Study your flashcards anywhere!

Download the official Cram app for free >

  • Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key


Play button


Play button




Click to flip

126 Cards in this Set

  • Front
  • Back
Simpson Grade
Grade 1
- Complete removal including resection of dura and bone
- Recurrence 9%
Grade 2
- Complete tumor removal with coagulation of dural attachment
- Recurrence 19%
Grade 3
- Complete tumor removal without resection or coagulation of dural attachments
- Recurrence 29%
Grade 4
- Subtotal removal
- Recurrence 40%
Incidence of meningiomas
9000 per year
6 per 100,000
What meningioma characteristics dictate management?
1 Signs or symptoms it produces
2 Age of the patient
3 Site and size of the tumor
Watchful waiting with serial imaging is a reasonable option for small, asx meningiomas. What situations would demand surgery?
1 Symptomatic lesion
2 Expanding, infiltrative, or considerable surrounding edema
3 Young patient age
Why is young patient age a reason to consider surgery?
1 Lower surgical morbidity
2 Prolonged follow-up with repeated imaging would be required with conservative therapy
Complete resection is usually attempted for meningiomas in which locations?
1 Convexity
2 Olfactory groove
3 Anterior third of sag sinus
4 Some tentorial and posterior fossa locations
In which locations is deliberate partial resection more likely?
1 Medial sphenoid wing
2 Cavernous sinus
3 Posterior parasagittal region
4 Clivus
Should anticonvulsants be started in a patient with a brain tumor who has never had a seizures and is preoperative?
Should you taper anticonvulsants in patients with brain tumors post-operatively?
Yes. If the patient has not had a seizure, tapering of anticonvulsants after the first opstop week is appropriate.
Which meningiomas may benefit from preop embolization?
Skull base tumors may benefit by decreasing intraop bleeding and increasing the number of tumors that can be safely resected.
What are the primary determinants of recurrence of meningioma postop?
1 Completeness of resection
2 Tumor grade
What is the ten-year progression free survival with total resection of meningiomas?
What is the ten-year PFS with partial resection of meningiomas without XRT?
What's the likelihood of recurrent meningioma with total resection?
What's the likelihood of recurrent meningioma with partial resection without XRT?
WHO Grades for Meningioma
Grade I: Not Grade II or III
Grade II: Either
- High mitotic index (>4 mitoses/HPF)
- At least 3 of the following
-- Hypercellularity
-- Prominent high N:C ratio
-- Prominent nucleoli
-- Sheeting architecture
-- Foci of necrosis
Grade III: Either
- Excessive mitotic activity (>20 mitoses/HPF)
- Loss of meningothelial differentiation
-- Sarcoma-
-- Carcinoma-
-- Melanoma-like appearance
Likelihood of disseminated meningioma
8/200 cases in one series
- 5 with cervical nodes
- 3 with pulmonary disease
Poor prognosis
What chromosomal changes are associated with recurrence of meningioma?
1 Monosomy 22 and deletion of 1p (30%)
2 Monosomy 22 and other hypodiploid features (10%)
3 Monosomy 2 alone or normal diploid chromosomes (4%)
Which patients should be offered adjuvant radiotherapy?
1 Incomplete resection
2 High-grade meningioma
Is there a benefit with XRT in subtotal resected meningioma?
Yes. Barbaro UCSF 1987
Recurrence Rate
-No XRT 60%
-With XRT 32%
Med Time To Recurrence
-No XRT 125 months
-With XRT 66 months
What difference have advances in radiation technology made in pts with benign meningioma treated with adj XRT?
Did these developments improve overall survival in patients with malignant meningiomas treated adjuvantly?
5yr PFS
- Before 1980: 77%
- After 1980: 98%
No improvement with malignant disease.
Name and describe four aggressive meningioma histologies.
1 Clear cell - Glycogen-rich cells forming vague whorls
2 Choroid - Lobular low-power architecture
3 Rhabdoid
- Increases with recurrence
- Sheets of loosely cohesive cells with eccentric nuclei
4 Papillary
- Striking papillary pattern
- Foci of necrosis
- Increased mitotic figures
- Local invasion
Describe XRT for benign meningiomas.
54 Gy in 1.8-2.0 Gy/fx with
1 cm margins
Describe XRT for malignant meningiomas.
