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Pathology of Brain tumors (CNS tumors) for undergraduate medical students.
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CNS TumorsCNS Tumors
CPC-4.3.7 – Jenna 27y teacher. Jenna is a 27 year old teacher in Ingham who collapsed
in her classroom today. She was seen by her pupils to ‘shake all over’.
Brought to ED by paramedics, accompanied by teaching colleague. Collapsed approx 30 mins ago.
(Aim: The aim of this CPC is to get students to initially look at a broad range of differential diagnoses for a witnessed, generalized tonic- clonic seizureseizure. Then get them to focus on idiopathic epilepsyepilepsy, convulsion secondary to infection (meningitismeningitis), and convulsion secondary to brainbrain tumourtumour. get them to discuss ‘what if’ questions; outlined below are a variety of scenarios for you to draw from.
please remind students re. importance of accurate collateral history in seizure description
CNS TumorsCNS Tumors
CPC-4.3.7 – Differential Diag. Epileptic seizure
Idiopathic - epilepsy Secondary:
Stroke - Cerebrovascular accident n.b. sub- arachnoid haemorrhage in this scenario.
Infection (meningitis,encephalitis) Tumour: primary or secondary Drugs: drug or alcohol withdrawal; drug overdose
cocaine; amphetamines; tricyclics, buproprion (Zyban) Genetic: neurofibromatosis;tuberous sclerosis.. Autoimmune: SLE; Hashimoto’s, encephalitis Head Injury: Trauma. Metabolic disorders: uraemia; hypoglycaemia; hypo-+
hypercalcaemia; hypo-+hypernatraemia Neurodegenerative diseases e.g. Alzheimer’s
Non epileptic events: consider syncope; cardiac arrythmias; pseudoseizures; TIA…etc
CNS TumorsCNS Tumors
Scenario: Epilepsy: ABC breathing spontaneously rr 14/min; 4l O2 via
mask , sats (O2 Sat study) 96% ; pulse 100 bpm regular good volume T 36.1 C BP 148/94.
GCS E2V3M4 Detailed check no neck stiffness, no skin lesions/rash Tongue has been bitten; pupils equal and reactive to
light; fundoscopy normal Decreased tone R upper limb, ?normal tone other limbs Reflexes increased on R upper + lower limb; decreased
on L upper +lower; Plantar reflexes upgoing Evidence of urinary incontinence All other systems : nil abnormal Ix - BSL : 5.1; toxicology screen : negative
CNS TumorsCNS Tumors
Scenario: Meningitis ABC breathing spontaneously rr 18/min 4l O2 via
mask, sats 90%; pulse 110 bpm reg small volume; BP 90/60 mmHg T39.6C
GCS - E2V3M4 Detailed check - petechiae non blanching rash
trunk, buttocks, Neck stiffness Small contusion L temperoparietal area Capillary refill time > 3 secs, peripheral cyanosis+ Brudzinski sign positive Ix skin scraping from lesion : gram negative
diplococci; CSF gram negative diplococci; FBC wcc 18 (polymorhic leucocytosis)
Brudzinski sign, Kernig sign, CSF findings
CNS TumorsCNS Tumors
Core Learning Issues: Pathology Major CLI:
Raised ICP – Pathology & Clinical features. Pathology of common Primary and secondary CNS tumors in
different age groups. Astrocytoma – grades, clinical types, presentation &
complications. Pathology & Microbiology of Meningitis – common types
*Bacterial, viral, fungal & others. Pathology Minor CLI:
Pathology of Epilepsy (note this is major clinical learning issue) Meningioma, Acoustic neuroma, Craniopharyngioma / pituitary
tumors. Medulloblastoma. Overview of Pathogenesis of Epilepsy (include theories for
idiopathic epilepsy). CJD-Creutzfeldt jakob's disease. (Mad cow disease).
In every person who comes near you look for what is good and strong;
honor that; try to learn it, and your faults will drop off like dead leaves
when their time comes.
--John Ruskin
Look for good in others “No one is without faults and everyone has some good qualities…!”
