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Neurosurgery Boards - Citow > Neurosurgery: Neoplastic Disease > Flashcards

Neurosurgery: Neoplastic Disease Flashcards

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1
Q

Approach to:

Inferior frontal lobe and parasellar region

A

Bicoronal incision with unilateral/bilateral subfrontal approach
Pterional approach

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2
Q

Approach to:

Sellar region

A

Transsphenoidal
Bicoronal incision with unilateral/bilateral subfrontal approach
Pterional approach

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3
Q

Approach to:

Frontal lobe

A

Frontal craniotomy (linear, curved, or horseshoe incision)

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4
Q

Approach to:

Anterior temporal lobe

A

Temporal craniotomy (linear incision)

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5
Q

Approach to:

Posterior temporal lobe

A

Temporal craniotomy (linear, reverse question mark, or Isle of Mann incision)

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6
Q

Approach to:

Parietal lobe

A

Parietal craniotomy (linear or horseshoe incision)

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7
Q

Approach to:

Occipital lobe

A

Occipital craniotomy (linear or horseshoe incision)

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8
Q

Approach to:

Trigone of lateral ventricle

A

Appropriate craniotomy for superior parietal, middle temporal gyrus, lateral tempero-occipital, or transoccipital approach (linear or horseshoe incision)

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9
Q

Approach to:

Anterior third ventricle

A

Frontal parasagittal craniotomy and interhemispheric/transcallosal or transcortical approach

Interforniceal or transchoroidal approach once within

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10
Q

Approach to:

Posterior third ventricle/pineal region

A

Suboccipital transtentorial
Supracerebellar infratentorial approach
Interhemispheric transcallosal (splenium) approach
Transcortical parietal approach (rarely used)

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11
Q

Approach to:

Midline posterior fossa/fourth ventricle

A

Suboccipital craniotomy (linear incision)

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12
Q

Approach to:

Lateral posterior fossa/CPA

A

Retrosigmoid craniotomy (linear incision)

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13
Q

Approach to:

Upper clivus

A

Subtemporal approach and anterior petrosectomy (linear or horseshoe approach)

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14
Q

Approach to:

Middle and lower clivus

A

Combined retrosigmoid posterior temporal craniotomy and posterior petrosectomy (curvilinear incision)

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15
Q

What is located two finger breadths above the zygomatic arch and one thumb’s breadth behind the frontal process of zygomatic bone?

A

Pterion

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16
Q

What landmark does the asterion represent?

A

Asterion is on skull over the lower half of the transverse/sigmoid sinus junction

Asterion: junction of lamboid, occipitomastoid, and parietomastoid sutures

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17
Q

What lays at the junction of the lamboid and sagittal suture?

A

Lambda

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18
Q

What lays at the junction of the coronal and sagittal sutures?

A

Bregma

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19
Q

Where is the inion located?

A

At indentation below external occipital protuberance

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20
Q

How can you roughly estimate the location of the Sylvian fissure? (Stepwise approach)

A

1) Draw a line connecting the nasion and inion, find the 75% point on the line (closer to inion)
2) Mark frontozygomatic point
3) Connect the two points and the Sylvian fissure travels along this axis

  • Pterion is located ~3cm behind the frontozygmatic point
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21
Q

How can you approximate location of Rolandic fissure (aka central sulcus)? (Stepwise approach)

A

1) Find upper Rolandic point (2cm posterior from 50% point on a line connecting nasion and inion)
2) Lower Rolandic point is at junction of line from upper rolandic to midzygomatic arch and sylvian fissure line (Lower Rolandic point is 2.5 cm behind pterion along Sylvian line)

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22
Q

How far behind the coronal suture is the motor stip usually located?

A

4 to 5.4 cm

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23
Q

What is a rough estimate of the location of the Angular gyrus (which is part of Wernicke’s area)?

A

Just above pinna of ear

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24
Q

Astrocytic tumors may be graded II, III, or IV. What are these specific types typically called?

