Neuro: SOL Flashcards
Clinical presentations of SOL?
Seizures
Focal neurology and gait disturbance
Raised intracranial pressure:
- Headaches
- Vomiting
- Papilodema
Neuropsychiatry effects
-Personality
- Mental state
- Memory and cognition
Endocrine abnormalities (pituitary)
Inicidental finding on imaging (e.g. minor head injury)
What invetigations to order when ?SOL?
CT +/- contrast
MRI (usually with contrast) - specilist units: MR sprectoscopy (to assess metabolism), MR perfusion (vascularity)
Diffusion weighted MRI
How is contrast useful in a CT head when looking for a SOL?
Areas of vascularity are more prominent, helpful if tumour or infection is suspected
What eGFR is insufficient for CT contrast?
Below 30
How to describe an MRI/CT?
Particularly Patient imaging technique details
Interesting Intra or extra exial
Surgeons Shape
Love Location (supra or inferiorlateral, lobes or parts of the brain involved)
Carefully Contrast enhancement (homogenous/hetrogenous, rim enhancement)
Drilling Density hypo/hyper (or intensity in MRI)
Massive Mass effects (effacement of sulci:ipsilateral/contralateral, midline shift, ventricle compression, basal cisterns: obliterated/patient)
Burr Border - how definied, oedema
Holes Hydrocephalus
Extra-axial SOL?
Pineal and pituitary lesions
Differential diagnosis for intracranial mass lesions?
Vascular - haemorrhage, infarct, vascular malformation, aneurysm
Infection - abcess
Neoplastic - metastasis, primary brain tumours
Cyst
Inflammatory - MS, granulomatous disease
Most common primary intracranial tumours in adults?
Benign: Meningioma
Mallignant: Gilioblastoma Multiforme (GBM)
Most common primary intracranial tumours in children?
Benign: Astrocytoma/Gliomas (Pilocytic astrocytoma, brainstem giloma, ependymoma)
Mallignant: Ependymoma, Medulloblastoma
Grading of CNS tumours
Grade I: Slow growing, relatively contained with well defined edges
Grade II: Slow, relatively contained with well definied edges
Grade III: Fast aggressive, mallignant
Grade IV: Fast, aggressive, mallignant
What is an Astrocytoma (Giloma) and what are its features?
Most common CNS tumour in children.
Arises from astrocytes
Mostly low grade
Develop anywhere in the CNS
Association with neurofibromatosis 1
Chuldren ages 5-8
M=F
Presentation: Non specific, morning headaches, N&V, double vision, seizures (fits)
What is a medulloblastoma and how does it present?
2nd most common childhood CNS tumour
Grade IV
Arise from neuroectoderm tissue
Majority arise in cerebellum, may cause compression of 4th ventricle, resulting in hydrocephalus.
Affects children aged 3-4 years, & 8-10 years
M>F
Can seed into spinal cord causing paraplegia
Presentation: non-specific, cerebellar dysfunction - poor co-oridnation, difficulty walking and clumsiness (ataxia), loss of appetite, behaviour changes (decreased social interaction, irritable/unsettled), mass effect
What is mass effect?
In a SOL when surrounding areas of the brain become compressedas a result and as a result of the lesion which manefests as focal neurology
Giloblastoma Multiforme vs Meningioma
Both: Common primary adult brain tumours.
Presentation: Headaches (worse in morning), seizures (fits), nausea and vomiting, cognitive or personality changes, focal weakness (arm or leg), loss of eyesight, hearing loss
GBM: High grade only (IV), a type of astrocytoma, affects over 65s
Meningioma: Mostly low grade (benign), arises from the dura mater of meninges, snowball effect on imaging, more comman in women
What is an oligodendroglioma and how does it present?
Variable (Grade I-Grade III)
Commonly located in cerebral hemisphere (frontal lobe)
Accounts for 2-5%
Arises from oligodendrocytes (giloma), affects 40-50 years
Presentation:
Headaches (worse in morning), seizures (fits), nausea and vomiting, cognitive or personality change, focal weakness (arm or leg), loss of eyesight, hearing loss)
What is Primary CNS lymphoma (PCNSL) and how does it present?
Mostly high-grade
Associated with immunocompromised individuals
M>F
Arise from dura mater of meninges
Affects>50 years
90% arise from B cells
Presentation:
Headaches (worse in morning), seizures (fits), nausea and vomiting, cognitive or personality change, focal weakness (arm or leg), loss of eyesight, hearing loss
Piocytic astrocytoma (Giloma) histological hallmarks?
