Neurosurgery case 1

1. Neurosurgery case 1

2. progressive on and off headache 6 months PTA

3. Progressive on and off headache 1 month PTA 6 months PTA Difficulty of walking : “dragging her left leg” Sought consult, Dx: Stroke Medications: metoprolol 50 mg BID Simvastatin 10mg OD Citicholine 500mg OD Referred to a psychiatrist for therapy

4. Progressive on and off headache 1 month PTA Difficulty of walking : “dragging her left leg” Sought consult, Dx: Stroke Medications: metoprolol 50 mg BID Simvastatin 10mg OD Citicholine 500mg OD Referred to a psychiatrist for therapy 6 months PTA 2 weeks PTA Progressive headache Nausea and vomiting Blurring of vision

5. Progressive on and off headache 1 month PTA Difficulty of walking : “dragging her left leg” Sought consult, Dx: Stroke Medications: metoprolol 50 mg BID Simvastatin 10mg OD Citicholine 500mg OD Referred to a psychiatrist for therapy 6 months PTA 2 weeks PTA Progressive headache Nausea and vomiting Blurring of vision 1 day PTA Focal seizures (L) foot, progressively involved her leg, thigh and the whole left half of the body lasting about 5 minutes

6. Past medical history: • Dx to have migraine • Physical exam: • PR 90/min • BP 170/86 • RR 18/min • T 37.0C

7. Physical Exam • 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 • 6th Nerve palsy left • Shallow L nasolabial fold • Tongue midline in protrusion • Able to do FNT, APST • L hemiparesis; grade 3/5 LE weaker than UE; Right: grade 5/5 UE grade 4/5 LE • DTR’s +++ on the left, ++on the right • Babinski on the left with ankle clonus

8. Know the incidence and location of the major types of primary and secondary brain tumors.

9. General clinical manifestations of brain tumors

10. General clinical manifestations of brain tumors • Intracranial tumors • Cause mass effect , dysfunction or destruction of adjacent neural structures, swelling, abnormal electrical activity, or a combination of these • Present in two major ways: focal compression or irritation of the brain and generalized increase in ICP • Supratentorial vs. infratentorial

11. Supratentorial tumors Focal neurologic deficit (contralateral limb weakness or visual field deficit) Headache Seizure Tumor growth in a brain region results in loss of neurologic function

12. Infratentorial tumors • Increased ICP • Direct mass effect from tumor bulk or hemorrhage into a tumor or from hydrocephalus • Headache • Nausea and vomiting • Reduction in LOC • Papilledema

13. Infratentorial tumors • Cerebellar hemisphere or brainstem dysfunction • Ataxia, nystagmus, cranial nerve palsies • Rarely cause seizures

14. Signs and Symptoms of Increased ICP and its Management

15. Intracranial Tumors and ICP Two common presentations of intracranial tumors: • Generalized increase in ICP • Focal compression and irritation of the brain

16. Causes of increased ICP • Direct mass effect • from tumor bulk • Hemorrhage into a tumor • Indirectly • Hydrocephalus • Communicating • Non-communicating

17. Most common symptoms • Headaches • usually worse in the morning, • Sleep (recumbent and rise in PCO2) • Nausea and vomiting • pressure exerted on the area postrema • Reduction in level of consciousness

18. Symptoms • Mild or unnoticed • until the tumor has become very large if the tumor growth rate is slow or • the tumor is located near the periphery of the brain. • Early symptoms • very small, with strategic location (ex. Foramen of Monroe)

19. Most common signs • Papilledema • Bilateral or unilateral 6th nerve palsy • Abnormalities of the ipsilateral 3rd nerve • Vital sign changes (Cushing’s Triad) • Elevation of SBP – late • Bradycardia – late • Abnormal respiratory pattern

20. Management (Medical) • head elevation at 30-45 degrees & keep midline • hyperventilation: PaCO2 30-40 mmHg • PaO2 > 70mm Hg • systemic arterial pressure maintained bet 100-160 mmHg for cerebral autoregulation to be normal: CPP =/> 90mmHg • normothermia: fever increases CBF

21. Management (Medical) • sedation & nm blockade for agitated px • anticonvulsants: seizures can inc CBF • fluid resuscitation : plain isotonic saline • cerebral decompressants • mannitol 20% by bolus IV • hypertonic saline solution (7.2%) • diuretics: furosemide 40- 60 mg per IVT • corticosteroids: dexamethasone • barbiturate coma: to lower metabolic rate and dec icp

22. Management (Surgical) • craniotomy/craniectomy for evacuation of hematoma or mass lession • decompressive crainectomy • ventriculostomy (EVD) for the release of CSF & placement of icp monitoring

23. Extra axial and intra axial in brain tumor presentation

24. Primary Brain tumor • Intra-axial brain tumor • Extra-axial brain tumor

25. Intra-axial Brain Tumor • Most are derived from glia and are called glioma • Low metastatic potential • Prognosis is poor; ability to infiltrate widely

26. Intra-axial Brain Tumor • Spread preferentially along white matter tracts and may cross corpus callosum into the contralateral hemisphere • Resistant to both radiation and chemotherapy

27. Astrocytoma • Most common type of glioma • 50% of all primary brain tumors • Four groups • Grade 1: well-circumscribed tumor with essentially no ability to transform into higher grades • Grade 2: low grade; increased cellularity, infiltrative and lack distinct boundaries • Grade 3: anaplastic; increased cellularity and either endothelial proliferation or mitotic figures • Grade 4: glioblastoma multiforme

28. Oligodendroglioma • Frequently found in frontal, temporal, or parietal lobes • On CT scan: calcification and hemorrhage • On MRI: similar to those of astrocytoma • Tx: chemotherapy, similar to astrocytomas • Median survival rate: 7 to 10 years

