Revision - Space Occupying Lesions & Cerebral Venous Thrombosis

Question 1

Location of majority of brain tumours in adults vs children?

Answer 1

Adults –> supratentorial (i.e. cerebrum)

Children –> infratentorial (i.e. cerebellum)

Question 2

which cancer most commonly spreads to brain?

Answer 2

lung

Question 3

What is the most common 1ary brain tumour in adults?

Answer 3

Glioblastoma

Question 4

Unusual changes in personality and behaviour would indicate a brain tumour in what location?

Answer 4

Frontal lobe

Question 5

What are glial cells?

Answer 5

They surround and support the neurones:

1) Astrocytes
2) Oligodendrocytes
3) Ependymal cells

Question 6

What is a glioma?

Answer 6

Tumour of the glial cells in the brain or spinal cord

Question 7

How gliomas graded?

Answer 7

1-4 depending on severity

4 is most malignant (glioblastoma multiforme)

Question 8

What are the 3 types of gliomas?

Answer 8

1) astrocytoma
2) oligodendroglioma
3) ependymoma

Question 9

What type of glioma is a glioblastoma multiforme?

Answer 9

Astrocytoma

Question 10

Prognosis of a glioblastoma?

Answer 10

Around 1 year

Question 11

How do glioblastomas appear on imaging?

Answer 11

Solid tumour with central necrosis and rim that enhances with contrast.

Associated with vasogenic oedema due to disruption of blood brain barrier.

Question 12

Histology of a glioblastoma?

Answer 12

Pleomorphic tumour cells border necrotic cells

Question 13

What do meningomas arise form?

Answer 13

Dura mater of the meninges

Question 14

Are meningiomas usually benign or malignant?

Answer 14

Usually benign

However, they take up space –> can lead to raised intracranial pressure and neurological symptoms

Question 15

Histology of meningiomas?

Answer 15

Spindle cells in concentric whorls and calcified psammoma bodies

Question 16

What is the most common 1ary brain tumour in children?

Answer 16

Pilocytic astrocytoma

Question 17

Histology of a pilocytic astrocytoma?

Answer 17

Rosenthal fibres (corkscrew eosinophilic bundle)

Question 18

What is a medulloblastoma?

Answer 18

An aggressive paediatric tumour that arises within the infratentorial compartment.

Question 19

How does a medulloblastoma spread?

Answer 19

Through CSF

Question 20

Where is an ependymoma commonly seen?

Answer 20

In the 4th ventricle

Question 21

What may an ependymoma cause?

Answer 21

Hydrocephalus

Question 22

Where are oligodendromas typically found?

Answer 22

Frontal lobes

Question 23

What is a haemangioblastoma?

Answer 23

A vascular tumour of the cerebellum

Question 24

What condition are haemangioblastomas associated with?

Answer 24

von Hippel-Lindau syndrome

Question 25

Hearing loss in a vestibular schwannoma?

Answer 25

Sensorineural

Question 26

Typical presentation of a vestibular schwannoma?

Answer 26

1) typically 40-60 y/o 2) unilateral sensorineural hearing loss 3) unilateral tinnitus 4) dizziness or imbalance 5) sensation or fullness in ear 6) facial nerve palsy (if the tumour grows large enough to compress the facial nerve)

Question 27

What is the most common paediatric SUPRAtentorial tumour?

Answer 27

Craniopharyngioma

Question 28

What is the 1st line investigation in patients with a possible brain tumour?

Answer 28

MRI

Question 29

What drugs can cause idiopathic intracranial HTN?

Answer 29

1) COCP 2) Steroids 3) Tetracyclines 4) Lithium 5) Retinoids

Question 30

Management of idiopathic intracranial HTN?

Answer 30

1) weight loss 2) carbonic anhydrase inhibitors e.g. acetazolamide 3) topiramate (has the added benefit of causing weight loss in most patients) 4) repeated lumbar puncture may be used as a temporary measure but is not suitable for longer-term management 5) surgery

Question 31

Role of carbonic anhydrase inhibitors (eg, acetazolamide) in idiopathic intracranil hypertension?

Answer 31

Can reduce CSF production at choroid plexus

Question 32

Which cranial nerve is most common affected by traumatic brain injury and/or elevated ICP?

Answer 32

CN VI (abducens)

Question 33

What is cerebral venous thrombosis caused by?

