Brain tumours Flashcards
What is a brain tumour?
Growth of cells Benign or malignant Primary or secondary Supra or infratentorial Extrinsic or intrinsic
What are common presentations for brain tumours?
Progressive neurological deficit
Motor weakness
Headache - raised ICP
Seizures
What can result in an increased ICP?
Contribution of mass within a rigid closed box
Tumour/ mass/ oedema mass effect
Hydrocephalus
Haemorrhage
What are symptoms of increased ICP?
Headaches
Vomiting
Mental changes
Seizures
What are different types of herniation?
Coning; tonsillar herniation
Uncal herniation
Subfalcine
What is cushing’s reflex?
Hypertension
Bradycardia
Respiratory depression
What occurs with an uncal herniation?
Ipsilateral blown pupil as the herniation presses on the 3rd CN (can also get down and out pupil)
What is a bad sign with headaches?
If it wakes you up in the morning or worse in the morning
What should be done immediately with a headache worse in the morning?
FUNDOSCOPY to look for papilloedema
Why will increased ICP result in vomiting?
Increased pressure on the medulla
Will a headache associated with increased ICP get better or worse on coughing and leaning forward?
Worse
What should be given immediately if cushing’s triad is present?
Mannitol
Where should you look if there are metastases in the brain?
Testes
Breasts
Melanoma (moles, subungal)
Axillary freckling for NF1
What are tumours of the neuroepithelial tissue?
Astrocytes Oligodendroglial cells Ependymal cells/ choroid plexus Neuronal Pineal Embryonic - AFP, LDH, b-hcg
What is a grade 1 astrocytic tumour?
Pilocytic
Pleomorphic xanthoastroytoma
Subependymal glial cell
What is a grade 2 astrocytoma?
Low grade
What is a grade 3 astrocytoma?
Anaplastic astrocytoma
What is a grade 4 astrocytoma?
Glioblastoma multiforme
Describe a grade 1 astrocytoma
Benign
Slow growing
Children and young adults
Cerebellum affected
How are grade 1 astrocytomas treated?
Surgery
What are poor prognostic factors associated with low grade astrocytomas?
Age over 50 Focal deficit Short duration of symptoms Raised ICP Altered consciousness Enhancement on contrast studies
What is the treatment of a grade 2 astrocytoma?
Surgery +/- radio and chemo
What will low grade astrocytomas commonly present with?
Seizures
What is the median survival for an anaplastic astrocytoma?
2 years
What is the median survival for a glioblastoma multiforme?
14 months
Where will a GBM spread?
White matter tracking through corpus callosum and corticospinal tracts
What should you think about if there are multiple gliomas?
NF
Tuberous sclerosis
PML (Progressive multifocal leukoencephalopathy)
What is the treatment for GBM?
Non curative surgery to reduce mass effect
Post-op radiotherapy
If MGMT promoter myelination; should get treatment with oral alkylating chemotherapy
What will a GBM look like on MRI?
Heterogeneously enhancing SOL with areas of necrosis and a butterfly appearance
What is the grading of gliomas based off?
Cellular and nuclear atypia
Mitotic activity
Vascular endothelial proliferation
Necrosis
What do pilocytic astrocytomas look like pathologically?
Bipolar cells with long hair like projections
What are common sites for pilocytic astrocytomas?
Cerebellum
Midline; thalamus or optic chiasm
Where will oligodendrocytes grow?
Frontal lobe of cerebral hemisphere and can affect white matter and cortex
From what cell type will meningiomas grow?
Arachnoid cap cells in the arachnoid membrane
What is Foster Kennedy Syndrome?
Optic atrophy in ipsilateral eye and papilloedema int he contralateral eye
What are the common presentations of meningiomas?
Headache
Increased ICP
What are the clinical features of a prolactinoma?
Amenorrhoea Infertility Galactorrhoea Loss of libido ED
How are prolactinomas treated?
Dopamine agonist; cabergoline
Basically never operated on
What are the clinical symptoms of a growth hormone secreting tumour?
Pre-puberty: gigantism
Post-puberty: acromegaly
What tests should be run in the diagnosis of acromegaly?
Growth hormone levels
IGF-1 levels
OGTT
What tests should be run to diagnose cushing’s disease?
Low dose dexamethasone test to confirm cortisol excess
High dose dexamethasone test to differentiate between adrenal or pituitary causes (high dose will suppress cortisol if the source is pituitary)
How are pituitary tumours operated on?
Transsphenoidal hypophysectomy
What is the medical management of a growth hormone secreting tumour?
Pegvisomant and a somatostatin analogue such as octreotide to shrink the tumour pre surgery
What is the treatment of pituitary tumours if they are too large or are invading the cavernous sinus?
Radiotherapy
What is a vestibular schwannoma?
Benign tumours of schwann cells at the cerebellopontine angle affect the vestibular portion of CN8
What are the symptoms of a vestibular schwannoma?
Unilateral: Tinnitus Vertigo \+/- headache \+/- facial numbness
What does a bilateral vestibular schwannoma indicate?
NF2
What do vestibular schwannomas look like histologically?
Verocay bodies which are palisading nuclei against a fibrillary background
What is a haemangioblastoma?
Benign, cystic, highly vascular tumour
Where do haemangioblastomas originate?
Posterior fossa - resulting in cerebellar dysfunction and increased ICP
What conditions are haemangioblastomas associated with?
VHL: Haemangioblastoma Retinal angioma Renal cell carcinoma Phaeo
Describe an upper motor neurone lesion
Hypertonia Hyperreflexia Spasticity \+ve babinski sign Clonus
Describe a lower motor neurone lesion
Hyporeflexia Hypotonia Flaccid muscle weakness Fasciculations Muscle atrophy
How will children commonly present with brain tumours?
Tiptoeing
Ataxia
Vomiting with headache
What occurring in childhood will increase the risk of developing a meningioma as an adult?
Radiotherapy e.g. child with leukaemia
Meningioma will typically present with midline shift in the frontal lobe
What are the signs of a vestibular schwannoma?
Facial nerve palsy
Corneal reflex absent
Nystagmus
Hydrocephalus
What should be performed in any child with a midline tumour?
AFP
Beta-hcg
LDH
But not in increased ICP (risk of herniation)
What are symptoms of frontal lobe tumours/stroke/lesions?
Contralateral weakness due to deficit in primary motor cortex
Personality changes including disinhibition and cognitive slowing
Urinary incontinence due to disruption of micturition inhibition centre
Gaze abnormalities if involvement of frontal eye fields
Expressive dysphasia if brocas involved
Seizures
What are the symptoms of a temporal lobe tumour/ stroke/ lesion?
Memory deficit
Receptive aphasia if wernickes
Contralateral superior quadrantanopia
Seizures
What are the symptoms of a parietal lobe tumour/ stroke/ lesion?
Contralateral weakness and sensory loss
Contralateral inferior quadrantanopia
Dyscalculia - difficulty with maths
Dysgraphia- difficulty in ability to write
Finger agnosia - inability to distinguish fingers
Left-right disorientation- confusion between right and left limbs
If dominant lobe affected; gerstmann syndrome
If non-dominant lobe affected; neglect, dressing apraxia and constructional apraxia
What are the symptoms of an occipital lobe tumour/ stroke/ lesion?
Contralateral homonymous hemianopia
Visual hallucinations
What are the symptoms of a cerebellar tumour/ stroke/ lesion?
Ipsilateral ataxia N+V Dizziness and vertigo Slurred speech Intention tremor
