Tumours and bleeds Flashcards
Gerstmann syndrome
4 clinical manifestations arising from a lesion near/ at the angular gyrus (temporal, parietal border)
- Acalculia (inability to calculate numbers/ understand maths)
- Left-right confusion
- Alexia without agraphia (inability to read what is written)
- Finger agnosia (inability to distinguish finger form hand)
Arteriovenous malformations
- Pathology
Malformation arises from a direct connection between the arteries and veins, without a capillary network
- Creates high-pressure communications.
- Predisposes to aneurysms
Name a genetic condition associated with cerebral AVMs
Hereditary haemorrhagic telangiectasia (HHT)/
Osler-Weber-Rendu syndrome
Hereditary haemorrhagic telangiectasia (HHT) is inherited in what fashion?
Autosomal dominant
What is the most common location for AVMs?
Supratentorial
Describe the presentation of AVMs
- As an intracranial haemorrhage
- Most commonly, intracerebrally - Headache
- Focal neurological deficit
- Most commonly due to mass effect from haemorrhage - Seizure
Which investigation is carried out in AVMs to rule out a haemorrhage?
Head CT
What investigation is carried out to assess the location, feeding arteries, associated aneurysms, and venous drainage of AVMs?
Brain digital subtracted angiogram
CT or MR angiograms can also detect the malformations and aneurysms
Management of small, superficial AVMs
Surgical resection
Management of large AVMs
Multi-method approach
- Embolisation
- Surgical resection
Management of inaccessible AVMs
Conservative if surgery is not appropriate
- Management of symptoms like seizures
Inaccessible AVMs
- Stereotactic radiosurgery
Subdural haematoma
- pathology
Bleed located between the dura matter and subarachnoid layer.
- Most commonly caused by the breaking of bridging veins from the subarachnoid space that permeate the dura mater and empty into the dural venous sinuses.
Most common cause of subdural haematoma
Head trauma
- Most commonly in the elderly
Risk factors for subdural haematoma
Older age
Coagulopathies
Anticoagulation
Arteriovenous malformations
Chronic subdural haematoma
- Pathology
An encapsulated subdural haematoma that occurs a few days after the bleed occurs.
Can cause a subdural hygroma.
What is a subdural hygroma
A collection of CSF subdurally that can occurs as a result of a chronic subdural haematoma.
Frontal lobe manifestations of intracranial bleeds
Confusion
Reduced cognitive/ executive function
Hemiparesis
Aphasia
Personality changes
Parietal lobe manifestations of intracranial bleeds
Aphasia
Sensory impairment
Posterior fossa manifestations of an intracranial bleed
CN palsy
Ataxia
Dysphagia
Vomiting
Unequal pupils
Signs of a chronic subdural haematoma
Headache
Cognitive impairment
Apathy
Depression
Seizures
First line imaging for a subdural haematoma
CT head
- Will reveal a crescent shaped bleed
Important blood tests for intracranial bleeds
FBC- rules out low platelets
Group and Save
U+Es
Clotting profile
- aPTT
- PT
- Bleeding time
LFTs
Management of drowsiness/ bulbar symptoms in intracranial bleeds
Airway support
What is an important management with medication that must be carried out in intracranial bleeds?
