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Principles of Supportive treatment : Supportive treatment has a significant role in brain tumour. Agents used in supportive management of brain tumour - § Corticosteroids –- Dexamethasone- Solumedrol§ Anticonvulsants –- Phenetoin- Valproic acid- Phenobarbitone- Carbapamazipine§ Anti-coagulants / IVC filterDescription of agents - Corticosteroid : Acts by : 1) Anti-oedema effect – by reducing capillary permeability. 2) Tumorcidal effect – by increasing apoptosis. Dexamethasone used with minimal dosage (4-8 mg/d).Max. dose = 100mg /day Dexamethasone is used in brain tumor for following reasons - 1. Crosses Blood Brain Barrier 2. Little mineralo-corticoid activity 3. Lower probability of infection 4. Lower cognitive dysfunction § Symptoms improve by 24-72 hr.§ Headache responds better than focal-deficit.§ But, imaging need >7 day for to show responseSide-effects – 1. Fluid retention , wt gain 2. Myopathy, gastritis , hyperglycemia 3. Infection (pneumocystis carinii ) Co-trimoxazole prophylaxis used to prevent infection Indications : 1. Symptomatic brain metastasis 2. During Radiotherapy, if volume of treatment is large. 3. Post surgery – usually < 4 week. 4. Sign of increased intracranial tension. Always used in minimal dose and least duration to prevent complication. Anticonvulsant : § Seizure is the presenting symptom in 10-20% and occurs during disease progression in another 15-20%. Thus, 25-50% patient have episodes of convulsion. Rest 45% patient never has convulsive episodes.§ If presents with seizure; treated with anticonvulsant (phenytoin). EEG may be done for confirmation.§ Role of anticonvulsant as prophylactic is doubtful.§ Brain tumour pts do have problem with anticonvulsants. Anticonvulsant should be used routinely or not is a matter of debate.Those who prefer anti-convulsant at the earliest, arguments are – 1. Epileptogenic foci always present. 2. May precipitate convulsion any time. And those who are against routine use of anti-convulsant, arguments are – 1. 50-55% never have convulsion. 2. Treatment of cause necessary to prevent convulsion. 3. Interfere with Chemotherapy / steroid. 4. More complications. Use of routine anticonvulsant in brain tumor are not without problem : 1. More drug rash (20%) – morbilliform rash, steven-johnson reaction, shoulder hand syndrome. 2. Induces hepatic metabolism of steroid. 3. Reduces blood concentration of chemotheraputic agents. 4. Chemotheraputic agents may reduce phenytoin level & precipitate break-through siezure. Indications of anticonvulsant: 1. Patient with seizure episodes or high risk for seizure episodes. 2. No definite role of prophylactic anti-convulsants. Except in few situations, like – § Lesion in highly epileptogenic area ( motor cortex)§ Both brain parenchymal & leptomeningeal disease.§ Multiple brain metastasis.§ No proper follow up and no immediate treatment facility in case of convulsive episodes.
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Brain Tumour Foundation Of India Tata Memorial Hospital,
Ernest Borges Marg, Parel, Mumbai - 400 012, INDIA
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