brain spinal tumors
TRANSCRIPT
![Page 1: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/1.jpg)
Man Bahadur Paudyal
![Page 2: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/2.jpg)
Introduction IClassification:
A. Based on origin of tumor1. Primary 2. Secondary (Metastatic) B. Based on nature of tumor1. Benign: well-encapsulated, slow-growing non-infiltrative, low tendency to invade 2. Malignant: non-encapsulated, rapid-growing highly infiltrative.
![Page 3: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/3.jpg)
Introduction IIOccurrence
CNS Tumor: 10% of all tumors Brain (80%) Spinal Cord (20%)
Ultimate outcome: increased ICP Mass effect tumor perifocal edema intratumoral hge Direct compressioninfiltration CSF pathway obstructionFocal effects CN deficits
![Page 4: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/4.jpg)
Clinical Manifestation
Depends on the location of the tumor.With supratentorial tumors:
1. Seizure2. Mental changes (memory loss, behavior changes)3. Focal deficits(visual field deficit, paralysis)
With infratentorial tumors:1. CN palsies2. Cerebellar signs (ataxia, dysmetria, tremor, nystagmus, diadodiskinesia)3. Obstructive hydrocephalus
![Page 5: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/5.jpg)
Clinical Syndromes Frontal lobe syndrome
1) Mental/ personality changes2) Incontinence3) Speech disorders4) Paralysis
Temporal lobe syndrome1) Aphasia2) Psychomotor seizures3) Visual field changes (hemianopia)
![Page 6: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/6.jpg)
Parietal lobe syndrome I
I. With dominant hemisphere1) Gerstman’s syndrome
a) agraphia without alexia (can read but not write)
b) left to right confusionc) digital agnosia ( can not name
fingers)d) acalculia (can not do simple
calculation)2) Language disorder3) Tactile agnosia4) Ideomotor apraxia
![Page 7: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/7.jpg)
Parietal Syndromes II
II. With non-dominant hemisphere1) Topographic memory loss2) Anosognosia3) Dressing apraxia
III. With either1) Focal seizures2) Agnosia3) Sensory changes4) Dyslexia
![Page 8: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/8.jpg)
General Clinical Manifestation1. Severe progressive headache, worst in morning
2. Vomiting, projectile, without prenauseate phase3. Seizures (generalized/focal)4. Altered sensorium5. Changes in mentation6. Abnormal sensations7. Increased ICP8. Papilledema9. Central herniation with brainstem dysfunction10. Compression of brain parenchyma/blood vessels/CSF
path(1) Ischemia (2) Infarction (3) Hydrocephalus(4) Edema (5) Hemorrhage
11. Suture separation in children < 5 yr12. Bony erosion
![Page 9: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/9.jpg)
Classification of CNS TumorIn adults, the majority are
supratentorial and of metastatic type; whereas in children, infratentorial tumors are more common.
![Page 10: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/10.jpg)
Common Pediatric Intracranial Tumors
I. MedulloblastomaII. EpendymomaIII. Cerebral AstrocytomaIV. Cerebellar AstrocytomaV. Brainstem Glioma (BSG)VI. Craniopharyngioma (CP)
![Page 11: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/11.jpg)
MedulloblastomaMost common malignant pediatric brain tumor (15 ~ 20%)Arises from cerebellar vermis & apex of IV ventricle roofPredispose to early obstruction of CSF pathwaysCSF seedlings
CT-scan: sold midline enhancing lesion
MRI:Banana signHighly radiosensitive/ moderately chemosensitive
![Page 12: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/12.jpg)
TreatmentSurgery Suboccipital craniectomy+Excision ShuntVentriculostomy Definitive surgeryPostoperative radiation/ chemotherapy
PrognosisPoor prognosis Younger age < 4 yrDisseminationUnable to perform total resectionHistological differentiationWithout treatment, survival 1 ~ 2 yrsWith treatment, 5 & 10 yr survival 56% & 43%
![Page 13: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/13.jpg)
![Page 14: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/14.jpg)
EpendymomaUsually benign but may be inoperable due to
locationIntracranial location is usually infratentorial and in
spine, especially in filum teminalis (myxopapillary)
May seed along CSF pathways/ occur along neuraxis
CT/MRI: commonly calcified, inhomogeneous on T1WI and exophytic component is high signal in T2WI
TreatmentSurgery & postoperative radiation
PrognosisWorse due to propensity to invade obex5 yr survival 41%
![Page 15: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/15.jpg)
Cerebral AstrocytomaTypes:
Low gr ( I + II ): less malignant better prognosisHigh gr ( III+IV ): highly malignant poor outcome
Usually involve:Frontal Basal ganglia ThalamusMidline structures
Butterfly glioma: arising from corpus callosum with bifrontal lobe involvement
Arises from neuro-ectodermal tissueTreatment: Surgery/Biopsy
Postoperative radio/chemotherapyPrognosis: Average survival < 1 yr in high grade
![Page 16: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/16.jpg)
IV. Cerebellar astrocytoma Usually benign & cystic Usually present during 2nd decade Usually involves pons, midbrain & medulla Does not seed along CSF pathway
Pilocytic typeoccur in younger age & have better prognosisRadiographically, cystic with mural nodulePathologically, compact/loose astrocytes with Rosenthal fibres
Treatment: Surgery + Postoperative radiotherapy
Prognosis: Long-term survival possible with combined
![Page 17: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/17.jpg)
![Page 18: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/18.jpg)
V. Brainstem Glioma (BSG)
Slow-growing & highly malignant with poor prognosis
Usually presents with multiple CN palsies & long tract signs
Treatment: Surgery + postoperative radiotherapy
Prognosis:With RXT, survival 4 yr Without RXT, only 1 yr
![Page 19: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/19.jpg)
![Page 20: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/20.jpg)
Craniopharyngioma (CP) Benign suprasellar lesion Arises from rakhte’s remnants May be prechiasmatic/retrochiasmatic Causes pituitary dysfunction, visual field deficits CT/MRI: almost all have solid & cystic
componentsSpoke & Wheel appearance
Treatment: Surgery: Subtemporal/subfrontal/transsphenoidal Postoperative XRT
Prognosis: Favorable if totally resected
![Page 21: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/21.jpg)
![Page 22: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/22.jpg)
![Page 23: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/23.jpg)
Common intracranial tumors in adults I. GliomaII. MeningiomaIII. Vestibular Schwanoma (Acoustic
neuroma)IV. Pituitary AdenomaV. Miscellaneous tumors
![Page 24: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/24.jpg)
I. Glioma
All tumors that arise from neuroglial cells Consists of (1) Astrocytoma (2)
Oligodendroglioma
Oligodendroglioma (Oligo)1. Slow-growing & often calcified2. Frequently presents with seizures3. Occurs in cerebral hemispheres4. Fried egg appearance in LP microscopic view
![Page 25: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/25.jpg)
Meningioma
Usually benign, slow-growing, frequently calcified & extra-axial
Commonly seen in middle-aged womenArising from arachnoid layerUsually located supratentorial along falx,
convexity/sphenoidTendency to compress than infiltrate brain
parenchymaClassic pathological findings is psammomna
bodiesUsually cured if completely removed which is
usually impossibleMay be highly vascular (angioblastic)
![Page 26: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/26.jpg)
CT-scan: Homogeneously enhancing lesion with broad base attachment along durausually with little/ no perifocal edema
MRI: Dural tailTreatment: Surgery & Postoperative XRTPrognosis:
Favorable with total resection, maybe recurrentIn totally resected case, recurrent rate 15%With partial resection upto 85% after 5 yr
![Page 27: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/27.jpg)
![Page 28: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/28.jpg)
![Page 29: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/29.jpg)
Pituitary AdenomaArises from anterior part of pituitary (Adenopypophysis)Type: Microadenoma < 1 cm Macroadenoma
Functional Non-functionalCauses
Compression of optic chiasma bitemporal hemianopiaCompression of cavernous sinus CN palsy(III, IV VI, V1,2)Endocrinologic disturbancesACTH Cushing’s diseasePRL Amenorrhea-galactorrhea syndromeGH Gigantism (Children) Acromegaly (adult)
Apoplexy: Abrupt onset of neurologic deterioration due to expanding mass as result of hemorrhageCauses visual deterioration, ophthalmoplegia, reduced MS & pituitary hypofunction
![Page 30: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/30.jpg)
![Page 31: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/31.jpg)
![Page 32: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/32.jpg)
![Page 33: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/33.jpg)
Acoustic SchwanomaBenign, usually unilateral or maybe part of MEN (bilateral)= NF2
Arises from vestibular branch of 8th CNCauses compression than infiltrationClassic signs: insidious/progressive