A

Grade II: Low grade astrocytoma
Grade III: Anaplastic astrocytoma
Grade IV: GBM

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25
What is standard treatment for astrocytomas?
Surgical resection (partial or complete) followed by external beam radiation and temozolomide
26
What are common locations for pilocytic astrocytomas?
Cerebellar Optic glioma type Hypothalamic hemisphere
27
Optic gliomas are common in what genetic condition? | What type of tumors are these typically?
NF1 | Pilocytic astrocytomas
28
What is tx of choice for cerebellar pilocytic astrocytomas?
Surgical resection They often have an enhancing mural nodule; if the mural nodule (contrast-enhancing) is removed the cyst wall doesn't need to be completely taken
29
What is treatment of choice for pilocytic astrocytomas of optic nerve or hypothalamus?
If sparing resection can be completed then removal but if resection risky then biopsy with chemo and radiation
30
How do oligodendrogliomas often present?
Seizures and/or hemorrhage
31
What is unique about oligodendrogliomas on CTH?
They may have associated calcifcation
32
What chromosomal loss is associated with better response to treatment in oligodendroglioma?
Loss of 1p and 19q
33
Where do ependymomas often arise from?
Floor of 4th ventricle
34
What is preferred treatment of ependymomas? | Should you aim for full resection?
Surgical resection | Maximal resection is associated with improved survival
35
Given proximity to CSF space. What adjunctive test should be done in patients with ependymoma?
LP (cytology) and spinal MRI to look for subarachnoid mets
36
In what age group do choroid plexus papillomas often present? How do they present? What is mgmt?
<2 yo HCP Resection followed by chemo (radiation if carcinoma)
37
What are the different types of pediatric brainstem glioma (3)?
Tectal glioma Focal tegmental mesencephalic Diffuse pontine glioma
38
What is general treatment of choice for each of following types of pediatric brainstem glioma: Tectal giioma Focal tegmental mesencephalic Diffuse pontine glioma
Tectal glioma: CSF diversion due to HCP risk Focal tegmental mesencephalic: Resection, chemo/rad Diffuse pontine glioma: radiation, experimental chemo, palliative
39
Angiocentric glioma
Rare, slow-growing low-grade glial often in kids/young adults with seizures. Resection often curative
40
Choroid glioma third ventricle
Rare low-grade glial often with HCP/chiasm compression/hypothalamic dysfunction often cured by resection
41
Astroblastoma
Rare low-grade glial tumor often in kids/young adults and surgically resected with adjuvant chemo/rad
42
What is dysplastic cerebellar gangliocytoma also known as? What syndrome is it associated with? How does it present and how is it managed?
Lhermitte-Duclos Disease Cowden Syndrome (multiple hamartomas) Inc'd ICP/HCP, cerebellar signs, slow progression Resection
43
Desmoplastic infantile ganglioglioma presents in what age group? How does it present? What is it's survivability? What is optimum treatment?
<2 yo (peak 3-6 months) Bulging fontanelles, inc'd head size, paresis, seizures >75% survive at 15 years Resection curative; chemo if anaplasia
44
In what age group do dysembryonic neuroepithelial tumors (DNETs) present? Are they fast or slow growing lesions? What will they commonly present with? What is treatment?
Children and young adults (<20 yo) Slow growing, benign Epilepsy Surgical resection +/- epileptogenic foci
45
In what age group do gangliogliomas/gangliocytomas present? What is typical presentation? What is mgmt?
<30 yo (peak 11 yo) Epilepsy; slow growing, benign lesions Resection +/- chemo if anaplastic
46
In what location do central neurocytomas often present? What is presentation? What is survivability? What is mgmt?
Intraventricular ICP rise and HCP; seizures 5 yr survival > 80%; benign and slow-growing Resection; SRS/chemo for recurrence
47
Central liponeurocytoma often presents in what age group and what location? What is appropriate management?
Adults; posterior fossa | Resection; possible radiation to prevent recurrence
48