Pathology of CNS TumorsCNS Tumors
Dr. Venkatesh M. Shashidhar, MDDr. Venkatesh M. Shashidhar, MDAssociate Professor & Head of Pathology
CNS TumorsCNS Tumors
CNS Tumors: General Features
10% of all tumors. Commonest solid cancers in children.(2nd to Leuk
for all malignancies) Age: double peak 1st & 6th decade Adults - 70% supratentorial Children - 70% infratentorial No/very rare extraneural
spread. Metastasis most common.
AdultsAdults
ChildrenChildren
CNS TumorsCNS Tumors
Clinical features:
Raised Intracranial Pressure* Headache (morning), vomiting,
slow pulse, papilloedema.Local damage:
Nerve & tract deficits, Paralysis, seizures etc.
CNS TumorsCNS Tumors
CNS Tum: Clinical Features-Pathogenesis Headaches (morning) Papilloedema Nausea or vomiting Bradycardia Seizures (convulsions). Drowsiness, Obtundation Personality or memory Changes in speech Limb weakness Balance/Stumbling eye movements or vision
Increased ICP Increased ICP ICP – Medulla ob. ICP – Parasymp. Irritation. Brain Stem compress Frontal lobe Temporal lobe Motor area Cerebellum Optic tract, occipital.
CNS TumorsCNS Tumors
CNS Anatomy - Clinical Features
CNS TumorsCNS Tumors
CNS Tumors Classification:
Primary Tumors:Meninges – Meningioma
Glial cells: GliomaAstrocytoma & Glioblastoma. Oligodendroma, ependymoma.
Nerve sheath – Schwanoma, Neurofibroma.
Embryonal – Medulloblastoma, neuroblastoma, teratoma.
Blood vessels – angioma, angiosarcoma etc.
* Other Epithelial, Pituitary & Pineal gland tumors.
Secondary Tumors - Metastasis – common Melanoma, breast, lung, GIT.
CNS TumorsCNS Tumors
Adults: Astrocytoma &
Glioblastoma. Meningioma Metastasis.
Children: Astrocytoma Medulloblastoma
Common:
CNS TumorsCNS Tumors
Meningioma:
Arise from arachnoid granulations of venous sinuses. Attached to dura.
Common sites: parasagittal (falx), sphenoidridge, olfactory groove, cerebellopontine angle. specific clinical features.
Females common (2:1) Slow growth, well differentiated &
demarcated. Does not invade brain (Benign). Reactive skull Hyperostosis over the tumor. Microscopy: spindle cells in whorls and
psammoma bodies(microcalcification).
Meningioma
CNS TumorsCNS Tumors
Meningioma
CNS TumorsCNS Tumors
Meningioma
CNS TumorsCNS Tumors
Meningioma
CNS TumorsCNS Tumors
Meningioma
CNS TumorsCNS Tumors
Meningioma
CNS TumorsCNS Tumors
Meningioma
•Well demarcated•Capsulated
CNS TumorsCNS Tumors
Meningioma – whorls of clear cells.
NormalArachnoidGranulation
CNS TumorsCNS Tumors
Meningioma NodulesNodules
Psammoma Body
Psammoma bodies
CNS TumorsCNS Tumors
Glioma:
Gliomas are neoplasms of glial cells. Commonest both in adults and
children Benign * to Aggressively malignant.
Astrocytoma (anaplastic & G.B.M) Ependymoma - Rare, 4th ventricle. Oligodendroglioma - Benign, adults,
rare
CNS TumorsCNS Tumors
Astrocytomas
Adults:Commonest 80%, Supratentorial.Solid – Fibrillary – low grade*. Varigated, Hemorrhagic - Malignant,
glioblastoma multiforme.Children:
Infratentorial (Cerebellum), Cystic, Low grade*, Pilocytic
CNS TumorsCNS Tumors
Astrocytoma-Lowgrade fibrillary
CNS TumorsCNS Tumors
Astrocytoma
CNS TumorsCNS Tumors
Astrocytoma: * Lat. Vent. *petechial hem.
