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common initial manifestation The localizing signi cance of seizure patterns has been discussed on pages 275 to 278 Seizures due to brain tumor most often have a focal onset, ie, are partial and then become generalized There may be one seizure or many, and they may follow the other symptoms or precede them by weeks or months or exceptionally, in patients with low-grade astrocytoma, oligodendroglioma, or meningioma by several years Status epilepticus as an early event is rare but has occurred in a few of our patients As a rule the seizures respond to standard anticonvulsant medications and may improve after surgery for tumor removal Regional or Localizing Symptoms and Signs Sooner or later, in patients with psychomotor asthenia, headaches, and seizures, focal cerebral signs will be discovered; some patients may present with such signs Nearly always, however, the focal signs are at rst slight and subtle Frequently, CT scanning or MRI will have disclosed the presence of a tumor before either focal cerebral signs or the signs of increased intracranial pressure have become evident The cerebral tumors that are most likely to produce the syndromes described above are glioblastoma multiforme, astrocytoma, oligodendroglioma, ependymoma, metastatic carcinoma, meningioma, and primary lymphoma of the brain The clinical aspects of these diseases, which happen to be the most common brain tumors in adults, are discussed in the sections below Glioblastoma Multiforme and Anaplastic Astrocytoma (HighGrade Gliomas) These tumors, which constitute the high-grade gliomas, account for about 20 percent of all intracranial tumors, or about 55 percent of all tumors of the glioma group, and for more than 80 percent of gliomas of the cerebral hemispheres in adults Although predominantly cerebral in location, they may also arise in the brainstem, cerebellum, or spinal cord The peak incidence is in middle adult life (mean age for the occurrence of glioblastoma is 56 to 60 years and 46 years for anaplastic astrocytoma), but no age group is exempt The incidence is higher in men (ratio of approximately 16:1) Almost all of the high-grade gliomas occur sporadically, without a familial predilection The glioblastoma, known since the time of Virchow, was de nitively recognized as a glioma by Bailey and Cushing and given a place in their histogenetic classi cation Most arise in the deep white matter and quickly in ltrate the brain extensively, sometimes attaining enormous size before attracting medical attention The tumor may extend to the meningeal surface or the ventricular wall, which probably accounts for the increase in CSF protein (more than 100 mg/dL in many cases) as well as for an occasional pleocytosis of 10 to 100 cells or more, mostly lymphocytes The CSF may be normal, however Malignant cells, carried in the CSF, may form distant foci on spinal roots or cause a widespread meningeal gliomatosis Extraneural metastases, involving bone and lymph nodes, are very rare; usually they occur only after a craniotomy has been performed About 50 percent of glioblastomas occupy more than one lobe of a hemisphere or are bilateral; between 3 and 6 percent show multicentric foci of growth and thereby simulate metastatic cancer The tumor has a variegated appearance, being a mottled gray, red, orange, or brown, depending on the degree of necrosis and presence of hemorrhage, recent or old The imaging appearance is usually that of a nonhomogeneous mass, often with a center that is hypointense in comparison to adjacent brain and demonstrating an irregular thick or thin ring of enhancement, surrounded by edema.

Figure 31-2 Glioblastoma multiforme T2- (left) and enhanced T1-weighted (right) MRI illustrate a large tumor deep within the left cerebral hemisphere and extending through the corpus callosum to the right hemisphere The black rim around a portion of the tumor (left) represents hemorrhage The patient was a 59-year-old male who presented with seizures

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Part of one lateral ventricle is often distorted, and both lateral and third ventricles may be displaced contralaterally (Fig 31-2) The characteristic histologic ndings of glioblastoma are great cellularity with pleomorphism of cells and nuclear atypia; identi able astrocytes with brils in combination with primitive forms in many cases; tumor giant cells and cells in mitosis; hyperplasia of endothelial cells of small vessels; and necrosis, hemorrhage, and thrombosis of vessels This variegated appearance distinguishes glioblastoma from the anaplastic astrocytomas, which show frequent mitoses and atypical cytogenic features but no grossly necrotic or hemorrhagic areas It is the necrotic and sometimes cystic areas that appear hypointense on imaging studies The vasculature and broblasts undergo a sarcomatous transformation with prominent reticulin and collagen in surrounding tissue The vascular and connective tissue changes suggest the elaboration of a growth factor by the tumor tissue Originally, the glioblastoma was thought to be derived from and composed of primitive embryonal cells, but it is now generally thought to arise through anaplasia of maturing astrocytes It should be emphasized that the histologic grade may vary from site to site within a tumor and it is common for sites of anaplastic astrocytoma and glioblastoma to coexist; in some tumors there are even sites of well-differentiated astrocytoma It is a fair statement that the most aggressive component (eg, glioblastic elements) determines the tumor s behavior To some extent, this behavior is related to some of the aforementioned genetic changes Ampli cation of the epidermal growth factor receptor gene (EGFR) is characteristic of older patients with tumors that begin entirely as glioblastomas, while mutations on the TP53 gene tend to occur in younger individuals whose tumors progress from an astrocytoma to a glioblastoma

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TIP One exception to this availability advantage occurs if a partition has a global index The global index will be unusable and will have to be recovered if even one partition becomes unavailable The ability of partitions to act as separate units means that you can use partitions to reduce storage costs through an ILM approach, moving less frequently accessed partitions to lower-cost storage platforms Partitions come with their own set of maintenance operations, including the ability to drop and add partitions to a table without taking the table offline, as well as the ability to merge partitions together or split a single partition into two

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