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47 Cards in this Set
- Front
- Back
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CNS Neoplasms
Statistics |
2% of all cancer deaths
20% of childhood malignancies 50% primary brain tumors 50% metastatic tumors to the brain |
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CNS Tumors
Issues to consider |
Age of patient
Location of lesion Radiology results Gross and Histologic features Molecular testing Prognosis and treatment |
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CNS Tumors
Age and Location |
Adults - supratentorial
Children - Infratentorial |
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Malignant growth
characteristics |
Infiltrative
Difficult to remove surgically Rarely metastasize Death due to direct impingement on vital centers or herniation |
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Benign growth
characteristics |
curable
may cause death due to inoperability or proximity to vital centers |
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Origins of CNS Neoplasms
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Intrinsic Cells
-Glial Cells --Astrocytes --Oligodendroglial cells --Ependymal --Microglia -Neurons Surrounding Cells -Vascular Origin -Meningeal cells Developmental rests (germ cell tumors Metastasis (MOST COMMON MALIGNANCY) |
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Gliomas
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From glial cells
-Astrocytes, Oligodendrocytes, Ependymal -Astrocytoma, Oligodendroglioma, Ependymoma |
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Grading of Astrocytomas
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WHO
I - Pilocytic Astrocytoma II - Astrocytoma III - Anaplastic Astrocytoma IV - Glioblastoma Multiform |
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Astrocytomas
Pilocytic Astrocytoma |
Grade I
20% of pediatric brain tumors Usually in cerebellum Indolent (little pain), potential for surgery |
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Diffuse Astrocytomas
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Astrocytoma - II
Anaplastic Astrocytoma - III Glioblastoma - IV |
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Astrocytoma
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Grade III
Adults, 30-40 yrs Usually in cerebral hemispheres Seizures, headache, focal neuro deficits Median survival: 80 months 50-75% progress to grade III/IV |
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Anaplastic Astrocytoma
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Grade III
Adults, ~40 yrs Cerebral hemisphere lesion Progression of lesion = worsening symptoms Median survival: 30 months |
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Glioblastoma Multiforme
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Grade IV
40-50% of all glial tumors Older adults, 40-60 yrs Large mass in cerebral hemisphere Ring-enhancing lesion PROGNOSIS BAD: 10 months |
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Pathogenesis of Grade IV Glioblastoma Multiforme
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Develops from Astrocytoma (II)
-Accumulation of genetic hits "Secondary glioblastoma" De novo GBM -Appears with no evidence of previous transformation "Primary Glioblastoma" |
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Loss of heterozygosity
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Loss of part of chromosome
Can be good or bad prognostic indicator LOH of 1p and 19q is seen in oligodendrogliomas and indicates good response to chemo |
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Oligodendroglioma
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Middle aged adults, 30-50 yrs
Cerebral white matter lesions MRI: calcified or cystic Seizures or other neuro signs may have been present for years Avg survival: 5-10 yrs |
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Grading of Oligodendrogliomas
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Grade II - favorable
Grade III - anaplastic LOH in chromosomes 1 & 19 may do better with chemo |
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Primary CNS Lymphoma
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1% of intracranial tumors
Usually in AIDs or elderly/immunocompromised Large lesion in cerebral hemisphere Poor Prognosis: avg 18 months Cannot give surgery, have to do chemo |
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Medulloblastoma
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Primitive neuroectodermal tumor
Bimodal age distribution -Young children and ~40 yrs Location -Children in cerebellar vermis -Adults in cerebral hemisphere 50% 10 year survival with therapy, kids better (85%) |
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Meningiomas
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Arise from meninges of brain, spinal cord
More common in women Symptoms are vague, result of brain/SC compression grows slowly for years Surgery possible |
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Metastatic Tumors to the brain
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Most common!
Usually carcinomas Most common from: -lung, breast, melanoma, kidney, colon, stomach Often multiple lesions Can be in meninges |
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What causes death in brain tumors?