59.4 Gy in 1.8-2.0 Gy/fx
2 cm margins
Common complications from external beam XRT for meningiomas.
1 Hypopituitarism
2 Cataracts
3 Worsening initial deficits
4 Short-term memory impairment
Describe retrospective results with SRS as primary therapy for benign meningiomas.
No progression in 84/127 patients at 23 months
Compared with resection, same 7yr PFS: 95-96%
Is resection with fractionated XRT better than primary SRS in incompletely resected meningiomas?
No. Same 5yr PFS of 92%.
Is there a site where SRS has particularly less morbidity than surgery for meningiomas?
Optic nerve sheath meningiomas
General recommendation for meningiomas.
Surgery as primary treatment
SRS or SRT for parasagittal or optic nerve sheath meningiomas
Is adjuvant chemotherapy useful in meningiomas?
Regimens with some activity
- Cyclophosphamide
- Adriamycin
- Vincristine
2 Dacarbazine and adriamycin
3 High-dose ifosfamide
No great trials.
How would a meningioma look on MRI?
T2W: Isointense with gray matter
T1W: Isointense with gray matter
Gad: Intensely enhancing
Dural tail sign
- In 60%
- Linear meningeal thickening with enhancement adjacent to peripherally located central mass
- Reactive change; not necessarily neoplastic involvement
Describe the appearance of meningioma on CT.
Well circumscribed.
Smooth in contour.
Most have homogeneously high density (25-33% isodense).
Most mod-intense homogeneous enhancement with contrast.
Peritumoral edema in 60%.
Bone destruction/hyperostosis in 20%.
Typical presenting symptoms for spinal meningiomas
1 Adults
2 Children
- Pain (72%) -->
- Sensory loss and weakness -->
- Bowel and bladder dysfcn
- Extremity weakness -->
- Back pain -->
- Bowel/bladder dysfcn -->
- Extremity pain
5yr PFS
Benign vs malignant meningiomas post XRT
5yr PFS
Benign: 90%
Malignant: 50%
What symptoms are associated with convexity and parasagittal tumors?
1 Seizures
2 Focal deficits
3 Signs of increased ICP
What symptoms are associated with intraventricular tumors?
1 Signs of increased ICP (HA/N/V)
2 Hemiparesis
3 Hemianopia
4 Increased head circumference in infants
What is the dose limitation to the optic nerve for treatment of meningiomas?
54 Gy
True or false:
There is a genetic link between meningiomas and type 2 neurofibromatosis.
True or false.
Even after complete surgical resection, up to 20% of all meningiomas will recur within 10 years of diagnosis.
True or false.
Meningioma is more common in women than men.
True or false.
Radiation-induced meningiomas are more likely to be malignant compared with nonradiation-induced meningiomas.
Not scored on 2005 in-service.
True or false.
Partially resected meningiomas have a less than 50% chance of progression.
Which one of the following statements about pituitary adenomas is NOT correct?
A. Medical therapy for prolactinomas is bromocriptine.
B. The dose to the optic chiasm should be restricted to 8-10 Gy with SRS.
C. 45 Gy in 25 fx is appropriate for recurrent pituitary adenoma.
D. Medical therapy for acromegaly is ketoconazole.
For a patient with standard-risk medulloblastoma undergoing craniospinal irradiation, which one of the chemotherapy agents is given concurrently?
A. Vincristine
B. Bleomycin
C. Temozolomide
D. Carmustine (BCNU)
Which one of the following statements about meningiomas is INCORRECT?
A. XRT is not indicated after gross total resection of a benign meningioma.
B. XRT is indicated after gross total resection of a malignant meningioma.
C. The incidence of benign meningiomas is equal in men and women.
D. Chemotherapy is not recommended for a patient with a subtotally resected meningioma.
Which one of the following best estimates the median survival for a 45yo GBM patient who has undergone gross total resection and has a KPS of 90?
A. 60m
B. 30m
C. 18m
D. 11m
Which one of the following molecular markers BEST predicts radiation and chemotherapy response for anaplastic oligodendroglioma?
A. 1p
B. 10p
C. 19p
D. 21p
Which one of the following statements BEST describes grade 2 astrocytomas?
