CNS tumors Flashcards
which part of the brain controls
Personality characteristics
Decision making
Voluntary muscle movement
Producing speech
Short term memory
frontal
which part of the brain
Sense of touch, taste, smell
Interpretation of objects and space
parietal
which part of the brain
Short and long-term memory
Understanding of speech
Hearing
Emotions
temporal
which part of the brain
Visual sense and interpretation
occipital
which part of the brain
Coordination
Balance and equilibrium
cerebellum
which part of the brain
Origination of 10 CN’s
Autonomic function
Consciousness
Balance
Reflexes
Brainstem
Symptoms of a CNS tumor will reflect one of 3 pathological processes:
- Functional area of the brain involved
- Compression of adjacent structures
- Increased ICP
generalized symptoms in CNS tumors often represent a result of what?
what are these sx?
increase in intracranial pressure
HA, seizures, N/V, depressed LOC, neurocognitive dysfunction
focal presentation of CNS tumor
seizures, weakness, sensory loss, aphasia, visual spatial dysfunction
What is the MC manifestation of brain tumors and is often the worst symptom
HA
CNS tumor HA are often nonspecific and resemble what other type of HAs? which is MC?
tension type HA (MC, 40-80%)
migraines (10%)
pt has a HA
Described as a dull, constant ache, occasional throbbing
Bifrontal with increased pain on left side
Pain often worsens with change in body position or any maneuver raising ICP (coughing, sneezing, vomiting, Valsalva)
Pain at night or waking from sleep
what is your possible dx?
CNS tumor - left
Bifrontal with increased pain on ipsilateral side of tumor - occasionally unilateral or generalized
Progresses over time
Red flag sx of a HA
- New onset HA in middle-age/older pt
- Change in prior HA
- N/V
- Abnormal neuro exam
- Worsening with change in body position or maneuvers that raise ICP
this sx is secondary to increased ICP
N/V
Factors that suggest tumor-associated emesis
- Emesis triggered by abrupt change in body position
- Neurogenic emesis – emesis present with other neurological sx (HA, neuro deficits)
Significant rise in ICP can lead to ? resulting in diminished and LOC
a loss of cerebral perfusion
Altered Level of Consciousness/Syncope associated with CNS tumors are triggered by what 2 factors?
position change
activities that further increase ICP
Syncope due to increased ICP may results in what?
seizure activity
what sx is one of the MC symptoms in primary and metastatic tumors
focal seizures
can develop into generalized tonic-clonic seizures
Intensity, type and frequency depends on location of the tumor, describe each
- Frontal - focal tonic-clonic movements w/ one extremity, inability to perform cognitive tasks
- Occipital - visual disturbances
- Temporal - abrupt behavioral/memory changes with or without aura
- Parietal - sensory seizures
- auditory, visual and/or tactile hallucinations or numbness in a part of the body
pt is presenting with
Memory problems
Intellectual decline
Personality changes
Mood changes and lability
Fatigue, malaise and loss of interest in everyday activities
this presentation is indicative of what?
Neurocognitive Dysfunction
presentation of frontal lobe lesion
- Personality change - lack of inhibition, inability to control emotions
- Progressive intellectual decline
- Difficulty w/ concentration and memory
-
Expressive aphasia
- May occur from involvement of the dominant frontal lobe - Broca’s region
- Word finding hesitation/word substitutions - Anosmia - pressure on the olfactory nerve
-
Weakness
- Direct involvement or edema compressing primary motor cortex
- Common and often subtle
presentation of parietal lobe lesion
- Sensory seizures - auditory, visual and/or tactile hallucinations
-
Contralateral disturbances of sensation
- Loss of sensation w/o respect to a dermatomal or peripheral nerve distribution
- Tactile discrimination
- Astereognosis - Written language interpretation - alexia, agraphia
- Visuospatial deficit
presentation of occipital lobe lesions
- Homonymous hemianopia
- Loss of color perception
- Prosopagnosia - Inability to recognize a familiar face
- Visual Simultagnosia - Inability to integrate and interpret a composite scene as opposed to its individual elements
presentation of Temporal Lobe Lesions
- Seizures with olfactory or gustatory hallucinations (taste)
- Motor phenomena such as licking or smacking of the lips
- Depersonalization, emotional changes and behavior disturbance
- Sensations of déjà vu
- Auditory illusions/hallucinations
- Long-term memory impairment
- No language comprehension (Wernicke’s)
presentation of Brainstem Lesions
Cranial nerve palsies (III - XII)
Ataxic gait
Nystagmus
Altered reflexes
presentation of cerebellar lesions
Marked ataxia of the trunk
Incoordination and hypotonia of the limbs
causes of Increased Intracranial Pressure
- Large mass
