Brain Tumours and Raised Intracranial Pressure Flashcards by Srishti D

When do the peaks in brain tumours occur during life?

Infancy and childhood
- Most are development related tumours
7th decade

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What is the WHO classification of CNS tumours?

Based on presumed cell of origin

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What are the common brain tumours?

Neuroepithelial tumours (gliomas) = 52%
- Astrocytoma = 44%
- Ependymoma
- Oligodendroglioma
- Medulloblastoma
Metastatic tumours = 15%
Meningioma = 15%
Pituitary adenoma
Acoustic neuroma

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How are pituitary adenomas classified based on size?

Micro <10 mm

Macro >10 mm

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What is the most common type of pituitary adenoma?

Prolactinoma

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What are some symptoms of an acoustic neuroma?

Features of vertigo that may have a central cause
Nystagmus
CN VI and/or CN VII palsy

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Why can an acoustic neuroma cause a CN VI and/or CN VII palsy?

Growth of Schwann cells on CN VIII can compress other 2 nerves, which are very close by

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What is the aetiology of brain tumours?

Few clearly defined environmental risk factors
- Ionising radiation in therapeutic radiotherapy/nuclear explosions increase risk for meningioma and glioma
- No role proven for EM radiation/other environmental factors
Family history rare
Some inherited/genetic conditions predisposing
- Neurofibromatosis 1 and 2
- Li Fraumeni syndrome

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Why is a sixth cranial nerve palsy a false lateralising sign?

It can occur with raised intracranial pressure (ICP) because of its long route

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What is a sensitive test for pyramidal problems?

Pronator drift

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What is Foster-Kennedy syndrome?

Brain tumour on one side of the brain causes optic nerve atrophy on ipsilateral side an papillary oedema on contralateral side due to raised ICP

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What are the differential diagnoses for raised intracranial pressure with focal neurological deficits suggesting intracranial mass enlarging over a few weeks?

Primary brain tumour
Metastatic brain tumour
Brain abscess
- Possible to have no fever
- More likely if fever present
Chronic subdural haematoma

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When do malignant astrocytomas most commonly occur?

6th-8th decade

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What is the prognosis for malignant astrocytomas?

Dismal

Medial survival for glioblastoma multiforme = 7-14 months

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What defines a malignant astrocytoma histopathologically?

Hypercellularity
Cellular atypia/pleiomorphism
Mitoses
Endothelial hyperplasia
Necrosis/pallisading necrosis

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What is the typical presentation of an intracranial mass?

Symptoms of raised intracranial pressure
Seizures in 40-80%
Focal neurological deficit
- Depends on location of mass
Duration of symptoms depends on rate of growth of mass

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What does the growth rate of a tumour depend on?

Grade of tumour

From weeks to years

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What are the things you see on a CT scan with raised intracranial pressure caused by a mass?

Tumour mass
Surrounding oedema
Hydrocephalus if CSF pathways blocked

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What are the symptoms of raised intracranial pressure?

Headache
Nausea and vomiting
Drowsiness

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Describe the headache presentation in raised intracranial pressure

Very common symptom in patients with brain tumours
Gradually progressive
Worse on waking > improves during day
Nausea and vomiting as intracranial pressure rises
- Vomiting may relieve headache temporarily

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What does drowsiness indicate in raised intracranial pressure?

Important sign of critically raised intracranial pressure
Implies impending deterioration
An alert patient with severely raised intracranial pressure may deteriorate very quickly with even a small further rise

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What does the clinical syndrome of raised intracranial pressure warrant?

Urgent investigation

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What is the Monro-Kellie doctrine?

Cranial cavity rigid box - increase in contents > rise in pressure
Some capacity for compensation
When critical point reached, even small increases in volume result in large increases in intracranial pressure

What are some focal neurological deficits seen when the tumour is in the frontal lobe?

Mood disturbance
Personality change
Psychiatric symptoms
Especially seen in butterfly gliomas, where tumour in both frontal lobes

Where is the tumour if there is limb weakness?

Motor cortex in posterior frontal lobe | Deep pyramidal pathways

Where is the tumour if there is a visual field deficit?

Anywhere along visual pathway - Occipital - Temporal - Parietal

Where is the tumour if dysphasia is present?