29. Ependymoma • Frequently diagnosed in younger patients • Typically present as a mass in the 4th ventricle and cause hydrocephalus • Symptoms: headache, nausea and vomiting, papilledema, gait ataxia, vertigo and diplopia • Tx: surgical resection and postoperative radiation therapy • May spread through CSF pathway; tx is craniospinal axis radiation • Median survival rate: 7 to 10 years

30. Medulloblastoma • 20 – 25% of all pediatric brain tumor • Most common primary brain tumor in children • Derived from undifferentiated precursor to both neurons and astrocytes • Most often found in the cerebellar vermis • Symptoms: hydrocephalus and cerebellar signs • In adults: lateral cerebellar hemisphere and present with dysmetria • Primitive neuroectodermal tumors – outside the posterior fossa

31. Medulloblastoma • Tx: maximal surgical resection followed by radiation therapy • Median survival time: 7 to 10 years, with complete surgical resection and lack of CSF spread

32. Hemangioblastoma • Most common posterior faussa tumor in adult, after metastases • Benign tumor composed of capillaries, dilated vessels and foamy stromal cells • Can occur as part of von Hippel-Lindau (VHL) disease • Present with cerebellar findings: headache, ataxia, vertigo and dysmetria

33. Hemangioblastoma • Most commonly found in cerebellum, also occur in the brainstem and spinal cord • Radiographically present as a solid enhancing mass or as a systic tumor with and enhancing mural nodule • Tx: Complete surgical removal of the solid component or nodule

34. Primary CNS Lymphoma • Rare intracranial tumor • Common in elderly patients and immunocompromised patients (AIDS) • Highly sensitive to radiation • Prognosis is poor • Median survival time is 4 years in person without AIDS and 3-6 months in person with AIDS

35. Germ cells and Pineal Region Tumors • Germ cells tumors • Germinoma • Embryonal carcinoma • Choriocarcinoma • Endodermal sinus tumor • Found in pineal or hypothalamic region of children and young adults • Often release tumor markers in the CSF • Endodermal sinus tumor - -Fetoprotein • Choriocarcinoma --human chorionic gonadotropin • Germinoma – placental alkaline phosphatase

36. Germ cells and Pineal Region Tumors • Germinoma • Radiosensitive tumor • curable • Other germ cell tumors • Carry poor prognosis • Require both radiation and chemotherapy

37. Germ cells and Pineal Region Tumors • Pineal gland tumors • originate in the posterior aspect of the 3rd ventricle • may cause hydrocephalus from the occlusion of aqueduct of Sylvius • Parinaud’s syndrome • Paralysis of upward gaze • Pupils that constrict on accommodation but fail to react to light • Nystagmus retractorius

38. Extra-axial Brain Tumors

39. Meningioma • Second most common primary brain tumor: 20% of the total • Arising from arachnoidal cap cells • Benign tumors that originate from the dura and displays the brain as they grow • Do not invade the brain unless they are malignant • Can invade and erode the skull or can cause a hyperostotic reaction

40. Meningioma • Most common locations • Parasagittal regions • Cerebral convexities • Subfrontal region • Cerebellopontine angle • Found in adults, more common in woman

41. Meningioma • Diagnosis: CT or MRI is the principal means of diagnosis • Tx: surgery, requires completer removal of the tumor, dural origin and involved skull

42. Schwannoma • Benign tumors • Arise from schwann cells • Most common type: • Vestibular schwannoma or acoustic neuroma • Originates from the vestibulocochlear • Presents with unilateral hearing loss, tinnitus, dizziness, facial numbness

43. Schwannoma • Appear isointense to brain on T1 MRI • MRI scan shows an enhancing mass in the cerebellopontine angle that enters the internal auditory canal • Tx: complete surgical resection

44. Pituitary Adenoma • Arise from the cells in the anterior pituitary gland • Functional or non-functional • Functional tumors • Cause an endocrinopathy from excessive hormone production • Prolactinoma – most common functional tumor • Causes amenorrhea and galactorrhea in women

45. Pituitary Adenoma • Non-functional Pituitary Adenomas • Presents with mass effect on adjacent structures notably the optic chiasm • Patients experiences a loss of peripheral vision and describes a bitemporal field cut on formal visual field testing

46. Pituitary Adenoma • Pituitary Microadenoma • Appear as a non-enhancing area even the pituitary gland that are seen best on coronal images • Pituitary Macroadenoma • Erode and enlarge the sella turcica in addition to elevating the optic chiasm • MRI shows a variable degree of enhancement and cannot usually distinguish between tumor and normal pituitary

47. Pituitary Adenoma • Sublabial or intranasal incision • Transsphenoidal craniotomy • Conventional intracranial surgery is chosen when the tumor is primarily suprasellar tumor • Radiosurgery • Good option for patients with small residual tumor

48. DIAGNOSTIC TOOLS

49. ROUTINE LABORATORY STUDIES • CBC and Blood tests • detect markers that may indicate pineal or pituitary tumors • Analysis of electrolytes • Glucose • BUN/Creatinine • Calcium and Magnesium • Liver function • Coagulation profile

50. LAB STUDIES • Lumbar Puncture (Spinal Tap) • needle is placed in the lower back to obtain a small sample of cerebrospinal fluid (CSF) • look for cancer cells, blood, or tumor markers • done only after CT or MRI scan • particularly important in people with suspected brain lymphomas • Neurological, vision, and hearing tests • help determine the suspected tumor's effects on the brain's functioning • Eye examination can detect changes to the optic nerve