Neurosurgery Case 2: CNS Neoplasms

1. Neurosurgery Case 2:CNS Neoplasms 3Med – C UST-FMS

2. 58 year-old female

3. Focal seizures involving left foot progressing to leg, thigh, whole left half body – 5 minutes • 1 day PTA Admission

4. Past Medical History: dx to have migraine • Physical Exam: • VS: PR 90/min, BP 170/86, RR 18/min, T 37C • Awake and oriented to 3 spheres • Pupils 6mm bilateral, sluggishly reactive to light • Fundoscopy: bilateral haziness of the temporal aspects of the optic disc with areas of retinal hemorrhages

5. Physical Exam: • 6 Nerve palsy L • Shallow L nasolabial fold • Tongue midline in protrusion • Able to do FTNT, APST • L hemiparesis; 3/5 LE weaker than UE • Right: 5/5 UE, 4/5 LE • DTR +++ on left, ++ on right • (+) Babinski L w/ ankle clonus

6. Primary and SecondaryBrain Tumors C1

7. Primary Brain Tumor • Arise from CNS tissue • In adults, 2/3 arise from structures above tentorium • In children, 2/3 arise from structures below tentorium • Gliomas, metastases, meningiomas, pituitary adenomas, and acoustic neuromas account for 95% of all brain tumors

8. Primary Brain Tumor Frequency • Annual incidence rate: 7-19.1 per 100k • An increase in HIV infection corresponds to an increase in occurrence of primary CNS lymphoma

9. Primary Brain Tumors Mortality/Morbidity • In the US, primary cancers of the CNS were the cause of death in 13,100 people (1999) • Brain tumors are the 2nd most common cancer in children – 15-25% of all pediatric malignancies

10. Primary Brain Tumor Sex • Meningiomas & pituitary adenomas: M<F • In general, M:F ratio is 1.5:1 Age • Tumors in posterior fossa predominate in preadolescent children, with the incidence of supratentorial tumors increasing from adolescence to adulthood. • Low-grade gliomas are more common in younger people than in older people. High-grade gliomas tend to originate in the fourth or fifth decade or beyond. • In children, brain tumors are the most prevalent solid tumor, second only to leukemia as a cause of pediatric cancer.

11. Secondary Brain Tumor • Metastatic tumors are among the most common mass lesions in the brain – can affect brain parenchyma, its covering and the skull

12. Secondary Brain Tumor Frequency • Incidence of metastatic brain tumor accounts for 50% of total brain tumors • Est. 100k new cases are diagnosed per year in the US

13. Secondary Brain Tumor • Mortality/Morbidity

14. Secondary Brain Tumor Sex • Although melanoma spreads to the brain more commonly in males than in females, gender does not affect the overall incidence of brain metastases Age • About 60% of patients are aged 50-70 years. • CNS metastasis accounts for only 6% of CNS tumors in children. • Leukemia accounts for most metastatic CNS lesions in young patients, followed by lymphoma, osteogenic sarcoma, and rhabdomyosarcoma. • Germ-cell tumors are common in adolescents and young adults aged 15-21 years

15. General clinical manifestations (focal deficits and irritation, mass effect; supratentoriaivsinfratentorial) of brain tumors • Signs and symptoms of increased ICP and its management C2

16. Intracranial tumors can cause brain injury from: • Mass effect • Dysfunction or destruction of adjacent neural structures • Swelling • Abnormal electrical activity (seizures) Schwartz's Principles of Surgery, 9th edition

17. SUPRATENTORIAL TUMORS • Commonly present with focal neurologic deficit, such as: • Contralateral limb weakness • Visual field deficit • Headache • Siezure Schwartz's Principles of Surgery, 9th edition

18. INFRATENTORIAL TUMORS • Often cause increased ICP due to hydrocephalus • From compression of the fourth ventricle • Leading to: • Headache • Nausea • Vomiting • Diplopia Schwartz's Principles of Surgery, 9th edition

19. Cerebellar hemisphere or brain stem dysfunction can result in: • Ataxia • Nystagmus • Cranial nerve palsies • Infratentorial tumors rarely cause seizures Schwartz's Principles of Surgery, 9th edition

20. RAISED INTRACRANIAL PRESSURE • ICP normally varies between 4 and 14 mmHg • Sustained ICP levels above 20 mmHg can injure the brain Schwartz's Principles of Surgery, 9th edition

21. SIGNS & SYMPTOMS OF INCREASED INTRACRANIAL PRESSURE (ICP) * or Intracranial Hypertension (ICH) • Patients with increased ICP often will present with: • Headache • Nausea • Vomiting • Progressive mental status decline Schwartz's Principles of Surgery, 9th edition

22. Cushing’s Triad is the classic presentation of ICH: • Hypertension • Bradycardia • Irregular respirations • This triad is usually a late manifestation Schwartz's Principles of Surgery, 9th edition

23. Focal neurologic deficits such as hemiparesis may be present if there is a focal mass lesion causing the problem • Patients with these symptoms should undergo head CT as soon as possible Schwartz's Principles of Surgery, 9th edition

24. MANAGEMENT OF INCREASED INTRACRANIAL PRESSURE (ICP) • Initial management of ICH includes: • Airway protection • Adequate ventilation • A bolus of mannitol up to 1g/kg causes: • Free water diuresis • Increased serum osmolality • Extraction of water from the brain Schwartz's Principles of Surgery, 9th edition

25. Cases of ICH typically require rapid neurosurgical evaluation • For definitive decompression, these may be needed: • Ventriculostomy • Craniotomy • Craniectomy Schwartz's Principles of Surgery, 9th edition