Early: Decreased hearing High-pitch tinnitusDizziness DysequilibriumLate:Hemifacial numbness (CN V palsy)Facial asymmetry, lidlag ( CN VII palsy)
Pathology: benign with Antoni A & BCT-scan: erosion/enlargement of IAC (bone
window)Ice cream cone
MRI: Round/oval enhancing lesion centered on IAC
Treatment: Surgery Retrosigmoid, Translabyrinthine, Subtemporal
![Page 34: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/34.jpg)
Miscellaneous Tumors IColloid cyst
Classically occur in III ventricle blocking Foramen of MonroCauses obstructive hydrocephalusSlow-growing, benign lesionTreatment: Surgery( Trancallous/Transcortical Vs Endoscopic)VP Shunt
HemangioblastomaMost common primary intra-axial tumor in adult posterior fossaMay be part of von Hippel Lindau diseaseMay be associated with erythrocytosis
Cerebral LymphomaCT/MRI: homogeneously enhancing lesion in central gray matterFluffy cotton ball appearanceMay present with multiple CN palsiesExtremely responsive to steroids ( ghost tumors)Diagnosis highly likely if uveitis is present
![Page 35: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/35.jpg)
![Page 36: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/36.jpg)
Miscellaneous Tumors IIChordoma
Benign, highly recurrent, slow-growing, locally aggressiveGenerally radio/chemoresistentArises from remnants of primitive notochordCranially, found in sphenooccipital region (clivus) & in sacrococcygeal region in spine
Chordosarcoma: Arises from paramedial region
Cerebral MetastasisMost common brain tumor seen clinicallySources: Adults: Lung, breast, kidney(, GI, melanoma, thyroidChildren: Neuroblastoma, rhabdomyosarcoma, Wilm’s High grade glioma, medullo, ependymoma, pineal tumorLocation: parenchyma/leptomeninges
80% in cerebral hemispheres, mostly parietal lobe
![Page 37: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/37.jpg)
Pseudotumor Cerebri (Benign/Idiopathic Intracranial Hypertension)Increased ICP papilledema without intracranial
mass, hydrocephalus or normal CT/MRI
Usually self-limited, easily recurring, chronicPreventable cause of blindness from optic atrophy
TreatmentFluid/salt restrictionDiamox 250 mg PO q8Lasix up to 160 mg/dSteroid Dexamethasone 4 mg PO q6
Prednisolone 40 ~ 60 mg PO qd
Surgery Serial LP, LP shuntOptic N sheath decompression
![Page 38: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/38.jpg)
Treatment in General
I. Surgery if accessibleII. Radiation if
radiosensitiveIII. Chemotherapy if chemosensitive
Prognosis depends on type & location
![Page 39: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/39.jpg)
![Page 40: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/40.jpg)
Introduction
15% of primary CNS tumors Cranial:Spinal astrocytoma = 10:1 Cranial: Spinal ependymoma = 3 ~20:1
Most primary spinal tumors are benign
Compression symptoms
![Page 41: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/41.jpg)
Types of Spinal Tumors
Extradural: (55%) Intradural Extramedullary: (40%)
Meningioma & neurofibroma Intramedullary: (5%)
![Page 42: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/42.jpg)
Extradural Spinal Tumors
Metastatic Lymphoma, lung, breast, prostate
Primary Chordoma, neurofibroma,
osteoblastoma, hemangioma Meningioma
![Page 43: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/43.jpg)
Intradural Extramedullary Spinal Tumor Meningioma neurofibroma
![Page 44: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/44.jpg)
![Page 45: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/45.jpg)
![Page 46: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/46.jpg)
![Page 47: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/47.jpg)
![Page 48: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/48.jpg)
![Page 49: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/49.jpg)
![Page 50: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/50.jpg)
Intramedullary Spinal Tumor Astrocytoma 30% Ependymoma 30% Other 30%
Glioblastoma, dermoid, epidermoid, lipoma
![Page 51: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/51.jpg)
Clinical Presentation
Pain Weakness Paresthesia Sphincter disturbance Other
Deformity: scoliosis/ torticollis SAH Mass
![Page 52: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/52.jpg)
Diagnosis
Plain X-ray LP Myelogram CT MRI Angiography
![Page 53: Brain spinal tumors](https://reader036.vdocuments.site/reader036/viewer/2022062302/587b59951a28abff1a8b78d1/html5/thumbnails/53.jpg)
Differential Diagnosis
Vascular malformation Demyelinating diseases ( MS) Transverse myelitis Paraneoplastic myelopathy