>Nevertheless, in patients with a contraindication for MRI, computed axial tomography (CAT) scan of the brain or PET (positron emission tomography) are the favoured options. CAT scan of the brain can be performed with or without a contrast medium to reveal metastatic lesions that are isodense to the brain parenchyma (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), whilst a hyperdense image suggests the presence of haemorrhage, which could lead to the diagnosis of lung tumour, renal tumour, thyroid tumour, choriocarcinoma or melanoma metastasis. Moreover, it determines whether the patient has hydrocephalus, brain oedema or brain herniation. When a contrast medium is administered the lesion is enhanced and multiple lesions become visible.<a class="elsevierStyleCrossRefs" href="#bib0275">16,17,26</a><elsevierMultimedia ident="fig0005"></elsevierMultimedia>MRI of the brain employs basic T1- and T2-weighted sequences, FLAIR, diffusion and perfusion, in addition to spectroscopy and tractography. Most metastatic lesions are hypointense on T1-weighted images, which could be indicative of haemorrhage, melanin and necrosis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). On T2-weighted images most lesions are hyperintense. Bleeding appears as hypointense when in acute state, and hyperintense when subacute, while vasogenic oedema is hyperintense.<a class="elsevierStyleCrossRef" href="#bib0285">18</a> Spectroscopy is a magnetic resonance imaging technique that enables the metabolic characteristics of the lesion to be evaluated. It can be represented in 2D (two dimensional) or 3D (three dimensional) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), detecting the ranges of spectra of normal brain tissue, metastasis, necrosis, gliosis and vasogenic oedema.<a class="elsevierStyleCrossRefs" href="#bib0290">19,20</a> PET and SPECT (single-photon emission computed tomography) used for the diagnosis of brain metastasis are limited, due to their low sensitivity for detecting small lesions or potentially recurring tumours, and PET is limited to differentiating between necrosis due to radiation or recurrence.<a class="elsevierStyleCrossRefs" href="#bib0300">21,22</a> Complementary studies such as chest–abdomen–pelvis CT scan, chest X-ray, bronchoscopy, CARBOWAX and tumour markers are conducted according to the clinical suspicion of the disease.<elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia>The use of brain resonance is recommended as part of the evaluation for some patients with tumours that have already been diagnosed, those on treatment and those in follow-up.<a class="elsevierStyleCrossRef" href="#bib0305">22</a>Stereotactic biopsy for the diagnosis of metastatic brain tumoursFor multiple lesions located deep in the brain or in highly specialised regions (language area, primary motor area, visual area) and when the primary tumour has not been identified in other studies, stereotactic biopsy is a valuable diagnostic resource, with a mortality rate of less than 1% (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).<elsevierMultimedia ident="fig0020"></elsevierMultimedia>RPA (recursive partitioning analysis) classificationThe RTOG (Radiation Therapy Oncology Group) developed a statistical method to categorise cancer patients, called the RPA classification system. It contemplates several factors such as patient age, Karnofsky Performance Status (KPS) and control of primary tumour, to better understand the prognostic factors for selecting patients who will benefit from surgery. Patients with RPA class 1 are under 65 years of age, with a KPS greater than 70% and control or absence of systemic disease. RPA class 2 patients are older than 65 years of age with a KPS greater than 70% and uncontrolled systemic disease. RPA class 3 patients have a KPS under 70%.RPA class 1 patients are considered to be good candidates for craniotomy and resection, while RPA class 3 patients are the worst candidates for surgical treatment. The selection of RPA class 2 patients is less clear, requiring survival time and medical risk factors for surgery to be taken into account.<a class="elsevierStyleCrossRef" href="#bib0310">23</a>TreatmentTreatment consists of surgery, radiotherapy, radiosurgery, chemotherapy and drugs such as antiepileptics and corticosteroids. Antiepileptic drugs, such as phenytoin (DPH) at a starting dose of 15–17mg/kg and a sustained dose of 5–7mg/kg, have been shown to be prophylactic treatment for generalised seizures, and other anticonvulsants have been used for focal seizures, such as carbamazepine or oxcarbazepine.<a class="elsevierStyleCrossRef" href="#bib0315">24</a> The corticosteroid of choice in the management of vasogenic cerebral oedema is dexamethasone, recommended for moderate symptoms at a dose of 4–8mg/day. For severe symptoms the dose may be increased up to 16mg/day, with a duration of treatment no longer than 2 weeks.<a class="elsevierStyleCrossRef" href="#bib0320">25</a>SurgeryIt provides different advantages over other treatments: firstly, complete resection immediately removes the mass effect, brain irritation and vasogenic cerebral oedema; secondly, surgery provides tissue to be sent for histopathological study in case the primary tumour is unknown; and thirdly, complete surgical resection provides local cure.<a class="elsevierStyleCrossRefs" href="#bib0330">27,28</a> Occasionally the risks of surgery exceed the benefits, such as: secondary neurological deficit due to lesion in an eloquent area, meningitis, brain abscess, intracranial haemorrhage or even death. Nevertheless, thanks to modern techniques and sophisticated technology, surgical mortality for brain metastases has dramatically decreased since the initial reports of craniotomies, and is now below 3%. The risk of haemorrhage or neurological deterioration associated with surgery is less than 5%, while the risk of meningitis and brain abscess is less than 1%. Non-surgery-related complications, such as infection, deep vein thrombosis, pulmonary embolism and pneumonia, occur in 8–10% of patients.<a class="elsevierStyleCrossRefs" href="#bib0335">28–30</a>Treatment protocols have been defined for single and multiple brain metastases, from which the following can be concluded: Patients with systemic disease and single brain metastasis should be treated with surgical resection plus whole brain radiotherapy. This has led to an increase in survival, fewer recurrences and greater quality of life.<a class="elsevierStyleCrossRef" href="#bib0360">33</a> Patients with three lesions or fewer, with good systemic control, should also be treated with surgery and whole brain radiotherapy, as the outcome is the same as for patients treated for single metastasis.