26. Recognize specific syndromes; extra-axial and intra-axial inbrain tumor presentation. C3

27. Extra-axial vs. Intra-axial radiological descriptions: *"extra-axial“--- extrinsic to brain e.g. meningioma and Schwannoma *"intra-axial“ ---in brain or spinal cord tissue e.g. astrocytoma and oligodendroglioma

28. Extra-axial Symptoms *Seizures -common in tumors of the meniniges, the thin covering layers of the brain and spinal cord. -caused by pressure and compression rather than by growth into brain tissue. *Some of the possible meningioma symptoms are:- • Vision Blurring • Memory blocks • Seizures • Vomiting • Persistent or severe headaches that occur frequently • Extreme feeling of pressure felt on the inside of the skull • Blind spots at the back of the eye

29. Extra-axial Symptoms • Mild to severe ringing in the ears, feeling as if the ears are obstructed • Hearing loss

30. Intra-axial Symptoms Brain Stem - the Midbrain, Pons, Medulla Oblongata Vomiting (usually just after awakening), Clumsy, uncoordinated walk, Muscle weakness on one side of the face causes a one-sided smile or drooping eyelid Difficulty in swallowing and slurred or nasal speech are also common. *Symptoms may develop gradually.

31. Intra-axial Symptoms Brain Stem - the Midbrain, Pons, Medulla Oblongata Double vision with an inability to fully move one or both eyes might occur. Headache, usually just after awakening, is common. Head tilt, drowsiness, hearing loss and/or personality changes can also be present. *Symptoms may develop gradually.

32. Intra-axial Symptoms • Cerebellopontine Angle Ringing or buzzing in the ear. Less often, dizziness might occur. As a tumor grows, deafness, loss of facial sensation and/or facial weakness can occur. *Other symptoms are similar to those of a brain stem tumor.

33. Intra-axial Symptoms • Frontal Lobe Tumors in the frontal lobe may initially be "silent." As they grow, they can cause a variety of symptoms including one-sided paralysis, seizures, short-term memory loss, impaired judgment and personality or mental changes. Urinary frequency and urgency can develop. Gait disturbances and communication problems are also common. If the tumor is at the base of the frontal lobe, loss of smell, impaired vision, and a swollen optic nerve can occur.

34. Intra-axial Symptoms • Occipital Lobe Blindness in one direction or other visual disturbances, and seizures are common symptoms.

35. Intra-axial Symptoms Parietal Lobe Seizures, language disturbances (if a tumor is in the dominant hemisphere) and loss of ability to read are common symptoms. Spatial disorders, such as difficulty with body orientation in space or recognition of body parts, can also occur. There may be difficulty knowing left from right and sentences containing comparisons or cross-references may not be understood.

36. Intra-Axial Symptoms • Temporal Lobe Seizures are the most common symptom of a tumor in this location. The ability to recognize sounds or the source of sounds may be affected. Vision can be impaired.

37. Intra-Axial Sypmtoms • Corpus Callosum Impaired judgment and defective memory are frequent symptoms of a tumor in the forward part of this area; behavioral changes are common with a tumor in the rear part. A tumor in the middle of the corpus callosum might cause few, if any, symptoms until it grows quite large. This tumor might invade other lobes of the cerebral hemispheres and produce symptoms common to tumors in those locations. Seizures are uncommon.

38. Intra-Axial Symptoms • Pineal Region A tumor in this location causes hydrocephalus with the symptoms of increased intracranial pressure. Problems with eye movement often occur. In children, hormonal disturbances such as precocious puberty may occur.

39. Intra-Axial Symptoms • Pituitary A tumor in this gland may cause headache, vision changes, and/or diabetes insipidus (a type of hormone disturbance). Because these tumors often secrete hormones inappropriately, other symptoms vary depending on the type of hormone secreted. Breast enlargement and secretion are common.

40. Intra-Axial Symptoms • Thalamus Common symptoms of a tumor in the thalamus include sensory loss such as the sense of touch on the side of the body opposite the side of the tumor; muscle weakness; decreased intellect; vision problems; speech difficulties; loss of urinary control; headache, nausea and vomiting difficulties in walking due to the increased pressure caused by obstructive hydrocephalus.

41. Intra-Axial Symptoms • Third Ventricle Hydrocephalus due to the blockage of cerebrospinal fluid is very common, causing symptoms of increased intracranial pressure. Leg weakness, fainting spells, impaired memory and hypothalamic dysfunction are frequent symptoms.

42. Diagnostic tools that are currently used for evaluation C4

43. Lumbar Puncture and CSF examination • The patient is positioned side-lying, with back vertical on the edge of the bed and knees flexed up to the chest • Area is prepared with an antiseptic solution and draped • Insterspinous area is palpated and the skin is injected with lidocaine • Lumbar puncture is done at the L3-L4 level in between two spinous process, pointed slightly cranially

44. Lumbar Puncture cont’d • Needle passes through the interspinous ligament and the dura • The fluid is drained and sent for examination

45. Lumbar Puncture cont’d • Contraindications: increased ICP • Complications: - progression of brain herniation - progression of spinal cord compression - injury to the neural structures - headache - backache - infection—local and meningitis - implantation of epidermoidtumour (rare)

48. Skull X-ray • Hyperostosis, eg. Meningioma

49. Skull X-ray cont’d • bone erosion due to skull vault tumours • midline shift of the pineal gland—from space occupying lesion

50. Skull X-ray cont’d • abnormal calcification, e.g. tumours such as meningioma, oligodendroglioma, craniopharyngioma or calcified wall of an aneurysm • signs of long-standing raised intracranial pressure—erosion of the dorsum sellae