Delta: Neuro-oncology

Question 1

the cerebrum is derived from what?

Answer 1

telencephalon

Question 2

what are the 6 lobes of the cerebral hemispheres?

Answer 2

frontal
parietal
temporal
occipital
insular
limbic

Question 3

where is the frontal lobe and what important structures are contained within it?

Answer 3

between central sulcus and frontal pole, above sylvian fissure

• precentral gyrus (motor)
• superior frontal gyrus
• middle frontal gyrus (frontal eye movement)
• inferior frontal gyrus (brocas area)

Question 4

damage to brocas area causes what?

Answer 4

expressive dysphasia

- can comprehend language but has difficulty with own language/speech

Question 5

where is the parietal lobe and what important structures are contained within it?

Answer 5

between central sulcus and occipital lobe, superior to temporal lobes

• postcentral gyrus (sensation)
• superior parietal lobule
• inferior parietal lobule

Question 6

what does damage to inferior parietal lobule cause?

Answer 6

nominal aphasia

- problems recalling words, names and numbers

Question 7

where is the temporal lobe and what important structures are contained within it?

Answer 7

inferior to sylvian fissure, between temporal pole and occipital lobe

• superior temporal gyrus (auditory cortex and wernickes speech area in dominant hemisphere)
• middle temporal gyrus
• inferior temporal gyrus

Question 8

where is the occipital lobe and what is contained within it?

Answer 8

caudal to parieto-occipital sulcus

contains visual cortex

Question 9

where is the insular lobe?

Answer 9

deep within lateral sulcus

Question 10

what is the limbic system?

Answer 10

group of structures located on medial hemisphere surface that encircle corpus callosum
serves for higher emotional functions and memory
- includes hippocampus

Question 11

where is the cerebellum derived from?

Answer 11

metencephalon

Question 12

what connects the right and left hemispheres of the cerebellum?

Answer 12

vermis

Question 13

what are the 3 functional components of the cerebellum?

Answer 13

vestibulocerebellum (balance and vestibulo-ocular reflexes)
spinocerebellum (muscle tone, posture and gait)
cerebrocerebellum (voluntary motor movement, corrects any error in movement to ensure smooth movements)

Question 14

pneumonic for symptoms of cerebellar dysfunction?

Answer 14

DANISH

• Dysdiadochokinesia
• Ataxia (broad based gait)
• Nystagmus
• Intention tremor
• Scanning dysarthria
• Hypotonia

Question 15

what 4 structures are derived from the diencephalon?

Answer 15

thalamus
hypothalamus
subthalamus
epthalamus

Question 16

what is the largest part of the diencephalon and what does it do?

Answer 16

thalamus

- major relay centre for the brain (motor function, sensory, visual and auditory impulses, ARAS system)

Question 17

what would a thalamic infarction cause?

Answer 17

hemiparesis
spontaneous pain
hemichorea
can cause severe impairment of consciousness

Question 18

what is the function of the hypothalamus?

Answer 18

influences 3 systems

• autonomic nervous system
• endocrine system
• limbic system

Question 19

list 5 roles of the hypothalamus

Answer 19

body thermal regulation
regulates release of hormones from adenohypophysis (anterior pituitary)
synthesises ADH and oxytocin which project to neurohypophysis (posterior pituitary)
regulates feeding and starvation
mammillary nucleus receives input from hippocampal formation (wernickes encephalopathy in thiamine deficiency)

Question 20

lesions of mammillary nucleus produce what symptoms?

Answer 20

confusion
ataxia
nystagmus
can progress to koraskoff’s syndrome (amnesia and confabulation)

Question 21

lesions of subthalamus cause what symptoms?

Answer 21

contralateral hemiballism

Question 22

what are the 5 basal ganglia?

Answer 22

caudate nucleus
putamen
globus pallidus
substantia nigra
subthalamic nucleus

Question 23

what is the general role of the basal ganglia?