A. Randomized trials have shown that XRT will improve survival in patients with incompletely resected low-grade astrocytomas.
B. There is improved disease control by giving 59.4-64.8 Gy compared with 45-50.4 Gy in patients with low-grade astrocytomas.
C. Grade 2 astrocytomas tend to occur in the cerebral hemispheres.
D. The standard treatment after gross total resection is radiotherapy.
Regarding spinal tumors, which one of the following is CORRECT?
A. Nerve sheath tumors are intradural and intramedullary.
B. Astrocytomas are intradural and extramedullary.
C. Metastatic carcinomas are usually extradural and extramedullary.
D. Myxopapillary ependymomas are usually extradural and extramedullary tumors.
Which one of the following hormones is MOST likely to be affected after 24 Gy hypothalamic irradiation?
A. Adrenocorticotropin
B. Thyrotropin
C. Gonadotropin
D. Growth hormone
All of the following statements are CORRECT regarding brainstem tumors EXCEPT:
A. High-grade astrocytoma is the most common histologic type of brainstem tumor.
B. Brain stem tumors are seen more commonly in children.
C. Dose escalation with a hyperfractionated regimen is associated with improved local disease control.
D. Radiation therapy is the mainstay treatment for diffusely infiltrating brain stem tumors.
All the following statements are correct regarding adult ependymomas EXCEPT:
A. Because of high incidence of CSF dissemination, standard radiation techniques for all types of adult ependymomas include craniospinal radiation followed by tumor boost.
B. Surgery alone may be sufficient in selected adult patients with low-grade noninvasive ependymomas who have undergone complete surgical resection and have negative CSF staging.
C. Workup of all patients with ependymoma will routinely include spine MRI and CSF cytology.
D. Most CSF failures in high-grade infratentorial ependymomas are local failures rather than isolated spinal relapse.
A 25yo man presented with a pineal region tumor. Which one of the following choices BEST describes pineal tumors?
A. Pineoblastoma is the most common type of neoplasm for this age group.
B. This patient's workup should include serum and CSF markers (HCG and AFP).
C. Craniospinal axis irradiation is recommended for all types of tumors in the pineal region even with negative CSF cytology because of their high risk of spread.
D. After radiology study, biopsy is the next step for making the diagnosis even in a patient with elevated CSF AFP levels.
For each of the sx or signs below, select the one lettered tumor type that is MOST closely associated with it.
Bitemporal hemianopsia
Unilateral deafness
A. Schwannoma
B. Oligodendroglioma
C. Pituitary adenoma
D. Brain stem glioma
E. Pineal tumor
Bitemporal hemianopsia: Pit adenoma
Unilateral deafness: Schwannoma
Seizures: Oligodendroglioma
For each of the tumors listed below, select the one lettered medial survival time that is MOST closely associated with it.
Low-grade astrocytoma
Low-grade oligodendroglioma
CNS lymphoma (HIV neg)
Pontine glioma
A. > 5 years
B. 3-5 years
C. 1-3 years
D. < 1 year
Low-grade astrocytoma: > 5y
Low-grade oligodendroglioma: > 5y
CNS lymphoma (HIV neg): 1-3y
Pontine glioma: < 1y
True or false:
A 15-mm solitary lesion in noneloquent brain should be treated with 15 Gy in 5 fx to the whole brain.
The estimated survival for a RTOG RPA class 1 patient is 12 months.
True or false.
The most important predictor for survival according to the RTOG RPA classification is the presence of extracranial disease.
True or false.
In a phase 3 study of WBRT vs WBRT and radiosurgery (RTOG 9508), the median survival was improved for patients with 1 brain metastasis.
True or false.
The estimated local failure rate for a completely resected single brain metastasis without WBRT is 25-30%.
Which one of the following statements in CORRECT concerning metastatic disease to the orbit?
A. The retina is the most common site within the orbit for metastasis.
B. Most pts present with decreased visual acuity and blurred vision rather than pain.
C. Biopsy is necessary to confirm diagnosis (even if a primary is known) and rule out melanoma.
D. Tilting lateral fields anteriorly 10 degrees is necessary to avoid irradiating the contralateral cornea and lens.
Regarding choroidal melanoma, which one of the following is CORRECT?
A. In the COMS randomized trial for medium-sized tumors treated with I-125, radiation affected vision in less than 20% of these cases.
