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Flashcards in Neuro-oncology Deck (136):
1

What is the evidence for extent of resection in GBM?

Level 2 evidence that those with complete resection have longer survival (Pichimerie et al ALA study patients)

2

What was the outcome of the Pichmeier et al study?

Patients with worse KPA and older have increased life expectancy with extent of surgical resection

3

What is the standard of care for GBM?

Stupp et al 2005 showed RT + concomitant temozolamide have better progression free and overall survival

4

What does MGMT methylation signify?

Better outcome

5

What is the evidence for operating on recurrent GBM?

Multiple small retrospective studies have shown a small improvement in survival with repeat surgery and extent of resection

6

What is a secondary line agent after Temezolamide for GBM?

Avastin (Bevacizumab) - approved for use with recurrent GBM as it improves progression free survival (not overall survival) compared to historical controls

7

What is a potential problem with Avastin (bevacizumab)

Disease may progress but the avastin prevents contrast enhancement so cannot see it on imaging

8

Would you give chemo/radiotherapy following resection of LGG?

If 40 y and/or subtotal resection had better progression free survival with chemoradiotherapy.

9

What is the role of TERT promoter mutations?

TERT mutation alone gives worst prognosis but TERT mutation with IDH-1 +/- 1p19q mutation gives the best prognosis!

10

What is the earliest mutation to occur in LGG?

IDH-1

11

What extra investigations can be performed prior to oncology surgery?

fMRI, intraoperative guidance, awake craniotomy, DTI for white matter tracts and angiography

12

What is the differential diagnosis of a durally based lesion?

Meningioma, haemangiopericytoma, lymphoma, metastasis, primary bone tumour and inflammatory lesions

13

What is the evidence for adjuvant therapy following surgery for a single metastasis?

SRS alone favoured survival and not giving WBRT prevents neurocognitive decline especially if

14

What is the differential diagnosis of a 4th ventricular lesion in a child?

Medulloblastoma
Pilocytic astrocytoma
Ependymoma / subependymoma
Haemangioblastoma

15

What is the management of a patient with a 4th ventricular lesion causing hydrocephalus?

Gross total resection of the lesion

16

Which foramen does the teloveoltonsillar approach open?

Foramen of magendie between the tonsil and the uvula

17

What is the disadvantage of a transvermian approach?

Cerebellar mutism

18

Should residual medulloblastoma be resected from the floor of the 4th ventricle?

No - chemoradiotherapy can be given to the residual

19

What is SUNCT?

Short lasting unilateral neuralgiform headache with conjunctival tearing

20

What does the spectroscopy for radionecrosis look like?

Flat line - lactate can be raised

21

AIDs, non-enhancing lesion with high flair signal - diagnosis?

PML - once treated with steroids will result in IRIS and start to enhance

22

What does the eccentric target sign in a ring enhancing lesion suggest?

Toxoplasmosis

23

What is the diagnosis of a T2 hypointensity with peripheral contrast enhancement and no restriction on DWI?

Granulomatous lesion - TB or sarcoid

24

Small cystic lesion with a vessel running through. Diagnosis?

Virchow Robin Cyst! (Dilated CSF space)

25

What should you think about in a patient with multiple VR lesions

Muchopolysacharidosis (Hurlers) and cryptococcus (if HIV)

26

What is TORCH?

Congenital infections that cause abnormalities:
Toxo, Rubella, CMV and Herpes encephalitis

27

What are the goals of surgery?

Decompression
Debulking
Tissue diagnosis
+/- seizure elimination

28

How are the white matter tracts classfied?

Association (short and long same side)
Projection (cranial to spinal)
Commissural (different side)

29

What are U fibres

Short adjacent association fibres between gyri

30

What are the components of the superior long fasciculus?

Arcuate fasciculus connects brocas and wernickes areas
...

31

What white matter tract runs to the post-central gyus?

Thalamocortical tracts

32

What sulcus seperates the insula into anterior and posteiror portions?

Central sulcus of the insula

33

What is the role of the extreme capsule?

White matter U association fibres of the insula

34

Where do the insular perforators arise from?

M2

35

What forms the corona radiata?

Both internal and external capsule fibres

36

Which arteries are found at the limen insula?

The lenticulostriate perforators

37

What forms the roof of the ventricular atrium?

Tapetum

38

Why are anterior cingulotomy performed?

Chronic refractory depression / OCD and Chronic pain

39

What are the projections of the medial and lateral olfactory gyri?

Medial to cingulate and lateral to amygdala

40

Where is the collateral sulcus?

Between the parahippocampal and fusiform gyri

41

Where is the diagonal band of Broca?

**
White matter fibre tract from the amygdala running to the anterior perforated substance

42

What histology marker suggests meningioma?

EMA (Epithelial membrane antigen)

43

What is the histology of a meningioma?

Psammoma bodies
Meningothelial whorls

44

What is a new change in the WHO 2016 tumour classification for meningioma>

Brain invasive alone makes it grade 2

45

What is the grade of haemangiopericytoma?

