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Yr 4 - ACC > Neurology: Space Occupying Lesions > Flashcards

Neurology: Space Occupying Lesions Flashcards

1
Q

Where are the majority of adult brain tumours located?

A

Supratentorial (i.e. cerebrum)

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2
Q

Where are the majority of child brain tumours located?

A

Infratentorial (i.e. cerebellum)

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3
Q

Name some different types of brain tumours

A

1) Brain mets

2) Glioblastoma

3) Meningioma

4) Vestibular schwannoma

5) Pilocytic astrocytoma

6) Medulloblastoma

7) Ependymoma

8) Oligodendroma

9) Haemangioblastoma

10) Pituitary adenoma

11) Craniopharyngioma

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4
Q

What is the most common type of brain tumours?

A

Brain mets

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5
Q

What cancers most commonly spread to the brain?

A

1) lung (most common)

2) breast

3) bowel

4) skin (namely melanoma)

5) kidney

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6
Q

What is the most common cancer to spread to the brain?

A

Lung

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7
Q

What is the most common primary tumour in adults?

A

Glioblastoma

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8
Q

Give some clinical features of brain tumours

A

1) Headaches

2) Seizures

3) Cognitive changes: memory loss, confusion, difficulty concentrating

4) Motor deficits: weakness, paralysis, difficulty walking, coordination problems

5) Sensory deficits e.g. numbness, tingling, loss of sensation

6) Vision changes

7) Speech difficulties e.g. slurred, difficulty finding words, difficulty understanding language

8) Personality changes: irritability, mood swings, depression

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9
Q

Unusual changes in personality and behaviour would indicate a brain tumour in what location?

A

Frontal lobe (this lobe is responsible for personality and higher-level decision-making).

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10
Q

What are some causes of increased pressure in the intracranial space?

A

1) brain tumour

2) brain abscess or infection

3) intracranial haemorrhage

4) idiopathic intracranial hypertension

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11
Q

What are some common headache features that may indicate intracranial hypertension?

A

1) constant headache

2) worse when bending over, straining, coughing

3) worse on waking

4) nocturnal (occuring at night)

5) vomiting

6) papilloedema on fundoscopy

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12
Q

What are some other presenting features of raised intracranial hypertension?

A

1) altered mental state

2) visual field defects

3) seizures (particularly partial seizures)

4) unilateral ptosis (drooping upper eyelid)

5) 3rd and 6th nerve palsies

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13
Q

What is papilloedema?

A

Papilloedema describes swelling of the optic disc secondary to raised intracranial pressure seen on fundoscopy.

Papill- refers to a small, rounded, raised area (the optic disc) and -oedema refers to the swelling.

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14
Q

How can raised intracranial pressure cause papilloedema?

A

1) The sheath around the optic nerve is connected with the subarachnoid space.

2) The raised cerebrospinal fluid (CSF) pressure flows into the optic nerve sheath, increasing the pressure around the optic nerve behind the optic disc causing the optic disc to bulge forward.

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15
Q

How can papilloedema be seen on fundoscopy?

A

1) Blurring of the optic disc margin

2) Elevated optic disc (look for the way the retinal vessels flow across the disc to see the elevation)

3) Loss of venous pulsation

4) Engorged retinal veins

5) Haemorrhages around the optic disc

6) Paton’s lines, which are creases or folds in the retina around the optic disc

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16
Q

How can looking at how the retinal vessels flow across the disc give indication as to whether there is papilloedema?

A

When looking for the optic disc’s elevation, look at how the retinal vessels cross disc. Vessels can travel straight across a flat surface, whereas they will curve over a raised disc.

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17
Q

What is a glioma?

A

A tumour of the glial cells in the brain or spinal cord.

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18
Q

What are glial cells?

What are 3 examples?

A

Glial cells surround and support the neurones.

  • astrocytes
  • oligodendrocytes
  • ependymal cells
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19
Q

How are gliomas graded?

A

From 1 to 4.

Grade 1 is the most benign (possibly curable with surgery) and grade 4 is the most malignant (e.g., glioblastoma multiforme).

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20
Q

What are the three types of gliomas?

A

1) astrocytoma (the most common and aggressive form is glioblastoma)

2) oligodendroglioma

3) ependymoma

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21
Q

Prognosis of a glioblastoma?

A

around 1 year

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22
Q

How do glioblastomas appear on imaging?

A

They are solid tumours with central necrosis and a rim that enhances with contrast.

Disruption of the blood-brain barrier and therefore are associated with vasogenic oedema.

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23
Q

Histology of a glioblastoma?

A

Pleomorphic tumour cells border necrotic areas.

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24
Q

Treatment of glioblastma?

A

1) Surgical with post-op chemo
2) And/or radiotherapy
3) Dexamethasone (for oedema)

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25
Q

What is the 2nd most common 1ary brain tumour in adults?

A

Meningioma

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26
Q

What is a meningioma?