CNS TumorsCNS Tumors
Glioma Brain Stem – note diffuse tumor
CNS TumorsCNS Tumors
Glioma Cerebrum cystic degeneration
CNS TumorsCNS Tumors
Glioma:
CNS TumorsCNS Tumors
Astrocytoma (Glioma)
CNS TumorsCNS Tumors
Glioma Brain Normal
CNS TumorsCNS Tumors
Astrocytoma
CNS TumorsCNS Tumors
Astrocytomas
Adults:Commonest 80%, Supratentorial.Solid – Fibrillary – low grade*. Varigated, Hemorrhagic - Malignant,
glioblastoma multiforme.Children:
Infratentorial (Cerebellum), Cystic, Low grade*, Pilocytic
CNS TumorsCNS Tumors
Glioblastoma Multiforme (GBM): High grade Astrocytoma - Grade IV Commonest & malignant brain tumor in adults –
mean survival <1y – cerebral supratentorial. Loss of heterozygosity on Chromosome 10 (80%) Most GBMs have lost one entire copy of C – 10 2 types: Primary (worst) or Secondary from low grade
astrocytomas (better prog). Variants: giant cell GBM, gliosarcoma Microscopy: Necrosis, palisading, hypercellularity, nuclear atypia
& vascular proliferation & mitoses.
CNS TumorsCNS Tumors
Genetic abnormalities in Glioma:Low grade Anaplastic GBM
CNS TumorsCNS Tumors
Glioma: high grade
CNS TumorsCNS Tumors
Glioma:Enhancement with peritumoral edema.
CNS TumorsCNS Tumors
Glioblastoma:
CNS TumorsCNS Tumors
GBM:+ glioma Enhancement with peritumoral edema.
CNS TumorsCNS Tumors
Glioblastoma – high grade Astrocytoma
CNS TumorsCNS Tumors
Glioblastoma – high grade Astrocytoma
CNS TumorsCNS Tumors
Glioblastoma Multiforme (high grade Astrocytoma)
CNS TumorsCNS Tumors
Glioblastoma Cerebrum
CNS TumorsCNS Tumors
Glioblastoma Cerebrum
CNS TumorsCNS Tumors
Glioblastoma Multiforme
PalisadingPalisading
NecrosisNecrosis
CNS TumorsCNS Tumors
Glioblastoma Multiforme
NecrosisNecrosisPalisadingPalisading
CNS TumorsCNS Tumors
Glioblastoma Multiforme
Palisading
B.V
Necrosis
CNS TumorsCNS Tumors
Glioblastoma Multiforme
PalisadingNecrosis
CNS TumorsCNS Tumors
Glioblastoma Multiforme
A Astrocytoma Low gradeB Glioblastoma Multiforme(GBM)C Necrosis with pseudopalisading in GBM.
CNS TumorsCNS Tumors
Astrocytomas
Adults:Commonest 80%, Supratentorial.Solid – Fibrillary – low grade*. Varigated, Hemorrhagic - Malignant,
glioblastoma multiforme.Children:
Infratentorial (Cerebellum), Cystic, Low grade*, Pilocytic
CNS TumorsCNS Tumors
Pilocytic astrocytoma
Common in childhood Most slow growing of the gliomas Sites: cerebellum, around 3rd Ventricle. optic
nerve. Grossly cystic with mural nodule Microscopic
elongated hair-like (pilocytic) elongated cells & Rosenthal fibers.
CNS TumorsCNS Tumors
Pilocytic Astrocytoma - children
CNS TumorsCNS Tumors
Pilocytic Astrocytoma - children
CNS TumorsCNS Tumors
Pilocytic astrocytomaMural nodule
CNS TumorsCNS Tumors
Pilocytic Astrocytoma: Microscopy
Palisading pilocytic astrocytes – note plenty of Rosenthal fibres between cells.
CNS TumorsCNS Tumors
Medulloblastoma: Children. Cerebellum – vermis. Primitive neuroectodermal tum. Blast cells – round scanty cytoplasm. 4th ventricle Obstruction – hydrocephalus. CSF seeding and Meningeal infiltration is
common. Rosettes & neuronal or glial differentiation
rarely seen.
CNS TumorsCNS Tumors
Medulloblastoma: Primitive neuroectodermal tumor:Children, vermis of cerebellum.
Origin
Spread
CNS TumorsCNS Tumors
Medulloblastoma
CNS TumorsCNS Tumors
Medulloblastoma
CNS TumorsCNS Tumors
Youtube Videos: Glioblastoma Multiforme:
http://www.youtube.com/watch?v=idSos1XOi7A http://www.youtube.com/watch?v=bGawC2RJ-Sc
Meningioma: http://www.youtube.com/watch?v=ddEB5ITx2fw
Pyogenic Meningitis: http://www.youtube.com/watch?v=L9jpjxTSLws
CNS TumorsCNS Tumors
Most common CNS Tumors:
Glioblastoma MF
CNS Tumors: Summary
Adults:Adults: Secondary commonSecondary common Lung, Skin, breast..Lung, Skin, breast.. Primary - SupratentorialPrimary - Supratentorial
Astrocytoma / Astrocytoma / glioblastoma.glioblastoma.