WHO 2 (Solitory fibrous tumour = 1 and anaplastic = 3)

46

Synaptophysin positive tumour with oligodendrocyte-like cells?

Central neurocytoma!

47

What is the grade of SEGA?

1

48

What the histological features of a colloid cyst?

Arises from the anterior roof of the 3rd ventricle

49

Pineal region with rosettes?

Pineocytoma

50

Pituitary lesion with microcysts and Rosenthal fibres?

Adamantinomatous craniopharyngioma

51

What is the difference between adamantinomatous and papillary craniopharyngioma?

Ada = 90% of all cranio's. Mainly in paediatric. Mutations in beta-catenin
Pap = 10% of all cranio's. Adults. BRAF mutation can be stained for!

52

What is the normal role of IDH-1?

Converts isocitrate to a-ketoglutarate

53

What is the function of mutated IDH-1?

Forms Hydroxyglutarate

54

What is the main IDH-1 mutation?

R132H

55

What is the prognostic benefit of IDH mutation?

In GBM survival is better with mutant IDH-1

56

What mutation is associated with astrocytoma?

ATRX mutation

57

What is ATRX?

Chromatin regulator. A loss of function mutation occurs in astrocytomas. The absence of ATRX in the nucleus suggests astrocytoma! Blood cells act as an internal control.

58

What does wild type mean?

No mutation

59

What are the features of oligodendroglioma?

Fried egg appearance with staghorn vascularisation

60

Tumour has no IDH1, no 1p19q and TERT promoter mutation. What is the grade?

GBM!

61

What is the diagnosis of a GBM which is Vimentin positive?

Gliosarcoma

62

What are the histological features of a pilocytic astrocytoma?

Elongated hair like astrocytes with rosenthal fibres

63

What is the histological difference between schwannoma and neurofibroma?

Neurofibroma has the nerve fascicles running through the tumour whilst schwannoma is eccentric from the nerve.

64

What is the differential of an esthesioneuroblastoma?

Sinonasal undifferentiated tumour (SUNT)
Olfactory groove meningioma
Metastasis

65

What abscess occurs in AIDS patients in the basal ganglia?

Toxoplasmosis! With eccentric target sign means there is a nodule at the edge of the ring enhancement

66

How can you differentiate radiation necrosis from tumour?

MR Spectroscopy
MR perfusion
PET

67

What does incomplete ring enhancement suggest?

Demyelination (open ring is towards the ventricle)

68

What radiological sign do you see with large aneurysms?

Phase encoding pulsation artefact

69

What is IRIS?

Immune reconstitution inflammation syndrome - when the immune system response is over exaggerated after starting treatment

70

Which demyelination syndrome occurs in a monophasic pattern?

ADEM - all lesions are of the same age so all enhance! May have recent viral infection.

71

What organism causes a fungal mucocoele?

Aspergillus

72

What T2 feature suggest TB abscess?

Dark on T2!

73

What are the causes of a miliary patter of lesions in the brain?

TB
Aspergillosis
Lupus vasculitis

74

What are neuroglial cysts?

Look up

75

What are choroidal fissure cysts?

Look up

76

What are the locations for Virchow-Robin spaces?

Basal ganglia
Centrum semi-ovale
Posterior perforated substance
Anterior temporal lobe (can have flair signal)

77

What condition should you think of in a patient with large VR spaces?

Mucopolysaccharidosis

78

What do you think of in a HIV patient with dilated VR spaces?

Cryptococcus!

79

Posterior fossa proteinaceous cyst without restriction?

Neuro-enteric cyst

80

What is TORCH?

Congenital infections that cause calcification within the walls of the ventricle:
Toxoplasmosis
Rubella
CMV
HIV

81

What is a sign of chronic venous congestion with DAVF?

Pseudo-phlebitic sign

82

What is the most common tumour of the cavernous sinus?

Meningioma

83

Which nerve courses through the pterygopalatine fossa?

V2 (Maxillary branch) goes through for. rotundum to the pterygopalatine fossa

84

Where does V3 go?

Through the for. ovale to the Infratemporal fossa

85

What are the treatments for cavernous sinus meningiomas?

Symptomatic in young patient = debulk to decompress nerves and then SRS for residual
Non-symptomatic = conservative or SRS

86

What grading system is used for encasement of the carotid artery with meningiomas?

Hirsch grading

87

What is the name given to a hyperostotic meningioma of the lateral orbital wall?

Spheno-orbital meningioma!!

88

What is a safe entry zone to the brainstem?

Areas with sparse brainstem nuceli or tracts

89

Should you resect a DVA with the cavernoma?

No, this is draining normal brain!

90

How do you manage carotid cave aneurysms?

Coiling

91

How do you manage opthalmic artery aneurysms?

Coiling>clipping

92

What factors affect coil vs clipping?

Localisation
Configuration
Circumstance
Vessel
Age
Etiology

93

Which AComs are easier to coil?