B. In the randomization between enucleation vs plaque, there was no diff seen in mortality.
C. In a trial with enucleation vs plaque, 10y f/u showed that 50% of patients with radiation had died.
D. Photocoagulation and cryotherapy are treatment options for medium-sized ocular melanomas.
Select the one lettered statement that is MOST closely associated with its treatment.
Choroidal melanoma
Orbital rhabdomyosarcoma
A. Conventional fx to 40-45 Gy
B. Conventional fx to 20-30 Gy
C. Conventional fx to 45-50 Gy plus VAC
D. I-125 plaque brachy to 45-50 Gy
E. I-125 plaque brachy to 85-100 Gy
Choroidal melanoma: E
Orbital rhabdomyosarcoma: C
Retinoblastoma: A
T or F.
In large ocular melanomas in the COMS studies, a large lesion is defined as > 8mm basal diameter and 16mm in apical height.
T or F.
Studies show that preop radiation offers a survival adv for large ocular melanomas.
Pre-enucleation radiation results in significantly more complications compared with eucleation alone.
Median survival for patients with large ocular melanomas is 7 years.
Liver and bone are the most common sites for metastatic ocular melanoma.
Breast cancer accounts for 30-40% of all choroidal metastates.
Tamoxifen is associated with increased risk of cataract formation.
Photophobia can be a clinically presenting symptoms for choroidal metastases.
Lobular carcinoma is the histology most frequently associated with choroidal metastasis.
Taxane chemotherapy is associated with acute effects of dry eyes and conjunctivitis.
Atypical lymphoid infiltrates of the orbit may disseminate.
Conjunctival lymphomas should be treated with photons and not electrons due to the risk of periorbital spread.
Lymphoid neoplasms of the lacrimal collecting system should be resected before radiation.
A 7yo boy was diagnosed with JPA of the left cerebellum and underwent complete resection. Which one of the following should be included in his subsequent care?
A. Observation alone
B. Postop SRT
C. Chemotherapy
D. XRT and chemotherapy
The primary management of CNS lymphoma does NOT include which one of these treatment options?
A. Complete surgical resection
C. Steroids
D. Intrathecal methotrexate
E. High dose intravenous methotrexate
Select the one lettered CNS tumor that is most closely associatd with the clinical syndromes listed below.
Neurofibromatosis type I
Von Hippel-Lindau disease
Tuberous sclerosis
A. Hemangioblastoma
B. High grade astrocytoma
C. Subependymal giant cell astrocytoma
D. Optic nerve glioma
E. Vestibular schwannoma
Neurofibromatosis type I: D
Von Hippel-Lindau disease: A
Tuberous sclerosis: C
Select the one lettered anatomical region most closed associated with the functional brain area listed below.
Primary auditory cortex
Primary sensory cortex
Primary visual cortex
Broca's area
Motor strip
A. Frontal lobe
B. Temporal lobe
C. Basal ganglia
D. Parietal lobe
E. Occipital lobe
Primary auditory cortex: B
Primary sensory cortex: D
Primary visual cortex: E
Broca's area: A
Motor strip: A
T or F.
The median survival with GBM is around 10-12 months.
In GBM the 19p deletion is commonly noted in this histology.
KPS and age are the most important prognostic factor for this condition.
Which one of the following tumor types is LEAST likely to be associated with spread within the craniospinal axis?
A. Pineoblastoma
B. Astroblastoma
C. Medulloblastoma
D. Germinoma
E. Ependymoma
Which one of the following choices BEST describes the overall expected median survival times for adults with Grade III vs Grade IV astrocytomas?
A. 12-15 months vs 6 months
B. 12-15 months vs 9 months
C. 2-3 years vs 1 year
D. 5-7 years vs 1 year
E. 5-7 years vs 2 years
Which one of the following choices in MOST accurate regarding findings of randomized trials for gliomas?
A. Randomized trials have shown that more complete resection is associated with significantly improved PFS.
B. A randomized trial has shown significantly improved survival with immediate postop XRT as opposed to observation with XRT at the time of tumor progression.
C. Randomized trials have shown significantly improved survival AND PFS with higher dose vs lower dose postop XRT.
E. Randomized trials have shown no benefit in terms of survival or PFS with higher dose vs lower dose postop XRT.
For each tumor type listed below, select the one lettered description that is MOST closely associated with it.
