Tumours of the Nervous System Flashcards
Supra/infra tentorial describes tumours above and below what structure in the brain?
Tentorium cerebelli
How do brain tumours usually present?
Neurological deficit
Motor weakness
Headache (due to raised ICP)
Seizures
Most brain tumours are secondary. TRUE/FALSE?
TRUE
Most are metastases
How does hydrocephalus usually present?
sudden raised ICP
=> headache
=> vomiting (due to vomiting centre in thalamus)
=> seizures
An uncal transtentorial herniation presses on which cranial nerve, causing what symptom?
Presses on CN III
=> prevents parasympathetics reaching pupil
=> sympathetics unopposed
=> dilated “Blown out” pupil
What features of a headache would make you suspicious of a raised ICP?
Headaches which wake the patient up
OR if it gets worse when coughing/leaning forward
What other symptoms are usually present with a tumour headache?
- Diplopia (double vision)
- difficulty focussing
- extreme hypertension (cushings triad)
- psychogenic
What behaviours would be affected if the frontal and/or parietal lobes were affected by a tumour?
Thought
Reasoning
Behaviour
Intellect
What would be impaired if the occipital lobe was affected by a tumour?
Speech
Vision
The referral guidelines suggest a referral after presentation of what symptoms?
- behaviour change
- seizure
- headache
- focal neuro deficit
What investigations would be carried out after a referral for a possible neurological tumour?
MRI
Lumbar puncture for CSF markers
Biopsy may be used, but ultimately surgeon may attempt full excision
Is papilloedema a late or early sign of raised ICP?
LATE
<10% have this on presentation with increased ICP
What general symptoms should be checked if suspicion of brain metastases is high?
- unintentional weight loss
- haemoptysis/haematuria
- evidence of melanoma on skin
- check axillae for freckling => neurofibromatosis Type 1
- check toenails for subungual keratomas => tuberous sclerosis
What are the 4 grades of nervous system tumours set out by the WHO?
I - benign
II - pre-malignant (can change over years)
III - malignant
IV - aggressively malignant
Where and in what what patient groups are Grade 1 astocytomas normally found?
Cerebellar/ brainstem tumours
found in children and young adults
How quickly do grade 1 astrocytomas grow, and how are they treated?
Grow slowly (benign) Tx: surgical excision
Grade 1 astrocytomas take up contrast on CT. TRUE/FALSE?
TRUE
Look like meningiomas on CT
Where do low grade astrocytomas (Grade II) present and what symptoms are usually experienced?
Temporal lobe
Anterior parietal/posterior frontal lobes
- present with seizures
DO grade II astrocytomas take up contrast?
No
Look well circumscribed BUT difficult to see exact margins
Grade II astrocytomas can progress to grade III or IV. TRUE/FALSE?
TRUE
What indicates a poor prognosis?
> 50 years old
- focal deficit
- short symptom duration
- raised ICP
- altered conciousness
- enhances with contrast (both grade III and IV do this)
When would it be unsafe to excise a tumour?
If it is in an area of the pons/brainstem where removal would cause significant damage
What genetic co-deletion increases chance of survival post-resection?
IDH-1 1p19q co-deletion
Radiotherapy and chemotherapy in combination after surgery have imporved life expectancy. TRUE/FALSE?
TRUE
What is the average life expectancy for a patient diagnosed with grade IV glioblastoma?
14 months
What substance is used to highlight tumour outlines during surgery?
5-ALA Protoporphyrin 9 (patients drink this prior)
When illuminated with blue light = pink
Patients who have surgery to excise a glioma are not allowed to drive afterwards. Why is this?
Seizure risk
OR visual field defect
What oral chemotherapy agent is sometimes used after surgery?
Temozolomide
Where do oligodendroglial tumours (grade II) usually arise and in which patient group are they most common?
Frontal lobe
25-45 years old
What is used to treat oligodendroglial tumours (grade II) ?
PCV (procarbazine, lomustine and vincristine)
- as they are chemosensitive
What symptoms in a child would make you consider a posterior tumour?
Tiptoeing OR ataxic gait
vomiting
headache
Who should all neurooncology patients be referred to?
Macmillan nurses
What is psychomotor retardation?
Patients lose capacity as a result of their tumour and become apathetic
Meningiomas are mainly asymptomatic. TRUE/FALSE?
TRUE
Females are more likely to get meningiomas than males. TRUE/FALSE?
TRUE (3:2)
What can patients with meningiomas possibly present with?
CN palsies
headache
What are the types of aggressive meningiomas?
Clear cell
Chordoid
Rhabdoid
Papillary
likely to recur and need second surgery
Why do frontal lobe tumours in the elderly present late?
Symptoms overlap with cognitive decline of elderly anyway
How are meningiomas treated?
Small => leave alone
Larger => surgery (esp. if neuro deficit)
When is complex surgery for acoustic neuromas used?
If 4th ventricle has become blocked off => causing hydrocephalus
How many hydrocephalus shunts stop working after 10 years?
50%
What side effects can occur after an operation to excise a tumour?
facial nerve palsy
corneal reflex
nystagmus
What symptoms are present in a pineal tumour?
- nystagmus
- weak upwards gaze
- eyes bulge forward as extra-ocular muscles are compressed
- hydrocephalus
What tumour markers are important in nervous system tumours?
Alpha-feto protein
HCG
LDH
if these are negative - do biopsy