<a class="elsevierStyleCrossRef" href="#bib0355">32</a> Despite advances in surgery and the safety of the anaesthesia technique, patients with more than three lesions have a particularly poor prognosis and are not good candidates for surgery. Data obtained from several retrospective studies show that for patients with controlled systemic disease and more than three surgically accessible lesions, surgical intervention should be discussed with a good neuro-oncology team.<a class="elsevierStyleCrossRef" href="#bib0360">33</a>The management of recurring metastases should be as per the most recent references similar to the newly diagnosed brain metastasis, as it is considered to have the same outcome.<a class="elsevierStyleCrossRef" href="#bib0365">34</a>RadiotherapyThe optimal dose for managing patients with brain metastasis includes 10 sessions of 3Gy (30Gy) split over two weeks or 15 sessions of 2.5Gy (37.5Gy) split over three weeks. These variations in dose and time have not demonstrated superior results; in fact, dose and time increases have been shown to cause more adverse effects.Complications caused by radiotherapy are classified as acute (under 90 days) and chronic (more than 90 days). Acute complications include hair loss, dermatitis, otitis externa, hearing loss, nausea, vomiting and drowsiness. Chronic complications include tissue necrosis, personality changes, memory loss, cerebellar disorders, cataracts and deterioration in cognitive function.<a class="elsevierStyleCrossRef" href="#bib0370">35</a>RadiosurgeryThe main candidates for this treatment are those patients who do not meet the criteria for surgical treatment, those with lesions under 3cm or lesions located in eloquent areas, and those with residual lesion after resection. The treatment parameters imply that the maximum tolerated dose depends on the diameter of the lesion: 15Gy for tumours under 20mm and 20Gy for tumours 31–40mm.<a class="elsevierStyleCrossRefs" href="#bib0375">36,37</a>ChemotherapyThe role of chemotherapy in the treatment of patients with brain metastasis is not clearly defined. Currently, chemotherapy is used very little in the management of patients not included in research protocols, with the exception of very chemo-sensitive tumours, such as small cell lung carcinoma, germ cell tumours and lymphoid neoplasms.<a class="elsevierStyleCrossRef" href="#bib0385">38</a>PrognosisThe prognosis of brain metastasis patients in the last two decades with the use of combined therapies shows an increase in survival compared to patients who only received radiotherapy or surgery. The final result of the studies conducted shows that surgery plus radiotherapy presents an increase in survival of 7–9 months.<a class="elsevierStyleCrossRefs" href="#bib0320">25,29,39</a>Dural metastasesThese usually affect patients at advanced disease stages and the mechanisms of dissemination are direct extension or haematogenous spread.The incidence of dural metastases has increased in recent decades as a result of developments in new neuroimaging techniques and an increase in the survival of cancer patients due to improved therapies. Most patients are asymptomatic; however, they may debut with progressive neurological deficit.<a class="elsevierStyleCrossRefs" href="#bib0360">33,34</a> The most recent study in the literature review was published by Laigle-Donadey, covering 198 cases from 1994 to 2003. The patient age range was from 4 months to 84 years (mean of 59 years) and the most common dural metastases reported (in order of frequency) were prostate, breast, lung and stomach cancer, making up 54.5% (108 patients). The exact incidence of dural metastases is difficult to ascertain<a class="elsevierStyleCrossRef" href="#bib0390">39</a> (see <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Clinical manifestationsThe symptoms presented are usually related to brain compression or invasion, production of subdural haematomas or fluid collection, and less frequently due to occlusion of branches to the dural sinuses. Approximately 20% of patients are asymptomatic, and the lesions are identified in a follow-up study or in necropsy<a class="elsevierStyleCrossRef" href="#bib0385">38</a> (see <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>Non-traumatic subdural haematomas resulting from neoplastic invasion of the meninges are a classic complication, with an incidence observed in 15–40% of cases.<a class="elsevierStyleCrossRefs" href="#bib0380">37,38</a>DiagnosisThe exam of choice is contrast-enhanced MRI of the brain (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). The classic image of dural metastasis is a mass with homogeneous enhancement on T2-weighted images, originating in the dura mater. When the dural tail sign appears, a differential diagnosis should be made for meningioma, particularly in patients with prostate cancer, which also causes a hyperostotic effect.<a class="elsevierStyleCrossRef" href="#bib0375">36</a><elsevierMultimedia ident="fig0025"></elsevierMultimedia>TreatmentSurgical resection is normally performed when there is a single, well defined lesion that is surgically accessible, with adequate control of extracranial disease. Surgical resection is recommended in patients with progressive systemic disease but good quality of life and symptoms caused by intracranial hypertension. Immediate evacuation can save the life of patients with subdural haematoma. Histopathological study can establish a diagnosis, especially in patients with known systemic primary disease.<a class="elsevierStyleCrossRefs" href="#bib0380">37,38</a> High doses of corticosteroids (dexamethasone) can cause temporary symptom relief.<a class="elsevierStyleCrossRef" href="#bib0385">38</a> Whole brain radiotherapy can be used as palliative therapy if the dural lesions are associated with parenchymal metastases, while radiosurgery is reserved for isolated lesions less than 3cm in diameter.<a class="elsevierStyleCrossRefs" href="#bib0375">36,38</a>PrognosisThe prognosis of dural metastases can be extrapolated from the prognosis of brain metastases under 1 year of survival. Most patients die due to systemic disease complications before they die from neurological complications. Prognosis is most favourable for haematological neoplasms, breast and lung cancer, with a survival of 365, 273 and 120 days respectively.