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Brain Tumours Flashcards

1
Q

Causes of raised ICP? [4]

A

Localised (Space Occupying) Lesions

  • Haemorrhage or haematoma
  • Tumour
  • Abscess

Also Oedema post trauma

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2
Q

Types of herniation due to raised ICP? [3]

A

Internal Shift or Herniation:

  • Right-left e.g. subfalcine herniation (cingulate gyrus herniates under falx)
  • Uncal Herniation (cerebrum moves down over tentorium)
  • Coning (Cerebellum, mainly tonsils, moves into foramen magnum)
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3
Q

What happens to tissue around a tumour? [1]

A

Ischaemia

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4
Q

Early symptom of a raising ICP via 2 mechanisms [3]

A

Morning Headaches and vomiting from cortex/brainstem compression

Papilloedema & Visual Disturbance from pressure on optic nerve

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5
Q

What other signs appear as ICP increases? [5]

A
  • Pupillary Dilation from stretch on III
  • 6th nerve palsy
  • Focal Neurological Deficits
  • Falling GCS from pressure on Cortex/brainstem
  • Brain Stem Death from coning
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6
Q

Intracranial tumours can be divided into 3 major categories?

A
  • Primary CNS tumours
  • Secondary (Metastatic) CNS tumours
  • Extra-axial tumors CNS
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7
Q

Types of intra-axial tumours [4]

A

Gliomas
Ependymomas
Medulloblastoma
CNS lymphoma

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8
Q

What cancers commonly metastasise to the brain? [5]

A
  • Breast
  • Lung
  • Kidney
  • Colon
  • Melanoma
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9
Q

Where anatomically in the brain would you find tumours in adults vs in children?

A

Adults - Above Tentorium

Children - Mainly below Tentorium

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10
Q

Astrocytoma = Glioma

Infiltrative tumours from glial cells
Low grade vs High grade
What difference in demographic are there?

A

Low grade include grade 1-2 astrocytomas
* Young adult and children
High grade include grade 3-4 astrocytomas
* Present in older adults in 4th-5th decades of life

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11
Q

What cell do glioblastomas and astrocytomas originate from?

What low grade glioma is benign? [1]

A

Both from Astrocytes

Low grade pilocytic astrocytomas are malignant while low grade gliomas are generally pre-malignant

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12
Q

Glioblastoma vs astrocytoma
What are similarities [2]
Whats the difference [3]

A

Both originate from astrocytes & are malignant

Astrocytomas:

  • Bland mostly normal cells
  • Low Grade tumour
  • Grows very slowly

Glioblastoma

  • Cellularly Atypical (multiple or irregular nuclei)
  • Grows very quickly
  • Grade 4 astrocytoma
  • Shows necrosis microscopically
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13
Q

What does a medulloblastoma originate from?

A

Primitive Neuroectoderm (primitive Neural cells)

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14
Q

Describe a medulloblastoma?

A
  • Forms sheets of small undifferentiated cells

- Malignant

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15
Q

Medulloblastoma

Which age group usually affected?
Arising from what cell?
Presentation
Location of tumour
Treatment

A

20% of all childhood CNS tumour
Arise from granule cell progenitors
5% are inherited or genetic related
Present with headache, ataxia, signs of brainstem involvement
Usually seen in posterior fossa in MRI
Tx: surgery + craniospinal irradiation, chemo

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16
Q

Meningioma

Epidemiology
Arise from what cells
Location
Classification: name 3 grades

A

Incidence increases with age, women, NF2, hx of cranial irradiation therapy
Arise from dura mater, neoplastic meningothelial cells
Located over cranial convexities, adjacent to sagittal sinus, skull base, spinal cord dorsum.
Grade 1: benign
Grade 2: atypical
Grade 3: Malignant

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17
Q

Meningioma

Presentation
Appearance on MRI
Mx

A

Presentation: headaches, seizures, focal neurologic deficits
Imaging: partially calcified, densely enhancing extra-axial tumour arising from dura, with dural tail.
Mx: complete resection usually results in no recurrence, +/- stereotactic radiotherapy

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18
Q

What do we call the calcifications of a meningioma seen under microscope?

