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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
Key points
- Brain metastases are the most common intracranial tumours overall (lung, breast, melanoma, renal, colon primary sites)
- Most common malignant primary tumour: glioblastoma (GBM, WHO grade 4). Most common benign: meningioma
- Red flag symptoms: progressive headache (worse in morning/with coughing), new focal neurology, new-onset seizures in adults, personality change, papilloedema
- MRI brain with gadolinium is the investigation of choice
- Dexamethasone reduces peritumoral oedema acutely; definitive management = surgery ± radiotherapy ± chemotherapy (temozolomide for GBM)
Overview
Brain tumours are classified as primary (arising from brain tissue) or secondary (metastatic). Brain metastases are the most common overall, typically from lung, breast, melanoma, renal, and colorectal primaries. Primary brain tumours are classified by the WHO CNS tumour classification (2021) incorporating histological and molecular features. Glioblastoma (GBM, WHO grade 4) is the most common malignant primary tumour with a median survival of ~15 months. Meningiomas are the most common benign primary tumour. Other types include astrocytomas, oligodendrogliomas, ependymomas, medulloblastomas (posterior fossa, children), and CNS lymphoma.
Epidemiology
Approximately 12,000 people are diagnosed with primary brain tumours annually in the UK. Incidence increases with age. GBM peak incidence is 65–75 years. Medulloblastoma and pilocytic astrocytoma are the most common childhood brain tumours (posterior fossa). Risk factors for primary brain tumours include ionising radiation (therapeutic cranial radiation) and rare genetic syndromes (neurofibromatosis, tuberous sclerosis, Li-Fraumeni, von Hippel-Lindau). There is no proven link to mobile phone use.
Clinical Features
Symptoms
Progressive headache: worse in morning, aggravated by coughing/straining/bending (raised ICP)
New-onset seizures in an adult (especially focal seizures) — most common presenting symptom of low-grade glioma
Progressive focal neurological deficit: hemiparesis, dysphasia, visual field defect (depending on location)
Personality and behavioural change (frontal lobe tumour)
Nausea and vomiting (raised ICP, or posterior fossa tumour)
Cognitive decline
Visual disturbance: bitemporal hemianopia (pituitary tumour compressing optic chiasm)
Signs
Papilloedema (raised ICP)
Focal neurological deficit corresponding to tumour location
Cushing response: hypertension + bradycardia + irregular breathing (impending herniation)
Cranial nerve palsies (especially III, VI)
Cerebellar signs: ataxia, nystagmus, dysarthria (posterior fossa tumours)
Investigations
First-line
MRI brain with gadolinium contrastInvestigation of choice. GBM: ring-enhancing lesion with central necrosis and surrounding oedema. Meningioma: dural-based, homogeneously enhancing. Metastases: multiple ring-enhancing lesions at grey-white matter junction
CT headFaster and more available for emergency presentation (raised ICP, herniation). Shows mass effect, midline shift, hydrocephalus
Second-line
CT chest/abdomen/pelvisIf metastatic disease suspected — search for primary tumour
Biopsy/surgical specimenHistological and molecular diagnosis — WHO classification includes IDH mutation status, 1p/19q codeletion, MGMT methylation (predicts temozolomide response in GBM)
Specialist
MR spectroscopyDifferentiates tumour from other diagnoses (e.g. abscess, demyelination). Choline:NAA ratio
PET scanDifferentiates recurrence from radiation necrosis
1
Acute management of raised ICP
- Dexamethasone 8–16 mg/day — reduces peritumoral vasogenic oedema. Start PPI for gastric protection
- Elevate head of bed 30 degrees
- Urgent neurosurgical referral if acute hydrocephalus (may need EVD)
- Anti-seizure medication if seizures occur (levetiracetam preferred). Prophylactic AEDs NOT recommended routinely
2
Definitive treatment (MDT decision)
- GBM: maximal safe surgical resection → radiotherapy (60 Gy in 30 fractions) + concurrent temozolomide (Stupp protocol). Median survival ~15 months
- Meningioma: surgical resection if symptomatic or growing. Observation if asymptomatic
- Brain metastases: single/few = stereotactic radiosurgery or surgical excision. Multiple = whole brain radiotherapy. Treat primary cancer
- Low-grade glioma: observation, surgery, or radiotherapy depending on molecular markers and symptoms
3
Supportive and palliative care
- MDT: neuro-oncologist, neurosurgeon, clinical oncologist, specialist nurse, physiotherapy, OT, psychology, palliative care
- Driving: must inform DVLA. Group 1: individual assessment depending on tumour type. Group 2 usually revoked
- Advance care planning — discuss preferences early
Complications
- Raised ICP and herniation: Life-threatening — uncal herniation causes third nerve palsy and contralateral hemiplegia, then death
- Seizures: Common — especially with cortical tumours. May be the presenting symptom
- Treatment-related: Surgical complications (haemorrhage, infection, neurological deficit), radiation necrosis, chemotherapy toxicity
- Cognitive decline: From tumour itself, surgery, and/or radiation
- Venous thromboembolism: Brain tumours are highly prothrombotic — anticoagulation may be needed
UKMLA Exam Tips
- 1New-onset seizure in an adult = brain tumour until proven otherwise — urgent MRI
- 2Progressive headache + papilloedema + focal neurology = raised ICP from mass lesion
- 3GBM on MRI: ring-enhancing lesion with central necrosis. Metastases: multiple lesions at grey-white junction
- 4Meningioma: dural-based, homogeneously enhancing, extra-axial. Most common benign primary tumour
- 5Dexamethasone reduces oedema acutely — does NOT treat the tumour
- 6Bitemporal hemianopia = pituitary tumour compressing optic chiasm
- 7Medulloblastoma: posterior fossa tumour in children — presents with cerebellar signs and hydrocephalus
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