<a class="elsevierStyleCrossRefs" href="#bib0380">37,38</a>ConclusionsAlthough brain metastasis is not an uncommon condition worldwide, in Mexico there are no multidisciplinary programmes established to provide continuity for patients in whom the primary tumour has been identified, even though up to 40% of patients with systemic cancer have brain metastases. It should be noted that even after a thorough study, the primary tumour cannot be identified in 15% of brain metastasis patients. The most common types of neoplasm that present brain metastasis are lung cancer, breast cancer, melanoma, colorectal cancer and renal cancer. More reliable statistics must be established in Mexico in order to combat brain metastasis. Given the new therapy techniques (surgery, chemotherapy and radiotherapy) and increased survival, in patients in whom the primary tumour has been identified there is a possibility that the risk of brain metastasis may increase, and therefore continual review protocols must be diligently applied in these patients. This will help in the diagnosis and suitable management of these patients.Conflict of interestThe authors declare that they have no conflict of interests." "textoCompletoSecciones" => array:1 [ "secciones" => array:23 [ 0 => array:3 [ "identificador" => "xres800889" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec799297" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres800890" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec799298" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical diagnosis" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Diagnostic imaging" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Stereotactic biopsy for the diagnosis of metastatic brain tumours" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "RPA (recursive partitioning analysis) classification" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Treatment" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Surgery" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Radiotherapy" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Radiosurgery" ] 13 => array:2 [ "identificador" => "sec0050" "titulo" => "Chemotherapy" ] 14 => array:2 [ "identificador" => "sec0055" "titulo" => "Prognosis" ] 15 => array:2 [ "identificador" => "sec0060" "titulo" => "Dural metastases" ] 16 => array:2 [ "identificador" => "sec0065" "titulo" => "Clinical manifestations" ] 17 => array:2 [ "identificador" => "sec0070" "titulo" => "Diagnosis" ] 18 => array:2 [ "identificador" => "sec0075" "titulo" => "Treatment" ] 19 => array:2 [ "identificador" => "sec0080" "titulo" => "Prognosis" ] 20 => array:2 [ "identificador" => "sec0085" "titulo" => "Conclusions" ] 21 => array:2 [ "identificador" => "sec0090" "titulo" => "Conflict of interest" ] 22 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-10-29" "fechaAceptado" => "2016-04-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec799297" "palabras" => array:4 [ 0 => "Brain metastasis" 1 => "Chemotherapy" 2 => "Surgical resection" 3 => "Radiotherapy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec799298" "palabras" => array:4 [ 0 => "Metástasis cerebral" 1 => "Quimioterapia" 2 => "Resección quirúrgica" 3 => "Radioterapia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Brain metastases frequently occur secondary to poorly controlled primary lung, breast, melanoma, colorectal and renal tumours. Because of this, correct diagnosis and early treatment of brain metastasis is difficult, which is why the condition should be treated and controlled by a multidisciplinary medical team so as to obtain real-life and reliable statistics and to lower the incidence of brain metastasis, improving the quality of life of patients and reducing mortality rates." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La enfermedad metastásica cerebral (EMC) es una patología, frecuente sobre todo en tumores primarios de pulmón, mama, melanoma, colorrectal y renal descontrolados. El diagnóstico oportuno y tratamiento temprano, es la falla sobre la EMC, debido a la misma causa. Por lo que debería ser manejado con un equipo médico multidisciplinario, para poder controlar, obtener estadísticas reales, y fidedignas, y así bajar la frecuencia de EMC, mejorando la calidad de vida de los pacientes, y reduciendo las estadísticas de mortalidad." ] ] "multimedia" => array:9 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1081 "Ancho" => 990 "Tamanyo" => 111198 ] ] "descripcion" => array:1 [ "en" => "Axial cut of non-contrast CT brain scan showing an isodense image to the left frontal brain parenchyma marked with an arrow, as well as perilesional oedema corresponding to the hypodense image." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 816 "Ancho" => 1501 "Tamanyo" => 133739 ] ] "descripcion" => array:1 [ "en" => "Axial cut of contrast MRI of the brain. On the left, T2-weighted image showing hyperintense left frontal region marked with arrows. On the right, T1-weighted image showing perilesional hypointensity and central hyperintensity of the left frontal region marked with arrows." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 772 "Ancho" => 1500 "Tamanyo" => 125268 ] ] "descripcion" => array:1 [ "en" => "Spectroscopy of right frontal lesion marked with arrows on the image to the left; and the image to the right marked with the arrow shows an increase in choline representing the accelerated formation of cell membranes compatible with metastatic lesion." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 932 "Ancho" => 990 "Tamanyo" => 121806 ] ] "descripcion" => array:1 [ "en" => "Stereotactic biopsy with ZD frame. Contrast-enhanced CAT image showing a thalamic tumour lesion, calculating coordinates for stereotactic-guided biopsy sampling." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 881 "Ancho" => 1500 "Tamanyo" => 134852 ] ] "descripcion" => array:1 [ "en" => "Magnetic resonance of the brain, T1-weighted sequence image with contrast. A shows the coronal cut and B the axial cut, with the presence of a hyperintense image in the right parietal–temporal–occipital with bone infiltration and displacement of brain parenchyma." ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Refs. <a class="elsevierStyleCrossRefs" href="#bib0245">10, 11</a>." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Primary tumour \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% Metastasis (12) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% Metastasis (13) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lungs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11,763/59,038 (19.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">156/938 (16.