- Restriction of CSF outflow causing hydrocephalus
- Tumors close to 3rd and 4th ventricles may impede flow of CSF
- Disruption of BBB by angiogenesis of tumor = edema
Classic triad of HA, N/V, and papilledema may not always be present
3 types of herniations that causes increased ICP
- Subfalcial - occlude anterior cerebral artery = frontal lobe infarction
- Transtentorial/uncal
- compression of CN III, midbrain, and posterior cerebral artery
- =ipsilateral pupillary dilation, stupor, coma, decerebrate posturing, rsp arrest - Cerebellar–foramen magnum/tonsillar - Compression of medulla = apnea, circulatory collapse, and death
initial work-up for CNS tumor
Imaging
- MRI Brain w/ contrast (gadolinium)
- CT w/ contrast (Iodine) - alt for MRI CI
- resolution is not as high
- unable to detect small lesions/in posterior fossa - Labs: CBC, coag, CMP
functions of a brain MRI w/ contrast (gadolinium) for CNS tumor?
- Detects lesion and defines its location, shape, and size
- identify extent to which nml anatomy is distorted
- Demonstrates degree of any associated cerebral edema/mass effect
CI for brain MRI w/ contrast (gadolinium) in CNS tumors
metallic implants, embedded devices, or uncontrolled claustrophobia
what imaging is indicated in tumors that do not enhance on MRI with contrast
MR Spectroscopy
- Measures biochemical changes (chemical metabolism) in the brain
- Compares normal brain tissue vs abnormal
- Can be used to determine tumor type and aggressiveness
management for CNS tumor
-
Referral to neurosurgery
- Emergent: large, sx tumors - signs of increased ICP or impending herniation
- Outpatient: smaller tumors, minimal sx
- neurosurgical subspecialty experts in CNS neoplasms
- Determination on resection vs bx
— Histopathology is needed to determine type of lesion - Dexamethasone
- +/- Antiseizure - only if had a seizure
- levetiracetam, topiramate, lamotrigine, valproic acid, and lacosamide - impending herniation - secure airway
- tx depends on type, site and size of the tumor, as well as condition of the pts
- surgical excision, radiation, chemo, sx therapy, palliative
___ are supportive cells located around the axon but do not transmit electrical impulses
glial cells
glia = glue for the neuron
4 types of CNS glial cells
- Astrocyte - projections link neurons to their blood supply while forming the BBB
- Oligodendrocytes - make myelin
- Ependymal cells - line spinal cord and ventricular system of brain. secretes CSF and beat cilia to circulate CSF and make up the blood-CSF barrier
- Microglia - clear cellular debris and dead neurons through phagocytosis
Two types of PNS glial cells
- Schwann cells
- myelination to axons of PNS
- phagocytic activity - Satellite cells
- surround/protect neuron cell bodies in sensory, sympathetic, and PS ganglia
— Highly sensitive to injury/inflammation - chronic pain
- Regulate external chemical environment
- Provide nutrients to the neuron
risk factor for CNS tumors
- ionizing radiation - only known RF
- Diagnostic radiation NOT associated
- latency after exposure - as early as 5 years
what type of CNS tumors can arise from ionizing radiation
meningiomas, gliomas, and schwannomas
what type of CNS tumor is common in immunosuppression
primary CNS lymphoma
2 classifications of brain tumors
- Primary tumor - arise de novo
- Metastatic tumor - MC
- MC: lung; breast, melanoma, renal, and colorectal cancer
work up for primary CNS tumor
- Dx - bx + histopathological eval
- Classified by WHO grading system
WHO Grading is based on the following:
- histologic pattern of cell differentiation in tumor
- histologic features associated with its aggressiveness
- mitotic figures, necrosis, vascular proliferation
Grade inversely correlated with prognosis
Grade I - least aggressive
Grade IV - most aggressive
Types of primary CNS tumors
-
Malignant
- Gliomas - MC primary brain tumor - glioblastoma, astrocytomas , oligodendrogliomas (ODs), ependymomas
- Medulloblastoma
- Primary CNS lymphoma - Benign - Meningioma
A malignant tumor of the glial cells
glioma
3 types of gliomas
-
Astrocytomas - astrocyte
- Most aggressive → Glioblastoma - Oligodendrogliomas - oligodendrocyte
-
Ependymomas - ependymal cells
- MC children
can occur in brain or spinal cord
management for Low Grade Glioma - WHO Grade I & II
- Step 1: Complete surgical resection; if not, bx to confirm staging
- Step 2: Determine RF → age >40 or subtotal resection
- 1 RF - radiation + chemo
- 0 RF - observe - Step 3: Monitor for relapse
- relapse = Surgery + Chemo + Radiation
management for High Grade Glioma - WHO Grade III and IV
- maximal resection + chemoradiotherapy
- Consider clinical trials at all stages: up front, adjuvant, and at relapse
- Multidisciplinary approach is necessary for optimal outcome
- Neurosurgery, Neuro-oncology, Radiation therapy, Psychiatry, Neuropsychology, rehab, Social work
what tumors are considered Grade III?
