CNS Tumors - Exam 3 Flashcards
_____ is responsible for personality characteristics, decision making,
voluntary muscle movement, speech production, short term memory
frontal lobe
_____ lobe is responsible for the sense of touch and interpretation of objects and space
Parietal
_____ lobe is responsible for short and long-term memory, understanding of speech,
hearing and emotions
temporal lobe
____ lobe is responsible for visual sense and interpretation
occipital lobe
____ lobe is responsible for coordination, balance and equilibrium
cerebellum
Cranial nerves _____ through ____ all arise from the brainstem
3-12 all arise from the brainstem
Symptoms of a CNS tumor will reflect one of 3 pathological processes. What are they? How do the symptoms present?
Functional area of the brain involved
Compression of adjacent structures
Increased intracranial pressure
insidious in onset and can be general or focal
Generalized symptoms of a CNS tumor often present like _______
increased intracranial pressure
_____ is the most common manifestation of brain tumors and is often the worst symptom– occurs in 50% of patients. Describe them
HA
HA’s are often nonspecific and resemble tension-type headaches (40-80%) or migraines
What are the characteristics of a HA that is consistent with a CNS tumor?
dull, constant ache, occasional throbbing
bifrontal with increased pain on the same side of the tumor
progresses over time
pain increases with change in body position or any raises in ICP
pain at night or pain that wakes you up from sleep
**What are the red flag symptoms associated with HA?
What is the N/V associated with CNS tumors due to? What can trigger them that would make you think it is due to CNS tumor?
due to increased ICP
Emesis triggered by abrupt change in body position
Neurogenic emesis – emesis present with other neurological symptoms such as headache or neuro deficits
HA
N/V
Altered Level of Consciousness/Syncope
seizure
neurocognitive dysfunction
What am I?
CNS tumor
In CNS tumors, what is the Altered Level of Consciousness/Syncope due to? What is it triggered by?
Significant rise in ICP can lead to a loss of cerebral perfusion resulting in diminished and loss of consciousness
Triggered by position change or activities that further increase ICP
Syncope due to increased ICP may results in ______
seizure activity
_____ are one of the most common symptoms in primary and metastatic tumors. What do these depend on?
Focal seizures
intensity, type and frequency depends on the location of the tumor
What lobe? _____ focal tonic-clonic movements involving one extremity, inability to perform cognitive tasks
Frontal lobe
What lobe? _____ visual disturbances
occipital lobe
What lobe? ______ abrupt behavioral/memory changes with or without aura
temporal lobe
What lobe? _____ sensory seizures
auditory and/or tactile hallucinations or numbness in a part of the body
parietal lobe
What are focal symptoms clinical presentation based on?
functional location of tumor or compression of surrounding structures
What lobe?
Personality changes
Progressive intellectual decline
Difficulty with concentration and memory
Expressive aphasia
anosmia
contralateral weakness
frontal lobe
What is expressive aphasia? What region of the brain?
Word finding hesitation or word substitutions
able to think clearly but not able to expressive themselves verbally
Broca’s region
What is anosmia? What part of the ____ lobe?
the partial or total loss of the ability to smell due to pressure on the olfactory nerve
base of the frontal lobe
Sensory seizures: tactile hallucinations
Contralateral disturbances of sensation: loss of sensation that is NOT consistent with dermatomes
astereognosis
Visuospatial deficit, R/L awareness
What lobe?
Parietal Lobe Lesions
Homonymous hemianopia
Loss of color perception
Sensory seizure- visual hallucinations
Prosopagnosia
Visual Simultagnosia
What lobe?
What is Prosopagnosia?
What is Simultagnosia?
occipital lobe
Prosopagnosia: Inability to recognize a familiar face
Simultagnosia: Inability to integrate and interpret a composite scene as opposed to its individual elements
Olfactory (smell) or gustatory (taste) hallucinations
Auditory illusions or hallucination
Motor phenomena such as licking or smacking of the lips
Depersonalization, emotional or behavioral changes
Sensations of déjà vu
long-term memory impairment
Lack of language comprehension (Wernicke’s)
What lobe?
What is the difference between illusions or hallucinations?
temporal
illusion have stimulus and hallucinations do NOT have a stimulus
Cranial nerve palsies (III - XII)
Ataxic gait
Nystagmus
Altered reflexes
Where is the lesion?
brainstem
Marked ataxia of the trunk
Incoordination and hypotonia of the limbs
Where is the lesion?
cerebellar lesion
What is the classic triad of ICP?
headache, nausea/vomiting, and papilledema
What are 3 pathophysiologic processes that result in ICP?