Pilocytic astrocytoma
A. Ventricular or periventricular tumor associated with tuberous sclerosis.
B. Neoplasm with potential for systemic mets, found in close association with the dura, with imaging appearance similar to meningioma.
C. Vascular benign neoplasm, often multiple, in the setting of neurofibromatosis type 2.
D. Well-circumscribed, benign neoplasm, most commonly arising in the cerebellum or spinal cord, often multiple, in the setting of von Hippel-Lindau disease.
E. Enhancing, sometimes cystic, tumor with benign behavior even when mitotic activity and necrosis are seen histologically.
Hemangioblastoma: D
Hemangiopericytoma: B
Pilocytic astrocytoma: E
For each of the drug therapies listed below, selected the one lettered mechanism or action that is MOST closely associated with it in the treatment of CNS tumors.
a. Methylation of DNA
b. Inhibition of protein kinase C
c. Disruption of microtubule formation
d. Inhibition of topoisomerase
e. Inhibition of tumor angiogenesis
Thalidomide: E
Temolzolomide: A
Vincristine: C
Oligodendrogliomas tend to be associated with a worse prognosis than pure astrocytomas of the same grade.
Oligodendrogliomas have a greater tendency to contain calcifications than do pure astrocytomas.
1p and 19q deletions are associated with greater chemosensitivity in oligodendrogliomas.
Oligodendrogliomas are characterized histologically by "fried egg" cells with round nuclei and perinuclear halos.
Oligodendrogliomas tend to have increased N-acetyl aspartate (NAA) signal and reduced or absent choline signal on magnetic resonance spectroscopy.
Concerning diagnosis and treatment of pterygiums, all of the following are correct EXCEPT
A. It is the most common benign ocular condition for which radiation is beneficial.
B. Recurrence rate after surgery alone is as high as 67%.
C. Strontium-90 surface applicator is used postop to reduce recurrences.
D. May be effectively treated with I-125 plaque application.
E. Recurrences are higher in female patients under age 40.
A 60yo female presents with lid lag, proptosis, and ophthalmoplegia, and is diagnosed with Grave's Opthalmopathy. Which one of the following statements is CORRECT?
A. Proptosis and ocular muscle impairment are more likely to improve than visual loss and corneal involvement after treatment with radiation therapy.
B. Treatment is best delivered with 6MeV electrons.
C. There is significant difference in outcome between 20 Gy in 10 fx and 30 Gy in 15 fx.
D. The less favorable prognostic factors are male gender and no history of hyperthyroidism.
E. After radiation therapy, more than 40% of patients will eventually require corrective surgery.
For each of the treatment choices listed below, select the one lettered pathology that is MOST closely associated with it.
Beta emitter applicator
I-125 plaque
Spontaneous regression over 3-4 years
A. Capillary hemangioma of eyelid
B. Pterygium
C. Ocular melanoma
D. Macular degeneration
E. Orbital lymphoma
Beta emitter applicator: B
I-125 plaque: C
Spontaneous regression over 3-4 years: A
Primary orbital lymphomas account for > 10% of all lymphomas diagnosed.
Intraocular lymphomas are more likely than orbital lymphomas to be low or intermediate-grade by the Working Formulation.
Doses in the range of 25-35 Gy using standard fx are used to treat orbital lymphomas.
CHOP chemotherapy followed by localized irradiation to the orbit is the treatment of choice for intermediate-grade lymphomas.
40-50% of pseudolymphomas may convert to malignant lymphoma.
In treatment a patient with Graves' Ophthalmopathy with external beam radiation, all of the following would be appropriate EXCEPT
A. Delivering a dose of 20 Gy in 10 fx
B. Adding bolus to ensure adequate delivery of dose to the anterior chamber
C. Consenting the patient for cataract formation
D. Using a conformal treatment technique
E. Attempting management with corticosteroids prior to applying radiation therapy
The MOST common adult malignancy affecting the eye is which one of the following
a. Retinoblastoma
b. Malignant melanoma
c. Metastatic carcinoma
d. Lymphoma
e. Rhabdomyosarcoma
For each of the ocular critical structures below, select the one tolerance dose that is associated with the listed complication
Optic neuropathy
Lacrimal gland failure
XRT-induced cataracts
A. 10 Gy
B. 30 Gy
C. 45 Gy
D. 54 Gy
E. 75 Gy
Optic neuropathy: D
Lacrimal gland failure: B
Retinopathy: C
XRT-induced cataracts: A
Brachytherapy with an I-125 plaque provides equivalent survival compared to enucleation in a patient with choroidal melanoma measuring 10mm at the base and 5mm in apical height.