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Breasts \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2635/51,898 (5.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">42/802 (5.0%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kidneys \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">467/7205 (6.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12/114 (9.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Melanoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">566/8229 (6.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12/150 (7.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Colorectal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">779/42,817 (1.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10/720 (1.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1343725.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Incidence of brain metastasis." ] ] 6 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Values in brackets represent percentage of symptoms." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Clinical presentation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Number of patients</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Primary tumour not identified \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Primary tumour identified \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Focal deficit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">78 (64) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">108 (51) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">186 (56) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Seizures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 (18) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 (17) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59 (18) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intracranial hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (11) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 (10) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Headache \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 (7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Asymptomatic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 (14) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 (10) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1343726.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical manifestations in patients with brain metastasis (Neurosurg. Focus/Volume 22/March, 2007)." ] ] 7 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Ref. <a class="elsevierStyleCrossRef" href="#bib0355">33</a>." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cancer \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Incidence % \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prostate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Breasts \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lungs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gastric \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Haematological \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1343724.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Types of cancer spread to the dura mater<a class="elsevierStyleCrossRef" href="#bib0330">27</a>" ] ] 8 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Ref. <a class="elsevierStyleCrossRef" href="#bib0355">33</a>." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n 89% \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Increased intracranial pressure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.5% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Neurological deficit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Coma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cranial neuropathy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Seizures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Headache \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Confusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.5% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Asymptomatic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1343723.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Signs and symptoms in patients with dural metastases<a class="elsevierStyleCrossRef" href="#bib0330">27</a>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:39 [ 0 => array:3 [ "identificador" => "bib0200" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of brain metastases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J. 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Brain metastases: Literature review

Enfermedad metastásica cerebral: revisión de la literatura

J.L. Navarro-Olvera

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luiginavarro97@hotmail.com

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, E. Ariñez-Barahona, M.A. Esqueda-Liquidano, A. Muñoz-Cobos

Neurology and Neurosurgery Service, Neurosurgery Department, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico

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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Axial cut of contrast MRI of the brain&#46; On the left&#44; T2-weighted image showing hyperintense left frontal region marked with arrows&#46; On the right&#44; T1-weighted image showing perilesional hypointensity and central hyperintensity of the left frontal region marked with arrows&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The real incidence of metastatic brain tumours remains unknown&#44;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">1&#44;2</span></a> although some countries such as the United States of America report 17&#44;000 cases annually&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">1</span></a> and some authors consider brain metastases such as intracranial tumour to be more common&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Brain metastases occur in 15&#8211;40&#37; of patients with systemic cancer&#44; which represents approximately 12 patients per 100&#44;000 inhabitants per year&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">It is usually diagnosed between the 5th and 7th decade of life&#46; This concurs with statistics from the American Cancer Society&#44; which reveal that the probability of developing invasive cancer is high between 60 and 79 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Even after performing a thorough study to identify the primary tumour&#44; it remains undetected in 15&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Certain types of cancers are more prone to spread to the central nervous