A
  • Tumours growing from the cells of the meninges
  • Usually benign.
  • However, they take up space –> can lead to raised intracranial pressure and neurological symptoms

i.e. cause symptoms by compression rather than invasion

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27
Q

What do meningomas arise form?

A

Dura mater of the meninges

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28
Q

Where are meningiomas typically located?

A
  • falx cerebri
  • superior sagittal sinus
  • convexity
  • skull base
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29
Q

Histology of meningiomas?

A

Spindle cells in concentric whorls and calcified psammoma bodies

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30
Q

Management of meningioma?

A

Will involve either observation, radiotherapy or surgical resection.

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31
Q

What is a vestibular schwannoma (previously termed acoustic neuroma)?

A

A benign tumour arising from the Schwann cells that surround the 8th cranial nerve (vestibulocochlear nerve).

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32
Q

Is a vestibular schwannoma malignant or benign?

A

Benign

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33
Q

Where are vestibular schwannomas often seen?

A

Cerebellopontine angle

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34
Q

How does a vestibular schwannoma present?

A
  • hearing loss
  • facial nerve palsy (due to compression of the nearby facial nerve)
  • tinnitis
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35
Q

What condition is associated with bilateral vestibular schwannomas?

A

Neurofibromatosis type 2

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36
Q

Histology of vestibular schwannomas?

A
  • Antoni A or B patterns are seen.
  • Verocay bodies (acellular areas surrounded by nuclear palisades).
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37
Q

Treatment of a vestibular schwannoma?

A

Treatment may involve observation, radiotherapy or surgery.

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38
Q

What is the most common primary brain tumour in children?

A

Pilocytic astrocytoma

39
Q

Histology of ailocytic astrocytomas?

A

Rosenthal fibres (corkscrew eosinophilic bundle)

40
Q

What is a medulloblastoma?

A

An aggressive paediatric brain tumour that arises within the infratentorial compartment. It spreads through the CSF system.

41
Q

Management of a medulloblastoma?

A

Surgical & chemo

42
Q

Histology of a medulloblastoma?

A

Small, blue cells. Rosette pattern of cells with many mitotic figures

43
Q

Where is an ependymoma commonly seen?

A

In the 4th ventricle

44
Q

What may an ependymoma cause?

A

Hydrocephalus

45
Q

What is an oligodendroma?

A

A benign, slow-growing tumour common in the frontal lobes.

46
Q

Where are oligodendromas typically found?

A

Frontal lobes

47
Q

Histology of oligodendromas?

A

Calcifications with ‘fried-egg’ appearance

48
Q

What is a haemangioblastoma?

A

A vascular tumour of the cerebellum

49
Q

What condition are haemangioblastomas associated with?

A

von Hippel-Lindau syndrome

50
Q

Histology of haemangioblastomas?

A

Foam cells and high vascularity.

51
Q

What is on Hippel-Lindau disease (VHL)?

A

A rare, genetic multi-system disorder in which non-cancerous tumors grow in certain parts of the body.

52
Q

What is a pituitary adenoma?

A

Benign tumours of the pituitary gland.

53
Q

What can pituitary adenomas be divided into?

A

Either secretory (producing a hormone in excess) or non-secretory.

Either microadenomas (<1cm) or macroadenomas (>1cm).

54
Q

What size defines a microadenoma?

A

<1cm

55
Q

What size defines a macroadenoma?

A

> 1cm

56
Q

Presentation of pituitary tumours?

A

1) Bilateral hemianopia

2) Hormone deficiencies (hypopituitarism): due to compression

3) Hormone excess:
- acromegaly (excess GH)
- hyperprolactinaemia (excess prolactin)
- Cushing’s disease (excess ACTH and cortisol)
- thyrotoxicosis (excess TSH and thyroid hormone)

57
Q

What causes bitemporal hemianopia in a pituitary adenoma?

A

If they grow large enough, they can press on the optic chiasm.

58
Q

Which excess hormone causes acromegaly?

A

Excess GH

59
Q

Management of pituitary adenomas?

A

1) trans-sphenoidal surgery (through the nose and sphenoid bone)

2) radiotherapy

3) bromocriptine (to block excess prolactin)

4) somatostatin analogues (e.g. octreotide) to block excess growth hormone

60
Q

What class of drug is bromocriptine?

A

Ergot derived dopamine D2 agonist.

61
Q

Role of somatostatin?

A

Somatostatin produces predominantly neuroendocrine inhibitory effects across multiple systems.

62
Q

What 2 medications can be used in pituitary tumours causing hormonal excess?

A

1) bromocriptine

2) somatostatin analogues e.g. octreotide

63
Q

Role of schwann cells?

A

Schwann cells provide the myelin sheath around neurones of the peripheral nervous system.

64
Q

Are vestibular schwannomas unilateral or bilateral?

A

They are usually unilateral.

Bilateral acoustic neuromas are associated with neurofibromatosis type 2.

65
Q

Typical presentation of a vestibular schwannoma?

