4. Space occupying lesion, raised ICP and brain tumours

Question 1

What is the different between primary and secondary brain tumours

Answer 1

primary usually arise from the intracranial structures such as meninges (meningioma) or glial cells (gliomas or astrocytomas)

Secondary arise from primary tumours usually arising from bronchus, breast, stomach, prostate, thyroid or kidneys

Question 2

Space occupying lesions in the brain:

what infections can cause SOL

Answer 2

brain abscess
subdural empyema
granuloma (eg TB)
Parasitic

Question 3

Space occupying lesions in the brain:

what vascular causes can cause SOL

Answer 3

any haemorrhage (extradural, subdural, subarachnoid, parenchymal

cavernoma (cluster of abnormal blood vessels) or vascular malformations

brain infarction (stroke)

Question 4

what may cause hydrocephalus (accumulation of CSF)

Answer 4

tumours, cysts, intraventricular haemorrhage

Meningitis, sub-arachnoid haemorrhage

choroid plexus papilloma (rare)

Question 5

Presentation of tumours, note the symptoms are due to raised ICP

What are the general common symptoms

Answer 5

headache, vomiting, blurred vision, deterioration of consciousness levels

Bradycardia, hypertension, Papilloedema

Question 6

If a patient has a tumour in the frontal lobe, what symptoms would they present with

Answer 6

weakness, dysphasia, personality changes, dementia

Question 7

If a patient has a tumour in the parietal lobe, what symptoms would they present with

Answer 7

sensory symptoms, dressing apraxia, visual field defects

Question 8

If a patient has a tumour in the temporal lobe, what symptoms would they present with

Answer 8

dysphasia and visual field defects

Question 9

If a patient has a tumour in the occipital lobe, what symptoms would they present with

Answer 9

visual field issues

Question 10

If a patient has a tumour in the posterior fossa, what symptoms would they present with

Answer 10

dysmetria (lack of co-ordination), gait ataxia, cranial nerve palsy, tremors, nystagmus

Question 11

Symptoms of neurological deficit is due to the compression or damage of adjacent structures. What is pronator drift and what does it show

Answer 11

when pt raises both arms horizontally with palms facing upwards, when they close their eyes one arm lowers or pronates (normally both should stay up) which indicates paresis

Question 12

If the brain is irritated what kind of seizures can occur

Answer 12

focal seizure
general tonic clonic seizure
irritation of meninges can cause headache

Question 13

What is the normal ICP in adults and at what point does it become pathological

Answer 13

less than 15mmHg in adults

pathological is when it is above 20 mmgHg

Question 14

how is ICP different in children compared to adults

Answer 14

children have lower ICP and can be negative in newborn

Question 15

how does ICP change when you sneeze or cough

Answer 15

it can go up to 75 at times

Question 16

what does Papilloedema look like

Answer 16

edges of the optic disc are blurred due to swelling and haemorrhage changes around the disc margins

Question 17

What can cause increased in ICP

Answer 17

increase in brain/tissue/mass volume (such as SOL or cerebral oedema)
increased in CSF volume
increase in blood volume (due to raised arterial PCO2, venous obstruction, raised temperature)

Question 18

Cerebral blood flow is dependant on cerebral perfusion pressure (CPP) which is equal to what

Answer 18

mean arterial pressure = ICP

Question 19

In the treatment of increased ICP what measures can you put in place to manage it acutely

Answer 19

head up tilt (30-45 degrees) to promote venous outflow

keep neck straight so not to obstruct jugular venous outflow

avoid hypotension to maintain cerebral blood flow (can use vasopressors)

maintain adequate sedation to reduce metabolic demands

maintain normal PCO2 as raised PCO2 causes cerebral vasodilation and increases cerebral blood volume

Question 20

What therapy can be prescribed to treated ICP

Answer 20

mannitol (it is an osmotic diuretic that reduces brain volume )
hyperventilation
barbiturate therapy (thiopentone, phenobarbitone which reduces brain metabolism and cerebral blood flow)

Question 21

Which medication to treat ICP would need continuous EEG monitoring as it reduces brain metabolism and cerebral blood flow

Answer 21

barbiturate therapy

Question 22

what specialist measures can be used to treat raised ICP

Answer 22

removal of the SOL
decompressive craniectomy to remove the rigid confines of the skull (craniectomy alone or by opening the dura in addition)

Question 23

if a patient was to present with personality and behavioural changes then which area of the brain would a tumour be indicated in

Answer 23

frontal lobe

Question 24

what is the key finding that would indicate raised ICP

Answer 24

Papilloedema in a fundoscopy

Question 25

What can cause raised ICP

Answer 25

* Brain tumours * Intracranial haemorrhage * Idiopathic intracranial hypertension * Abscesses or infection

Question 26

Concerning features of a headache that should prompt further examination and investigate would be if the headache is .........

Answer 26

* Constant * Nocturnal * Worse on waking * Worse on coughing, straining or bending forward * associated with Vomiting

Question 27

what would be some other presenting features of raised ICP aside from the very concerning ones

Answer 27

* Altered mental state * Visual field defects * Seizures (particularly focal) * Unilateral ptosis * Third and sixth nerve palsies * Papilloedema (on fundoscopy)

Question 28

what actually is Papilloedema and what causes it

Answer 28

swelling of the optic disk secondary to raised intracranial pressure sheath around the optic nerve is connected with the subarachnoid space therefore when CSF under high pressure it flows into the optic nerve sheath

Question 29

what fundoscopic changes would you see in someone presenting with Papilloedema

Answer 29

* Blurring of the optic disc margin * Elevated optic disc (look for the way the retinal vessels flow across the disc to see the elevation) * Loss of venous pulsation * Engorged retinal veins * Haemorrhages around optic disc * Paton’s lines which are creases in the retina around the optic disc

Question 30

when looking for elevation of the optic disk in patients with papillodema, what can the blood vessels tell yo about the disk

Answer 30

the retinal vessels are able to flow straight across a flat disk whereas they will curve over a raised disc

Question 31

what are the common cancers that metastases to the brain

Answer 31

lung breast colorectal prostate

Question 32

what are gliomas and name the three types (from most too least malignant)

Answer 32

tumours of the glial cells • Astrocytoma (glioblastoma multiforme is the most common) • Oligodendroglioma • Ependymoma

Question 33

what are meningiomas

Answer 33

tumours growing from the cells of the meninges in the brain and spinal cord -usually benign but can lead to increased ICP and neurological symptoms

Question 34

what common symptom does a pituitary tumour cause

Answer 34

bitemporal hemianopia as it presses on the optic chasm

Question 35

What is acoustic neuroma aka vestibular schwannoma

Answer 35

tumours of the scwann cells surrounding the auditory nerve | occur around the cerebellopontin angle and sometimes referred to as cerebellopontine angle tumours

Question 36

what are the common symptoms of an acoustic neuroma

Answer 36

hearing loss tinnitus balance problems

Question 37

what are the main management options for brain tumours

Answer 37

palliative care chemotherapy radiotherapy surgery

Question 38

what is the difference between CT and MRI

Answer 38

CT is X ray based whereas MRI uses magnetic waves

Question 39

which type of scan provides better spatial resolution of soft tissue lesions

Answer 39

MRI