Neurology - brain tumours

Question 1

Generally how do brain tumours present

Answer 1

Asymptomatic at first

Focal neurological symptoms

Signs and symptoms of raised ICP

Question 2

Causes of raised ICP

Answer 2

Brain tumours

Intracranial haemorrhage

Idiopathic intracranial hypertension

Abscesses or infection

Question 3

Presentation of raised ICP and key investigations

Answer 3

Headache is:

• Constant
• Nocturnal
• Worse on waking
• Worse on coughing, straining or bending forward
• Vomiting

Altered mental state 
Visual field defects - third and sixth nerve palsies
Seizures (particularly focal)
Unilateral ptosis
Papilloedema (on fundoscopy)

Cranial nerves and neurological examination
CT head
Fundoscopy

Question 4

Why does papilloedema occur in raised ICP?

Answer 4

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

Question 5

Findings suggesting papilloedema on fundoscopy?

Answer 5

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

Question 6

Types of brain tumour - broad

Answer 6

Secondary metastasis

Primary tumours:

• Gliomas
• Meningiomas
• Pituitary tumours
• Acoustic neuromas

Question 7

Which cancers commonly metastasise to the brain?

Answer 7

Lung

Breast

Renal cell carcinoma

Melanoma

Question 8

What are gliomas?

Answer 8

Tumours of the glial cells.

There are 3 types:

• Astrocytoma (glioblastoma multiforme is the most common) - most malignant
• Oligodendroglioma
• Ependyoma

Grade 1- 4 with grade 1 being most benign and grade 4 the most malignant (glioblastomas).

Question 9

What are meningiomas?

Answer 9

Tumours arising from the meninges

Usually benign

But have mass effect and can lead to raised ICP and neuro Sx

Question 10

How do pituitary tumours present?

Answer 10

Usually benign

If large enough can compress the optic chiasm - bitemporal hemianopia

Potentially can lead to hormone deficiencies or release excess hormone:

• Acromegaly
• Hyperprolactinaemia
• Cushing’s
• Thyrotoxicosis

Question 11

How do acoustic neuromas typically present?

Answer 11

Usually these are unilateral tumours.

Bilateral acoustic neuromas are associated with neurofibromatosis type 2.

Classical symptoms of hearing loss, tinnitus and balance problems

Can also have facial nerve palsy

Question 12

Management of brain tumours

Answer 12

There is massive variation in brain tumours from completely benign to extremely malignant.

Surgery is dependent on the grade and behaviour of the brain tumour.

Management options include:

• Palliative care
• Chemotherapy
• Radiotherapy
• Surgery

Question 13

Treatment of pituitary tumours

Answer 13

Trans-sphenoidal surgery

Radiotherapy

Bromocriptine to block prolactin-secreting tumours

Somatostatin analogues (e.g. ocreotide) to block growth hormone-secreting tumours