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Medscape > Brain Neoplasms > Flashcards

Brain Neoplasms Flashcards

1
Q

Brain tumors may originate from neural elements within the brain, or they may represent spread of distant cancers.

Gliomas, metastases, meningiomas, pituitary adenomas, acoustic neuromas account for …?

A

95% of all brain tumors.

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2
Q

Presenting complaints of pts with intracranial neoplasm tend to be …?

A

Similar for 1o brain tumors and intracranial metastases.

==> The onset of symptoms is usually insidious, but an acute episode may occur with bleeding into the tumor, or when an intraventricular tumor suddenly occludes the 3rd ventricle.

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3
Q

Manifestations may be nonspecific and include the following:

A
  1. Headache.
  2. Altered mental status.
  3. Ataxia.
  4. Nausea.
  5. Vomiting.
  6. Weakness.
  7. Gait disturbance.
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4
Q

CNS neoplasms may also manifest as follows:

A
  1. Focal seizures.
  2. Fixed visual changes.
  3. Speech deficits.
  4. Focal sensory abnormalities.
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5
Q

HEADACHE associated with intracranial neoplasms have the following characteristics:

A
  1. Often is a late complaint.
  2. Usually not an isolated finding.
  3. The worst symptom in only 1/2 of pts.
  4. Usually nonspecific an resembles tension-type headaches.
  5. In pts with established headache, may manifest as a change in the headache pattern.
  6. New onset of headaches in middle-aged or older pts is worrisome.
  7. The location of the headache reliably indicates the side of the head affected, but it does not indicate the precise site of the tumor.
  8. Headaches are more common with posterior fossa tumors.
  9. Headache is a more frequent symptom of intracranial tumor in pediatric pts.
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6
Q

Prevailing inaccurate portrayals of a tumor headache include the following:

A
  1. Pain that is worse in the early morning than at other times.
  2. Accompanying vomiting (+/- nausea).
  3. Exacerbation with Valsalva maneuvers, bending over, or rising from a recumbent position.
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7
Q

Physical findings of CNS neoplasms may include:

A
  1. Papilledema, which is more prevalent with pediatric brain tumor tumors, reflects an increase in ICP of several DAYS or longer.
  2. Diplopia may result from displacement or compression of the VI CN at the base of the brain.
  3. Impaired upward gaze, called Parinaud syndrome, may occur with pineal tumors.
  4. Tumors of the occipital lobe specifically may produce homonymous hemianopia or partial visual field deficits.
  5. Anosmia may occur with frontal lobe tumors.
  6. Brainstem and cerebellar tumors induce cranial nerve palsies, ataxia, incoordination, nystagmus, pyramidal signs, and sensory deficits on one or both sides of the body.
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8
Q

Diagnosis - With clinical suspicion of cancer, obtain …?

A

Routine lab studies on admission, including the following:

  1. CBC.
  2. Coagulation studies.
  3. Electrolyte levels.
  4. Comprehensive metabolic panel.
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9
Q

Obtain neuroimaging studies in pts with symptoms suggestive of an intracranial neoplasm, such as the following:

A
  1. Acute mental status changes.
  2. New-onset seizures.
  3. Focal motor or sensory deficits, including gait disturbances.
  4. Suspicious headache.
  5. Signs of elevated ICP (eg papilledema).
  6. Generally, CT is the imaging modality of choice for the ED physician.
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10
Q

CT findings are as follows:

A
  1. Most tumors demonstrate enhancement with contrast material administration.
  2. Tumors may appear hypodense, isodense, or hyperdense or have mixed density.
  3. Metastases to the brain tend to be multiple, but certain tumors (eg RCC) tend to produce SOLITARY metastatic brain lesions.
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11
Q

Features of MRI for imaging intracranial neoplasms:

A
  1. Most helpful for identifying tumors in the posterior fossa (including acoustic neuromas) and hemorrhagic lesions.
  2. Useful in pts with an allergy to iodinated contrast material or renal insufficiency.
  3. Drawbacks to MRI include incompatibility with certain medical equipment, longer imaging times (increased risk of motion artifact), and poor visualization of the subarachnoid space.
  4. Neither CT nor MRI can be used to differentiate tumor recurrence from RADIONECROSIS.
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12
Q

Management - Acute Tx for cerebral edema from intracranial neoplasms is as follows:

A
  1. CS may dramatically reduce signs and symptoms, bringing relief within a few hours.
  2. Dexamethasone is the agent of choice.
  3. Recommended doses generally range from 4-24mg daily.
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13
Q

Definitive Tx is as follows:

A
  1. Generally, care of pts with a brain tumor is multidisciplinary, requiring assistance from a neurosurgeon, an oncologist, a radiologist, and an expert in radiation therapy.
  2. Management varies greatly depending on tumor location, tissue type, and comorbid conditions.
  3. Surgical Tx options may include tumor removal or debulking, installation of a ventricular shunt, and placement of radioactive implants.
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14
Q