20Gy preop external beam radiation delivered to the globe provides a survival benefit for tumors measuring 15mm in apical height.
Despite equivalent results between brachytherapy and enucleation for choroidal melanoma measuring 8mm at the base and 3mm in apical height, metastatic disease remains a problem with death from recurrent melanoma approaching 40% at 5 years.
In the COMS randomized study of brachytherapy for medium-sized choroidal melanomas, visual acuity in the brachytherapy treatment group was found to be excellent with less than 10% of patients having any measurable visual loss.
Define Parinaud's syndrome.
Paralysis of conjugate upward gaze with a lesion at the level of the superior colliculi
Bell's phenomenon in present
AKA Parinaud's ophthalmoplegia
Define Hoffmann's sign
In latent tetany, mild mechanical stimulation of the trigeminal nerve causes severe pain
Define Hoffmann's reflex
Flexion of the terminal phalanx of the tumb and of the 2nd and 3rd phalanges of one or more of the fingers when the volar surface of the terminal phalanx of the fingers is flicked.
Ependymoma grading
I: Myxopapillary or subependymoma
II: Ependymoma
III: Anaplastic ependymoma
Posterior fossa tumor diff dx
JPA (cerebellum into 4th ventricle)
Brainstem tumors
Choroid plexus tumors
Supratentorial tumor diff dx
Glial tumors
Choroid plexus carcinoma
Choroid plexus papilloma
Atypical rhabdoid tumors
Odd sarcomas
Radiographic appearance of ependymoma
Radiographic appearance of ependymooma
- Hyperdense with homogeneous enhancement
- Calcifications and cysts are common
- Location in the fourth ventricle
- Hypotenintese on T1
- Hyperintense on T2
- Prominent gad enhancement
Radiographic appearance of subependymoma
Radiographic appearance of subependymoma
CT: Isodense
- Isointense on T1
- Hyperintense on T2
Ependymoma chemotherapy
Ependymoma chemotherapy
Adults: None effective
Kids: Cisplatin/Etoposide
Ependymoma recurrence
Ependymoma recurrence
- Aggressive resection
- SRS: 3.4 yrs median survival
Ependymoma prognosis
Overall survival at 10 years
OS at 10 years: 45-55%
- Extent of resection (90% recurrences are local)
- Histologic grade
-- Grade I: Good prognosis
-- Higher grade: Worse Ependymoma prognosis
- In children
-- Better performance status
-- Older age better
Ependymoma staging
Biopsy to establish dx
MR brain
MR spine
CSF cytology
Ependymoma follow-up
MR brain
MR spine if +CSF or spinal primary
Endocrine if CSI or pit in field
Ependymoma Treatment in Brain
Grade I-II GTR
Grade I-II STR
Ependymoma Treatment in Brain
Grade I-II GTR: 45-54 Gy
Grade I-II STR: 45-54 Gy
Grade III GTR: 45-54 Gy
Grade III STR: 60 Gy
Ependymoma Treatment in Spine
Grade I-II GTR
Grade I-II STR
Ependymoma Treatment in Spine
Grade I-II GTR: Observation
Grade I-II STR: 45-54
Grade III GTR: Observation
- 50.4 Gy if neg imaging
- 54 Gy if pos imaging
In children with ependymoma what is the maximum time of delay for chemotherapy prior to post-op RT?
One year.
More resulted in decreased survivals.
Located in the dorsal region of the mesencephalon (mid brain)
- Superior colliculi: visual receptors
- Inferior colliculi: auditory receptors
In ventral region of mesencephalon (mid brain)
- Cerebral aqueduct
- Periaquedeuctal gray
- Reticular formation
- Substantia nigra
- Red nucleus
- Motor functions
- Awareness and attention
- Some autonomic functions