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Space occupying lesions
(brain compression, herniation) Compromise of essential brain functions Large volume hemorrhage into tumor Complications of treatment |
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Pituitary Tumors
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Usually benign adenomas
Headache loss of peripheral vision (optic chiasm compression) Endocrine disturbances -growth hormone: acromegaly -prolactin: milk production |
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Infectious/inflammatory CNS Disease
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Meningitis - meninges
Encephalitis - brain Myelitis - spinal cord Abscess - walled-off collection of neutrophils and dead tissue |
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Acute Bacterial Meningitis
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Neonatal - vaginal delivery
-Group B Strep -E. coli -Listeria monocytogenes Childhood -Haemophilus influenzae (vaccine now) -Strep pneumoniae -Neisseria meningitis Adolescence -Neisseria meningitidis Adult -Strep pneumoniae -Gram-negative bacteria |
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Causes of Bacterial Meningitis
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Hematogenous Spread
Shunt infections Traumatic injury Mastoiditis, sinusitis |
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SX of meningitis
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Babies
fever, crying, unresponsiveness Adults fever, headache, stiff neck, rash Changes in CSF by lumbar puncture -Lots of neutrophils -Culture may grow bacteria High morbidity and mortality if untreated |
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DX of meningitis
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Kernigs sign
pain with combined hip flx/knee ext Brudzinski's sign flx neck produces flx knees |
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Brain Abscess facts
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50% spread from sinus, middle ear, dental infections
25% hematogenous spread due to bacteria, AFB, fungus 20% mortality 50% of survivors have persistent deficits |
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Viral infections
Aseptic Meningitis |
Usually self limiting
Acute - Echovirus & Coxsackie virus (late usmjmer), arthropod borne Subacute - mesales (winter, spring) |
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Viral infections
Parenchymal infection with tissue destruction |
Acute - HSV, CMV, rabies
Subacute - SSPE (measles), PML (JC virus) |
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Herpes Simplex Virus (HSV)
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Most common sporadic, non epidemic viral encephalitis
Adults - HSV-1 spread through retrograde axonal transport Neonates - HSV-2 acquired through delivery, mucous membranes (eyes, mouth) with no tx progresses rapidly and is usually fatal SX can include phantom smells |
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HIV/AIDS
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HiV infects macrophages and T-cells which import virus into brain
Direct infection of CNS by HIV -neuro deterioration, dementia Opportunistic infections CNS lymphoma |
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Alzheimers Disease
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Most common cause of dementia
50-60 yrs memory, personality, disorientation steadily progressive, death in 3-12 yrs Down's Syndrom ppl at greater risk Pathogenesis multifactorial and complex Gross appearance of brain -Cortical atrophy -Enlarged (appearance of) ventricles |
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Histopathology of Alzheimers
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Senile plaques - extracellular w/pink amyloid core
Neurofibrillary tangles - intraeuronal cytoplasmic filament collections Amyloid angiopathy (sometimes) *All of this is only observable after death* |
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Seizure
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def: finite event resulting from paroxysmal excessive discharge of cerebral neurons
Transcient impairment, loss of consciousness Many causes Children - constitutional Adults - acquired over time |
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Types of seizures
Partial Seizures |
Local onset in cortex
Focal EEG abnormality Simple parital -No consciousness loss, just one hemisphere Complex Partial -Alteration/loss of consciousness, both hemispheres |
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Types of seizures
Generalized Seizures |
Onset not localized in brain
Diffuse EEG abnormalities Generalized absence -person just stares off into space (petit mal) Generalized tonic-clonic -Tonic generalized rigidity -Clonic generalized jerking -Loss of consciousness, BB control -Post-ictal tiredness (grand mal) |
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Seizures in childhood
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Febrile seizures
Hypoglycemia, hypocalcemia Epilepsy Intracranial lesions |
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Seizures in adults
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Epilepsy
Trauma Stroke Hypozia Drugs Intracranial lesions |
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Tx of seizures
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look for cause
anti-epileptic drugs |
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Prognosis of epilepsy
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75% remission rate in children where it is idiopathic
major lifestyle impact Death can occur if the seizures don't stop, or they choke on food or drown in bath |
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Near-drowning
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def: surviving 24+ hours after hypoxemia and acidosis from fluid immersion
Dry drowning - 15%, little fluid inhalation Wet drowning - 85%, fluid aspiration Recurrence of respiratory distress |
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Drowning stats
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Major cause of accidental death
-#2 in children less than 15yrs -#3 in all ages 80% male risk factors -epilepsy, trauma, retardation 50% involved with alcohol |
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Complications of near drowning
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Prolonged anoxia/hypoxia
-Brain most affect -Cold may decrease oxygen requirements = less damage Acute lung injury from aspiration |
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Prognosis of near drowning
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20% of pt have permanent sequelae
Many also have CNS traumatic injuries Many ultimately die |
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Key associations for headache
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Worse headache of life
=subarachnoid hemorrhage =possible ruptured aneurysm Fever and stiff neck =meningitis or meningoencephalitis New onset seizure in older adult =intracranial lesion Papilledema =brain is swelling (no lumbar punctures!) |
