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Gwen - Neurology > Brain tumours > Flashcards

Brain tumours Flashcards

1
Q

Whats the difference between malignant and benign brain tumours?

A

Malignant = do not metastasise outside CNS, occur within the substance of the brain.

Benign = extrinsic, ie occur outwith the CNS

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2
Q

Name some malignant tumours

A

Neuropithelial tissue - glioma

Embryonal tumours - medulloblastoma

Lymphoma (in immunosupressed)

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3
Q

Name some benign tumours

A

Meninges - meningioma

Pituitary - adenoma

Neurofibroma

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4
Q

What are examples of intrinsic tumours found in the CNS?

A
  • Astrocystoma
  • Glioblastoma
  • Oligodendroglioma
  • Ependymoma
  • Choroid plexus papilloma
  • Haemangioblastoma
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5
Q

Name some gliomas

A

Astrocytoma, medulloblastoma, ependymomas, oligodendrogliomas

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6
Q

What is an astrocytoma?

A

Tumour arising from astrocytes. It is thought that many anaplastic astrocytomas arise as a consequence of dedifferentiation within a pre-existing astrocytic neoplasm. The prognosis for patients with astrocytomas (and gliomas generally) depends on the degree of tumour differentiation, the age of the patient at diagnosis, and the site and size of the neoplasm.

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7
Q

What gene is associated with astrocytomas?

A

P53

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8
Q

How are astrycytomas graded?

A

WHO grade 1-4

1+2 = benign course

3+4 = malignant course

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9
Q

What is gliobastoma multiforme?

A

Grade 4 astrocytoma. Leads to necrosis and cyst formation, spreads through white matter and CSF pathways.

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10
Q

What percentage of primary brain tumours do astrocytomas account for?

A

10%

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11
Q

What percentage of primary CNS tumours do glioblastomas account for?

A

30%

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12
Q

Where do most glioblastomas arise?

A

Cerebral hemispheres

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13
Q

What is glioblastoma?

A

Glioblastomas are characterised histologically by a pleomorphic tumour cell population. Although some glioblastomas may arise de novo, many arise as a consequence of dedifferentiation within a pre-existing astrocytoma. Dedifferentiation is accompanied by, or is the result of, a series of genetic events. Mitotic activity in glioblastomas is abundant, and vascular endothelial proliferation and necrosis are prominent.

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14
Q

What are Oligodenrogliomas?

A

Ill-defined, infiltrating neoplasms, usually arising in the white matter of the cerebral hemispheres. In a well-differentiated tumour, the neoplastic cells are small, rounded and uniform. Small foci of calcification are common, and an interweaving vascular pattern is often present.

Slow growing

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15
Q

What is an ependymoma?

A

Ependymomas arises from an ependymal surface, usually in the fourth ventricle, and project into the CSF pathway. Most ependymomas are well differentiated, and extensive invasion of adjacent CNS structures is uncommon.

Usually affects 4th ventricle

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16
Q

What are medulloblastomas?

A

Commonest astryocytoma in children, arrised in cerebellum

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17
Q

What is a haemangioblastoma?

A

Haemangioblastoma is an uncommon neoplasm arising most often in the cerebellum and forming a well-defined, frequently cystic mass. Histologically, the tumour is composed of blood vessels, separated by irregular stromal cells.

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18
Q

What syndrome is haemangioblastoma associated with?

A

von-Hippel-Lindau

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19
Q

What are extrinsic tumours of the CNS?

A
  • Meningioma
  • Schwannoma
  • Neurofibroma
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20
Q

Are astrocytomas malignant?

A

Yes

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21
Q

Are Oligodendroglioma’s malignant?

A

Yes

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22
Q

Are Ependymomas malignant?

A

Yes

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23
Q

Are meningiomas malignant?

A

No

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24
Q

Are neurofibroma’s malignant?

A

No

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25
Q

What are gliomas?

A

Malignant tumours of neuroepithelial origin are usually seen within the hemispheres, but occasionally in the cerebellum, brainstem or cord.

Examples include Astrocytomas, Glioblastoma, Oligodendroglioma

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26
Q

What are meningiomas?

