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Neurology > Brain Tumours > Flashcards

Brain Tumours Flashcards

1
Q

How common are primary brain tumours in children compared to other tumours?

A

2nd most common tumour in children

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2
Q

What is the commonest cause of cancer death in people under 40?

A

Brain tumours

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3
Q

How do the majority of brain tumours present?

A

Progressive neurological deficit - 68%
Motor weakness - 45%
Headache - 54%
Seizures - 26%

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4
Q

What is mass effect?

A

A mass within a ‘rigid closed box’ i.e. the skull causes increased intracranial pressure
Can be due to blockage of CSF flow (hydrocephalus) and haemorrhage for example
This would present as headaches, vomiting, mental changes, seizures

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5
Q

How would a headache due to raised ICP be described?

A

Worse in the morning - wakes them up
Worse when coughing or leaning forward
May be associated with and worsened by vomiting
I.e. symptoms similar to tension HA/migraine

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6
Q

List some reasons why a headache would occur due to a tumour

A

Raised ICP
Invasion/compression of dura, BVs, periosteum
Secondary to diplopia
Secondary to difficulty focusing
Extreme hypertension (Cushings triad of increased ICP)
Psychogenic (stress of loss of functional capacity)

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7
Q

What would you see on fundoscopy if there was a tumour pushing on the optic chiasm and causing increased ICP?

A

Papilloedema

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8
Q

What symptoms would a patient have with a frontal lobe brain tumour?

A

Perseveration - repetition of a particular response (such as a word, phrase, or gesture) regardless of the absence or cessation of a stimulus
Broca’s area - speech impairment

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9
Q

What symptoms would a patient have with a parietal lobe brain tumour?

A

Dyspraxia, spatial awareness and coordination e.g. a person may bump into furniture that they have seen, but have misjudged where it is in relation to themselves

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10
Q

What symptoms would a patient have with an occipital lobe brain tumour?

A

Visual problems - the occipital lobe is where visual stimuli are processed so can result in visual loss or difficulty seeing colours

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11
Q

What symptoms would a patient have with a cerebellar tumour?

A

DANISH:
dysdiadochokinesis - inability to execute rapidly alternating movements, particularly of the limbs, demonstrated by asking the patient to pronate and supinate an arm at speed, with a tap on the opposite forearm at the extremes of movement
ataxia - broad-based clumsy gait
nystagmus - involuntary rhythmic movement of the eyes
intention tremor - tremor which is worse during voluntary movement
scanning dysarthria - speech is jerky, explosive, slurred and loud, with separated syllables, ask them to say British constitution and west register street
heel-shin test positivity - patient runs the sole of one foot up and down the shin of the opposite leg, if cerebellar disease is present, then the test is performed poorly and intention tremor may become pronounced

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12
Q

List some investigations that would be used in a suspected brain tumour

A

CT, MRI, LP, PET, lesion biopsy, EEG, angiograms, radionucleotide studies

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13
Q

Name some examples of neuroepithelial tissue that tumours can arise in

A

Astrocytes (60%), oligodendrogial cells, ependymal cells/choroid plexus, neuronal cells, pineal cells, embryonic

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14
Q

Astrocytic tumours are graded from I-IV. What is a grade IV astrocytic tumour called?

A

Glioblastoma multiforme

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15
Q

Astrocytic tumours are graded from I-IV. What are grade II and III astrocytic tumours called respectively?

A

II - low grade astrocytoma

III - anaplastic astrocytoma

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16
Q

Describe grade I astrocytomas

A

Truly benign, slow growing
More common in children and young adults
Pilocytic astrocytomas - optic nerve, hypothalamic gliomas, cerebellum and brainstem

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17
Q

What is the treatment of choice for grade I astrocytomas?

A

Surgery - curative

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18
Q

Describe the pathology of low grade astrocytomas (grade II)

A

Hypercellularity, pleomorphism, vascular proliferation, necrosis

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19
Q

Where do low grade astrocytomas tend to arise?