Background - Pathophysiology - Tumors of the brain produce neurologic manifestations through a number of mechanisms:

A
  1. Small, critically located tumors may damage specific neural pathways transversing the brain.
  2. Tumors can invade, infiltrate, or supplant normal parenchymal tissue, disrupting normal function.
  3. Because the brain dwells in the limited volume of the cranial vault, growth of intracranial tumors with accompanying edema may cause increased ICP.
  4. Tumors adjacent to the 3rd and 4th ventricles may impede the flow of CSF, leading to obstructive hydrocephalus.
  5. In addition, tumors generate new blood vessels (ie angiogenesis), disrupting the normal BBB and promoting edema.
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15
Q

The cumulative effects of tumor invasion, edema, and hydrocephalus may …?

A

Elevate the ICP and IMPAIR CEREBRAL PERFUSION.

==> Intracranial compartmental rise in ICP may provoke shifting or herniation of tissue under the falx cerebri, through the tentorium cerebelli, or through the foramen magnum.

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16
Q

Slow-growing tumors, particularly tumors expanding in the so-called silent areas of the brain, such as the frontal lobe, …?

A

May be associated with a more insidious clinical course.

==> These tumors tend to be larger at detection.

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17
Q

Most primary brain tumors do NOT metastasize, but if they do metastasize, …?

A

Intracranial spread precedes distant dissemination.

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18
Q

Leptomeningeal infiltration may present with …?

A

Dysfunction of multiple cranial nerves.

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19
Q

Frequency - US - The ACS estimates that …?

A

22,850 brain and other nervous system cancers will be diagnosed in 2015.

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20
Q

Estimates of the annual incidence rate of 1o brain tumors ranges from …?

A

7-19.1 /100.000.

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21
Q

Metastatic tumors to the brain are more common with …?

A

> 200,000 pts /y in the US with a new diagnosis of intracranial metastasis.

22
Q

Pituitary adenomas - Frequency?

A

Exceptionally common - Frequent incidental findings on autopsy.

23
Q

Autopsy series of pts with systemic cancer show that intracranial metastases are present in …?

A

18-24% of pts.

24
Q

Frequency - International:

A

WHO ==> Estimates that in 2012, brain and nervous system cancers occurred in 139,608 men and 116,605 women worldwide.

25
Q

Mortality/Morbidity - In the US, brain and other nervous system cancers are expected to cause approx …?

A

15,320 deaths in 2015.

26
Q

Brain tumors in pediatric population:

A

15-25% of all pediatric malignancies - 2nd MC behind leukemias.

27
Q

Race and brain tumors:

A

Differences are seen between ethnic groups within the same country, and a 3-fold difference in incidence has been reported between countries worldwide.

==> Developed countries appear to have the highest rates, but this may reflect better registration systems.

28
Q

Sex:

A

Meningiomas + Pituitary adenomas are SLIGHTLY more common in women than in men.

==> Males are more likely to be diagnosed with brain tumors than females, with a male-to-female ratio of 1.5:1.

29
Q

Age-related variations in brain tumors:

A
  1. Tumors in the posterior fossa predominate in preadolescent children, with the incidence of supratentorial tumors increasing from adolescence to adulthood.
  2. Low-grade gliomas, such as astrocytomas, are more common in younger people. High-grade gliomas, such as anaplastic astrocytoma and GBM, tend to originate in the 4th or 5th decade or beyond.
  3. In children, brain tumors are the most prevalent SOLID tumor (3.6/100,000 each year).
30
Q

Brain neoplasms - Clinical presentation - Hx - Manifestations depend on the cause of the symptoms, which may comprise any of the following:

A
  1. Increased ICP.
  2. Direct compression of essential gray or white matter.
  3. Shifting of intracranial contents.
  4. 2o cerebral ischemia.
31
Q

Symptoms may be non specific and include:

A
  1. Headache.
  2. Altered mental status.
  3. Ataxia.
  4. Nausea.
  5. Vomiting.
  6. Weakness.
  7. Gait disturbance.
32
Q

CNS neoplasms also may manifest as follows:

A
  1. Focal seizures.
  2. Fixed visual changes.
  3. Speech deficits.
  4. Focal sensory abnormalities.
33
Q

In a UK study of 139 children with brain tumors, the median time from symptom onset to diagnosis of a brain tumor was …?

A

3.3 months.

***Head tilt, CN palsies, endocrine and growth abnormalities, and reduced visual acuity were associated with a longer delay in diagnosis.

==> Headache = MCC initial manifestation, occurring in 55pts (40%).

==> By the time of diagnosis pts had a median of 6 signs +/- symptoms.