A

Meningiomas arise from cells of the arachnoid cap (a component of arachnoid villi) (arise from arachnoid cells in meninges). The most frequent sites are the parasagittal region, sphenoidal wing, olfactory groove and foramen magnum. Meningiomas are smooth lobulated masses, which are broadly adherent to the dura. Infiltration of the adjacent dura and overlying bone is common, but invasion of the brain is rare. The brain, however, may be markedly compressed by a meningioma, resulting in considerable anatomical distortion

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27
Q

What genetic abnormality is associated with meningiomas?

A

Chromosome 22 loss in 70%

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28
Q

Typical characteristics of a meningioma

A

Benign and slow growing

Extra-axial so usually affects brain by external expression.

Frequently occurs along the falx, convexity or sphenoid bone

USUALLY CURE IF COMPLETELY SURGICALLY EXCISED

29
Q

What are schwannomas?

A

Schwannomas derive from Schwann cells in the nerve sheath of the intracranial or intraspinal sensory nerve roots. By far the commonest site is the vestibular branch of the 8th cranial nerve in the region of the cerebello-pontine angle; such neoplasms are often known as ‘acoustic neuromas’.

30
Q

What are the features of an acoustic neuroma?

A

Initially puts pressure on CN’s 5 and 7 (then 9, 10,12 as it expands)

Arises from cerebellopontine angle

Unilateral deafness, facial weakness, unilateral ataxia, hemifacial numbness

Sugical excision but risks nerv damage

31
Q

What are neurofibromas?

A

In the CNS, neurofibromas usually arise on the dorsal nerve roots of the spinal cord. Unlike schwannomas, neurofibromas are not encapsulated, but tend to involve an entire nerve root, occasionally involving several nerves (plexiform neurofibroma).

32
Q

What are the most common sites for secondary mets to spread from into the brain?

A
  • Bronchus
  • Breast
  • Stomach
  • Prostate
  • Thyroid
  • Kidney
33
Q

What are clinical features of a CNS tumour?

A
  • Direct effect features
  • Signs of raised ICP
  • Seizure activity - focal/generalised
34
Q

What are examples of false localising signs that can be seen in brain tumours?

A
  • VIth nerve lesion - first on the side of a mass and later bilaterally as the VIth nerve is compressed or stretched during its long intracranial course.
  • IIIrd nerve lesion - develops as the temporal lobe uncus herniates caudally, compressing III against the petroclinoid ligament
  • Ipsilateral Hemiparesis - from compression of the contralateral cerebral peduncle on the edge of the tentorium.
35
Q

Are meningiomas slow growing or fast growing?

A

Slow growing

36
Q

What symptoms might suggest a brain tumour?

A
  • Raised ICP headache
  • Progressive focal neurological deficit
  • Focal or generalised epilepsy - seen in <50%, exclude space ocupying lesion in all adult onset seizures
  • CSF obstruction - obstructive hydrocephalus: severe headache, sometimes with collpase/loss of consciousness
37
Q

Signs of raised ICP

A

Presenting feautre in 20%

  • Headache - typically early morning, worse on coughing, straining, bending, lying down etc
  • Gait ataxia
  • 3rd and 6th nerve palsy
  • N+V
  • Papilloedema
  • Seizure
  • Altered consciousness - stupor/coma (reduced GCS)
  • Cognitive impairment
  • Visual disturbance
  • Drowsiness (BAD!)
38
Q

Signs/symptoms when the frontal lobe is affected

A

Hemiparesis, personality change, apathy, intellectual decline, Broca’s dysphasia

39
Q

Signs/symptoms when the temporal lobe is affected

A

Dysphasia, contralateral homonymous hemianopia, amnesia, many odd phenoma

40
Q

Signs/symptoms when the parietal lobe is affected

A

Hemisensory loss, reduced 2 point discrimination, agnosia, sensory inattention, Wernicke’s dysphasia

41
Q

Signs/symptoms when the occipital lobe is affected

A

Contralateral visual field defects, palinopsia, polyopia

42
Q

Signs/symptoms when the cerebellum lobe is affected

A

DANISH

Ddysdiadochokinesis

Ataxia

Nystagmus

Intension tremor (past pointing)

Scanning speech (dysarthria)

Hypotonia, Hyporeflexia

43
Q

Signs/symptoms when the cerebellopontine angle lobe is affected

A

Ipsilateral deafness, nystagmus, facial weakness and numbness, ipsilateral cerebellar signs

44
Q

What are signs that might be present in someone with a brain tumour?