Dominant frontal lobe | Temporal lobe

What sort of deficits can be caused with brainstem tumours?

``` Multiple Weakness Sensory loss Diplopia Cranial nerve deficits ```

What are the principles of treatment of malignant astrocytomas?

Steroids = dexamethasone - Reduction of vasogenic cerebral oedema and intracranial pressure Resection of as much of tumour as safely possible Adjuvant therapy - Radiotherapy and chemotherapy

What does surgery for a malignant astrocytoma involve?

``` Tissue diagnosis essential Resection of all visible tumour if possible - Still leave microscopic tumour - Reduces mass effect and symptoms - Tissue for banking and research ```

Why is tumour resection often not possible?

``` Tumour extent - Large - Diffuse Tumour location Patient age/fitness for surgery ```

What is the prognosis for anaplastic astrocytoma?

2-5 years

When is prognosis worse in the cases of malignant astrocytoma?

Older age at diagnosis, especially >65 Poor neurological condition Higher grade Incomplete surgical removal

What is the histopathology of a low grade glioma?

``` Like malignant astrocytoma, but less abnormal for - Hyper-cellularity - Cellular atypia/pleiomorphism - Nuclear atypia/pleiomorphism Very few mitoses No necrosis Invades diffusely through normal brain May have calcifications ```

What sorts of tumours are included in low grade gliomas?

Oligodendroglioma Astrocytomas Mixed forms

Who is most commonly affected by low grade gliomas?

Young = 25-40

How do low grade gliomas often present?

Neurologically intact | Often only have seizures

What is the prognosis for low grade gliomas?

Prolonged = years-decades | Eventual growth of low grade tumour/progression to higher grade will occur

What are the principles of treatment of low grade glioma?

Side effects of treatment important and should be avoided Removal of as much tumour as safely possible Often only biopsy taken to avoid deficit Tissue diagnosis essential Defer radiotherapy and chemotherapy until tumour progression

What is the proportion of solitary to multiple metastatic brain tumours?

``` Solitary = 1/3 Multiple = 2/3 ```

What is the cause of symptoms with metastatic brain tumours?

Often cause intense cerebral oedema that causes more symptoms than tumour mass

What are the commonest primary tumours to cause brain metastases?

``` Carcinoma of lung Carcinoma of breast Metastatic melanoma Carcinoma of kidney Gastrointestinal carcinoma Unknown primary ```

What is the presentation of metastatic brain tumours?

Similar to any mass - Raised intracranial pressure - Focal deficits - Seizures

What is the treatment of brain metastases?

Steroids = dexamethasone Surgery to remove metastasis if - Solitary - Primary disease stable and patient has reasonable life expectancy If primary cancer unknown, metastasis removed to confirm diagnosis Occasionally 1 of multiple metastases removed for palliation Whole brain radiotherapy Stereotactic radiotherapy

When is whole brain radiotherapy used in brain metastases?

Multiple metastases | After removal of single metastasis

When is stereotactic radiotherapy used in brain metastases?

Single high dose focused radiation for 1-3 metastases

How can large meningiomas be asymptomatic?

Slow growing so brain has more time to adjust | Not destroying neurons

What is the most common benign brain tumour?

Meningioma

When are meningiomas most likely to occur?

Middle age

Do meningiomas affect men and women equally?

No, more common in women than men

What is the cell of origin of meningiomas?

Arachnoid cells in meninges

What are the characteristic locations of meningiomas?

Most common - Falx - Convexity - Sphenoid wing

What is the histopathology of meningiomas?

``` Multiple subtypes - Generally have no prognostic significance - Few portend poorer prognosis Whorls common features Malignancy infrequent ```

What is the presentation of meningiomas?

As for any intracranial mass - Raised intracranial pressure - Seizures - Focal neurological deficit Slow growing, therefore can reach very large size - Symptoms may be present for years - May be symptomatic and discovered incidentally

What are the principles of treatment of meningiomas?

Total surgical excision and obliteration of dural attachment most effective Subtotal excision and diathermy of dural attachment if complete excision not possible Radiosurgery/radiotheray for small, residual, recurrent, or malignant tumours Extent of resection related to risk of recurrence