system&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">8</span></a> The most common&#44; in order of frequency&#44; are lung cancer&#44; breast cancer&#44; melanoma&#44; colorectal and renal cancer&#44; and less frequently thyroid cancer&#44; gastrointestinal cancer and prostate cancer&#46; Haematological neoplasms constitute only 10&#37; of brain metastases and primarily affect the leptomeninges<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">9&#8211;11</span></a> &#40;see <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Most patients&#8217; initial manifestations are neurological&#44; and therefore their first point of contact is commonly with a neurosurgeon or neurologist before they are referred to an oncologist&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">12</span></a> It is considered that 15&#37; of patients in whom the primary tumour has been identified at the time of diagnosis and 45&#37; of these who moreover present neurological symptoms will be diagnosed with metastatic brain tumour&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">13&#44;31</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The most common symptoms include &#40;see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; headache&#44; weakness&#44; alterations of higher brain functions&#44; focal neurological deficit and seizures&#44; which are caused due to a local mass&#44; cerebral oedema and increased intracranial pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">14</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Diagnostic imaging</span><p id="par0040" class="elsevierStylePara elsevierViewall">Nuclear magnetic resonance imaging &#40;MRI&#41; of the brain is considered to be the exam of choice in patients with clinical suspicion of brain metastasis because it has a high sensitivity and specificity&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">15</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Nevertheless&#44; in patients with a contraindication for MRI&#44; computed axial tomography &#40;CAT&#41; scan of the brain or PET &#40;positron emission tomography&#41; are the favoured options&#46; CAT scan of the brain can be performed with or without a contrast medium to reveal metastatic lesions that are isodense to the brain parenchyma &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; whilst a hyperdense image suggests the presence of haemorrhage&#44; which could lead to the diagnosis of lung tumour&#44; renal tumour&#44; thyroid tumour&#44; choriocarcinoma or melanoma metastasis&#46; Moreover&#44; it determines whether the patient has hydrocephalus&#44; brain oedema or brain herniation&#46; When a contrast medium is administered the lesion is enhanced and multiple lesions become visible&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">16&#44;17&#44;26</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">MRI of the brain employs basic T1- and T2-weighted sequences&#44; FLAIR&#44; diffusion and perfusion&#44; in addition to spectroscopy and tractography&#46; Most metastatic lesions are hypointense on T1-weighted images&#44; which could be indicative of haemorrhage&#44; melanin and necrosis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; On T2-weighted images most lesions are hyperintense&#46; Bleeding appears as hypointense when in acute state&#44; and hyperintense when subacute&#44; while vasogenic oedema is hyperintense&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">18</span></a> Spectroscopy is a magnetic resonance imaging technique that enables the metabolic characteristics of the lesion to be evaluated&#46; It can be represented in 2D &#40;two dimensional&#41; or 3D &#40;three dimensional&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; detecting the ranges of spectra of normal brain tissue&#44; metastasis&#44; necrosis&#44; gliosis and vasogenic oedema&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">19&#44;20</span></a> PET and SPECT &#40;single-photon emission computed tomography&#41; used for the diagnosis of brain metastasis are limited&#44; due to their low sensitivity for detecting small lesions or potentially recurring tumours&#44; and PET is limited to differentiating between necrosis due to radiation or recurrence&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">21&#44;22</span></a> Complementary studies such as chest&#8211;abdomen&#8211;pelvis CT scan&#44; chest X-ray&#44; bronchoscopy&#44; CARBOWAX and tumour markers are conducted according to the clinical suspicion of the disease&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The use of brain resonance is recommended as part of the evaluation for some patients with tumours that have already been diagnosed&#44; those on treatment and those in follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Stereotactic biopsy for the diagnosis of metastatic brain tumours</span><p id="par0060" class="elsevierStylePara elsevierViewall">For multiple lesions located deep in the brain or in highly specialised regions &#40;language area&#44; primary motor area&#44; visual area&#41; and when the primary tumour has not been identified in other studies&#44; stereotactic biopsy is a valuable diagnostic resource&#44; with a mortality rate of less than 1&#37; &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">RPA &#40;recursive partitioning analysis&#41; classification</span><p id="par0065" class="elsevierStylePara elsevierViewall">The RTOG &#40;Radiation Therapy Oncology Group&#41; developed a statistical method to categorise cancer patients&#44; called the RPA classification system&#46; It contemplates several factors such as patient age&#44; Karnofsky Performance Status &#40;KPS&#41; and control of primary tumour&#44; to better understand the prognostic factors for selecting patients who will benefit from surgery&#46; Patients with RPA class 1 are under 65 years of age&#44; with a KPS greater than 70&#37; and control or absence of systemic disease&#46; RPA class 2 patients are older than 65 years of age with a KPS greater than 70&#37; and uncontrolled systemic disease&#46; RPA class 3 patients have a KPS under 70&#37;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">RPA class 1 patients are considered to be good candidates for craniotomy and resection&#44; while RPA class 3 patients are the worst candidates for surgical treatment&#46; The selection of RPA class 2 patients is less clear&#44; requiring survival time and medical risk factors for surgery to be taken into account&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">23</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Treatment</span><p