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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
Q

Clinical Presentation of Intracranial Tumours? [4]

A
  • 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
Q

Investigation of intra-axial tumours

A

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
Q

What are the approaches of Intracranial tumour management? [3]

A
  • Diagnosis of benign vs malignant
  • Improve quality of life (reducing symptoms and neurological deficits)
  • Prolonging life expectancy
28
Q

What treatments are available for Intracranial Tumours?
Medical [5]
Surgical [2]

A
  • 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
Q

Meningioma management

A
  • 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
Q

Prognosis for Gliomas: astrocytoma vs glioblastoma multiformes [2]

A

Astrocytomas have a longer life expectancy which higher rate of cure, grade 1 is potentially curable.

Glioblastoma Multiformes have a 1yr survival avg.

31
Q

Extra-axial brain tumours types [5]

A
  • Meningioma
  • Schwannoma/Neurofibroma
  • Pituitary adenoma
  • Lymphoma
  • Haemanioblastoma (Capillaries)
32
Q 
Diffuse low grade astrocytoma
Epidemiology
Location [2]
Presentation [3]
Imaging [2]
What can you see?
A

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
Q 
High grade astrocytoma
Epidemiology [3]
Can originate from \_\_\_\_ [2]
Prognosis
Location [3]
Presentation [3]
Progression [1]
A

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
Q

What tumor can infiltrate along white matter tracts and cross corpus callosum? Whats the name of this sign on imaging?

A

High grade astrocytoma can show a butterfly lesion

35
Q

Gliomas: High grade astrocytoma
Imaging:
What will CT show? [3]
Management [2]

A

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
Q 
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?
A

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
Q

Types of presentations of brain tumours [7] depending on location

A 
Cerebral
Cerebellar
Brainstem
Frontal
Parietal
Temporal
Occipital
38
Q

Cerebral tumor presentation [8]

A 
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
Q

Brain stem tumor presentation [7]

A

Hearing loss - acoustic neuroma
Facial pain, weakness
Dysphagia, decreased gag reflex
Nystagmus
Hoarseness
Ataxia
Dysarthria

40
Q

Frontal lobe tumor presentation [8]

A

Headache
Inappropriate behaviour
Personality changes
Inability to concentrate
Impaired judgement
Memory loss
Expressive aphasia
Motor dysfunction

41
Q

Parietal lobe tumor presentation [3]

A

Sensory deficits - paresthesia
Visual field deficits
Dyspraxia

42
Q

What is dyspraxia

A

Partial loss of ability to co-ordinate and perform skilled purposeful movements and gestures with normal accuracy

43
Q

Occipital lobe tumor - major symptom [3]

A
  • contralateral visual field defects
  • palinopsia (persisting images once object has left field of view)
  • polyopia (multiple images seen)
44
Q

Other than tumors what are other space occupying lesions [4]

A
  • Aneurysm
  • Chronic subdural haematoma
  • Granuloma
  • Cyst
45
Q

Third Ventricle Colloid Cyst
What are they
Onset
Management

A
  • Congenital cysts
  • present in adulthood

Mx is excision or ventriculoperitoneal shunting

46
Q

Third Ventricle Colloid Cyst

Presentation [7]

A
  • amnesia
  • positional headache
  • obtundation (blunted consciousness)
  • dim vision
  • blunted paresthesiae
  • weak legs
  • drop attacks
47
Q

Management of space occupying lesions

Benign vs malignant

A

• 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
Q

Management of space occupying lesions
Seizure only when there has been a seizure beforehand
Cerebral edema [2]

A
  • Seizure prophylaxis: LEVETIRACEM 500mg BD IV/oral no difference

* Cerebral oedema: DEXAMETHASONE (MANNITOL if ICP rapidly rises)

49
Q

Management of raised ICP [11]

A

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
Q

When can you use dexamethasone in raised ICP?

A

IV DEXAMETHASONE ONLY IF oedema surrounding tumour

51
Q

CNS lymphoma

Immunocompetent vs immunocompromised patients
Presentation
Ix

A

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
Q

CNS lymphoma

Management

A
  • 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

Neuro (42 decks)

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