A
  • Papilloedema
  • CNVI/III palsy
  • Decreased GCS
  • Hemiparesis
  • Focal signs
45
Q

How would you investigate someone with suspected brain tumour?

A
  • CT - usually initial investigation, may miss small lesions
  • MRI - particualrly valuable in posterior fossa tumours
  • Tests to rule out extracranial primary source - CT chest/abdo/pelvis, CXR, mammography, lymph node biopsy
  • Biopsy
46
Q

What are the general priciples to management of a brain tumour?

A
  • Support
    • Corticosteroids - (dexamethasone) cerebral oedema
    • Anticonvulsants - seizures (managed as focal seizures)
    • Analgesia
    • Anti-emetics
  • Radiotherapy - for gliomas and radiosensative metastases
  • Chemotherapy - temazolamide
  • Endocrine replacement - pituitary adenoma
  • Surgery
47
Q

What is the average survival of glioblastoma multiforme?

A

Approximately 1 year

48
Q

Difference between primary and secondary brain tumours

A

Primary = original lesion in brain. Usually one big lesion with less oedema.

Secondary = many lesions, lesions small, oedema big. (Most common brain tumour - 15% of those with cancer get cerebral mets).

49
Q

Commonest tumours that spread to brain

A

Breast, lung, malignant melanoma.

(Also GI tract, kidney)

50
Q

Most common primary brain tumour in adults?

A

Glioblastoma multiforme

51
Q

Most common brain tumour in children?

A

Astrocytoma - medulloblastoma

52
Q

What is the most common pituitary tumour?

A

Adenoma, benign

(Others inlcude prolactinoma, growth hormone secreting, non secreting)

53
Q

Typical features in adenomas

A

Space occupying and endocrine effects:

  • Bitemporal hemianopia
  • Hypopituitarism
  • Hypersecretion of specific hormones
    • Acromegalu
    • Hyper-prolactinaemia
    • Cushing’s
54
Q

How high does prolactin have to be to suggest a prolactinoma?

A

>4000

55
Q

How are prolactinomas managed?

A

With dopaminergic antagonists, eg carbeorgoline

56
Q

What is mannitol used

A

Rapid reduction of ICP.

Arterial BP must be maintained to overcome icnreased ICP and maintain cerebral perfusion

57
Q

Surgical managemnt of brain tumours

A

Surgical exploration, debulking or for biopsy

Resection (especially for benign tumours eg meningioma)

Pituitary adenoma - trans-sphenoidal surgery (hormone replacement)

Hydrocephalus - intraventricular shunts

58
Q

Prognosis of meningioma

A

Commonly cured by surgical excision, may require anticonvulsants

59
Q

Prognosis of glioma/astrocytoma

A

Low grade - long life expectancy

High grade - GBM, average 1 year life expectance

60
Q

Prognosis of metastases

A

Frequently good medium term survivial

61
Q

Prognosis of lymphoma

A

Poor survival (often <1 year)

62
Q

DDx brain tumour

A

Stroke

Other intracranial mass - cerebral abscess, tuberculoma, subdural haematoma, intracranial haematoma

Intracranial hypertension - presents as headache and papilloedema in young obese women, think this if mass but no mass present. Neuroimaging is normal but LP there is increased pressure

Post-ictal (Todd’s palsy)

Venous thrombosis

MS, Encephalitis

63
Q

What is gerstmann’s sundrome

A

Caused by left dominant parietal lobe lesion

Presentation: Agraphia, acalculia, finger agnosia, left/right confusion

64
Q

What is agraphia?

A

Writing disability

65
Q

What is acalculia?

A

Lack of understanding of the rules for calculation

66
Q

What is finger agnosia

A

Inability to identify fingers

67
Q

What is left/right confusion?

A

Inability to distinguish right from left

68
Q

What are paraneoplastic syndromes?

A

Paraneoplastic syndromes are symptoms that occur at sites distant from a tumor or its metastasis.

These symptoms may be secondary to substances secreted by the tumor or may be a result of antibodies directed against tumors that cross-react with other tissue.

The most common cancers associated with paraneoplastic syndromes include

Lung carcinoma (most common)

Renal cell carcinoma

Hepatocellular carcinoma

Leukemias

Lymphomas

Breast tumors

Ovarian tumors

Neural cancers

Stomach cancers

Pancreatic cancers

Gwen - Neurology (38 decks)

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