A

Temporal lobe, posterior frontal and anterior parietal lobe

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20
Q

How do low grade astrocytomas typically present?

A

Seizures

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21
Q

What are some poor prognostic factors for low grade astrocytomas?

A

Age>50, focal deficits, short duration of symptoms, raised ICP, altered consciousness, enhancement on contrast studies

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22
Q

Are low grade astrocytomas benign?

A

Ultimate behaviour is not benign - dedifferentiation to high grade malignancy

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23
Q

Name the 3 types of low grade astrocytoma

A

Fibrillation, gemistocytic, protoplasmic

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24
Q

How are grade II astrocytomas (low grade) treated?

A

Surgery +/- chemo, radiation, combined chemo + radiation depending on molecular profile

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25
What can grade II astrocytomas transform in to and what factors would indicate a poor prognosis with this?
Glioblastoma!! | Poor prognostic factors - age>45, low performance score, large tumours/crossing midline, incomplete resection
26
What are the malignant astrocytomas?
Anaplastic astrocytoma and glioblastoma multiforme
27
What is the median survival associated with anaplastic astrocytoma?
2 years | Can arise de novo
28
Describe glioblastoma multiforme
Multiple gliomas Most common primary tumour Median survival <1 year
29
Where do glioblastoma multiforme tumours spread?
White matter tracking/ CSF pathways
30
What is the treatment for malignant astrocytomas?
Non-curative surgery for survival quality - cytoreduction, reduce mass effect Post-op radiotherapy - external beam radiation Stupp protocol - surgery + radiotherapy + temozolomide (TMZ) - improves median survival to 14 months
31
What are some of the side effects of radiotherapy treatment in brain tumours?
Drops IQ by 10!, skin, hair, fatigue
32
When is radiotherapy used in brain tumours?
Clear role in malignant tumours post-surgery Low grade astrocytomas - incomplete removal Benign astrocytomas - only if recurrence/progression not responsive to surgery
33
Where do oligodendroglial tumours typically arise in the brain and what is the typical patient presentation?
Frontal lobes | Present with seizures
34
What is the peak incidence of oligodendroglial tumours?
Adults 25-45 y/o (smaller peak in children 6-12 y/o)
35
Describe the pathology of oligodendroglial tumours
Difficult to distinguish against astrocytomas - calcification, cysts, peritumoural haemorrhage Collision tumours Grading - low grade or anaplastic/astrocytic component Malignant conversion can occur
36
How are oligodendroglial tumours treated?
They are chemosensitive - procarbazine, lomustine, vincristine (PCV) Surgery + chemo Surgery for high grade has less convincing evidence Radiotherapy decreases seizures RT + PCV doubles survival!
37
What is the median survival for low grade oligodendroglial tumours?
10 years
38
What is a key histopathologic feature of meningiomas?
Arachnoid cap cells - arachnoid cell layer forms cap cell aggregates that contains calcified organelles (psammoma bodies), which are also one of the histopathologic features of meningiomas
39
What percentage of intracranial neoplasms are meningiomas?
20%
40
How do meningiomas typically present and what are they associated with?
Majority are asymptomatic but symptoms can include; headaches, cranial nerve neuropathies and regional anatomical disturbance M:F = 2:3 Associated with breast cancer and neurofibromatosis type II (22q)
41
Describe the pathology of meningiomas
Histologically benign in 90% of cases Slow growing Classification; classic (meningotheliomatous, fibrous, transitional), angioplasties, atypical, malignant
42
What do meningiomas look like on CT?
Homogenous, densely enhancing Oedema Hyperostosis/skull blistering
43
What do meningiomas look like on MRI?
Dural tail | Patency of dural venous sinuses
44
Why would a patient with previous childhood leukaemia later develop a meningioma?
