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Neurosurgery > Neurooncology > Flashcards

Neurooncology Flashcards

1
Q

Types of Gliomas

A

Astrocytoma
Oligodendroglioma
Oligoastrocytoma
Ependymoma

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2
Q

WHO Grades of malignany

A 
WHO Grade 1
  Pilocytic Astrocytoma (children)
 WHO Grade 2
  Low-grade Glioma 
 WHO Grade 3
   Anaplastic Glioma
 WHO Grade 4
   Glioblastoma multiforme
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3
Q

Why is a Glioblastoma called ‘multiform’?

A

Different parts of of the tumor looks different (necrosis, bleeding)

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4
Q

When do people get Glioblastomas?

A

In their 60’s

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5
Q

What are the established methods of treatment?

A

surgery, radiotherapy and chemotherapy

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6
Q

What types of treatments are currently being tested?

A

TT fields and immunotherapies

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7
Q

What is the best treatment for brain tumors?

A

Surgery

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8
Q

By how much does adjuvant Radiotherapy increase life expectancy?

A

6 months (from 5 to 11)

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9
Q

By how much does Chemotherapy with temozolomide increase life expectancy?

A

2 months (from 12 to 14)

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10
Q

What’s the biggest issue with glioblastomas?

A

They come back and infiltrate healthy tissue

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11
Q

What charatherizes a low grade glioma?

A

It’s a continuously growing lesion

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12
Q

How much does a low grade glioma grow per year?

A

3-4 mm in diameter per year

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13
Q

low grade gliomas are usually present in?

A

Eloquent areas of the brain (area for speech)

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14
Q

What is typically the first symptom of a low grade glioma?

A

Seizures

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15
Q

What is best: taking a biopsy of the tumor or resection?

A

Resection

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16
Q

How do we diagnose tumors?

A

MRI, MR Proton Spectroscopy, PET

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17
Q

What is MR proton spectroscopy?

A

MR proton spectroscopy gives us the concentrations of important substances

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18
Q

What substances are present in the brain for malignant tumors?

A

Laktate and Lipids. Additionally, the decrease of N-acetyl-asparate & Cholin with an increase in Creatine is a sign of malignant tumor growth.

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19
Q

What tracer do we use for PET and why?

A

Fluor-Ethyltyrosin - it is taken up by the part of the tumor with the highest level of metabolism while also showing the difference between tumor and radiation-affected tissue

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20
Q

What is the trade-off when it comes to surgery?

A

Removing a lot of tissue leads to longer survival time, but removing a lot of tissue can also affect functionality, which decreases quality of life

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21
Q

What happens to brain functions during tumor growth?

A

As tissue dies, functions are relocated (brain plasticity)

22
Q

What functional domains should we be careful about when operating?

A

sensorimotor function
language function
visiuo-spatial function
socio-cognitive function

23
Q

Which fascicle connects brocas and Wernickes area?

A

The arcuate fascicle

24
Q

What’s the problem with the classical Brocas-Wernickes model?

A

lesions studied were often much larger than those of the specific region studied and there might have been functional reorganization between damage and meeting the researchers

25
Q

Association fibers constitute which 2 streams?

A

Meaning: semantic ventral pathway
Naming: phonological dorsal pathway

26
Q

The phonological dorsal pathway includes which fascicles?

A 
Dorsal ILF (inferior lateral fascicle - connecting V1 an posterior parietal)
Arcuate fascicle (connects the posterior parietal to the pars opercularis)
SLF (superior lateral fascicle - projects from the object recognition center in the posterior temporal to the supramarginal gyrus and premotor areas)
27
Q

Phonemic Paraphasia is caused by?

A

Damage to the Arcuate fascicle in the phonological dorsal pathway

28
Q

The semantic ventral pathway includes which fascicles?

A 
IFOF (inferior fronto-occipital fascicle - from the V1 to the pars orbitaris (longest fascicle))
Ventral ILF (inferior longitudinal fascicle - connects the posterior temporal to the temporal pole)
The uncinate fascicle (from the temporal pole to the pars orbitaris)
29
Q

Semantic paraphasia is caused by?

A

Damage to the IFOF

30
Q

Sort the following fascicles from superior to inferior:

IFOF, ILF, SLF, SFOF

A

SFOF, SLF, IFOF, ILF

31
Q

The longest fascicle?

A

IFOF (inferior fronto-occipital fascicle)

32
Q

Preoperative diagnostics

A

Neuropsychological assessment
fMRI
Navigated transcranial magnetic stimulation
MR diffusion tensor imaging based tractography

33
Q

What does the preoperative neuropsychological assessment look at?

A 
Preoperative: 
  affection of language
  attentional deficits
  deficits in visuospatial cognition
  deficits in social cognition
34
Q

What does fMRI measure?

A

The BOLD signal

35
Q

Issues with fMRI

A

Artifacts near tumors, depends on statistics for border of the signal

36
Q

Navigated repetitive transcranial magnetic stimulation

A

TMS on areas we can find based on our MRI scan - locating the important functional aras so we don’t remove them during surgery

37
Q

The principles of DTI

A

Water molecules will follow the tracts, which we can measure with MR. Our fractional anisotropy (FA) becomes a number for wether a voxel is a part of a tract or not (degree of directionality). An algorithm can track the fibers from one region to another.

38
Q

Problems with DTI

A

It’s purely anatomic, is prone to false negatives when 2 tracts come close to each other and whether we’re in an a voxel with a tract of not is depended on algorithm specifications

39
Q

Intraoperative safety strategies

A

Electrophysiological monitoring and mapping (cortex stimulation and mapping of the results)
Sending light into the patients eyes to have visual evoked potentials
Awake mapping for language functions

40
Q

When is the patient awake during surgery?

A

From post-craniotomy to after tumor is removed

41
Q

What’s the most important awake-task?

A

Picture naming task. We can test for Dysarthria, Speech arrest, Anomia.

42
Q

What’s the 2nd most important awake-task?

A

Pyramid and palm tree test

43
Q

What’s the pyramid and palm tree test?

A

1 top image is presented and the patient has to choose from 2 bottom pictures which matches the semantic context of the first image

44
Q

What’s the 3rd most important awake-task?

A

Visual field test: you have to name objects in your peripheral vision

45
Q

In what localization of the brain are there indications for performing awake surgery?

A

Classically left temporal, frontal or insular lesions
Phonological disorders induced by right-hemisphere stimulation
Occipital lesions to preserve visual field, reading ability and semantic dysfunction (IFOF, ILF)
Parietal lesion to preserve space orientation and phonologic dysfunction (SLF)

46
Q

Which tumor types benefit from awake surgery?

A

Greatest effect in low-grade glioma
Enhances safety and resection result in glioblastoma multiforme
Metastases
cavernomas in eloquent regions

47
Q

Who can’t have an awake surgery?

A 
Age: over 60 years
Large mass effect with significant midline shift
High vascularization
Severe aphasia
Psychological instability
48
Q

Intraoperative neuronavigation

A

We have a pointer to show us where in our pre-operative MRI image we are

49
Q

Is navigated tractography a good idea for surgery?

A

Yes, the more modern version gives probabilities of being in the tracts, which has shown to increase safety of the procedure

50
Q

Drawbacks of navigated tractography

A

The fractional anisotropy (FA) decreases unintentionally when the fibers cross or “kiss”. Similar issue with perifocal edema

51
Q

How can we improve navigated tractography?

A

By using probabilistic DTI with continuous ultrasound images to overlay on the MRI

52
Q

Why is continuous navigated ultrasound smart?

A

It allows us to track the brain shift that happens when we open the cranium

Neurosurgery (10 decks)

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