Reversal or cessation of anticoagulants
How to reverse warfarin
- Rapidly (1-2 hours)
- Quickly (non-emergency surgery)
- Slowly
Rapidly
- Prothrombin complex concentrate Octaplex/Beriplex
Quickly
- Vitamin K 10mg IV
Slowly
- Oral Vitamin K therapy
The effects of dabigatran is reversed using…
Idarucixumab
The effects of heparin/ LMWH is reversed using…
Protamin sulfate
Epidural haemorrhage
- Pathology
Bleed between the skull and outer dura
- Most commonly caused by head trauma lacerating the middle meningeal artery
The “lucid phase” is associated with what type of intracranial bleed
Epidural haematoma
- Presents with a lucid phase after the incident, before a deterioration in brain function
Signs of raised ICP include
Nausea and Vomiting
Blurred vision
Drowsiness
Seizures
Headache
Ipsilateral dilated pupil
Features of the Cushing’s triad
Sign of raised ICP:
Hypertension
Bradycardia
Respiratory depression
Indications of surgery for intracranial bleeds
Large haematomas
changes in brain function
Midline shift >5mm
Fixed, dilated pupils
Management of raised ICP in intracranial bleeds
Mannitol
- Osmotic diuretic
Hypertonic saline
CT appearance of epidural bleeds
Convex/ lens haematoma
CT appearance of subarachnoid bleeds
Bleeds in the sulcus
- Above the pia matter
Blood in the ventricles
CT appearance of intracerebral bleeds
Hyperdensity (new bleed) or hypodensity intraparanchymal cerebral tissue.
Features of a large vestibular schwnomma
Ataxia/ balance problems
- Due to compression of brainstem
Hydrocephalus–> raised ICP
- Due to compression of 4th ventricles
Conditions caused by a pituitary adenoma
Prolactinoma (excess prolactin)
Cushing’s disease (excess ACTH)
Acromegaly (excess GH)
Panhypopituitarism (non-secreting adenoma)
Apoplexy (bleed into pituitary)
The most common glioma is…
Glioblastoma multiforme (astrocytoma)
What genetic conditions increase the risk of gliomas?
Neurofibromatosis 1 and 2
Li-Fraumeni syndrome
The most common primary malignant tumour of the brain in adults is…
Glioblastoma
The gold standard imaging for glioma diagnosis is…
Gadolinium contrast MRI head
Presentation of gliomas
Headache
Raised ICP features
Frontal= Personality/ executive function/ cognition changes
CN palsy
Spinal cord compression
Cerebellar signs
Features of raised ICP
Headache
Nausea/ vomiting
Blurred vision
Altered consciousness
Seizures
Managemnt of raised ICP/ vasogenic oedema in gliomas
Dexamethasone
Management of seizures in glioma
Keppra / phenytoin
Meningioma most commonly arises from….
The arachnoid layer of the meninges
Most meningiomas are located…
Supratentorially
Meningiomas can cause compression of _______ or lead to excessive ________
Compression of optic nerve
Excessive bone growth/ protrusion
Meningiomas are associated with which genetic condition
Neurofibromatosis type 2
Pituitary macroadenomas are defined as sizes…
> 10mm
Pituitary adenomas are associated with which genetic condition?
Multiple endocrine neoplasia 1 (MEN1)
Types of pituitary adenomas causing hyperpituitarism
Cushing’s disease (corticotrophic)
Acromegaly (somatotrophic)
Prolactinoma (lactrotrophic)
Hyperthyroidism (thyrotrophic)
Gonadotrophic
Pitutary adenoma can cause central diabetes insipidus via…
Hypopituitarism (macroadenoma)= low ADH production
Prolactinoma is primary treated with…
Cabergoline (dopamine antagonist)
The surgical management of Cushing’s disease is…
Trans-sphenoidal adenectomy
___________ is a somatostatin analogue used to treat _________
Octreotide - treats somatrophic adenoma
The most common type of intracranial vascular anuerysm is…
Saccular aneurysm (90%)
Saccular aneurysms common occur at which part of the Circle of Willis?
Anterior communicating artery
What 3 genetic conditions are associated with intracranial aneurysms?
Autosomal dominant polycystic kidney disease
Elhers Danlos syndrome
Neurofibromatosis
Lifestyle factors associated with intracranial aneurysms
Alcohol, smoking
Age
Hypertension
Posterior communicating aneurysm can present with what nerve palsy?
Unilateral CN3
What intracranial aneurysm can present with bitemporal hemianopia?
Anterior communicating artery aneurysm
What is the gold-standard investigation for intracranial aneurysms?
Cerebral intra-arterial digital subtraction angiography
What are the surgical options of symptomatic intracranial aneurysms
Endovascular coiling
Open surgical clipping
