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Flashcards in Brain tumours Deck (43):
1

How can brain tumours present? 4

Progressive motor deficit (68%)
Motor weakness (45%)
Headache 54%
Seizures 26%

2

Describe what symptoms are caused by a raised ICP?

headaches:
-worse in morning/awakening
-worse on coughing/leaning forward
-may be assoc. and get better with vomiting

3

Why can tumours cause raised ICP?

-tumour mass or oedema effect
-blockage of CSF flow
-haemorrhage

4

What would be the clinical features of a parietal lobe lesion?

sensory inattention
apraxias
astereognosis (tactile agnosia)
inferior homonymous quadrantanopia
Gerstmann's syndrome (lesion of dominant parietal): alexia, acalculia, finger agnosia and right-left disorientation

5

What would be the clinical features of a temporal lobe lesion?

Wernicke's aphasia: unable to understand language
superior homonymous quadrantanopia
auditory agnosia
prosopagnosia (difficulty recognising faces)

6

What would be the clinical features of an occipital lobe lesion?

homonymous hemianopia (with macula sparing)
cortical blindness
visual agnosia

7

What would be the clinical features of a frontal lobe lesion?

expressive (Broca's) aphasia: located on the posterior aspect of the frontal lobe, in the inferior frontal gyrus. Speech is non-fluent, laboured, and halting
disinhibition
perseveration
anosmia
inability to generate a list

8

What would be the features of a cerebellar lesion?

midline lesions: gait and truncal ataxia
hemisphere lesions: intention tremor, past pointing, dysdiadokinesis, nystagmus

9

What is the most common type of brain tumour?

Astrocytic tumours

10

What is the WHO grading of astrocytic tumours?

I - pilocytic/pleomorphic xanthoastrocytoma/supependymal giant cell

II - low grade astrocytoma

III - anaplastic astrocytoma

IV - glioblastoma multiforme

(III and IV are malignant)

11

WHO I astrocytoma:
-benign or malignant?
-fast or slow growing?
-who is affected?
-where are these found?
-what is the treatment of choice?

Truly benign

Slow growing

Children, young adults

Pilocytic astrocytomas:

- optic nerve, hypothalamic gliomas

- cerebellum, brainstem

Treatment of choice: surgery - curative

12

WHO II astrocytoma:
-where do these tend to occur?
-what is the presentation?
-what are poor prognostic factors?

Occur in the temporal/posterior frontal/anterior parietal

-presentation: siezures

-grow slowly but can transform into malignant neoplasms

13

what are poor prognostic factors for WHO II astrocytoma?

-age >50
-focal deficit
-short duration of symptoms
-raised ICP
-altered consciousness
-enhancement of contrast studies

14

What is the treatment of WHO II astrocytomas?

Surgery +/- one of below
-no treatment
-radiation
-chemo
-combined radio and chemo

15

What is the median survival of WHO III astrocytoma?

can arise de novo

- Median survival: 2 yrs

16

WHO IV
-is this common?
-what is the median survival?
-what is the spread?

- most common primary tumor

- Median survival: < 1yr

- spread: white matter tracking/ CSF pathways

17

What is the first line approach of brain tumours?

surgical

18

What are the three goals of surgery for brain tumour?

(i)to obtain a histological diagnosis
(ii) reduce the mass of the
tumour whilst preventing iatrogenic neurological deficit as effectively as possible and
(iii) to treat hydrocephalus if present.

-Surgery can be curative for most benign
tumours whilst debulking improves prognosis for malignant tumours provided the tumour is not infiltrating essential areas of the brain such as language areas

19

What chemotherapy is used for brain tumours?

-Temozolomide
-PCV
-Carmustine wafer

20

What is the role for radiotherapy in brain tumours? what are the skin effects?

