Neurology

Brain SOL

Brain SOL
Traumatic Subdural haematoma Extradural haematoma Vascular Intracerebral haematoma Infective Cerebral abscess ;pyogenic, Toxoplasma Tuberculoma Cysticercosis Hydatid cyst Schistomiasis

Brain SOL

Inflammatory Sarcoid mass Neoplastic Cerebral neoplasms (benign or malignant ) Other Embryonic dysplastic lesions e.g. craniopharyngioma &hamartomas Arachnoid cyst

CNS tumours

Primary or Secondary Account for 2% of all deaths The majority are metastatic Meningeomas account for 20 %of all intracranial tumours

Benign intracranial tumours

Age
Common site
Histologic type
Adulthood
Corticaldura,Para-sagittal, Sphenoidal ridge,Suprasellar, Olfactory groove
Meningeoma
Adulthood
Acoustic neuroma
Neurofibroma
Childhood / Adolescence
Suprasellar
Craniopharyngioma
Adulthood
Pituitary fossa
Pituitary adenoma
Any age
Third ventricle
Colloid cyst
Childhood(teratoma) Adulthood(germ cells)
Quadrigeminal cistern
Pineal tumors

Malignant intracranial tumours

Age
Common site
Histologic type
Adulthood Childhood /Adulthood
Cerebral hemisphere Cerebellum Brainstem
Glioma
Adulthood
Cerebral hemisphere
Oligodendroglioma
Childhood
Posterior fossa
Medulloblastoma
Childhood /Adolescence
Posterior fossa
Ependymoma
Adulthood
Cerebral hemisphere
Cerebral Lymphoma

Even malignant tumours don’t metastasize outside the CNS

Secondaries (metastases)
Usually located in the white matter of cerebral or cerebellar hemispheres;common sources are bronchus ,breast &gastrointestinal tract.

CLINICAL FEATURES

Insidious Onset = May be acute with cystic degeneration, hemorrhage or with seizures. Progressive course. Space- occupying effect Site of the tumor False localizing signs

Space occupying effectRaised intracranial pressure

HEADACHE: Non specific;dull aching, eventually in most patients, more severe in early morning in 10-15 % , aggravated by cough, sneezing, straining &change of posture (bending,lying ). It is ipsilateral to supratentorial tumors in 80% of cases

Space occupying effect

Nausea &vomiting Seizures : more if tumor in ant. Cranium e.g. more than 50% of frontal lobe tumours have seizures ;generalized or partial . Papilloedema : more in infratentorial tumours, leading to transient visual obscurations. Altered mentation.

SITE OF TUMOR FOCAL SIGNS &SYMPTOMS

Frontal lobe : Altered mood &behavior, contra. Motor deficit, incontinence,primitive reflexes Parietal lobe : Sensory s.&s. may predominate, contra. Visual field &motor deficit Non dominant parietal l. :sensory or visual inattention, dressing apraxia Temporal lobe : Wernicke aphasia, sup. Quadrantanopia, temporal lobe epilepsy Occipital lobe : visual field abnormality

FALSE LOCALIZING SIGNS

Pupillary dilatation. 6th cranial nerve palsy(unilateral or bilateral). Hemiparesis (ipsilateral to the lesion ). Bilateral extensor plantar responses.



The rise in intracranial pressure from a mass lesion is not usually uniform within the cerebral substance and alterations in pressure relationships within the skull may lead to displacement of parts of the brain between its various compartments. Downward displacement of the temporal lobes through the tentorium due to a large hemisphere mass may cause 'temporal coning This may stretch the 3rd and/or 6th cranial nerves, or cause pressure on the contralateral cerebral peduncle (causing ipsilateral upper motor neuron signs).


Downward movement of the cerebellar tonsils through the foramen magnum may compress the medulla-(tonsillar coning) This coning may result in brain-stem haemorrhage and/or acute obstruction of the CSF pathways. As coning progresses, the patient may adopt a decerebrate posture and, unless rapidly treated, death almost invariably ensues. The process may be acutely accelerated if the pressure dynamics are suddenly disturbed by lumbar puncture

INVESTIGATIONS

Plain X Ray ; Signs of raised ICP, Calcification…EEG : Focal slowing CT Scan ,MRI &MRA

TREATMENT

Reduce ICP : Osmotic diuretics, SteroidsOften required when surgery is not possible or when life is threatened.Dexamethasone 8- 12 mg 12-hourly orally or by injection ;a striking improvement in consciousness is often produced &focal deficits may regress.Mannitol 0.25 – 1 mg /Kg /Dose IVI.

Surgery

Mainstay of treatment Only partial excision may be possible if the the tumour is inaccesible or its removal is likely to cause unacceptable damage. Biopsy should be considered even if the tumour is not removable ?prognosis &management. Meningeomas,acoustic neuromas &pituitary adenomas.

Radiotherapy &Chemotherapy

Marginal effect on survival in metastases &malignant gliomas. Combined therapy has improved prognosis in medulloblastomas in children. Radiotherapy reduces the risk of recurrence of pituitary adenoma after surgery. Ependymomas,some pineal tumours &low gradegliomas in children &young adults are often radiosensitive.



Prognosis
For benign tumours is good if removed completely.Ependymomas &Medulloblastomas may recur with seeding via the CSF.Oligodendrogliomas may transform to more malignant form ---- glioma .Related to histologic grade ; G1&2 may survive for years G 4 –only 20 %survive for 1 year.

Meningiomas

Arise from the dura mater and are nearly always benign, well-demarcated lesions that displace rather than invade the adjacent neural tissue as they grow. These mesodermal tumors most often become clinically evident between the ages of 40 and 50. They are diagnosed by MRI or CT scanning which reveals marked, homogeneous contrast enhancement. Meningiomas tend to appear in certain classic locations with corresponding typical neurological manifestations. They often grow very slowly and are not uncommonly discovered as an incidental radiological finding. The indications for treatment must then be carefully considered: resection may be desirable in younger patients, but unnecessary in older ones.

للاطلاع

Common sites of meningiomas, and associated clinical features
Special features
course
Most common initial manifestations
Site
The frontal branch of the temporal artery may be enlarged
Epilepsy,personality changes,possible involvement of optic nerve
Anosmia
Olfactory groove
Hemiparesis
Epileptic seizures
Convexity
Rarely causes hemiparesis
Epileptic seizures
Lower limb paresis;sometimes bilateral babinski sign
Parasagittal &falx
Lateral tumors may be evident as temporal hyperostosis
Exophthalmus, hemiparesis
Visual disturbances(when medially located adjacent to optic nerve
Sphenoidal wing

Common sites of meningiomas, and associated clinical features

Special features
Course
Most common initial manifestation
Site
Progressive visual field defect
Visual disturbances,pale optic disc
Tuberculum sellae
Diff.diagnosis Acoustic neuroma
facial&5th nerve deficit Brainstem compression
Deafness,vertigo
Cerebellopontine angle
Lower cranial n.palsy
Spastic quadriparesis,dys- phasia,dysarthria
Foramen magnum
Often found in trigone
Progressive hydrocephalus
Intermittent headaches,vomiting
Intraventricular

Meningioma of the left cerebral convexity

Falx meningioma

Sphenoid wing meningioma

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