Large mass
Restriction of CSF outflow causing hydrocephalus
Disruption of the blood brain barrier by angiogenesis of the tumor leading to edema
What are 3 types of herniation due to ICP?
subfalcial
transtentorial/uncal
cerebellar-foramen magnum/tonsillar
a subfalcial herniation may occlude the _______ leading to _____ lobe infarction
anterior cerebral artery
frontal
position 1
a transtentorial/uncal herniation compresses _______, midbrain and ________. What does it lead to?
compression of CN III
posterior cerebral artery
Leads to ipsilateral pupillary dilation, followed by stupor, coma, decerebrate posturing, and respiratory arrest
aka a unilateral blown pupil is NOT GOOD
position 2
Cerebellar–foramen magnum/tonsillar compression of the ______ causing apnea, circulatory collapse, and death
medulla
position 3
What is the imaging of choice for a CNS tumor? Why is it better?
MRI Brain with contrast (gadolinium)
Detects the lesion and defines its location, shape, and size. Can detect normal anatomy distortion. demonstrates the degree of any associated cerebral edema or mass effect
What are the CI for a brain MRI? What is the next best option?
metallic implants, embedded devices, or uncontrolled claustrophobia
CT scan with iodine
A brain CT with contrast is not helpful in detecting _______ or _____ lesions
unable to detect small lesions or those in the posterior fossa
When is a MR spectroscopy indicated? How does it work?
indicated in tumors that do not enhance on MRI with contrast
Measures biochemical changes (chemical metabolism) in the brain and compares it to the chemical composition of the normal brain tissue. Tissue activity is plotted on a graph with varying heights
What is the management for a pt with a CNS tumor? How do you determine urgent vs outpt?
refer to neurosx!!
urgent: large, symptomatic tumors - signs of increased ICP or impending herniation
outpt: smaller tumors and those with minimal symptoms
What do you do pharm management wise for a CNS tumor?
Dexamethasone-> to reduce seizures
if the pt has had a seizure: start AED medications (levetiracetam (Keppra), topiramate (Topamax), lamotrigine (Lamictal), valproic acid, and lacosamide (Vimpat))
What antiseizure drugs do you want to avoid in a pt with a CNS tumor?
AVOID phenytoin and fosfphenytoin
**What is MORE IMPORTANT for a pt with a CNS tumor that is showing s/s of an impending herniation or midline shift?
**secure an airway!!!
super important that this gets done ASAP
What are the generic tx options for CNS tumors?
Surgical excision
Radiation - main treatment if needed after resection
Chemotherapy
Symptomatic therapy: Corticosteroids, Anticonvulsants
Palliative care
What are glial cells? What are the 4 types of CNS glial cells?
Glial cells are supportive cells located around the axon but do not transmit electrical impulses
Astrocyte
Oligodendrocytes
Ependymal cells
Microglia
What type of glial cell? _______ have numerous projections that link neurons to their blood supply while forming the blood-brain barrier
astrocyte
link neurons to their blood supply
What type of glial cell? _______ create myelin which forms the myelin sheath around the axon
Oligodendrocytes
create myelin
What type of glial cell? _______ line the spinal cord and the ventricular system of the brain. They secrete CSF and beat their cilia to help circulate the CSF and make up the blood-CSF barrier
Ependymal cells
secrete CSF and beat their cilia to help circulate the CSF
What type of glial cell? _______ clear cellular debris and dead neurons from nervous tissue through phagocytosis
microglia
clear cellular debris and dead neurons
What are the 2 types of PNS glial cells?
Schwann cells
Satellite cells
What type of PNS cell? ________ provide myelination to the axons of the PNS
have phagocytic activity, clearing cellular debris allowing regrowth of PNS neurons
Schwann cells
provides myelination and have phagocytic activity
What type of PNS cell? ________ surround (and protect) neuron cell bodies in sensory, sympathetic, and parasympathetic ganglia. Highly sensitive to injury and inflammation. Regulate the external chemical environment
Provide nutrients to the neuron
satellite cells
What are the 4 responsibilities for a satellite cell?
surround (and protect) neuron cell bodies in sensory, sympathetic, and parasympathetic ganglia
Highly sensitive to injury and inflammation and contribute towards chronic pain syndromes
Regulate the external chemical environment
Provide nutrients to the neuron
_____ cells are highly sensitive to injury and inflammation and contribute towards _______
satellite cells
chronic pain syndromes
What are the 2 classifications of CNS tumors?
primary: arises from nothing aka originated in the brain
metastatic tumor: MC- come from a cancer somewhere else in the body
What is the MC type of metastatic tumor that travels to the brain? give 4 more
lung- MC
breast, melanoma, renal and colorectal
What is the only known risk factor for CNS tumor? ______ and _____ are at the highest risk
Exposure to ionizing radiation is the only known risk factor
Therapeutic radiation and atomic bomb survivors are at highest risk
with regards to diagnostic radiation, ____________ is a risk factor for a CNS tumor. When will they typically present?
