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Neuro > Lecture 6: CNS Tumors > Flashcards

Lecture 6: CNS Tumors Flashcards

1
Q

What 2 CNs do NOT originate in the brainstem?

A

CN1 and CN2

Smell and Sight

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2
Q

What are the symptoms of a CNS tumor based on? (3 processes)

A
  1. Functional areas of the brain involved
  2. Compression of adjacent structures
  3. Increased ICP
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3
Q

If a patient has a generalized symptomatic presentation due to CNS tumor, what is the most likley underlying pathological process?

A

Increased ICP

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4
Q

What is the MC manifestation of brain tumors?

A

Headache

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5
Q

Describe the HA that typically presents with CNS tumor.

A
  • Non-specific
  • Resembles tension or migraines
  • Bifrontal, but increased pain on ipsilateral side
  • Worsens with body position change or valsalva/coughing
  • Pain at night or waking from sleep

Pain at night is due to the hypoventilation that occurs during sleep, causing increased CO2 and increased vasodilation.

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6
Q

What are the red flag symptoms regarding HAs?

A
  • New onset in middle/old
  • Change in prior HA
  • Associated N/V
  • Abnormal neuro exam
  • Worsening with body position change
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7
Q

What suggests that emesis is neurologic in etiology?

A
  • Triggered by body position change
  • Presence of other things like HA or neuro deficits.
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8
Q

What kind of seizure is MC in primary tumors and mets?

A

Focal seizures

Specific symptoms are related to the lobe it affects.

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9
Q

What might occur to CPP with significant rises in ICP?

A

Decreased cerebral perfusion, leading to ALOC or syncope.

CPP = MAP - ICP

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10
Q

A tumor in what location of the brain might result in personality changes?

A

Frontal lobe

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11
Q

What clinical presentations might suggest a frontal lobe tumor?

A
  • Personality cahnges
  • Intellectual decline
  • Difficulty focusing
  • Expressive aphasia
  • Anosmia (Smell)
  • Weakness
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12
Q

What clinical presentations might suggest a parietal lobe tumor?

A
  • Sensory seizures
  • Contralateral disturbances of sensation
  • Written language interpretation
  • Visuospatial deficit
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13
Q

What clinical presentations might suggest an occipital lobe tumor?

A
  • Homoymous hemianopsia (loss of same side visual field in both eyes)
  • Loss of color perception
  • Prosopagnosia (can’t recognize familiar faces)
  • Visual simultagnosia (can’t integrate a composite scene)
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14
Q

What clinical presentation might suggest a temporal lobe tumor?

A
  • Seizures with olfactor or gustatory hallucinations
  • Motor phenomena like lip licking
  • Depersonalization, emotional changes, or behavioral disturbances
  • Deja vu
  • Auditory illusions or hallucinations
  • Long-term memory impairment
  • Lack of language comprehension (Wernicke’s)

Random words coming out the mouth in Wernicke’s aphasia

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15
Q

How do brainstem lesions typically present?

A
  • CN palsies from 3-12
  • Ataxic gait
  • Nystagmus
  • Altered reflexes
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16
Q

How does a brain tumor cause increased ICP?

A
  • Large mass
  • Restriction of CSF outflow, esp if close to 3rd and 4th ventricles
  • Disruption of BBB causing angiogenesis and edema
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17
Q

What is the classic triad of increased ICP?

A
  1. HA
  2. N/V
  3. Papilledema
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18
Q

What are the 3 types of herniation?

A
  1. Subfalcial: occlusion of anterior cerebral artery causing frontal lobe infarction
  2. Transtentorial/uncal: compresses CN3, midbrain, and posterior cerebral artery.
  3. Cerebellar-foramen magnum/tonsillar: compresses medulla, causing apnea, circulatory collapse, and death

3 is the most dangerous herniation that could occur in someone with increased ICP

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19
Q

What is the preferred imaging modality for a CNS tumor?

A

MRI brain with contrast (gadolinium)

2nd is CT w/ con

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20
Q

What are the CIs to MRI?

A
  • Metal implants
  • Embedded devices
  • Claustrophobic

It is a giant metal donut that your head sits in

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21
Q

What is MR spectroscopy used for?

A

Measures biochemical changes for tumors that aren’t enhanced on MRI w/ con

22
Q

What is the first-line therapy for brain tumors?

A
  1. Dexamethasone to reduce cerebral edema
  2. Anticonvulsants only if hx of seizure
  3. If impending herniation, secure airway asap.

Preferred anticonvulsants:
levetiracetam, topiramate, lamotrigine, VPA, and lacosamide

23
Q

What are the 4 types of CNS glial cells?

A
  • Astrocyte: link neurons to blood supply (starlink)
  • Oligodendrocytes: create myelin
  • Ependymal cells: secrete CSF and beat their cilia to circulate the CSF
  • Microglia: clear debris and dead neurons
24
Q

What are glial cells?

