Tumours of the Nervous System

Question 1

presentation of brain tumour?

Answer 1

PROGRESSIVE neurological deficit
usually motor weakness
headache
seizures
(from most to least common)

Question 2

features of raised ICP?

Answer 2

headache
vomiting
mental changes
seizures

Question 3

causes of raised ICP?

Answer 3

mass
oedema
CSF flow blockage (hydrocephalus)
haemorrhage

Question 4

uncal herniation causes what symptoms?

Answer 4

blown pupil (compresses CN III)

Question 5

tonsillar herniation causes what symptoms?

Answer 5

cushings response?

Question 6

can brain cope well with raised ICP?

Answer 6

no

Question 7

headache die to raised ICP?

Answer 7

worse in the morning
wakes you up
worse with coughing/leaning forward
associated with and worsened by vomiting
basically similar to migrane

Question 8

what do you do if suspected ICP headache?

Answer 8

fundoscopy

look for papilloedema

Question 9

causes of tumour heacache?

Answer 9

raised ICP
invasion/compression of dura, BVs, periosteum
2ndary to diplopia
2ndary to trying to focus eyes
extreme hypertension

Question 10

DANISH?

Answer 10

//

Question 11

suspected brain tumour investigations?

Answer 11

imaging
lesion biopsy
EEG
evoked potential
angiograms
radionucleotide studies

Question 12

most common cause of brain tumour?

Answer 12

metastases

Question 13

what cells can cause primary brai tumours?

Answer 13

astrocytes (60%)
oligodendroglial cells
ependymal cells
neuronal cells
..

Question 14

grading of brain tumours?

Answer 14

molecular classification now
was graded 1-4
- 1 = pilocytic, pleomorphic xanthanoastrocytoma subependymal giant cell
- 2 = low grade astrocytoma
- 3 = anaplastic
- 4 = glioblastoma

Question 15

grade 1 astrocytoma?

Answer 15

truly benign
slow growing
children/young adults
optic nerve, cerebellum generally
take up contrast very well
treatment = surgery (curative)

Question 16

grade 2 astrocytoma?

Answer 16

fibrillary, gemistocytic, protoplasmic
hypercellularity
don’t take up contrast (unlike grade 1)
tend to present with seizures
ultimately not benign (turn malignant and higher grade over time)
treatment = surgery if safe +/- chemo/radiotherapy

Question 17

poor prognostic factors for grade 2 astrocytoma?

Answer 17

age >50
focal deficit
short duration of symptoms
raised ICP
altered conscious
enhancement on contrast studies

Question 18

grade 3 astrocytoma?

Answer 18

malignant
anaplastic
can arise de novo
median survival = 2 years

Question 19

grade 4?

Answer 19

glioblastoma multiforme
most common primary tumour
median survival = <1 year
spread along white matter, tracking CSF pathways

Question 20

management of grade 3-4?

Answer 20

surgery not curative but can help symptoms
post op radiotherapy
combination of surgery + radiotherapy + chemo = survival increased to 14 months but often not done as 2 months doesn’t really make a difference

Question 21

how is tumour identified during surgery?

Answer 21

patient given drink of 5-ALA which causes tumour cells to appear pink under blue light

Question 22

who must be informed after a patient has had any brain surgery?

Answer 22

DVLA

patient cannot drive after any brain surgery (seizure risk)

Question 23

what chemo is used?

Answer 23

temozolomide
PCV
carmustine wafers

Question 24

use of radiotherapy in brain tumours?

Answer 24

clear role in post op malignant tumours

………

Question 25

oligodendroglial tumour?

Answer 25

``` 20% of glial tumours …. present with seizures generally in frontal lobe … difficult to distinguish ………. treatment = surgery + chemotherapy (PCV) ```

Question 26

danger signs of brain tumour in children?

Answer 26

tiptoeing, ataxia, vomiting with headache

Question 27

meningioma?

Answer 27

``` arachnoid cap cells extra-axial 20% of intracranial neoplasms most are asymptomatic most common in women can spread from breast cancer? presentation = cranial nerve palsy, headache slow growing ```

Question 28

aggressive meningiomas?

Answer 28

``` clear cell choroid rhabdoid papillary radiation induced meningiomas (after childhood leukaemia, typically in midline) ```

Question 29

investigation of meningioma?

Answer 29

CT - homogenous, dense enhancing, oedema MRI - ……. angiography +/- embolization - ………..

Question 30

management of meningioma?

Answer 30

``` expectant if small (leave alone) pre-op embolization surgery radiotherapy recurrence 90% 5 year survival ```

Question 31

types of nerve sheath tumours?

Answer 31

schwannomas (AKA neuromas) neurofibromas malignant peripheral nerve sheath tumours

Question 32

commonest nerve sheath tumour?

Answer 32

acoustic neuroma/schwannoma (vestibular) - hearing loss, tinnitus, disequilibrium, can cause hydrocephalus 5th/7th/8th CNs

Question 33

management of acoustic schwannoma?

Answer 33

expectant (25%) surgery radiation manage hydrocephalus

Question 34

how do pineal tumours present?

Answer 34

para.... syndrome nystagmus? ….. all extra-ocular muscles are compromised?

Question 35

pineal tumour?

Answer 35

``` // can be germ cell? ```

Question 36

tumour makers on bloods?

Answer 36

``` AFP HCG LDH - perform for any midline brain tumour in a child - perform a biopsy if negative ```

Question 37

how is hydrocephalus managed?

Answer 37

VP shunt

Question 38

features of pituitary tumour?

Answer 38

bitemporal hemianopia headache endocrine abnormality

Question 39

tests for pituitary tumour?

Answer 39

``` prolactin measure (prolactinoma can generally be managed with cabergoline) early morning cortisol GH/IGF-1 thyroid function tests FSH/LH visual fields ```