Brain tumours Flashcards
Right handed, woman presents with acalculia, agraphia,
finger agnosia and right/left confusion.
Where would you suspect her lesion to be?
Left parietal lobe
Left handed, woman presents with ataxia and in-coordination.
Where would you suspect her lesion to be?
Cerebellum
Right handed, man presents with a bi temporal hemianopia.
Where would you suspect his lesion to be?
Pituitary gland
Right handed man presented to medical team with cognitive language dysfunction:
difficulty reading e mails
difficulty expressing what he wished to say
short-term memory impairment
Also a 6 week history of posterior rib pain
PMHx included a left nephrectomy for renal cell carcinoma
Where is his suspected lesion
Left temper-parietal area
Which cranial fossa are GBMs not common in
Posterior
Woman presented to A&E with decreased level of consciousness
- “slowing down”
- making uncharacteristic mistakes at work
- 4 day history of drowsiness
- headache and nauseated
GCS 11: e3v3m5
Pupils equal and reactive to light
No apparent focal neurological signs
Mild pyrexia (37.5°C)
Examination of chest/abdomen/breast normal
No palpable lymphadenopathy or skin lesions
What investigation next?
CT/MRI brain
If symptoms/signs suggest intracranial lesion, DO NOT do what investigation + why
Lumbar puncture because you might cause herniation of cerebellum –> death
Brain tumours classified into what 2 tumour types
Primary
Secondary
Name 3 primary brain tumours
Gliomas, e.g. glioblastoma multiforme (GBM) - malignant
Meningioma - usually benign
Pituitary tumour - usually benign
What are secondary brain tumours
Metastases
Brain metastases are commonly from what 5 places
Kidney Lung Breast Melanoma (i.e. skin) Colon
Gliomas (e.g. glioblastoma multiforme, oligodendroglioma) are derived from what cells
Glial cells - e.g. astrocytes, oligodendrocytes
Function of astrocytes
Provide structural and nutritional support to neurons
Meningiomas arise from which layer of the meninges usually
Arachnoid mater
Pituitary tumours are most of the time what type of tumour
Adenoma
How do brain tumours affect ICP
Raise ICP
Focal neurological deficits that brain tumours may present with (5)
Motor weakness - hemiparesis etc Dysphasia Visual impairment - hemianopi, diplopia etc Memory impairment Cranial nerve palsy
An early warning sign of a tumour could be…
Seizures
Symptoms of raised ICP (5)
Headache - usually morning Nausea Vomiting Visual disturbance - blurry vision etc Sleepiness
Signs of raised ICP (5)
Papilloedema - pressure on CN II CN III palsy --> pupillary dilation CN VI palsy --> convergent squint --> diplopia Cognitive decline Altered consciousness Hydrocephalus
Signs of pituitary tumours (2)
Visual disturbance - bitemporal hemianopia (due to compression of optic chasm)
Hormone imbalance
Investigations of brain tumours (3)
If metastases suspected, what other investigations (5)
CT head
MRI head
PET
CXR
CT chest/abdo/pelvis
Biopsy of skin lesions/lymph nodes
Treatment of glioblastoma multiforme (5)
Surgical debulking of tumour \+ Radiotherapy \+ Chemotherapy - temozolomide
Steroids - dexamethasone
Anticonvulsants - if have seizures
Treatment of meningiomas
- if asymptomatic
- if symptomatic (2)
- if surgery unsuitable (2)
If asymptomatic - observe
If symptomatic - surgical resection + radiotherapy
If surgery not suitable - radiotherapy/stereotactic radiosurgery (not actually surgery, still radiation)
Treatment of brain metastases (3)
Steroids,
Anticonvulsants
Radiotherapy
3 localised lesions/space occupying lesions that cause raised ICP
Haemorrhage
Tumour
Abscess
Name a generalised (i.e. not localised) lesion that causes raised ICP
Oedema post trauma
Consequences of space occupying lesions leading to raised ICP (3)
Increases amount of tissue in the skull so unstable ICP
Internal shift between the intracranial spaces
Local ischaemia as tumours squeeze nearby tissue
Internal shift (herniation) between the intracranial spaces can shift in what directions (4)
Right –> left
Left –> right
Cerebrum can move inferiorly over edge of tentorium cerebelli (tentorial herniation)