A

1) typically 40-60 y/o

2) unilateral sensorineural hearing loss

3) unilateral tinnitus

4) dizziness or imbalance

5) sensation or fullness in ear

6) facial nerve palsy (if the tumour grows large enough to compress the facial nerve)

66
Q

What is often the first symptom of a vestibular schwannoma?

A

Unilateral sensorineural hearing loss

67
Q

What is the most common paediatric SUPRAtentorial tumour?

A

Craniopharyngioma

68
Q

What is a Craniopharyngioma?

A

A craniopharyngioma is a solid/cystic tumour of the sellar region that is derived from the remnants of Rathke’s pouch

69
Q

How does a craniopharyngioma present?

A

It may present with hormonal disturbance, symptoms of hydrocephalus or bitemporal hemianopia.

70
Q

What is the 1st line investigation in patients with a possible brain tumour?

A

MRI

71
Q

What investigation gives the definitive histological diagnosis of a brain tumour?

A

Biopsy

72
Q

What is idiopathic intracranial HTN?

A

High pressure in the brain.

73
Q

Who is idiopathic intracranial HTN typically seen in?

A

Young, overweight females

74
Q

Risk factors for idiopathic intracranial HTN?

A

1) obesity
2) female sex
3) pregnancy
4) drugs:
- COCP
- steroids
- tetracyclines
- retinoids (isotretinoin, tretinoin) / vitamin A
- lithium

75
Q

What drugs can cause idiopathic intracranial HTN?

A

1) COCP

2) steroids

3) tetracyclines

4) retinoids (isotretinoin, tretinoin) / vitamin A

5) lithium

76
Q

Features of idiopathic intracranial HTN?

A

1) headache

2) blurred vision

3) papilloedema (usually present)

4) enlarged blind spot

5) 6th nerve palsy may be present

77
Q

Management of idiopathic intracranial HTN?

A

1) weight loss

2) carbonic anhydrase inhibitors e.g. acetazolamide

3) topiramate (has the added benefit of causing weight loss in most patients)

4) repeated lumbar puncture may be used as a temporary measure but is not suitable for longer-term management

5) surgery

78
Q

Role of carbonic anhydrase inhibitors (eg, acetazolamide) in idiopathic intracranil hypertension?

A

Can reduce cerebrospinal fluid (CSF) production at the choroid plexus.

79
Q

Give an example of a carbonic anhydrase inhibitor

A

acetazolamide

80
Q

Role of topiramate in IIH?

A

Can lead to weight loss and improve migraine headache control.

81
Q

What is the most common headache phenotype in IIH?

A

Migraine

82
Q

Role of surgery in IIH?

A

1) optic nerve sheath decompression and fenestration may be needed to prevent damage to the optic nerve.

2) a lumboperitoneal or ventriculoperitoneal shunt may also be performed to reduce intracranial pressure.

83
Q

Give some causes of a brain abscess

A

1) contiguous spread of infection from:
- sinusitis
- otitis media
- dental infections

2) haematogenous spread from distant sources:
- infective endocarditis
- pulmonary infections

3) direct inoculation from trauma or neurosurgical procedures

84
Q

Risk factors for brain abscesses?

A

1) immunocompromised

2) congenital heart disease (right to left shunts)

3) chronic otitis

4) chronic sinusitis

5) IVDU

85
Q

Clinical features of a brain abscess?

A

1) headache (50-70%)

2) focal neurological deficits (50%):
- hemiparesis
- language or speech disorders (e.g., aphasia or dysarthria)
- visual field defects etc

3) fever (50%)

4) signs of raised ICP

5) others: seizures, lethargy, altered mental status

86
Q

Describe typical headache in brain abscesses

A

It is typically described as dull, constant and progressively worsening, often localised to the site of the abscess.

87
Q

Management of a brain abscess?

A

1) surgery:
- a craniotomy is performed and the abscess cavity debrided

2) IV antibiotics: IV 3rd-generation cephalosporin + metronidazole

3) intracranial pressure management: e.g. dexamethasone

88
Q

What is vasogenic oedema?

A

The extracellular accumulation of fluid due to disruption of the BBB and extravasations of serum proteins (e.g. albumin) into the cerebral parenchyma –> results in raised ICP.

89
Q

What is cytotoxic oedema?

A

Cell swelling caused by intracellular accumulation of fluid.

90
Q

What are the ependymal cells?

A

A type of neuronal support cell (neuroglia) that forms the epithelial lining of the ventricles in the brain and the central canal of the spinal cord.

91
Q

What 3 cranial nerves are most commonly affected by traumatic brain injury and/or elevated ICP?

A
  • CN VI (abducens) –> most commonly affected
  • CN IV (trochlear)
  • CN III (oculomotor)
92
Q

What is the role of acetazolamide in IIH?

A

acetazolamide is a carbonic anhydrase inhibitor that reduces CSF production, therefore reducing ICP.

93
Q
A

Yr 4 - ACC (73 decks)

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