Answer 23

role in initiation and facilitation of movement and in the control of muscle tone

Question 24

what causes parkinsons disease?

Answer 24

neuronal loss and presence of alpha-synuclein protein inclusions (Lewy Bodies) in areas of the brain, mainly the substantia nigra where dopaminergic neurons are found

Question 25

what are the 3 main features of parkinsons disease?

Answer 25

akinesia (slowness, difficulty initiating movement) rigidity resting tremor ("pill rolling tremor")

Question 26

tumours of the CNS essentially present with what 5 symptoms?

Answer 26

progressive, focal neurological deficits headaches (ICP features) seizures gradual cognitive decline and personality changes endocrine disturbances (in hypothalamus/pituitary tumours)

Question 27

when might a tumour cause acute symptoms?

Answer 27

if it bleeds

Question 28

6 features of a frontal lobe tumour/lesion?

Answer 28

- contralateral weakness (motor cortex deficit) - personality changes - urinary incontinence (disruption of micturition inhibitory centre) - gaze abnormalities - expressive dysphasia/aphasia (if left sided and brocas affected) - seizures

Question 29

4 features of a temporal lobe tumour/lesion?

Answer 29

memory deficits receptive aphasia/dysphasia (wernickes affected) contralateral superior quadrantanopia seizures

Question 30

4 features of a parietal lobe tumour/lesion?

Answer 30

contralateral weakness and sensory loss (somatosensory cortex damage) contralateral inferior quadrantanopia gerstmann syndrome neglect, apraxia

Question 31

what is gerstmann syndrome?

Answer 31

dyscalculia-maths, dysgraphia-writing, finger agnosia- distinguish fingers, right/left disorientation occurs due to parietal lobe damage

Question 32

2 features of occipital lobe tumour/lesion?

Answer 32

contralateral homonymous hemianopia (with macular sparing?) | visual hallucinations

Question 33

5 features of cerebellar tumour/lesion?

Answer 33

``` ipsilateral ataxia nausea and vomiting dizziness and vertigo slurred speech intention tremor ```

Question 34

how are the 4 grades of CNS tumours defined?

Answer 34

``` 1 = no morphological features 2 = atypia alone 3 = atypia and mitosis 4 = atypia, mitosis with vascular proliferation or necrosis ```

Question 35

what are the most common primary brain tumours?

Answer 35

high-grade gliomas - anaplastic astrocytoma (grade 3) - glioblastoma multiforme (grade 4, most common)

Question 36

describe an anaplastic astrocytoma

Answer 36

WHO grade 3 may have progressed from low-grade astrocytoma or can be seen without any underlying lesion often progress to a glioblastoma multiforme

Question 37

who and where in the brain is a glioblastoma multiforme most common?

Answer 37

``` older people (60-70) usually in cerebral hemispheres (temporal, parietal and frontal lobes) ```

Question 38

how does a GBM appear on imaging?

Answer 38

MRI is best heterogeneously enhancing space occupying lesions with areas of necrosis can have a butterfly appearance

Question 39

how is a GBM diagnosed?

Answer 39

MRI | if MRI suggestive of high grade glioma then a histology sample is required

Question 40

how is a GBM managed?

Answer 40

surgery + radiotherapy +/- chemotherapy | - improves median survival to 14 months

Question 41

what are the most common low grade gliomas and when do they most commonly occur?

Answer 41

``` pilocytic astrocytoma (grade 1) diffuse astrocytoma (grade 2) oligodendroglioma (grade 2) peak incidence = 20s and 30s ```

Question 42

who and where is pilocytic astrocytoma most common in?

Answer 42

children and young adults | most common sites = cerebellum and midline structrures (thalamus, chiasm etc)

Question 43

clinical features of pilocytic astrocytoma?

Answer 43

depends on site of tumour

Question 44

optic pathway gliomas are common in which condition?

Answer 44

NF1

Question 45

how are grade 2 tumour different to grade 1?