id="par0075" class="elsevierStylePara elsevierViewall">Treatment consists of surgery&#44; radiotherapy&#44; radiosurgery&#44; chemotherapy and drugs such as antiepileptics and corticosteroids&#46; Antiepileptic drugs&#44; such as phenytoin &#40;DPH&#41; at a starting dose of 15&#8211;17<span class="elsevierStyleHsp" style=""></span>mg&#47;kg and a sustained dose of 5&#8211;7<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#44; have been shown to be prophylactic treatment for generalised seizures&#44; and other anticonvulsants have been used for focal seizures&#44; such as carbamazepine or oxcarbazepine&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">24</span></a> The corticosteroid of choice in the management of vasogenic cerebral oedema is dexamethasone&#44; recommended for moderate symptoms at a dose of 4&#8211;8<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#46; For severe symptoms the dose may be increased up to 16<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; with a duration of treatment no longer than 2 weeks&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Surgery</span><p id="par0080" class="elsevierStylePara elsevierViewall">It provides different advantages over other treatments&#58; firstly&#44; complete resection immediately removes the mass effect&#44; brain irritation and vasogenic cerebral oedema&#59; secondly&#44; surgery provides tissue to be sent for histopathological study in case the primary tumour is unknown&#59; and thirdly&#44; complete surgical resection provides local cure&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">27&#44;28</span></a> Occasionally the risks of surgery exceed the benefits&#44; such as&#58; secondary neurological deficit due to lesion in an eloquent area&#44; meningitis&#44; brain abscess&#44; intracranial haemorrhage or even death&#46; Nevertheless&#44; thanks to modern techniques and sophisticated technology&#44; surgical mortality for brain metastases has dramatically decreased since the initial reports of craniotomies&#44; and is now below 3&#37;&#46; The risk of haemorrhage or neurological deterioration associated with surgery is less than 5&#37;&#44; while the risk of meningitis and brain abscess is less than 1&#37;&#46; Non-surgery-related complications&#44; such as infection&#44; deep vein thrombosis&#44; pulmonary embolism and pneumonia&#44; occur in 8&#8211;10&#37; of patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">28&#8211;30</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Treatment protocols have been defined for single and multiple brain metastases&#44; from which the following can be concluded&#58; Patients with systemic disease and single brain metastasis should be treated with surgical resection plus whole brain radiotherapy&#46; This has led to an increase in survival&#44; fewer recurrences and greater quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">33</span></a> Patients with three lesions or fewer&#44; with good systemic control&#44; should also be treated with surgery and whole brain radiotherapy&#44; as the outcome is the same as for patients treated for single metastasis&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">32</span></a> Despite advances in surgery and the safety of the anaesthesia technique&#44; patients with more than three lesions have a particularly poor prognosis and are not good candidates for surgery&#46; Data obtained from several retrospective studies show that for patients with controlled systemic disease and more than three surgically accessible lesions&#44; surgical intervention should be discussed with a good neuro-oncology team&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">33</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The management of recurring metastases should be as per the most recent references similar to the newly diagnosed brain metastasis&#44; as it is considered to have the same outcome&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">34</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Radiotherapy</span><p id="par0095" class="elsevierStylePara elsevierViewall">The optimal dose for managing patients with brain metastasis includes 10 sessions of 3<span class="elsevierStyleHsp" style=""></span>Gy &#40;30<span class="elsevierStyleHsp" style=""></span>Gy&#41; split over two weeks or 15 sessions of 2&#46;5<span class="elsevierStyleHsp" style=""></span>Gy &#40;37&#46;5<span class="elsevierStyleHsp" style=""></span>Gy&#41; split over three weeks&#46; These variations in dose and time have not demonstrated superior results&#59; in fact&#44; dose and time increases have been shown to cause more adverse effects&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Complications caused by radiotherapy are classified as acute &#40;under 90 days&#41; and chronic &#40;more than 90 days&#41;&#46; Acute complications include hair loss&#44; dermatitis&#44; otitis externa&#44; hearing loss&#44; nausea&#44; vomiting and drowsiness&#46; Chronic complications include tissue necrosis&#44; personality changes&#44; memory loss&#44; cerebellar disorders&#44; cataracts and deterioration in cognitive function&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">35</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Radiosurgery</span><p id="par0105" class="elsevierStylePara elsevierViewall">The main candidates for this treatment are those patients who do not meet the criteria for surgical treatment&#44; those with lesions under 3<span class="elsevierStyleHsp" style=""></span>cm or lesions located in eloquent areas&#44; and those with residual lesion after resection&#46; The treatment parameters imply that the maximum tolerated dose depends on the diameter of the lesion&#58; 15<span class="elsevierStyleHsp" style=""></span>Gy for tumours under 20<span class="elsevierStyleHsp" style=""></span>mm and 20<span class="elsevierStyleHsp" style=""></span>Gy for tumours 31&#8211;40<span class="elsevierStyleHsp" style=""></span>mm&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">36&#44;37</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Chemotherapy</span><p id="par0110" class="elsevierStylePara elsevierViewall">The role of chemotherapy in the treatment of patients with brain metastasis is not clearly defined&#46; Currently&#44; chemotherapy is used very little in the management of patients not included in research protocols&#44; with the exception of very chemo-sensitive tumours&#44; such as small cell lung carcinoma&#44; germ cell tumours and lymphoid