A

Psammoma body formation

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19
Q

Give one major example of a schwannoma? Location? [2]

A

VIII nerve Schwannoma (Acoustic Neuroma)

Generally at angle of Pons & Cerebellum

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20
Q

Schwannoma

A

Arise from nerve roots so can be cranial nerve or spinal nerve.
Most known is the vestibular schwannoma/acoustic neuroma assoc with NF2. NF1 assoc with schwannoma in spinal nerve roots.
Presenting with unilateral symptoms, deafness, dizziness, tinnitus.
Mx: surgery or SRS

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21
Q

What does a pituitary adenoma do? [2]

A
  • Impinge on optic chiasm

- Dysregulation of pituitary hormone secretion

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22
Q

What makes up a CNS lymphoma? [1]

A

Diffuse Large B-cell lymphoma

23
Q

Consequences of haemangioblastoma? [2]

A

Space occupying and may bleed

24
Q

What makes up most secondary tumours in the brain?

A

Carcinomas

25
Clinical Presentation of Intracranial Tumours? [4]
- Symptoms/signs of raised ICP - Focal Neurological Deficits - Seizures (in lesions of cerebral cortex, think tumour in an adult onset seizure) - CSF obstruction (Hydrocephalus)
26
Investigation of intra-axial tumours
Cranial MRI is ppreferred CT for patients incompatible with MRI Malignant - will enhance with gadolinium Low grade gliomas - wont enhance fMRI for surgical planning PET MR perfusion Cancer markers - BHCG, HCG
27
What are the approaches of Intracranial tumour management? [3]
- Diagnosis of benign vs malignant - Improve quality of life (reducing symptoms and neurological deficits) - Prolonging life expectancy
28
What treatments are available for Intracranial Tumours? Medical [5] Surgical [2]
- Chemo/radiotherapy - Corticosteroids (reduces ICP from oedema) - Anti-epileptics to prevent seizures - Analgesia - Anti-emetics Surgery - Either as complete resection - Or debulking to reduce symptoms/ICP
29
Meningioma management
* If small and asymptomatic, incidental finding, just monitor with serial MRI. * Surgical resection for larger lesions and symptomatic. But needs to be complete resection otherwise it will recur. * Irresectable tumours will go for stereotactic radiosurgery
30
Prognosis for Gliomas: astrocytoma vs glioblastoma multiformes [2]
Astrocytomas have a longer life expectancy which higher rate of cure, grade 1 is potentially curable. Glioblastoma Multiformes have a 1yr survival avg.
31
Extra-axial brain tumours types [5]
- Meningioma - Schwannoma/Neurofibroma - Pituitary adenoma - Lymphoma - Haemanioblastoma (Capillaries)
32
``` Diffuse low grade astrocytoma Epidemiology Location [2] Presentation [3] Imaging [2] What can you see? ```
Young adults Location: frontal region, subcortical white matter Presentation: seizures, headache, very slow progression of neurological deficits Imaging: - CT - well circumscribed non enhancing hypodense or isodense lesion - T2 MRI showing surrounding area of edema
33
``` High grade astrocytoma Epidemiology [3] Can originate from ____ [2] Prognosis Location [3] Presentation [3] Progression [1] ```
Adults, 40-60 M>F De-novo or evolve from low-grade glioma Poor prognosis Location: frontal and temporal lobes, basal ganglia Presentation: seizures, headache, slowly progressive neurological deficits Progression over weeks (quicker than low grade)
34
What tumor can infiltrate along white matter tracts and cross corpus callosum? Whats the name of this sign on imaging?
High grade astrocytoma can show a butterfly lesion
35
Gliomas: High grade astrocytoma Imaging: What will CT show? [3] Management [2]
Central hypodense area of necrosis [1] surrounded by thick enhancing rim [1] (center is necrotic due to cancer outgrowing its blood supply) + surrounding edema [1] Chemo radiotherapy - survival 14m Surgery not cure as recurrence is high