Clear role in Malignant tumours post surgery

Low grade astrocytomas:
-incomplete removal
-malignant degeneration ( +/- surgery)

Benign astrocytomas:
-only if recurrence/ progression not amenable to surgery

Side effects:
–drops IQ by 10, skin, hair, tired

21

what novel therapies can be used for brain tumours?

immunotherapy

22

What is the second most common brain tumour?

oligodendroglial tumours
-20% of glial tumours

23

Oligodendroglial tumours:
-where do these occur?
-who is affected?
-what is the presentation?

-frontal lobes
-adults 25-45yrs (small peak in 6-12yrs)
-siezure presentation

24

Oligodenroglial tumours:
are these low or high grade?

low grade but can undergo malignant conversion

25

What is the treatment for oligodendroglial tumours?

Chemosensitive- Procarbazine, Lomustine, Vincristine

Surgery + Chemotherapy

Surgery for high grade less convincing

Radiotherapy controversial but decreases seizures

Median survival: 10 yrs (low grade)

26

Meningiomas:
-are these common?
-M:F
-what syndromes can exist with these?

20 % of intracranial neoplasms

Majority asymptomatic

M:F = 2:3

Syndromes:
Breast cancer, NF II (22q)
Multiple meningiomas (8%) Meningioma en plaque

27

What symptoms can occur from meningiomas?

Headaches

Skull base - cranial nerve neuropathies

Regional anatomical disturbance

28

What is the pathology of meningiomas?
-benign or malignant?
-slow or fast growing?

-90% benign
-slow growing

29

What is involved in the preop evaluation of meningiomas?

CT:
-homogenous, densely enhance, skull blistering (hyperostosis)

MRI:
-dural tail, patency of dural sinuses

If embolisation planned then angiography +/- embolisation:
-external carotid artery feeders, occlusion of sagittal sinus

30

What is the treatment of meningioma?

Small meningiomas: expectant

Preoperative embolisation

Surgery

Radiotherapy

Recurrence –depends on grade and extent of resection

Outcome: 5 yr survival 90 %

31

what is an acoustic neuroma?
what can this occur as part of?

Vestibular schwannomas ( of 8th nerve)

Can occur as part of Neurofibromatosis II

32

What symptoms can occur due to an acoustic neuroma?

Hearing loss

Tinnitus

Dysequilibrium

33

What is the treatment of an acoustic neuroma?

1st do audiologic/audiometry and radiological evaluation

Expectant - 25% managed medically

Hydrocephalus management

Radiation

Surgery - 50% managed surgically

34

Describe the medical management of acoustic neuroma?

i. Periodic neuro exam
ii. Hearing aid
iii. Periodic MRI

between 10 and 43% of patients "useful" hearing & 75% increase in size over 2yrs

35

Describe the surgical management of acoustic neuroma

earing preservation surgery" rarely preserves useful hearing, which tends to deteriorate fairly rapidly with time, with or without a tumour still being there

36

What is done for acoustic neuroma if <3cm?

gamma knife:
If high risk or refusal of surgery. Give low dose

Single sitting & MRI monitoring after

Hearing tends to gradually decline over several years in the treated ear.

Vestibular function tends to worsen substantially in the first 6 months and remain stable thereafter.

Malignant transformation is rare

37

What is experienced post-op after acoustic neuroma treatment?

Facial nerve palsy

Corneal reflex

Nystagmus

Abnormal eye movement

38

Germ cell tumours:
-who is affected?
-what is seen on CT?
-what is the histology often?
-how can these metastise?
-which are the most common?
-which are radiosensitive?

-10-12 yr (90% <20yrs)
-M>F

CT: iso or hyper dense

may metastasize via CSF

Germinomas most common - these are radiosensitive

Non-germinomatous are not radiosensitive

39

What tumour marker is present in yolk sac tumours and teratomas?

-alpha fetoprotein

40

What tumour marker is present in choriocarcinoma and germinomas?

beta-HCG

41

What tumour marker is present in germinomas and choriocarcinoma and yolk sac?

Placental alkaline phosphatase

42

What is best management for siezures post neurosurgery?

phenytoin or lorazepam

43

what is initial treatment for a CNS tumour?

dexamathasone with lansoprazole cover