How common is papillary glioneuronal tumor? What is presentation? What is mgmt?
Rare adult tumor Seizures; slow-growing, benign tumors Resection
49
How do rosette-forming glioneuronal tumors of the 4th ventricle often present? What is mgmt?
Rising ICP and HCP with ataxia (In young adults often) Resection usually curative
50
Paraganglioma at the carotid bifurcation is known as ...
Carotid body tumor
51
Paraganglioma at the superior vagal ganglion is known as ...
Glomus jugulare tumor
52
Paraganglioma at the auricular branch of vagus is known as ...
Glomus tympanicum
53
Paraganglioma at the inferior vagal ganglion is known as ...
Glomus intravagale
54
Paraganglioma of the adrenal medulla and sympathetic chain is known as ...
Pheoochromocytoma
55
How rapidly do paragangliomas grow and what is appx 5 year survivability?
Slow; 90%
56
How are paragangliomas managed?
If catecholamine secreting (i.e. pheochromocytoma) then alpha and beta blockers to prevent BP lability and arrhythmias Resection; radiation is nonresectable Preop embolization can reduce blood loss
57
``` What is the peak age incidence for pineocytomas? How do they present? What is survivability? What is treatment? What treatment is high risk? ```
``` 10-20 yo ICP issues; Parinaud's syndrome 90% at 5 years Resection SRS is a high risk procedure for these tumors ```
58
What age group do pineoblastomas arise in? How do they present? What is survivability? What is treatment?
Peak incidence 2 yo ICP issues; Parinaud's syndrome Median survival 2 years Resection + chemo + rad if > 3 yo
59
Why is pineoblastoma associated with worse survival than pineocytomas?
Pineoblastoma is a PNET type of tumor with associated CSF seeding in ~50% of patients
60
What is appropriate treatment of a papillary tumor of the pineal region?
Surgical resection followed by radiation
61
What is a key distinguishing feature of embryonal/primitive neuroectodermal tumors (PNETs) regarding their spread?
CSF seeding/dissemination in many patients
62
What are types of PNET tumors?
Medulloblastomas CNS PNET/Supratentorial PNET ATRT Pineoblastomas
63
At what age and at what location do medulloblastomas often present?
``` 5 years old median Posterior fossa (1/3) ```
64
How quickly do medulloblastomas present and with what signs?
Rapidly | ICP rise, HCP, cerebellar signs
65
If there is no metastasis and there is a gross total resection then what is the 5 yr survivability of medulloblastomas? (Hint: it depends on a genetic factor)
If ERBB-2 tumor protein negative then near 100% | If ERBB-2 tumor protein positive then 54%
66
What is the 5 year survival of medulloblastomas which exhibit metastasis or if there is residual postresection?
~20%
67
What are variants of CNS PNET tumors?
``` CNS neuroblastoma (including esthesioneuroblastoma) Ganglioneuroblastoma Medulloepithelioma Pineoblastoma Ependymoblastoma ```
68
What is the appx 5 year survival of CNS PNET tumors? | What factors increase chances of survival?
~ 30% | Complete resection, no metastasis, age > 2, heavily calcified lesion
69
What is appropriate treatment of CNS PNET tumors?
Aggressive surgical resection (since extent of resection impacts prognosis in most cases) + chemo + rads if > 3 yo
70
At what age do atypical teratoid-rhabdoid tumors present? How do they present? What is prognosis? What is treatment?
< 3 yo ICP elevation, developmental regression, seizures, torticollis Median survival is 6 months Gross total resection
71
How does the presentation of schwannoma differ based on age?
<30 yo more likely to be parnechymal with seizure/epilepsy presentation >30 yo more likely vestibular schwannoma with sensorineural hearing loss, tinnitus, and dizziness
72
How often do schwannomas recur?
They're slow growing and only recur in ~ 10% of cases post-resection
73
For schwannomas < 3cm in diameter what are options for management?
May follow symptoms, audiology, and scans every 6 month. SRS is an option for these. Surgery can also be an acceptable option but the risk of CN VII damage or hearing loss may be high relative to risk of the small lesion
74
Approximately what is the chance of hearing preservation in removing a schwannoma > 3cm?