36
``` Gliomas: Oligodendroglioma Mean age of onset [1] Location [1] Presentation [3] Imaging CT [3] - would you see hemorrhage and edema in CT scan of these patients? ```
Mean age of onset 40y Location: superficially in frontal lobe Presentation: seizures, headache, slowly prog neurological deficits Imaging CT - Well circumscribed, hypodense lesions [1] with heavy calcification [1] , cystic degeneration [1], hemorrhage and edema uncommon
37
Types of presentations of brain tumours [7] depending on location
``` Cerebral Cerebellar Brainstem Frontal Parietal Temporal Occipital ```
38
Cerebral tumor presentation [8]
``` Headache Vomiting unrelated to food intake Changes in visual fields and acuity Hemiparesis, hemiplegia Hypokinesia Decreased tactile discrimination Seizures Changes in personality or behaviour ```
39
Brain stem tumor presentation [7]
Hearing loss - acoustic neuroma Facial pain, weakness Dysphagia, decreased gag reflex Nystagmus Hoarseness Ataxia Dysarthria
40
Frontal lobe tumor presentation [8]
Headache Inappropriate behaviour Personality changes Inability to concentrate Impaired judgement Memory loss Expressive aphasia Motor dysfunction
41
Parietal lobe tumor presentation [3]
Sensory deficits - paresthesia Visual field deficits Dyspraxia
42
What is dyspraxia
Partial loss of ability to co-ordinate and perform skilled purposeful movements and gestures with normal accuracy
43
Occipital lobe tumor - major symptom [3]
- contralateral visual field defects - palinopsia (persisting images once object has left field of view) - polyopia (multiple images seen)
44
Other than tumors what are other space occupying lesions [4]
* Aneurysm * Chronic subdural haematoma * Granuloma * Cyst
45
Third Ventricle Colloid Cyst What are they Onset Management
- Congenital cysts - present in adulthood Mx is excision or ventriculoperitoneal shunting
46
Third Ventricle Colloid Cyst | Presentation [7]
- amnesia - positional headache - obtundation (blunted consciousness) - dim vision - blunted paresthesiae - weak legs - drop attacks
47
Management of space occupying lesions | Benign vs malignant
• Benign: surgical excision unless inaccessible • Malignant: o Surgical excision (margins are unclear) for tissue dx, debulking before RT and carmustine wafer insertion o Adjuvant chemo-radiotherapy (or as sole therapy if inoperable)
48
Management of space occupying lesions Seizure only when there has been a seizure beforehand Cerebral edema [2]
* Seizure prophylaxis: LEVETIRACEM 500mg BD IV/oral no difference | * Cerebral oedema: DEXAMETHASONE (MANNITOL if ICP rapidly rises)
49
Management of raised ICP [11]
ABCDE Hypotension correction maintain MAP >90mmHg Positioning elevate to 30-40 Full sedation and paralysis to reduce brain metabolic activity Hyperventilation Osmotic agents Fluid restriction <1.5l/d Monitoring neuro obs, consider ICP bolt Correct electrolyte abnormalities Surgery: craniotomy or extra-ventricular drain
50
When can you use dexamethasone in raised ICP?
IV DEXAMETHASONE ONLY IF oedema surrounding tumour
51
# CNS lymphoma Immunocompetent vs immunocompromised patients Presentation Ix
In immunocompetence: DLBCL In immunocompromised: HIV, organ transplant Presentation: neuropsychiatric symptoms, raised ICP sign, seizures Immunocompetent - solitary lesion Ix: stereotactic bx Withhold steroids in CNS lymphoma before obtaining biopsy as it melts away lymphoma and bx may not yield anything
52
# CNS lymphoma Management
* responsive to steroids, chemo and radiotherapy * high dose methotrexate * radiotherapy assoc with neurotoxicity * 50% recurrence * In immunocompromised: think about ddx like toxoplasmosis, investigations like CSF, EBV, brain PET will help
53

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