Diagnostic radiation: head CT exposure in children
usually as early as 5 years after exposure
_______ increases your risk for CNS lymphoma
immunosuppression
What is the grading of CNS tumors based on? What is the scale?
cell differentiation and aggressiveness (mitotic figures, necrosis, vascular proliferation)
Grade I-IV: 1 is least aggressive and IV is most aggressive
What are the 3 different kinds of MALIGNANT CNS tumors? Which one is MC?
Gliomas- MC
Medulloblastoma
Primary CNS lymphoma
What are the 3 different types of gliomas? Are these malignant or benign? Where can they occur?
astrocytomas
oligodendrogliomas (ODs)
ependymomas
all are malignant
brain or spinal cord
What is the only benign type of CNS tumor?
Meningioma
**WHO grade III will have the word _______ in the name
“anaplastic”
**WHO grade IV will either start with ______ or end with ________
“Glio” or “-blastoma”
What is the most aggressive type of astrocytoma?
Glioblastoma
______ is the MC type of glioma that is common in young children
Ependymomas
What is the management for glioma WHO grade I and II? **What are the 2 criteria/risk factors for observation as the next step?
complete surgical resection
NEED BOTH in order to qualify for observation:
less than 40 and clean margins on bx
If 1 of the risk factors are present with regards to WHO I and II management after bx, what is the next step? then what is next?
radiation followed by chemotherapy
monitor for relapse: if occurs: sx, chemo and radiation
What is the management for WHO III and IV?
Maximal, safe resection with concurrent chemoradiotherapy
consider clinical trials!!!!
______ is the MC malignant brain tumor in children. What is another name for it? Where does it originate?
Medulloblastoma
cerebellar primitive and neuroectodermal tumor (PNET)
cerebellum (posterior fossa)
What is the management for a Medulloblastoma? What is the survival rate?
Surgical resection
Chemotherapy
Radiation therapy
75% of pts survive into adulthood
_______ is MC associated with immunodeficiency states. If one is not obviously present, what do you need to do?
Primary CNS Lymphoma
need to go find the source!! aka need to test for some immunodeficiency states
in primary CNS lymphoma, need to order CSF analysis to rule out Ddx of _______ in immunocompromised patients
toxoplasmosis
What is the management for primary CNS lymphoma?
glucocorticoids
chemo
radiation
in primary CNS lymphoma, want to avoid giving ______ if possible because it will interfere with the histology results. When should you give it?
glucocorticoids
but need to give if you suspect herniation, midline shift or edema!!!!
______ is the 2nd MC primary CNS tumor. What is it?
Meningioma
A tumor that develops on the dura mater or arachnoid mater
What is the WHO grading system for Meningiomas? What is causing the s/s?
I is benign
II is “atypical”
III is malignant
Symptoms occur due to compression of surrounding neural structures and size
What is considered small in a meningioma? What is the tx?
Small (<2 CM) asymptomatic
tumors may be conservatively managed with observation and repeat MRI in 3-6 months. If growth consider surgery vs irradiation
What is the management for Grade II and III meningiomas?
Grade II and III tumors require wide resection of tumor margins
What cancers are the MC to spread to the brain? Which one has the highest propensity to spread to the brain?
lung** MC, breast, melanoma, renal, colorectal
melanoma has the highest propensity
What is the management for a metastatic CNS tumor? **Is bx necessary? Do s/s tend to progress more rapidly or slowly?
glucocorticoids, radiotherapy, chemotherapy and palliative surgery
**Biopsy is usually not necessary
progress more rapidly than primary tumors
What are the 3 kinds of spinal cord tumors?
intramedullary
intradural-extramedullary
extradural
What is the MC type of cancer found in the intramedullary spinal cord?
gliomas specifically -> ependymomas are the MC spinal glioma
What type of CNS tumors are found in the Intradural-extramedullary location of the spinal cord?
meningiomas
nerve sheath tumors: Schwannoma, neurofibroma
What kinds of metastatic cancers tend to spread into the extradural location of the spinal cord?
prostate, breast and lung
What are some pathophys reasons behind the s/s seen with spinal cord tumros?
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
may start unilaterally but progresses to bilateral involvement
Bladder, bowel and sexual dysfunction may occur
Progressive difficulty in ambulation
What am I?
What is the imaging of choice?
What is the management?
spinal cord tumor
tx: MRI spine with contrast
management:
glucocorticoids
surgical decompression/removal
radiotherapy
What is the SPIKES model for delivering bad news? just read the slide a couple times and you should be fine
