Brain Metastases

Brain metastases occur in 20–40% of patients with systemic cancer — commonest primaries are lung, breast, melanoma, renal, and colorectal. Presentation includes morning headache (worse lying flat), focal neurology, and seizures. Dexamethasone 8mg BD…

NICE NG99 / ESMO Brain Metastases Guideline

The pathway

1 · Assess and stabilise

GCS, focal neurology, papilloedema (suggests raised ICP)
ABCDE approach if GCS reduced
SpO₂ target ≥94%, high-flow O₂
Seizure: lorazepam 4mg IV — see status epilepticus pathway

2 · Emergency management of raised ICP

Dexamethasone 16mg IV stat (emergency dose for herniation)
Mannitol 20%: 1g/kg IV over 20 minutes for acute herniation
Head of bed at 30°
Hyperventilate if intubated: target PaCO₂ 4.0–4.5 kPa
Contact neurosurgery immediately

3 · Imaging

CT head with contrast acutely if raised ICP suspected (before MRI if unstable)
MRI brain with gadolinium: gold standard for number, size, location, leptomeningeal disease
CT chest/abdomen/pelvis if primary unknown
PET-CT if oligometastatic disease and curative intent being considered

4 · Seizure prophylaxis and management

Do NOT give prophylactic anticonvulsants in seizure-naive patients (NICE NG99)
First seizure with brain metastasis: levetiracetam 500mg BD PO or IV (preferred over phenytoin — fewer drug interactions)
Titrate levetiracetam to 1000–3000mg/day based on response
DVLA notification: patient must not drive — document advice

5 · Dexamethasone for symptomatic oedema

Dexamethasone 8mg BD for symptomatic peritumoral oedema (headache, focal deficit)
Do NOT treat asymptomatic patients — no survival benefit, significant side effects (Cushingoid, myopathy, glucose dysregulation)
Taper over weeks once definitive treatment started
Add omeprazole 20mg OD and monitor blood glucose

6 · Prognosis: GPA score

Graded Prognostic Assessment (GPA): based on age, KPS, number of metastases, extracranial metastases, histology-specific factors
Guides treatment intensity — discuss at neuro-oncology MDT
Median survival: 3 months (poor GPA) to >20 months (good GPA, favourable histology e.g. HER2+ breast)

7 · Definitive treatment options

Single/oligometastatic (1–3): stereotactic radiosurgery (SRS) preferred — local control without neurocognitive side effects
Single accessible lesion with mass effect or diagnostic uncertainty: surgical resection + post-op SRS
Multiple metastases (>3): whole brain radiotherapy (WBRT) or best supportive care based on performance status
Leptomeningeal disease: intrathecal chemotherapy (methotrexate) ± craniospinal radiation — very poor prognosis
Chemo-sensitive histology (SCLC, germ cell, lymphoma): systemic chemotherapy may control CNS disease

Drugs

Drug	Dose	Route	Notes
Dexamethasone	8mg BD (16mg IV stat in emergency)	PO or IV	8mg BD for symptomatic oedema. 16mg IV stat for acute raised ICP or herniation. Taper over weeks. Monitor blood glucose.
Mannitol 20%	1g/kg IV over 20 minutes	IV	Acute cerebral herniation. Ensure Foley catheter in situ. Monitor serum osmolarity (target <320 mOsm/kg).
Levetiracetam	500mg BD	PO or IV	Preferred anticonvulsant for brain metastasis-associated seizures. Titrate to 1000–3000mg/day. Fewer drug interactions than phenytoin.
Omeprazole	20mg OD	PO	Gastric protection with dexamethasone. Check for interactions with systemic anticancer therapy.
Lorazepam	4mg IV	IV	Acute seizure management. See status epilepticus pathway for full protocol.

When to escalate

Falling GCS or papilloedema — raised ICP: dexamethasone 16mg IV stat + mannitol 1g/kg, neurosurgery emergency,Cushing's triad (hypertension, bradycardia, irregular respiration) — impending tonsillar herniation, emergency neurosurgery,Status epilepticus — full lorazepam protocol, ITU, neurology input,Leptomeningeal disease suspected (cranial nerve palsies, cauda equina, multilevel spinal cord signs) — MRI spine, neuro-oncology MDT,Single large accessible metastasis with significant mass effect — emergency neurosurgical resection discussion,New neurological presentation in patient on immune checkpoint inhibitor — consider immune-mediated encephalitis; neurology and oncology review

Reference: NICE NG99 Brain Tumours (Primary and Metastatic) 2018 / ESMO Brain Metastases Clinical Practice Guidelines 2021

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