Answer 45

grade 2 has potential to transform to high grade | less histologically stable

Question 46

describe how diffuse astrocytomas develop

Answer 46

usually in cerebral hemispheres (frontal and temporal lobes) slow growing tendency to progress to higher grade

Question 47

how does diffuse astrocytoma commonly present?

Answer 47

often in young adults | often presents with seizures

Question 48

how is a diffuse astrocytoma managed?

Answer 48

maximal resective surgery + chemo/radiotherapy

Question 49

high cure rate is seen in pilocytic astrocytoma with what treatment?

Answer 49

maximal resective surgery with or without adjuvant treatment

Question 50

which tumours have the best prognosis?

Answer 50

oligodendrogliomas

Question 51

where do oligodendrogliomas usually affect in the brain?

Answer 51

frontal lobe and can affect the white matter and the cortex | invade the subarachnoid space leading to a white toothpaste appearance

Question 52

how do oligodendrogliomas typically present?

Answer 52

25-45 yrs old | seizures and headaches

Question 53

what is a meningioma?

Answer 53

common, benign, slow growing extra-axial tumours originating from arachnoidal cap cells in arachnoid mater

Question 54

who are meningiomas most common in?

Answer 54

elderly 6th and 7th decade | slightly more common in females

Question 55

multiple meningiomas are common in which condition?

Answer 55

NF2 | radiation in childhood

Question 56

how does a meningioma present?

Answer 56

usually asymptomatic and found incidentally on imaging can have headaches and symptoms of increased ICP can have foster kennedy syndrome if olfactory groove affected

Question 57

what is foster kennedy syndrome?

Answer 57

optic atrophy in ipsilateral eye and papilloedema in contralateral eye

Question 58

imaging features of meningioma?

Answer 58

well demarcated | do not infiltrate the brain

Question 59

most pituitary adenomas are functional or non-functional?

Answer 59

non-functional

Question 60

what is the most common functional pituitary adenoma?

Answer 60

prolactinoma

Question 61

features of prolactinoma?

Answer 61

``` amenorrhoea infertility galactorrhoea loss of libido ED ```

Question 62

how is a prolactinoma managed?

Answer 62

dopamine agonists | - cabergoline

Question 63

features of GH secreting adenoma?

Answer 63

gigantism/acromegaly

Question 64

features of ACTH secreting adenoma?

Answer 64

cushings features

Question 65

features of thyrotropin secreting adenoma?

Answer 65

``` palpitations weight loss insomnia nervousness/anxiety goiter ```

Question 66

most common surgical intervention for pituitary tumours?

Answer 66

transphenoidal hypophysectomy

Question 67

how is GH secreting adenoma managed?

Answer 67

pegvisomant and somatostatin analogues (octreotide) | surgery

Question 68

what is an acoustic neuroma and where are they found?

Answer 68

benign tumours derived from schwann cells commonly arise in cerebellopontine angle affecting the vestibular portion of CN8 AKA vestibular schwannoma

Question 69

bilateral acoustic neuroma suggests what?

Answer 69

NF2

Question 70

what can be seen on pathology in acoustic neuroma?

Answer 70

verocay bodies | - palisading nuclei against a fibrillary background

Question 71

how does an acoustic neuroma present?

Answer 71

30-50 year olds unilateral sensorineural hearing loss tinnitus vertigo can have a headache depending on size of tumour can have facial pain if trigeminal nerve affected

Question 72

how is an acoustic neuroma managed?

Answer 72

serial observation stereotactic radiosurgery microsurgical excision

Question 73

what is a haemangioblastoma?

Answer 73

beningn, cystic, highly vascular tumour

Question 74

where do haemangiobatomas develop and what do they cause?

Answer 74

posterior fossa | lead to cerebellar dysfunction symptoms and raised ICP

Question 75

haemangioblastomas are associated with what condition?

Answer 75

von-hippel lindau syndrome