Rosenthal fibers, eosinophillic fibres with corckscrew-like configuration
GFAP
Medulloblastoma histopathological hallmarks
Small round blue cells
Homer Wright rosettes
Giloblastoma Multiforme (GBM) histopathological hallmarks
Pleomorphic anaplastic cells that form pseudopalisades due to central necrosis or haemorrhage
Microvascular proliferation
GFAP positive
Menigioma histopathological hallmarks
Spindle cells arranged in whorls
Psammoma bodies
Oligodendroglioma histopathological hallmarks
Large caculoated cells with round nuclei (fried egg cells)
Chicken wire pattern of capillary anastomoses
Primary CNS lymphoma histopathological hallmarks
Diffuse large B cell lymphoma
Dense cellular aggregates of atypical lymphoid cells with dense perivascular aggregates
Anatomical differentiation of primary tumours
Tentorium cerebelli (extension of dura matter) seperates the crainial cavity inro supratentorial and infratentorial compartments
Supratentorial structures: cerebrum, third ventricle, lateral ventricle, chroid plexus, pineal gland, hypothalamus and pituitary gland
Generally adult forms
Infratentorial structues (located in the posterior fossa): cerebellum, fourth ventricle and brainstem (midbrain, pons and medulla)
Generally child forms
Clinical presentation of infants with brain tumours?
Balance/co-ordination/walking issues
Persistent, recurrent vomiting
Behaviour change/lethargy
Increasing head circumferance
Abnormal head position
Clinical presentation of brain tumours in teenagers?
Persistent, recurrent headaches
Persistent, recurrent vomiting
Balance and coordination. walking issues
Visual disturbance (diplopia, blurred)
Behaviour change
Seizures
Clinical presentation of brain tumours in children (5-11yrs)
Persistent, recurrent headaches
Persistent, recurrent vomiting
Balance and coordination. walking issues
Visual disturbance (diplopia, blurred)
Behaviour change
Seizures
Abnromal head position
Clinical presentation of primary brain tumours in adults?
Headache: upon walking, postural
Seizure: focal/generalised
Nausea/vomiting: prolonged/recurrent
Confusion: altered conciousness
Visual disturbance: VFD, diplopia
Progressive weakness: paresis
Primary brain tumours - first line and gold standard investigations?
First line: Cranial (T2 weighted, FLAIR, DWI, series and T1 pre- and post-contrast volume)
Goldstandard: Biopsy (histopathology, surgical excision or debulking (stereotactic biopsy may be performed)
What might PCNSL require that other brain tumours don’t need to aid diagnosis?
LP and CSF analysis
How does a pilocytic astrocytoma appear on MRI?
Large partially cystic mass with a solid component which is nodular and hyperintense in T2 compared to the cerebelum.
How does a medulloblastoma appear on MRI?
Large well cricumscribed hyper intense (T2) cerebral mass.
Low vs high grade primary brain tumours on imaging?
Low grade: well circumscribed
High grade: diffuse
How does a giloblastioma multiforme appear on MRI?
Peripherally ring enhancing mass
Butterfly glioblastoma mutliforme - extensions across midline (poor prognosis)
How does a menigioma appear on MRI?
Well circumscribed hyperintense mass +/- mass effect
Hypointense line showing blood vessels
Management and prognosis of astrocytoma?
Surgery (rescetion/debulking)
Radiotherapy (stereotatic/gamma knife) +/- chemothreapy
Dexamethasone
Anti-epileptics (manage seizures)
VP shunt
Very good prognosis for low grade poorer for high grade
Management of medulloblastoma (and prognosis)
Surgery (rescetion/debulking)
Radiotherapy (stereotatic/gamma knife) +/- chemothreapy
Dexamethasone
Anti-epileptics (manage seizures)
VP shunt
50% five year survival - moderate profnosis
Management and prognoses of ependymoma?
Surgery (rescetion/debulking)
Radiotherapy (stereotatic/gamma knife) +/- chemothreapy
Dexamethasone
Anti-epileptics (manage seizures)
VP shunt
Good prognosis
Management and prognosis of brainstem giloma?
Palliative radiotherapy - poor prognosis <10% survival
How is glioblastoma multiforme managed and what is the prognosis?
Operable: surgical debulking (gold standard) with postoperative radiotherapy and temozolomide
Dexamethasone to treat the oedema
Non-operable: Based on Karnofsky performance status, preferences, time from last treatment
Poor prognosis
How is meningioma managed and what is the prognosis?