Answer 33

Partial or total occlusion of the cerebral veins and sinuses by a thrombus.

Question 34

What are some genetic thrombophilias that can predispose to CVT?

Answer 34

1) APS 2) Antithrombin III deficiency 3) Protein C deficiency 4) Protein S deficiency 5) Factor V Leiden 6) Hyperhomocysteinemia

Question 35

What is the most common cause of infection causing CVT?

Answer 35

Staph aureus - spread from infection of the sinuses

Question 36

Give 3 examples of infections causing CVT

Answer 36

1) Staph. aureus from sinusitis 2) Meningitis 3) Subdural empyema

Question 37

Give 2 procedures that can cause CVT

Answer 37

1) Jugular venous cannulation 2) LP

Question 38

Give some examples of chronic inflammatory diseases that can cause CVT

Answer 38

1) SLE 2) IBD 3) Sarcoid 4) Granulomatosis with polyangiitis

Question 39

What medication increases the risk of CVT?

Answer 39

Steroids

Question 40

What is the 1ary mechanism of injury in CVT?

Answer 40

1) a cerebral vein or sinus becomes partially or totally occluded by a venous thrombus 2) deoxygenated blood will begin to pool within the brain parenchyma 3) this causes an increase in cerebral venous pressure

Question 41

Resulting complications from CVT?

Answer 41

1) cerebral ischaemia 2) oedema 3) haemorrhage 4) raised ICP

Question 42

Symptoms of CVT?

Answer 42

1) headache 2) seizures 3) focal neurological deficits: - hemiparesis - fluent aphasia - sensory/visual field defects 4) changes in metnal state: - encephalopathy Symptoms will vary depending upon the site and extent of thrombosis.

Question 43

What is the most common site of CVT?

Answer 43

Sagittal sinus thrombosis (60%)

Question 44

How does sagittal sinus thrombosis typically present?

Answer 44

Most commonly presents with bilateral motor deficits and seizures

Question 45

Which sinus is most likely to be affected by septic CVT?

Answer 45

Cavernous sinus - with infection spreading from nearby sinuses, nose and middle ear

Question 46

CVT can be classified into what two categories depending upon its aetiology?

Answer 46

1) aspectic CVT 2) septic CVT

Question 47

What is aseptic CVT?

Answer 47

An embolism arising from a non-infective cause, often due to underlying hypercoagulable state but has a variety of causes. This is the most common type of CVT

Question 48

Where does aspetic CVT typically occur?

Answer 48

Superior sagittal sinus

Question 49

What is septic CVT?

Answer 49

An embolism arising from a primary source of infection, most commonly sinusitis, osteomyelitis, otitis media or rarely septicaemia.

Question 50

Where does septic CVT typically occur?

Answer 50

Cavernous sinus

Question 51

What is the most frequent symptom experienced by CVT patients?

Answer 51

Headache

Question 52

1st line investigation in suspected CVT?

Answer 52

MRI + MR venography

Question 53

Management of CVT involves what 3 key elements?

Answer 53

1) acute antithrombotic therapy 2) acute symptom management 3) long term management

Question 54

What is used for acute antithrombotic therapy in CVT?

Answer 54

LMWH or UH

Question 55

What does acute symptom management involve in CVT?

Answer 55

1) Raised ICP: - bed elevated - osmotic therapy (mannitol or hypertonic saline) - brain herniation may need emergency decompressive surgery 2) Seizures: anticonvulsants 3) Infection/inflammation: Abx, steroids

Question 56

Mx of raised ICP?

Answer 56

1) elevate bed 2) osmotic therapy: IV mannitol or hypertonic saline

Question 57

Long term management of confirmed CVT?

Answer 57

Long-term mx with warfarin

Question 58

What is anticoagulant of choice for long-term mx in CVT?

Answer 58

Warfarin

Question 59

INR target in patients on warfarin in CVT?

Answer 59

2.5

Question 60

How long is warfarin continued for in CVT?

Answer 60

Provoked CVT –> 3-6 months Unprovoked CVT –> 6-12 months

Question 61

Which artery is typically affected in temporal arteritis that causes vision loss?

Answer 61

Occlusion of the posterior ciliary artery (a branch of the ophthalmic artery) –> ischaemia of the optic nerve head.

Question 62

What will a temporal artery biopsy show in temporal arteritis?

Answer 62

Multinucleated giant cells --> skip lesions may be present