40% | Chances of hearing preservation decrease as the size of the tumor increases
75
There are 4 approaches to consider for removing a vestibular schwannoma. What are they and which is best and worst for hearing preservation?
Translabyrinthine (sacrifices hearing but may better preserve CN VII) Suboccipital (may best preserve hearing) Retromastoid Subtemporal
76
Neurofibromas (including the plexiform type) often arise from where? What condition are they associated with?
In the orbit (V1), scalp, parotid (CN VII) NF1
77
Are neurofibromas fast or slow growing? | Do they recur often?
Slow growing but 2-12 % degenerate into malignant nerve sheath tumors Recurrence is high
78
What is the main indication for surgical resection of neurofibromas? How likely is complete resection?
Neural compression | Complete resection nearly impossible
79
What is a perineurioma?
Rare, slow-growing, benign lesions growing on perineurial cells often treated with surgical removal (may be plexiform)
80
In cases of malignant peripheral nerve sheath tumors what adjunct to resection is there?
Chemo and radiation
81
What are the two most important risk factors for recurrence of a meningioma? What is the 20 year rate of recurrence?
Atypical histology Extent of resection 20-50%
82
Risk of meningiomas is higher in what condition?
NF
83
What are examples of benign mesenchymal tumors and tumor-like lesions? Do these need to be resected?
Lipoma, angiolipoma, rhabdomyoma, chondroma, leiomyoma, osteochondroma, benign fibrous hisiocytoma, osteoma, solitary fibrous tumor, and hemangioma No. Sometimes they are for cosmetic reasons
84
Unlike benign types, malignant mesenchymal tumors and tumor-like lesions often require resection. What are some types? What is median survival generally? (Hint: there is one exception, what is it?)
Rhabdomyosarcoma, chondrosarcoma, Ewing tumor, osteosarcoma, leiomyosarcoma, Kaposi sarcoma, liposarcoma, epithelioid hemangioendothelioma, angiosarcoma, and malignant fibroid histiocytoma Aggressive and median survival 6-24 months Exception is hemangiopericytoma which is 80% at 5 years
85
Hemangioblastoma is associated with what condition? Hemangioblastoma makes up ____ % of posterior fossa tumors
Von Hippel Lindau Syndrome 10%
86
What is survivability of hemangioblastoma? | What is treatment?
85% at 10 years (slow growing) | Resection +/- preop embolization
87
How are primary malignant melanomas of meninges treated? What is the prognosis?
Surgical resection with chemo and radiation | Poor prognosis
88
What other operation may a patient with diffuse melanosis/meningeal melanomatosis require and why?
Shunt placement for HCP
89
If a patient presents with primary CNS lymphoma and is 30 how will your management differ than if they were 60? What if they were 10?
The younger the patient the more likely an acquired or inherited immunodeficiency state. If 10 yo consider an inherited immunodeficiency, if 30 think acquired (e.g. AIDS)
90
With what predominant symptom may primary CNS lymphomas often present?
Neuropsychiatric changes
91
How does median survival in primary CNS lymphoma change depending on treatment?
1-4 months if left untreated | 1-4 years if treated
92
What is the treatment for primary CNS lymphoma?
No surgery usually. High dose methotrexate for young patients Steroid response is helpful and dramatic but may be short-lived
93
Where do plasmacytomas arise and why? | What is treatment and what must be ruled out and how?
Often skull due to plasma cells in marrow Complete surgical resection but need to rule out multiple myeloma with urine and serum protein electrophoresis. There is a high risk of developing multiple myeloma
94
In what age group does granulocytic sarcoma arise and associated with what other malignancy? What is median survival? What is first line treatment?
Pediatrics, usually associated with AML 2-20 months median survival Chemo/Rad therapy first line; surgical resection reserved for emergent mass effect

Neurosurgery Boards - Citow (9 decks)

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