A

Supportive cells around axons that DO NOT transmit any electrical impulse

25
Q

What are the 3 types of malignant CNS tumors?

A
  • Gliomas
  • Medulloblastomas
  • Primary CNS lymphomas
26
Q

What is the benign CNS tumor?

A

Meningioma

27
Q

Where do brain tumors usually appear from?

A

Mets.

  1. Lung cancer
  2. Breast
  3. Melanoma
  4. Renal
  5. Colorectal
28
Q

What is the only risk factor for CNS tumors?

A

Ionizing radiation (not diagnostic radiation)

Immunosuppression for CNS lymphoma

29
Q

How do you remember stage 3 and 4 WHO for primary CNS tumors?

A
  • Grade 3: all the anaplastics
  • Grade 4: all the blastomas

3 and 4 are treated identically.

30
Q

What are the two types of PNS glial cells?

A
  • Schwann cells: myelination and phagocytic
  • Satellite cells: Surround and protect neuron cell bodies, regulate external environment, and provide nutrients.

Satellite cells are very vulnerable to inflammation and injury

31
Q

What are the 3 types of gliomas?

A
  1. Astrocytoma (most aggressive: glioblastoma)
  2. Oligodendroglioma
  3. Ependymomas (MC in young children)
32
Q

What are the 3 steps of treatment for Low grade gliomas (1-2)?

A
  1. Resect if possible; biopsy to confirm
  2. Determine risk factors: age > 40 or subtotal resection
  3. Monitor for relapse

1+ risk factor: radiation followed by chemo
0 risk factor: observe

33
Q

For high grade gliomas, what is the management?

Grades 3-4

A
  • Maximal safe resection with concurrent chemoradiotherapy
  • Multidisciplinary approach
34
Q

What is the main thing a CT CANNOT see that a MRI can for the brain?

A

Posterior fossa or small tumors

Posterior fossa includes cerebellum and brainstem

35
Q

What is the MC malignant brain tumor in children?

A

Medulloblastoma, which originates in the posterior fossa

Cerebellar primitive neuroectodermal tumor (PNET)

36
Q

How do you treat medulloblastomas?

A
  • Resect
  • Chemo
  • Radiation therapy
37
Q

What kind of lymphoma is primary CNS lymphoma?

A

Non-hodgkin’s

Associated with immunocompromised people.

38
Q

What should we make sure to r/o in someone with suspected primary CNS lymphoma?

A

Toxoplasmosis via CSF

39
Q

How do we manage a primary CNS lymphoma?

A
  • Glucocorticoids once biopsy is obtained.
  • Chemo
  • Radiation therapy
40
Q

What is the 2nd MC primary CNS tumor?

A

Meningiomas

Dura mater or arachnoid mater

41
Q

What WHO grading is considered malignant for meningiomas?

A

Grade 3

42
Q

What is the treatment for a small meningioma?

A

If < 2cm, conservative management with repeat MRI after 3-6 months.

43
Q

What is the treatment for a grade 2 or 3 meningioma?

A

Wide resection

44
Q

What are the MRI features that suggest metastatic CNS tumors?

A
  • Multiple lesions
  • Localization at the junction of the gray and white matter
  • Circumscribed margins
  • Large amounts of vasogenic edema compared to lesion size

You do NOT need to biopsy if lesion is metastatic appearing and pt has a primary cancer that is known to metastasize

45
Q

What are the management steps for metastatic CNS tumors?

A
  • Glucocorticoids
  • Radiotherapy
  • Chemo
  • Palliative surgery
46
Q

What are the 3 types of spinal cord tumors?

A
  • Intramedullary: glioma (MC, specifically ependymomas)
  • Intradural-extramedullary: meningiomas, nerve sheath tumors (schwannoma or neurofibroma)
  • Extradural: probably metastatic
47
Q

What S/S may suggest a spinal cord tumor?

A
  • Localized pain that wakes nocturnally
  • Sensory dysthesias and muscular weakness
  • Bladder, bowel, and sexual dysfunction
  • Progressive difficulty in ambulation
48
Q

How do we locate a spinal cord tumor?

A

MRI spine w/ con

49
Q

How do we manage a spinal cord tumor?

A
  • Glucocorticoids
  • Surgical decompression/removal
  • Radiotherapy
50
Q

What is the SPIKES protocol?

A
  1. Setup the interview
  2. Perception
  3. Invitation
  4. Knowledge
  5. Emotions
  6. Set goals
51
Q

What are the 4 goals to keep in mind when delivering bad news to a patient?

A
  1. Discover what they already know
  2. Provide clear information that is within the boundary of what they know
  3. Support them emotionally
  4. Develop a treatment plan with their help
52
Q

What are the MC cancers that metastasize to the spinal cord?

A
  • Prostate
  • Breast
  • Lung

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