Cranial pointing

94

What are the aneurysm configuration factors that need to be considered?

Pointing of aneurysm
Perforators / branches
Neck to dome ASPECT ratio
Bifurcation vs side wall aneurysm
Size
Shape

95

What is the impact of angulation on coiling outcome?

Angles >90 deg have a higher chance of recurrance

96

What are the factors at angiography that suggest a false aneurysm?

Delayed inflow and outflow of contrast

97

Should you coil a false aneurysm?

NO! It will rupture

98

How do neck calcifications effect clipping?

If they are in the plane of the clip then it will prevent the clip from closing

99

When should you do a prophylactic EVD in a patient having endovascular treatment?

When there is blood in the 4th ventricle and they are having a stent (as this will need dual antiplatelet agents)

100

Does opening the lamina terminalis prevent hydrocephalus in SAH?

Yes, reduces risk from 14 to 4%

101

What are the endovascular types of angioplasty

Chemical (nimodipine)
Balloon

102

What factors suggest which aneurysm has ruptured when there are mutliple ones?

Shape (round vs elongated)
Size
Aspect ration
Blood distribution
Local vasospasm

103

Why should Marfans / FMD patients not be coiled?

The catheters can cause dissections on the way up

104

Should large partially thrombosed aneurysms be coiled?

No, surgery or flow diverter is needed

105

How do you manage false aneurysms?

Parent vessel occlusion or coil the part that is before the false aneurysm

106

What is the prevalence of aneurysms?

2%

107

In a population of 100,000 how many aneurysms ruputure?

10

108

ISUIA trial rupture risks per 5 years?

Size: <7, 7-12, 13-24 and >25
Ant circ: 0, 2.6, 14, 40
Post circ: 2.5, 14, 18.4, 50

109

How is risk of aneurysm rupture calculated?

= 1 - (Risk of rupture per year x Life expectancy)

110

What factors are part of the PHASES score?

Population
Hypertension
Age
Size of aneurysm
Earlier SAH
Site of aneurysm

111

What are the non-surgical treatments of craniopharyngioma?

Gamma knife to the solid component
Brachytherapy (Yterrium)

Cyst - ommaya reservior for aspiration
Bleomycin injection into the cyst

112

Lesions of the 3rd ventricle?

Paces:
Germinoma
Pilocytic astrocytoma

Adults:

113

What factors should you consider when approaching a ventricular lesion?

Site
Hydrocephalus
Histology
Blood supply
Hemispheric dominance if transcortical

114

What are the approaches to the lateral ventricle?

Anterior callosal
Posterior callosal
Supracerebellar infratentorial
Transtentorial
Temporal (lateral or subtemporal)

115

What is the circulating volume of a child?

80 ml / kg

116

What is the surface marking for transcortical approach to the lateral ventricle?

MFG = 1 cm precoronal, 3.5cm lateral to the midline

117

What are the features of a colloid cyst on CT?

Hyperdense

118

What are the causes of an intracranial cyst?

Developmental - neurenteric / arachnoid / porencephalic cyst
Neoplastic - benign / malignant / subependymoma
Infectious - hydatid cyst / neurocystercocosis / toxoplasmosis

119

Where is the most common location for an arachnoid cyst?

Middle temporal fossa

120

What is the Galassi classification of arachnoid cysts?

Look up

121

Why do arachnoid cysts grow?

Ball valve mechanism
Fluid production from the wall
Osmotic gradient

122

What does head-bobbing suggest?

Large 3rd ventricle dilatation (pyramidal tract sign) LOOK UP

123

Large cyst within the brain, no oedema and no contrast uptake?

Hydatid cyst

124

How do you resect a hydatid cyst?

Dowling's water dissection technique!

125

What is the incidence of a colloid cyst?

1 in a million person years

126

Why do you need an MRI for a brain tumour?

Surrounding Brain structures anatomy
Characterisation of the lesion
Vascular relations
Surgical planning

127

What are the management options for a brain tumour?

Conservative
Surgery - biopsy / open
Chemotherapy
Radiotherapy
Depending on lesion - immunological / biological therapies

128

Approaches to a lateral ventricular lesion

Look up

129

Approaches to third ventricle

Look up

130

6 month old with cortical lesion, lots of oedema, string enhancement and seizures?

Desmoplastic infantile ganglioglioma

131

Which patients should you not do awake craniotomy on?

COPD as they don't ventilate well, CO2 rises and brain swells!

132

Is IDH1/2 seen in Pilocytic astrocytoma?

NO

133

What is the management for oligos?

Surgery
PCV
Radiotherapy

134

What are adjuvant therapies for LGG?

Radiation + PCV IF HIGH RISK = residual tumour
Better Oligo>Astrocytoma
NEJM study Buckner et al 2016

135

When should you operate on a met?

KPS>70
Age < 65
Survival >6 months
3 or less lesions
Posterior fossa
Mass effect
Limited systemic disease

136

What is the recurrence rate of a cerebral met after excision?

>50%