Space Occupying Lesions and Tumour Lecture

Question 1

Causes of Raised ICP (5)

Answer 1

Focal lesion in brain (SOL)
Diffuse lesion in brain (eg oedema)
Increased CSF (hydrocephalus)
Increased venous volume
Physiological (hypoxia, hypercapnia, pain)

Question 2

Definition of hydrocephalus

Answer 2

Accumulation of excessive CSF within the ventricular system of the brain

Question 3

Where is CSF produced and where is it absorbed?

Answer 3

Produced by choroid plexus in the lateral and fourth ventricles
Absorbed by arachnoid granulations

Question 4

What is CSF composed of?

Answer 4

Lymphocytes, Protein, Glucose

Question 5

Causes of hydrocephalus (3)

Answer 5

Obstruction to flow of CSF eg inflammation, tumours
Decreased resorption of CSF
Overproduction of CSF - rare - tumour of the choroid plexus

Question 6

Definition - Non-communicating hydrocephalus

Answer 6

Obstruction to flow of CSF occurs within ventricular system

Question 7

Definition - Communicating hydrocephalus

Answer 7

Obstruction to flow of CSF outside of the ventricular system eg in the subarachnoid space or at the arachnoid granulations

Question 8

Outcome is hydrocephalus develops

1. before closure of cranial sutures?
2. after closure of cranial sutures?

Answer 8

1. Enlargement of head

2. Expansion of ventricles and increase in intracranial pressure

Question 9

Effects of raised ICP (4)

Answer 9

Intracranial shifts and herniations
Distortion and pressure on cranial nerves and vital neurological centres
Reduced level of consciousness
Impaired blood flow

Question 10

Types of shifts and herniations (4)

Answer 10

1. Falcine
2. Uncal
3. Cerebellar
4. Transcalvarium

Question 11

Clinical signs of raised ICP (4)

Answer 11

Papilloedema
Nausea and vomiting
Headache
Neck stiffness

Question 12

SOL - 4 examples

Answer 12

Tumours - primary brain tumours, mets
Abscess - single/multiple
Haematoma
Localised brain swelling - eg swelling and oedema around infarct

Question 13

Astrocytoma grading system

Answer 13

1 - pilocytic astrocytoma - 95% survival at 10yrs
2 – diffuse astrocytoma - median survival 7yrs
3 - anaplastic astrocytoma - median survival 2-3yrs
4 - glioblastoma - median survival 10months

Question 14

Glioblastoma - which has a better prognosis - primary or secondary?

Answer 14

Primary glioblastoma - sx for under 3months, survival 4.7months, common age 62
Secondary glioblastoma - survival 7.8 months, common age 45

Question 15

Presentation of brain tumour
Symptoms (5)
Signs (2)

Answer 15

Symptoms - focal symptoms, headache, vomiting, seizures, visual disturbances
Signs - focal deficit, papilloedema

Question 16

Causes of single abscess (7)

Answer 16

Usually focal cause...
Otitis media
Sinusitis
Nasal
Facial and dental infections
Skull fracture
Penetrating injury
Neurosurgical procedures

Question 17

Causes of multiple abscesses (4)

Answer 17

Usually result from septicaemia..
Acute bacterial endocarditis
Bronchiectasis and lung abscess
Cyanotic heart disease
IV drug abuse

Question 18

Types of cerebral oedema (5)

Answer 18

Vasogenic 
Cytotoxic
Hydrostatic
Interstitial
Hypo-osmotic

Picture usually mixed

Question 19

Extradural haemorrhages - usual cause

Answer 19

Usually due to rupture of meningeal arteries and assoc. with skull fractures

Question 20

Results of extradural haemorrhage

Answer 20

Compress subjacent dura and flatten gyral crests to underlying brain

• uncal gyral/ cerebellar tonsillar herniation
• brainstem compression
• death

Question 21

What is a subdural haemorrhage and what causes it?

Answer 21

Collections of blood between the internal surface of dura mater and arachnoid mater.
Can vary in size.
Caused by disruption of bridging veins that extend from the surface of the brain into subdural space

Question 22

Most common site of subdural haemorrhage?

Answer 22

Cerebral hemisphers

Question 23

What is an acute or chronic subdural haemorrhage?

Answer 23

Acute - clotted blood

Chronic - liquefied blood clot

Question 24

Acute subdural heamorrhages

Answer 24

Clear history of trauma
Unilateral or bilateral
Assoc. with other traumatic lesions
Gyral contours preserved - pressure evenly distributed
Swelling of cerebrum on side of haematoma
Mass effect

Question 25

Chronic Subdural Haemorrhages

Answer 25

Less frequently assoc. with a well defined traumatic insult
Often assoc. with brain atrophy
Composed of liquefied blood/yellow tinged fluid separated from inner surface of dura mater and underlying brain by neomembrane

Question 26

Clinical symptoms of chronic subdural haemorrhages (2)

Answer 26

Altered mental status

Focal neurological deficits

Question 27

Types of subarachnoid haemorrhage

Answer 27

Spontaneous or traumatic

Question 28

Most common cause of a spontaneous subarachnoid haemorrage

Answer 28

Rupture of a saccular aneurysm

Question 29

Another name for a saccular aneurysm

Answer 29

Berry aneurysm

Question 30

Where do saccular aneurysms occur (2) and which location is more common

Answer 30

90% arise as arterial bifurcation in territory of internal carotid artery
10% in vertebro-basilar circulation

Question 31

Morphology of subarachnoid haemorrhage

Answer 31

Rupture of berry aneurysms may result in bleeding into the subarachnoid space
May also get intracerebral haematomas adjacent to aneurysms
Infarcts of brain parenchyma may also develop - due to arterial spasm - seen in 40% cases - mass effect of haematoma and raised ICP

Question 32

Clinical features of subarachnoid haemorrhage (6)

Answer 32

Onset ABRUPT
Assoc with...
- severe headache
- vomiting
- loss of consciousness
Usually no history of precipitating factor
50% die within several days of onset