Brain tumours

Question 1

How can brain tumours present? 4

Answer 1

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

Question 2

Describe what symptoms are caused by a raised ICP?

Answer 2

headaches:

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

Question 3

Why can tumours cause raised ICP?

Answer 3

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

Question 4

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

Answer 4

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

Question 5

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

Answer 5

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

Question 6

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

Answer 6

homonymous hemianopia (with macula sparing)
cortical blindness
visual agnosia

Question 7

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

Answer 7

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

Question 8

What would be the features of a cerebellar lesion?

Answer 8

midline lesions: gait and truncal ataxia

hemisphere lesions: intention tremor, past pointing, dysdiadokinesis, nystagmus

Question 9

What is the most common type of brain tumour?

Answer 9

Astrocytic tumours

Question 10

What is the WHO grading of astrocytic tumours?

Answer 10

I - pilocytic/pleomorphic xanthoastrocytoma/supependymal giant cell

II - low grade astrocytoma

III - anaplastic astrocytoma

IV - glioblastoma multiforme

(III and IV are malignant)

Question 11

WHO I astrocytoma:

• benign or malignant?
• fast or slow growing?
• who is affected?
• where are these found?
• what is the treatment of choice?

Answer 11

Truly benign

Slow growing

Children, young adults

Pilocytic astrocytomas:

     - optic nerve, hypothalamic gliomas 
     - cerebellum, brainstem 

Treatment of choice: surgery - curative

Question 12

WHO II astrocytoma:

• where do these tend to occur?
• what is the presentation?
• what are poor prognostic factors?

Answer 12

Occur in the temporal/posterior frontal/anterior parietal

• presentation: siezures
• grow slowly but can transform into malignant neoplasms

Question 13

what are poor prognostic factors for WHO II astrocytoma?

Answer 13

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

Question 14

What is the treatment of WHO II astrocytomas?

Answer 14

Surgery +/- one of below

• no treatment
• radiation
• chemo
• combined radio and chemo

Question 15

What is the median survival of WHO III astrocytoma?

Answer 15

can arise de novo

• Median survival: 2 yrs

Question 16

WHO IV

• is this common?
• what is the median survival?
• what is the spread?

Answer 16

• most common primary tumor
  - Median survival: < 1yr
  - spread: white matter tracking/ CSF pathways

Question 17

What is the first line approach of brain tumours?

Answer 17

surgical

Question 18

What are the three goals of surgery for brain tumour?

Answer 18

(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

Question 19

What chemotherapy is used for brain tumours?

Answer 19

• Temozolomide
• PCV
• Carmustine wafer

Question 20

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

Answer 20

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

Question 21

what novel therapies can be used for brain tumours?

Answer 21

immunotherapy

Question 22

What is the second most common brain tumour?

Answer 22

oligodendroglial tumours

-20% of glial tumours

Question 23

Oligodendroglial tumours:

• where do these occur?
• who is affected?
• what is the presentation?

Answer 23

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

Question 24

Oligodenroglial tumours:

are these low or high grade?

Answer 24

low grade but can undergo malignant conversion

Question 25

What is the treatment for oligodendroglial tumours?

Answer 25

Chemosensitive- Procarbazine, Lomustine, Vincristine Surgery + Chemotherapy Surgery for high grade less convincing Radiotherapy controversial but decreases seizures Median survival: 10 yrs (low grade)

Question 26

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

Answer 26

20 % of intracranial neoplasms Majority asymptomatic M:F = 2:3 Syndromes: Breast cancer, NF II (22q) Multiple meningiomas (8%) Meningioma en plaque

Question 27

What symptoms can occur from meningiomas?

Answer 27

Headaches Skull base - cranial nerve neuropathies Regional anatomical disturbance

Question 28

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

Answer 28

- 90% benign | - slow growing

Question 29

What is involved in the preop evaluation of meningiomas?

Answer 29

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

Question 30

What is the treatment of meningioma?

Answer 30

Small meningiomas: expectant Preoperative embolisation Surgery Radiotherapy Recurrence –depends on grade and extent of resection Outcome: 5 yr survival 90 %

Question 31

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

Answer 31

Vestibular schwannomas ( of 8th nerve) Can occur as part of Neurofibromatosis II

Question 32

What symptoms can occur due to an acoustic neuroma?

Answer 32

Hearing loss Tinnitus Dysequilibrium

Question 33

What is the treatment of an acoustic neuroma?

Answer 33

1st do audiologic/audiometry and radiological evaluation Expectant - 25% managed medically Hydrocephalus management Radiation Surgery - 50% managed surgically

Question 34

Describe the medical management of acoustic neuroma?

Answer 34

i. Periodic neuro exam ii. Hearing aid iii. Periodic MRI between 10 and 43% of patients "useful" hearing & 75% increase in size over 2yrs

Question 35

Describe the surgical management of acoustic neuroma

Answer 35

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

Question 36

What is done for acoustic neuroma if <3cm?

Answer 36

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

Question 37

What is experienced post-op after acoustic neuroma treatment?

Answer 37

Facial nerve palsy Corneal reflex Nystagmus Abnormal eye movement

Question 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?

Answer 38

- 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

Question 39

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

Answer 39

-alpha fetoprotein

Question 40

What tumour marker is present in choriocarcinoma and germinomas?

Answer 40

beta-HCG

Question 41

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

Answer 41

Placental alkaline phosphatase

Question 42

What is best management for siezures post neurosurgery?

Answer 42

phenytoin or lorazepam

Question 43

what is initial treatment for a CNS tumour?

Answer 43

dexamathasone with lansoprazole cover