“Anaplastic”
Anaplastic astrocytoma, Anaplastic oligoastrocytoma, Anaplastic oligodendroglioma, Anaplastic ependymoma,
what tumors are considered Grade IV
“Glio-”
“-blastoma”
MC malignant brain tumor in children
Medulloblastoma
Medulloblastoma originates in what part of the brain?
cerebellum (posterior fossa)
management for Medulloblastoma
resection + Chemo + Radiation
Prognosis: 75% of patients survive into adulthood
a rare non-Hodgkin lymphoma
MC associated with immunodeficiency states
Primary CNS Lymphoma
AIDS, iatrogenic immunosuppression
additional eval for Primary CNS Lymphoma
assess for immunodeficiency diseases - if not previously dx
CSF analysis to r/o ddx of toxoplasmosis
management for Primary CNS Lymphoma
-
glucocorticoids
- hold until after bx d/t cytolytic effect of steroid on lymphoma cells = false negative bx - chemotherapy
- radiation
A tumor that develops on the dura mater or arachnoid mater
Second MC primary CNS tumor
Meningioma
WHO grading for Meningioma
I is benign
II is “atypical”
III is malignant
sx in Meningioma are dependent on what?
- sx occur due to compression of surrounding neural structures
- sx will depend on size and location of compression
if a pt has a Small (<2 CM) asymptomatic meningioma, what is the managment?
observe x repeat MRI in 3-6 mo
if growth = surgery/irradiation
management for Grade II & III meningiomas
wide resection of tumor margins
how do sx of metastatic CNS tumors differ from regular primary tumors?
tend to progress more rapidly
MRI features of metastatic CNS tumors/lesions
- presence of multiple lesions
- Localization at junction of gray + white matter
- Circumscribed margins
- Large vasogenic edema compared with size of lesion
T/F: bx is needed to establish dx of metastatic CNS tumor
F - Bx is usually not necessary if the lesion looks metastatic and a preexisting primary cancer is known to have a propensity for metastasis
management for metastatic CNS tumors
glucocorticoids, radiotherapy, chemo and palliative surgery
3 types of spinal cord tumors based upon location
-
Intramedullary: MC - glioma
- Ependymomas - MC spinal glioma -
Intradural-extramedullary
- meningiomas
- nerve sheath tumors - Schwannoma, neurofibroma -
Extradural
- often metastatic - MC prostate, breast, lung
ways of how spinal cord tumors cause s/s? (pathophys)
- Direct compression of neurologic structures
- Ischemia secondary to arterial or venous obstruction
- Invasive infiltration
Localized pain - wakes nocturnally - gnawing and unremitting
Sensory dysesthesias and muscular weakness - unilaterally but progresses to bilateral involvement
Bladder, bowel and sexual dysfunction may occur
Progressive difficulty in ambulation
what is the dx?
spinal cord tumor
imaging for spinal cord tumors
MRI spine w/ contrast
management for spinal cord tumors
glucocorticoids
surgical decompression/removal
radiotherapy
what is SPIKES?
Patient-first approach to notify a pt of a brain tumor
- Setting
- perception
- invitation
- knowledge
- emotion
- summarize