neoplasms&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">38</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Prognosis</span><p id="par0115" class="elsevierStylePara elsevierViewall">The prognosis of brain metastasis patients in the last two decades with the use of combined therapies shows an increase in survival compared to patients who only received radiotherapy or surgery&#46; The final result of the studies conducted shows that surgery plus radiotherapy presents an increase in survival of 7&#8211;9 months&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">25&#44;29&#44;39</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Dural metastases</span><p id="par0120" class="elsevierStylePara elsevierViewall">These usually affect patients at advanced disease stages and the mechanisms of dissemination are direct extension or haematogenous spread&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The incidence of dural metastases has increased in recent decades as a result of developments in new neuroimaging techniques and an increase in the survival of cancer patients due to improved therapies&#46; Most patients are asymptomatic&#59; however&#44; they may debut with progressive neurological deficit&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">33&#44;34</span></a> The most recent study in the literature review was published by Laigle-Donadey&#44; covering 198 cases from 1994 to 2003&#46; The patient age range was from 4 months to 84 years &#40;mean of 59 years&#41; and the most common dural metastases reported &#40;in order of frequency&#41; were prostate&#44; breast&#44; lung and stomach cancer&#44; making up 54&#46;5&#37; &#40;108 patients&#41;&#46; The exact incidence of dural metastases is difficult to ascertain<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">39</span></a> &#40;see <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Clinical manifestations</span><p id="par0130" class="elsevierStylePara elsevierViewall">The symptoms presented are usually related to brain compression or invasion&#44; production of subdural haematomas or fluid collection&#44; and less frequently due to occlusion of branches to the dural sinuses&#46; Approximately 20&#37; of patients are asymptomatic&#44; and the lesions are identified in a follow-up study or in necropsy<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">38</span></a> &#40;see <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">Non-traumatic subdural haematomas resulting from neoplastic invasion of the meninges are a classic complication&#44; with an incidence observed in 15&#8211;40&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">37&#44;38</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Diagnosis</span><p id="par0140" class="elsevierStylePara elsevierViewall">The exam of choice is contrast-enhanced MRI of the brain &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; The classic image of dural metastasis is a mass with homogeneous enhancement on T2-weighted images&#44; originating in the dura mater&#46; When the dural tail sign appears&#44; a differential diagnosis should be made for meningioma&#44; particularly in patients with prostate cancer&#44; which also causes a hyperostotic effect&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">36</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Treatment</span><p id="par0145" class="elsevierStylePara elsevierViewall">Surgical resection is normally performed when there is a single&#44; well defined lesion that is surgically accessible&#44; with adequate control of extracranial disease&#46; Surgical resection is recommended in patients with progressive systemic disease but good quality of life and symptoms caused by intracranial hypertension&#46; Immediate evacuation can save the life of patients with subdural haematoma&#46; Histopathological study can establish a diagnosis&#44; especially in patients with known systemic primary disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">37&#44;38</span></a> High doses of corticosteroids &#40;dexamethasone&#41; can cause temporary symptom relief&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">38</span></a> Whole brain radiotherapy can be used as palliative therapy if the dural lesions are associated with parenchymal metastases&#44; while radiosurgery is reserved for isolated lesions less than 3<span class="elsevierStyleHsp" style=""></span>cm in diameter&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">36&#44;38</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Prognosis</span><p id="par0150" class="elsevierStylePara elsevierViewall">The prognosis of dural metastases can be extrapolated from the prognosis of brain metastases under 1 year of survival&#46; Most patients die due to systemic disease complications before they die from neurological complications&#46; Prognosis is most favourable for haematological neoplasms&#44; breast and lung cancer&#44; with a survival of 365&#44; 273 and 120 days respectively&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">37&#44;38</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusions</span><p id="par0155" class="elsevierStylePara elsevierViewall">Although brain metastasis is not an uncommon condition worldwide&#44; in Mexico there are no multidisciplinary programmes established to provide continuity for patients in whom the primary tumour has been identified&#44; even though up to 40&#37; of patients with systemic cancer have brain metastases&#46; It should be noted that even after a thorough study&#44; the primary tumour cannot be identified in 15&#37; of brain metastasis patients&#46; The most common types of neoplasm that present brain metastasis are lung cancer&#44; breast cancer&#44; melanoma&#44; colorectal cancer and renal cancer&#46; More reliable statistics must be established in Mexico in order to combat brain metastasis&#46; Given the new therapy techniques &#40;surgery&#44; chemotherapy and radiotherapy&#41; and increased survival&#44; in patients in whom the primary tumour has been identified there is a possibility that the risk of brain metastasis may increase&#44; and therefore continual review protocols must be diligently applied in these patients&#46; This will help in the diagnosis and suitable management of these patients&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interest</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interests&#46;</p></span></span>"
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          "titulo" => "Stereotactic biopsy for the diagnosis of metastatic brain tumours"