Low grade: active monitoring, radiotherapy (simpson 1-3), further surgery (simpsome 4-5)
High grade Radiothreapy (simpson 1-5)
Very good prognosis
Astrocytoma: first line treatment
Dexamethasone +/- mannitol if elevated ICP
Surgical resection/debulking, radiotherapy and chemotherapy
GBM firstline treatment?
Acessible: surgical resection/debulking
Inaccesible: radiotherapy/radiosurgery
Meningioma 1st line treatment?
Accessible: surgical resection/debulking
Inacessible: radiotherapy +/- radiosurgery
Oligodendrogiloma first line treatment
Accessible: surgical resection/debulking
Inacessible: radiotherapy +/- radiosurgery
Primary CNS lymphoma 1st line treatment and gold standard?
1st line: Dexamethasone post-biopsy (pre-biopsy, may shrink tumour so that it cannot be biopsied to guide treatment)
Gold standard: Methotrexate-based chemotherapy with adjunctive whole-brain radiation therapy
What drug might be used to manage a prolactin-secreting tumour?
Bromocriptine to block prolactin-secreting tumours
How are pituitary tumors managed?
Trans-sphenoidal surgery
Radiotherapy
Bromocriptine to block prolactin-secreting tumours
Somatostatin analogues (e.g. ocreotide) to block growth hormone-secreting tumours
Where might n SOL causing an unusual change in personality and behavior be located?
This indicates a tumour in the frontal lobe (the frontal lobe is responsible for personality and higher-level decision making)
Causes of raised ICP and therefore papilodema on fundoscopy?
Brain tumours
Intracranial haemorrhage
Idiopathic intracranial hypertension
Abscesses or infection
Signs/symptoms of raise intracranial pressure?
Concerning features of a headache that should prompt further examination and investigation include:
Constant
Nocturnal
Worse on waking
Worse on coughing, straining or bending forward
Vomiting
Other presenting features of raised intracranial pressure may be:
Altered mental state
Visual field defects
Seizures (particularly focal)
Unilateral ptosis
Third and sixth nerve palsies
Papilloedema (on fundoscopy)
What is papilledema and why does it occur?
Papilloedema is a swelling of the optic disc secondary to raised intracranial pressure.
Papill- refers to a small rounded raised area (the optic disc) and -oedema refers to the swelling.
The sheath around the optic nerve is connected with the subarachnoid space. Therefore it is possible for CSF under high pressure to flow into the optic nerve sheath.
This increases the pressure around the optic nerve where it connects with the back of the eye at the optic disc, causing optic disc swelling.
This can be seen on fundoscopy examination.
Fundoscopic changes in papilodema?
Blurring of the optic disc margin
Elevated optic disc (look for the way the retinal vessels flow across the disc to see the elevation)
Loss of venous pulsation
Engorged retinal veins
Haemorrhages around optic disc
Paton’s lines which are creases in the retina around the optic disc
Common cancers metastesising to the brain?
Lung
Breast
Renal cell carcinoma
Melanoma
What is a glioma?
Gliomas are tumours of the glial cells in the brain or spinal cord. There are three types to remember (listed from most to least malignant):
Astrocytoma (glioblastoma multiforme is the most common)
Oligodendroglioma
Ependymoma
Gliomas are graded from 1-4. Grade 1 are most benign (possibly curable with surgery). Grade 4 are the most malignant (glioblastomas).
Meningioma
Meningiomas are tumours growing from the cells of the meninges in the brain and spinal cord. They are usually benign, however they take up space and this mass effect can lead to raised intracranial pressure and neurological symptoms.
Pituitary tumour
Pituitary tumours tend to be benign. If they grow large enough they can press on the optic chiasm causing a specific visual field defect called a bitemporal hemianopia. This causes loss of the outer half of the visual fields in both eyes. They have the potential to cause hormone deficiencies (hypopituitarism) or to release excessive hormones leading to:
Acromegaly
Hyperprolactinaemia
Cushing’s disease
Thyrotoxicosis
What is an acoustic neuroma and how might it present?
Acoustic neuromas are tumours of the Schwann cells surrounding the auditory nerve that innervates the inner ear. They occur around the “cerebellopontine angle” and are sometimes referred to as cerebellopontine angle tumours. They are slow-growing but eventually grow large enough to produce symptoms and become dangerous.
Acoustic neuromas are usually unilateral. Bilateral acoustic neuromas are associated with neurofibromatosis type 2.
Classic symptoms of an acoustic neuroma are:
Hearing loss
Tinnitus
Balance problems
They can also be associated with a facial nerve palsy.
Where do menigiomas arise from
Meningiomas are typically benign tumours that arise from the arachnoid cap cells of the meninges but are typically located next to the dura
