This article explores brain tumours presenting diagnostic challenges due to their vague symptoms and rarity, often leading to medicolegal claims regarding delayed diagnosis.

Despite medical advancements, misdiagnosis or missed early signs complicate treatment, raising “What If” questions in legal cases about patient outcomes.

Brain Tumours are devastating for patients and their families alike and are laden with emotional associations of a fatal illness preceded by rapid physical, intellectual and emotional decline. While this is true for the most common primary brain tumour, glioblastoma (GBM), known as “The Terminator” in the USA, many brain tumours are benign, curable and even if not curable associated with a long survival with little impairment of quality of life.

Having said that, even the most benign tumour can cause neurological mayhem particularly if it’s deeply embedded in the skull base compressing various vital structures.

Treatments for brain tumours have advanced in the last few decades particularly in the field of focussed radiotherapy and safer neurosurgery and patients are being diagnosed earlier with increased access to brain scans. But the complexity of brain tumour treatment means that sometimes things don’t always go to plan.

The most common medicolegal issues that I am asked to opine on involve delays in diagnosis and effect on outcome.

The difficulty in diagnosing brain tumours arises from the fact that many early symptoms, particularly headache, are commonly seen in the general and frequently attributed to other conditions particularly stress and anxiety.

This, together with the observation, that brain tumours are very rare compared to other neurological conditions, e.g. migraine, make it difficult to identify the ‘wheat from the chaff’.

As a neurologist with 25 years of experience in looking after patients with all types of brain tumours, from diagnosis to death, I have accumulated a considerable wealth of experience in what can go wrong.

These cases are invariably interesting from a number of perspectives, not least opining on the “What ifs” and the “But fors”.

The medicolegal expert has the benefit of hindsight as the diagnosis has eventually been made but must keep in mind that the clinicians at the time did not have a crystal ball and, in most cases, were acting in the best interests of their patients based on their knowledge and experience at the time.

When it comes to brain tumours, nothing screams “medicolegal nightmare” quite like delays in diagnosis.

The first issue is thinking of the diagnosis – a patient walks into a GP surgery with vague complaints of headaches, dizziness, and the occasional bout of forgetting where they parked the car.

It’s all too easy for a doctor to brush this off as stress, or perhaps a case of middle-age brain fog. But lurking beneath those vague symptoms could be a brain tumour.

I would like to give an insight into the types of cases that I have been asked to give opinions on. I have split them into four different areas:

“It’s Probably Just a Migraine” – The Diagnosis Dilemma.

The patient presents to the GP on a number of occasions with persistent severe headaches with nausea and vomiting and not investigated further.

Yes, it could be a brain tumour, but it’s much more likely to be a migraine.

Unfortunately for doctors, picking the very rare brain tumour out of the much more common migraine is a bit like trying to find a needle in a haystack while blindfolded.

And of course, who’s to say the two can’t coexist? Sometime later a brain tumour is diagnosed and the claim is based around the fact that the GP did not send the patient off for a scan earlier.

The case will revolve around the question that had the tumour been found earlier, the patient could have avoided unnecessary pain and suffering, or worse, neurological and cognitive deficits.

The doctor, of course, will argue that the symptoms weren’t specific enough to warrant a brain scan—because, in the real world, GPs can’t order an MRI every time someone has a headache, or the NHS would implode.

Yet, the legal world doesn’t always operate on common sense; it operates on ‘What Ifs’, ‘But fors’ and before-and-after comparisons of the patient’s cognitive abilities (or lack thereof).

Once that tumour is finally discovered, lawyers may argue that their client’s cognitive and physical decline could have been halted, or at least slowed down, had their GP acted sooner.

The legal argument often boils down to this simple (yet devastating) idea: had the doctor been more vigilant, the patient might still be the same charming, witty person they were before the tumour’s rude intrusion into their brain.

Instead, they’re now someone who can’t remember how dress themselves, and that is worth a lot in court.

A similar scenario to 1. but a scan is requested and reported as normal. Years later a tumour is diagnosed, and, with the benefit of hindsight, there was a subtle abnormality that was overlooked.

In a recent case, a patient had a severe headache after childbirth and was scanned.

There was a subtle abnormality which was missed and three years later the patient presented with a combination of neurological symptoms due to a very rare tumour at the base of skull.

In retrospect, the tumour was there and expanding the skull base but missed by a radiologist, who was not specifically trained in the nuances of neuroradiology. Despite successful treatment, the patient has ongoing issues.

Here the question is “Had the tumour been picked up earlier, would earlier treatment have prevented further growth and the patient’s symptoms?”

A ‘lesion’ is detected as an incidental finding which is felt to be non-specific and either not followed up at all or only followed up for a year or two.

The patient lives a normal life for many years but then presents with a large symptomatic tumour.

This is particularly applicable to patients with low-grade gliomas where the tumour can appear as a non-specific blob, then grows very slowly and turns malignant after many years.

In a recent case, the patient needed brain surgery to reduce the tumour bulk.

The surgery was not curative but left the patient with permanent neurological deficits.

This may not have happened had the tumour been diagnosed earlier.

However, the flip side is that the patient had many years of ‘blissful ignorance’ without the anxiety associated with the knowledge of a tumour which was never going to be curable and which may not have been treated initially as it was so small and not causing any symptoms.

These are nuanced concepts and can only be validated after a professional lifetime of experience managing hundreds of patients with brain tumours and seeing all the different outcomes. It is difficult for patients to accept that gliomas can come back even after successful surgery – in one US study of over 100 patients with low-grade gliomas that the neurosurgeon thought they had completely removed, nearly 50% had returned within 5 years.

A tumour is treated appropriately with surgery but an early recurrence is missed and not acted upon and, due to a combination of circumstances, a further scan is not done for many years later by which time the tumour is much larger and surgery is more hazardous.

Again, similar considerations apply as with 3, but this time there is the heightened expectation that the tumour would have been picked up earlier as the patient was under follow-up. In some cases, the patient moves to a different area and there is a breakdown in continuity of care – who is ultimately responsible?

In all these cases, there are grounds for arguing that even if Breach could be proven, the Claimant has not invariably come to more harm than they would had an earlier diagnosis been made.

Ultimately, brain tumours represent a diagnostic challenge with significant medicolegal ramifications.

Delays in diagnosis, the high-risk nature of treatment, and the often-vague nature of initial symptoms create a perfect storm of potential claims.

From the first headache to the final courtroom showdown, everyone involved must navigate a minefield of medical decisions and legal liabilities.

Dr. Rees is a Consultant Neurologist and Honorary Associate Professor in Neurology at the National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, London.

He has been clinical lead for the brain tumour unit at Queen Square, the pathway director for brain cancer at London Cancer and was the neurology expert member of the NICE guidelines committee, which published national guidelines on the treatment of primary and secondary brain tumours in 2018.

He leads a research team investigating the role of multimodality imaging in the management of low grade gliomas, has edited a textbook on neuro-oncology, written numerous peer-reviewed research papers and chapters on neuro-oncology.

He runs an educational course on neuro-oncology and lectures extensively to different professional groups.

To request his CV or for any medico-legal matters he can be reached at jeremyrees@inneg.co.uk