34
Q

In a study from the US, the mean time to diagnosis in the ED from onset of symptoms:

A

86.3 days - 104.5 days for headache.

==> Approx. 91% of cases were diagnosed by CT scan, with 48% of tumors located in the posterior fossa.

==> Headache, nausea/vomiting, and gait disturbances were the MC presenting symptoms.

35
Q

Manifestations of tumor may reflect the tumor site, as follows:

A
  1. Mental status changes, especially memory loss and decreased alertness, may be subtle clues of a FRONTAL LOBE tumor.
  2. TEMPORAL LOBE neoplasms may lead to depersonalization, emotional changes, and behavioral disturbances.
  3. Vision, smell, and other sensory disturbances may be caused by a brain tumor.
  4. An acoustic neuroma may present as intermittent (then progressive) hearing loss, disequilibrium, and tinnitus.
  5. Symptoms of pediatric posterior fossa tumors include increased irritability, unsteadiness, ataxia, headache, vomiting, and progressive obtundation.
  6. Supratentorial tumors in children are more commonly associated with seizures, hemiparesis, visual field cuts, speech difficulties, intellectual disturbance.
36
Q

2 categories of pituitary adenomas:

A
  1. Non functional.

2. Hypersecretory.

37
Q

Non functional pituitary adenomas remain asymptomatic until they are …?

A

Large enough to encroach the optic chiasm and disturb normal vision.

38
Q

Most hypersecretory pituitary adenomas secrete prolactin, with affected women noting an …?

A

Amenorrhea-galactorrhea syndrome.

39
Q

Men with prolactin-secreting pituitary adenomas more commonly complain of …?

A
  1. Headache.
  2. Visual problems.
  3. Impotence.
40
Q

Seizures, focal or generalized, may be the earliest expression of a brain tumor:

A
  1. A Jacksonian pattern (ie, one in which a focal seizure begins in one extremity and then progresses until it becomes generalized) is distinctive in suggesting a focal structural lesion of the cortex.
  2. Depending on the rate of growth of the tumor, seizures may present for months to years before a brain tumor is diagnosed.
  3. Any middle-aged or elderly pts presenting with a first seizure should have CNS tumor high in the DDx.
  4. Pts with a brain tumor may present with acute neurologic changes mimicking those associated with stroke.
41
Q

PE - Papilledema:

A
  1. More prevalent with pediatric brain tumors, reflects an increase in ICP of several DAYS or longer.
  2. Usually does NOT cause visual loss.
  3. Not all pts with CNS tumors develop papilledema.
42
Q

PE - Diplopia:

A

May result from displacement or compression of the 6th at the base of the brain.

43
Q

PE - Anosmia:

A

With frontal lobe tumors.

44
Q

PE - Tumors in the region of the cerebellopontine angle may …?

A

Impair the functions of the 3 cranial nerves that transverse this region.

==> Facial, Vestibular, Cochlear.

45
Q

Causes - Although few factors are unequivocally associated with an increased risk of brain cancer, the following are consequential:

A
  1. Most CNS neoplasms are thought to arise from individual cell mutations.
  2. Hx of radiation to the head.
  3. NF, TS, MEN 1, Retinoblastoma.
  4. MC tumor originating from the cerebellopontine angle are acoustic neuroma and meningioma.
  5. Primary CNS lymphoma is a relatively frequent occurrence in HIV patients.
  6. Metastatic tumors reach the brain via hematogenous dissemination through the arterial system.
46
Q

Sources of brain mets:

A
  1. Lung (by far).
  2. Breast.
  3. Melanoma.
  4. Colon.

==> Less common: malignant melanoma, testicular cancer, RCC.

==> Unlikely: prostate, uterine, ovarian.

47
Q

Brain neoplasms - Workup - Lab:

A
  1. CBC.
  2. Coag studies.
  3. Electrolytes.
  4. Comprehensive met panel.

==> Pts are prone to bleeding disturbances (hyperviscosity), metabolic disorders (hypercalcemia), and SIADH.

48
Q

Obtain neuroimaging studies in pts with symptoms suggestive of an intracranial neoplasm:

A
  1. Acute mental status changes.
  2. New-onset seizures.
  3. Focal/motor/sensory deficits, including gait disturbance, suspicious headache, signs of elevated ICP, such as papilledema.
49
Q

Drawbacks of the MRI:

A
  1. Incompatibility with certain medical equipment.
  2. Longer imaging times (increased risk of motion artifact).
  3. Poor visualization of the subarachnoid space.
50
Q

Neither CT nor MRI can be used to …?

A

Differentiate tumor recurrence from radionecrosis.

51
Q

LP?

A

NOT indicated in the ED in a pt with suspected CNS neoplasms.

Medscape (7 decks)

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