Astrocytomas (see the image below) are CNS neoplasms in which the predominant cell type is derived from an

immortalized astrocyte.[1] Survival correlates most highly with the intrinsic properties of the astrocytoma and
typically ranges from approximately 10 years from the time of diagnosis for patients with pilocytic astrocytomas
to less than 1 year for patients with glioblastoma.

Axial T2-weighted MRI shows a low-grade astrocytoma of the

inferior frontal lobe with mild mass effect and no surrounding edema.

Signs and symptoms

Neurologic symptoms from astrocytoma development depend foremost on the site and extent of tumor growth
in the CNS but may include any of the following:

Altered mental status

Cognitive impairment
Headaches
Nausea and vomiting
Visual disturbances
Motor impairment
Seizures
Sensory anomalies
Ataxia
Astrocytomas of the spinal cord or brainstem are less common and present as motor/sensory or cranial nerve
deficits referable to the tumor's location.
On physical examination, patients may demonstrate signs of increased ICP or localizing and lateralizing signs
such as the following:

Cranial nerve palsies

Hemiparesis
Sensory levels
Alteration of deep tendon reflexes (DTRs)
Pathologic reflexes (eg, Hoffman sign, Babinski sign)
See Clinical Presentation for more detail.

Diagnosis
No laboratory studies are diagnostic of astrocytoma, but the following baseline laboratory studies may be
obtained for general metabolic surveillance and preoperative assessment:

Basic metabolic profile

CBC
Prothrombin time (PT)
Activated partial thromboplastin time (aPTT)
MRI

MRI is considered the criterion standard imaging study

Astrocytomas are generally isointense on T1-weighted images and hyperintense on T2-weighted
images

While low-grade astrocytomas uncommonly enhance on MRI, most anaplastic astrocytomas enhance
with paramagnetic contrast agents

The possibility of metastatic disease must be considered in cases in which a cortically based
enhancing mass is discovered, particularly if multiple lesions are identified

High-resolution MRI is now often used to provide intraoperative image guidance

CT scanning

A CT scan may be useful in the acute setting or when MRI is contraindicated

On CT, low-grade astrocytomas appear as poorly defined, homogeneous, low-density masses without
contrast enhancement; however, slight enhancement, calcification, and cystic changes may be evident early
in the course of the disease

Systemic imaging, generally consisting of a contrast-enhanced CT scan of the chest, abdomen, and
pelvis, may be warranted to evaluate for the possibility of an alternate primary lesion

Anaplastic astrocytomas may appear as low-density lesions or inhomogeneous lesions, with areas of
both high and low density within the same lesion; unlike low-grade lesions, partial contrast enhancement is
common
Angiography

May be used to rule out vascular malformations and to evaluate tumor blood supply
A normal angiographic pattern or a pattern consistent with an avascular mass that displaces normal
vessels is usually observed with both low-grade and high-grade lesions

In rare instances, a tumor blush may be observed with high-grade lesions

Radionuclide scans

PET, SPECT, or technetium-based imaging can permit study of tumor metabolism and brain function
PET and SPECT may be used to distinguish a solid tumor from edema, to differentiate tumor
recurrence from radiation necrosis, and to localize structures

Metabolic activity of a lesion can be used to determine tumor grade; hypermetabolic lesions often
correspond to higher-grade tumors
Other studies

EEG may be used to evaluate and monitor epileptiform activity

ECG and chest radiographs are indicated to evaluate operative risk
CSF studies may be used to rule out other diagnoses (eg, metastasis, lymphoma, medulloblastoma)
See Workup for more detail.

Management
There is no accepted standard of treatment for low-grade or anaplastic astrocytoma. Treatment decisions are
generally best made through a team approach, including input from the involved neurosurgeon, radiation
oncologist, and medical oncologist or neurologist.
Typically, anaplastic astrocytomas are treated with the following:

Surgery
Radiotherapy
Adjuvant temozolomide
Some practitioners add concomitant temozolomide [2, 3]
Some smaller survival benefit has been shown with adjuvant carmustine [4]
Treatment of low-grade astrocytomas remains more controversial. The role of maximal surgical resection,
timing of radiotherapy, and the role, timing, and appropriate agents of chemotherapy are not clear.
Surgical care

Stereotactic biopsy is a safe and simple method for establishing a tissue diagnosis
Tumor resection can be performed safely and is generally undertaken with the intent to cause the least
possible neurologic injury to the patient

Surgical resection provides improved survival advantage and histologic diagnosis of the tumor rather
than offering a cure

Total resection of an astrocytoma is often impossible because the tumors often invade eloquent
regions of the brain and exhibit tumor infiltration that is only detectable on a microscopic scale

Diversion of CSF by external ventricular drain (EVD) or ventriculoperitoneal shunt (VPS) may be
required to decrease ICP
Symptomatic therapy

Patients with an astrocytoma and a history of seizures should receive anticonvulsant therapy, with
monitoring of the serum drug concentration; levetiracetam (Keppra) is often used

Prophylactic use of anticonvulsants in astrocytoma patients with no prior history of seizures has been
reported but remains controversial

The use of corticosteroids, such as dexamethasone, yields rapid improvement in most patients
secondary to a reduction of tumor mass effect; patients receiving corticosteroids should have concurrent
prophylaxis for gastrointestinal ulcers
Brainstem gliomas
Treatment and prognosis for brainstem gliomas typically depends on whether the tumor is diffuse or focal.
Treatment of diffuse brainstem gliomas is as follows:

No benefit of surgical resection has been shown

Corticosteroids may provide temporary benefit by reduction of edema
Irradiation and chemotherapy are sometimes used, but neither has been shown to cure or prolong
survival, and radiation necrosis and chemotherapy side effects can be significant
Treatment of focal brainstem gliomas is as follows:
Surgery is often the primary treatment, although the decision to operate, the surgical approach, and
the extent of resection depend on location, patient factors, and the surgeon's judgment
Obstructive hydrocephalus is common and usually treated by a separate procedure, either endoscopic
third ventriculostomy or shunt placement [5]