neuro-CNS tumors

Question 1

most common CNS malignancies…

Answer 1

1. “Metastases are the most common CNS malignancy” – 
(lung most common, breast, kidney, GI)
2. Of intrinsic, gliomas most common
Others:
CNS lymphoma, meningiomas, 
Infectious (e.g. in AIDS patients)

Question 2

how do CNS tumors present?

Answer 2

All due to mass effect on specific areas of brain, or increasing intracranial pressure

• Progressive headache/ nausea
• Cranial nerve involvement
• Seizures, sensorimotor changes
• Cognitive impairment
• Visual field changes
• Brainstem or uncal herniation leading to sudden death

Question 3

what is an uncal herniation?

Answer 3

cerebellar tentorium (white area above cerebellum- seperates cerebral cortex from cerebellum) - uncal- pushes past this tenorium - can cause death

from temporal lobe herniating down into the brain stem

Question 4

hemispheric and central diencephalic tumors cause…

Answer 4

Hemispheric and central diencephalic tumors – focal motor deficits occur in ~40%

Question 5

hypothalamic tumors cause…

Answer 5

Hypothalamic tumors – neuroendocrine abnormalities, may impinge on the optic chiasm –>visual deficits

Question 6

astrocytoma in the cerebellum, brain stem, visual pathway cause…

Answer 6

Astrocytomas of the cerebellum – weakness, tremor, ataxia
Astrocytomas of the brain stem – isolated cranial nerve deficits and contralateral hemiparesis
Astrocytomas of the visual pathways – strabismus, proptosis, nystagmus, or developmental delay

Question 7

astrocytoma in the spinal cord causes…

Answer 7

Astrocytomas of the spinal cord – pain localized to the vertebral segments adjacent to the tumor, weakness, gait disturbance, and sphincter dysfunction; paresthesias and loss of sensation occur later in the disease course

Question 8

intramedullary vs extramedullary spinal cord tumors

Answer 8

Intramedullary ~10%- arise from inside the spinal cord:
-Ependymoma most common intramedullary tumor; the remainder are other types of glioma

Extramedullary may be extradural or intradural
neurofibromas and meningiomas are relatively common, are benign, and may be intradural or extradural
…others are usually extradural

Question 9

___ of pts with a brain tumor complain of what first?

Answer 9

1/3, HA … a progressive headache disorder or the new onset of headaches in middle or later life merits investigation if no cause is apparent

Question 10

Dx of CNS tumor

Answer 10

• MRI (bony artifacts complicate CT)
• angiography: for solid mass vs aneurysm
• brain biopsy

Question 11

txt of brain tumor

Answer 11

Oncology, neurosurgery consults

Surgery, irradiation, chemotherapy, depending on tumor type

Question 12

primary intracranial tumors

Answer 12

Most common/malignant
Glioblastoma multiforme (GBM) is the most common and most aggressive of the primary brain tumors
-in kids: medulloblastoma & brainstem glioma
-ependymoma

Question 13

pseudotumor cerebri - what is it? symptoms? who does it effect?

Answer 13

“Idiopathic Intracranial Hypertension” (better term for this) -mild HAs
-Increase in CSF production/decrease in absorption= increased pressure
-optic nerve atrophy and visual loss (papilledema)
Mostly affects obese women of childbearing age (20x more common)

Question 14

pseudotumor cerebri signs? early vs later

Answer 14

Early:
Headache, diplopia, visual complaints

Later:
Limited abduction from increased ICP
Visual loss, starting in inferior nasal visual fields

Question 15

txt pseudotumor cerebri?

Answer 15

lower ICP and CSF volume, treat papilledema

• Acetazolamide decreases CSF production
• Steroids
• Weight loss
• Serial LPs to remove CSF pressure
• **Peritoneal shunts, optic nerve sheath fenestration to relieve pressure

Question 16

neurofibromatosis.. what is it? symptoms?

Answer 16

A.K.A. Von Recklinghausen Disease
neural tissue tumor
-genetic, arises spontaneousl. doesn’t mean you got from your parents but if you have it you will pass it on.
-Abnormal NF1 gene on Chr. 17, with decreased tumor suppression activity
-NF2 gene on Chr. 22, also tumor suppressor function

Question 17

what are the S&S of neurofibromatosis?

Answer 17

• Nodules along peripheral nerves
• Axillary freckling, multiple café au lait spots, bony and connective tissue proliferation
• Can cause an intracranial mass, most dangerous in brainstem and on cranial nerves
• NF2 is specific to VIII nerve, and is bilaterally symmetrical

Question 18

dx and txt for neurofibromatosis

Answer 18

dx: part genetic, part PE
txt: surgery, if malignant transformation= chemo

Question 19

what are “honorary” CNS tumors?

Answer 19

Pituitary gland tumors (very common)
Sits below optic chiasm (in sella turcica, so growth tends to impinge central chiasm –> loss of affected retinal projections
-acromegaly from excess growth hormone

Question 20

affected retinal projections in honorary CNS tumor…

Answer 20

-Nasal fibers cross in anterior chiasm
Superiotemporal visual field loss for each eye (bitemporal hemianopsia)
-Macular fibers cross in posterior chiasm
Central scotomata (blind spot)

Question 21

main symptoms from CNS tumor are from…

Answer 21

mass effects- focal deficits, HA, seizures

Question 22

what are our particular pts in regards to CNS tumors?

Answer 22

Watch for at-risk patients with pseudotumor cerebri/IIH (obese women with headache and papilledema)