Radiation induced meningioma - i.e. radiotherapy induced
45
Why would angiography +/- embolisation be needed as preoperative evaluation in a meningioma?
Occlusion of sagittal sinus
46
How are meningiomas treated?
``` Small meningiomas - expectant Preoperative embolisation Surgery Radiotherapy Outcome - 5 year survival 90% ```
47
What is the rate of recurrence associated with meningiomas?
Depends on grade and extent of resection Simpson’s grading for extent of resection is used to estimate rates of recurrence based on extent of resection e.g. grade I = complete removal including underlying bone and associated dura, 9% symptomatic recurrence at 10 years & grade V = simple decompression with or without biopsy, 100% symptomatic recurrence at 10 years
48
Name some nerve sheath tumours
Schwannomas (aka neuromas) Neurofibromas Malignant peripheral nerve sheath tumours (MPST)
49
What are acoustic neuromas associated with?
Vestibular schwannomas of CN VIII | Neurofibromatosis II
50
What symptoms do patients get with an acoustic neuroma?
Hearing loss, tinnitus, dysequilibrium
51
What structures can acoustic neuromas affect?
CN V, VII & VIII Brainstem function Leading to hydrocephalus
52
How are acoustic neuromas treated?
``` Audiometry, radiographic evaluation Expectant Hydrocephalus management Radiation Surgery ```
53
What percentage of patients with ANs are treated medically and surgery respectively?
25% medically - periodic neuro exam, hearing aid and periodic MRI 50% surgically - rarely preserves useful hearing which tends to deteriorate rapidly with time anyway
54
What are common post-op complications with acoustic neuroma surgery?
Facial nerve palsy, corneal reflex, nystagmus, abnormal eye movement
55
Who do germ cell tumours tend to affect?
90% affect those younger than 20y/o Peak incidence 10-12y/o M>F
56
What is the most common germ cell tumour and how is it treated?
Germinoma - radiosensitive (65-95% 5-year survival)
57
Give some examples of non-germinomatous tumours and are these tumours radiosensitive?
Teratoma, yolk sac tumour, choriocarcinoma, embryonal carcinoma - less radiosensitive (17-38% 5-year survival)
58
Which tumour markers should be investigated in any child with a midline brain tumour?
AFP, HCG and LDH (alpha fetoprotein, human choriogonadotrophin and lactate dehydrogenase) - high levels of any of these could indicate a germ cell tumour
59
What is a VP shunt and when is it used?
Ventriculoperitroneal shunt - used to treat hydrocephalus | 50% revision rate within 10 years
60
Presenting complaint = bitemporal hemianopia, headache and endocrine abnormality. What is your top differential diagnosis?
Pituitary tumour!
61
How do you treat a prolactinoma?
Cabergoline cures, rarely needs surgery
62
How would you treat a GH releasing pituitary adenoma?
Surgery and somatostatin analogues e.g. octreotide - acromegaly can kill from hypertrophic obstructive cardiomyopathy
63
What does GH stimulate release of and what can a GH-releasing hormone pituitary adenoma cause as a result?
IGF-1 is released from the liver in response to GH GH-releasing pituitary adenoma would cause increased levels of IGF-1 causing acromegaly (coarsening of features, thickened skin, swollen hands and feet, carpal tunnel syndrome), HOCM, diabetes mellitus, sleep apnoea
64
What happens as a result of a ACTH producing pituitary adenoma?
Cushing’s disease - can be fatal Cushing’s disease = excess cortisol due to excess ACTH produced from a pituitary tumour Symptoms include; striae, fatigue, proximal myopathy, buffalo hump, lemon on sticks, depression and bruising of skin
65
List some features of panhypopituitarism
Pallor, yellowish tinge to skin Fine wrinkling of skin Absent axillary hair Face puffy and expressionless Hypothyroidism - fatigue, weight gain Decreased LH and FSH - amenorrhoea and decreased libido Decreased ACTH - adrenal insufficiency causing fatigue, weight loss, muscle weakness, depression
66
Which hormones are affected in hypopituitarism first?
GH first then LH + FSH then TSH, ACTH and prolactin

Neurology (18 decks)

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