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          "titulo" => "RPA &#40;recursive partitioning analysis&#41; classification"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Brain metastases frequently occur secondary to poorly controlled primary lung&#44; breast&#44; melanoma&#44; colorectal and renal tumours&#46; Because of this&#44; correct diagnosis and early treatment of brain metastasis is difficult&#44; which is why the condition should be treated and controlled by a multidisciplinary medical team so as to obtain real-life and reliable statistics and to lower the incidence of brain metastasis&#44; improving the quality of life of patients and reducing mortality rates&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La enfermedad metast&#225;sica cerebral &#40;EMC&#41; es una patolog&#237;a&#44; frecuente sobre todo en tumores primarios de pulm&#243;n&#44; mama&#44; melanoma&#44; colorrectal y renal descontrolados&#46; El diagn&#243;stico oportuno y tratamiento temprano&#44; es la falla sobre la EMC&#44; debido a la misma causa&#46; Por lo que deber&#237;a ser manejado con un equipo m&#233;dico multidisciplinario&#44; para poder controlar&#44; obtener estad&#237;sticas reales&#44; y fidedignas&#44; y as&#237; bajar la frecuencia de EMC&#44; mejorando la calidad de vida de los pacientes&#44; y reduciendo las estad&#237;sticas de mortalidad&#46;</p></span>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Axial cut of non-contrast CT brain scan showing an isodense image to the left frontal brain parenchyma marked with an arrow&#44; as well as perilesional oedema corresponding to the hypodense image&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Axial cut of contrast MRI of the brain&#46; On the left&#44; T2-weighted image showing hyperintense left frontal region marked with arrows&#46; On the right&#44; T1-weighted image showing perilesional hypointensity and central hyperintensity of the left frontal region marked with arrows&#46;</p>"
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          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Refs&#46; <a class="elsevierStyleCrossRefs" href="#bib0245">10&#44; 11</a>&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Primary tumour&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37; Metastasis &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37; Metastasis &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lungs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#44;763&#47;59&#44;038 &#40;19&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">156&#47;938 &#40;16&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Breasts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2635&#47;51&#44;898 &#40;5&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42&#47;802 &#40;5&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kidneys&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">467&#47;7205 &#40;6&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#47;114 &#40;9&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Melanoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">566&#47;8229 &#40;6&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#47;150 &#40;7&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Colorectal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">779&#47;42&#44;817 &#40;1&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#47;720 &#40;1&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Clinical presentation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Focal deficit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">78 &#40;64&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">108 &#40;51&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">186 &#40;56&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37 &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">59 &#40;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intracranial hypertension&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Headache&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Asymptomatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29 &#40;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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Article information

ISSN: 01851063
Original language: English

DOI:10.1016/j.hgmx.2016.04.006

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Year/Month	Html	Pdf	Total

2024 October	125	16	141
2024 September	231	44	275
2024 August	270	40	310
2024 July	262	57	319
2024 June	213	47	260
2024 May	215	47	262
2024 April	232	36	268
2024 March	242	38	280
2024 February	258	66	324
2024 January	365	68	433
2023 December	250	59	309
2023 November	386	78	464
2023 October	385	89	474
2023 September	288	71	359
2023 August	221	47	268
2023 July	182	43	225
2023 June	199	47	246
2023 May	194	38	232
2023 April	216	51	267
2023 March	262	48	310
2023 February	210	26	236
2023 January	135	7	142
2022 December	111	12	123
2022 November	130	23	153
2022 October	150	32	182
2022 September	154	27	181
2022 August	166	49	215
2022 July	177	38	215
2022 June	135	31	166
2022 May	151	29	180
2022 April	180	36	216
2022 March	185	25	210
2022 February	240	36	276
2022 January	277	52	329
2021 December	179	27	206
2021 November	156	25	181
2021 October	141	40	181
2021 September	138	30	168
2021 August	141	22	163
2021 July	91	20	111
2021 June	161	29	190
2021 May	176	17	193
2021 April	386	79	465
2021 March	268	51	319
2021 February	137	34	171
2021 January	160	47	207
2020 December	143	32	175
2020 November	126	23	149
2020 October	78	15	93
2020 September	97	23	120
2020 August	99	24	123
2020 July	79	21	100
2020 June	89	13	102
2020 May	85	21	106
2020 April	72	27	99
2020 March	78	11	89
2020 February	105	20	125
2020 January	97	16	113
2019 December	84	19	103
2019 November	54	7	61
2019 October	54	12	66
2019 September	42	9	51
2019 August	30	3	33
2019 July	34	17	51
2019 June	81	2	83
2019 May	111	5	116
2019 April	77	1	78
2019 March	15	8	23
2019 February	21	3	24
2019 January	23	6	29
2018 December	22	7	29
2018 November	29	7	36
2018 October	42	7	49
2018 September	83	8	91
2018 August	62	10	72
2018 July	37	7	44
2018 June	30	12	42
2018 May	67	18	85
2018 April	40	9	49
2018 March	27	2	29
2018 February	28	2	30
2018 January	16	1	17
2017 December	18	2	20
2017 November	24	2	26
2017 October	21	4	25
2017 September	22	4	26
2017 August	27	3	30
2017 July	28	2	30
2017 June	40	19	59
2017 May	53	1	54
2017 April	54	6	60
2017 March	66	40	106
2017 February	62	11	73
2017 January	4	3	7
2016 December	0	6	6
2016 November	0	5	5
2016 October	5	10	15
2016 September	0	6	6
2016 August	2	4	6
2016 July	1	2	3

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