Cerebellum can move inferiorly down forage magnum (coning)
What is subfalcine herniation (2)
MIDLINE SHIFT:
Cingulate gyrus pushed to one side and herniates underneath the falx to the other side
So falx cerebri is pushed to one side as well
What is tentorial/uncal herniation (3)
Brain herniates inferiorly over the side of the tentorium cerebelli –> pushing the brainstem medially –> narrowing the cerebral aqueduct
What is cerebellar tonsillar herniation (3)
Tonsils move medially and inferiorly down foramen magnum –> crushing the brainstem –> brainstem death
Grave complication of raised ICP
Brainstem death
Primary brain tumours can be classified by cell of origin - what are the 2 subcategories
Tumours arising from cells inside brain, i.e. neurons or glial cells
Tumours arising from cells outside brain
Name 3 main types of gliomas (i.e. tumours arising from glial cells)
Astrocytoma
Oligodendroglioma
Ependymoma
Name a common astrocytoma
Glioblastoma multiforme
How are astrocytomas graded
Low grade (slow growing) High grade (Fast growing)
or
Grades 1 - 4
What grade astrocytoma is a glioblastoma multiforme
Grade 4
Name a tumour arising from embryonic neural cells
Medulloblastoma (childhood malignant tumour)
Name 5 primary brain tumours arising from cells outside the brain (i.e. not arising from neurons or glial cells)
Meningioma Schwannoma Pituitary adenoma Lymphoma Haemangioblastoma
What cells do mengiomas arise from
Arachnoid cells
What vessels do haemangioblastomas arise from
Capillaries
Brain tumours in adults are mostly above what fold of dura
Tentorium cerebelli
Brain tumours in children are mostly BELOW what fold of dura
Tentorium cerebelli
Are gliomas encapsulated
No
Do gliomas metastasise outside CNS
No
What cells are GBMs derived from
Astrocytes
Histological appearance of low grade astrocytomas (slow growing)
Bland cells, similar to normal astrocytes
Histological appearance of high grade astrocytomas (slow growing)
Large abnormal astrocytes with multiple/irregular nuclei
Histological appearance of meningiomas
Bland cells clustering together –> ARACHNOID GRANULATION
Psammoma - calcified clustered cells
Do meningiomas metastasis
No
Are meningiomas usually being or malignant
Benign
Medulloblastomas affect who most
Children
Medulloblastomas usually found in what fossa + are they usually benign/malignant
Posterior
Malignant
Histology of medulloblastomas
Layers of undifferentiated cells
Nerve sheath tumours only affect nerves where
Nerves in the PNS, i.e. peripheral nerves covered by Schwann cells
A common schwannoma is schwannoma of CN VIII - what is it also known as
Acoustic neuroma
Main clinical feature of acoustic neuromas (benign)
Unilateral sensorineural hearing loss
CNS lymphomas are usually lymphomas of what cells
B cells
Haemangioblastomas are most often found where in the brain
Cerebellum
Are schwannomas usually benign or malignant
Benign
What is a psammoma
Calcified cluster of arachnoid cells that can occur with meningiomas
Treatment of pituitary adenomas (3)
Trans-sphenoidal resection of tumour
Radiotherapy if there’s residual tumour after surgery
Hormone replacement
Treatment of acoustic neuroma (2)
Focused radiotherapy (stereotactic radiosrugery)
or surgery
Symptoms of a medulloblastoma (Childhood malignant tumour) (4)
morning headaches,
nausea/vomiting
Visual disturbance - diplopia
Behavioural changes
Symptoms/signs of a meningioma (4)
Often ASYMPTOMATIC until large (symptoms come from mass effect)
Headache
Neurological deficit - visual impairment, hearing/smell impairment, muscle weakness
Seizure
Where are acoustic neuromas often anatomically found
At the cerebellopontine angle
Symptoms/signs of astrocytomas, e.g. GBM (7)
SEVERE morning headache Nausea/vomiting Visual disturbance - diplopia, visual field cut, visual acuity loss Seizures Motor weakness Dysphasia
Can get spontaneous … without nausea in brain tumours
Vomiting
Symptoms/signs of frontal lobe tumours (4)
Behaviour + personality change
Loss of concentration and judgement
Memory impairment
Headache