MeningiomaMeningioma
Children:Children: 22ndnd common (leuk / lymph) common (leuk / lymph) InfratentorialInfratentorial
Astrocytoma (cystic Astrocytoma (cystic cerebellar)cerebellar)
MedulloblastomaMedulloblastoma Hydrocephalus.Hydrocephalus. Meningeal spread.Meningeal spread.
CNS TumorsCNS Tumors
Learning Medicine...! Learning medicine should be a JOY, not an ordeal. Everybody learns according to their own best style. The Hippocratic oath issues of patient privacy,
compassion, and FREE sharing of knowledge have to be honored.
Exam and grade anxieties are the CANCERS of medical education.
If your school admitted students which they feel need to be whipped, the SCHOOL has failed, not YOU!
If you claim you NEED to be pushed, I do not want you as my doctor.
John R. Minarcik, MD (http://www.medicalschoolpathology.com)
CNS TumorsCNS Tumors
Pathology of Pathology of
Increased Intracranial PressureIncreased Intracranial Pressure
CNS TumorsCNS Tumors
Pathogenesis: Increased intracranial pressure (ICP): - if >
40 mm Hg cerebral hypoxia, cerebral ischemia, cerebral edema, hydrocephalus, and brain herniation.
Cerebral edema: Edema - Disruption of the blood brain barrier – vasodilatation – swelling.
Hydrocephalus communicating type common in Total Body Irradiation.
CNS TumorsCNS Tumors
Pathogenesis: Brain herniation: Supratentorial herniation common.
3 sub types Subfalcine herniation: The cingulate gyrus of the frontal
lobe (commonest) Central transtentorial herniation: displacement of the
basal nuclei and cerebral hemispheres downward Uncal herniation: Medial edge of the uncus and the
hippocampal gyrus Cerebellar herniation: infratentorial herniation -
tonsil of the cerebellum is pushed through the foramen magnum and compresses the medulla, leading to bradycardia and respiratory arrest.
CNS TumorsCNS Tumors
Common CNS Herniations: Subfalcine:
CNS TumorsCNS Tumors
Subfalcine Herniation: in brain trauma.
Contusion of the inferior temporal lobe (blue arrow) has resulted in diffuse edema. (compressed and flattened gyri on the right).
This has resulted in subfalcine herniation of the cingulate gyrus (red arrow), with a secondary hemorrhagic infarction above that (black arrow). A midline shift from right to left is also present, as is uncal herniation (yellow arrow).
CNS TumorsCNS Tumors
Uncal Herniation:
Inferior view, The herniated uncus is bulging over the position of the tentorium (black arrows) and compressing the midbrain. The two mammillary bodies (blue arrows) have been shifted to the patients right due to the pressure.
CNS TumorsCNS Tumors
Uncal Herniation:
CNS TumorsCNS Tumors
acute brain swelling + Uncal Herniation
Swelling of the left cerebral hemisphere has produced a shift with herniation of the uncus of the hippocampus through the tentorium, leading to the groove seen at the white arrow.
CNS TumorsCNS Tumors
Cerebellar Tonsil - Herniation Note the cone shape of the
herniated tonsils around the medulla in this cerebellum specimen.
Results in compression and Duret hemorrhages in the pons.
CNS TumorsCNS Tumors
Transtentorial herniation: Transtentorial herniation
at the base of the brain. A prominent groove surrounds the displaced parahippocampal gyrus (arrow). The adjacent 3rd nerve (N) is compressed and distorted and the ipsilateral cerebral peduncle (P) is distorted with small areas of haemorrhage.
CNS TumorsCNS Tumors
Cerebral Herniation: PathogenesisSite of Site of herniationherniation EffectEffect Clinical consequenceClinical consequenceTranstentorial Ipsilateral 3rd cranial nerve
compressionIpsilateral fixed dilated pupil
Ipsilateral 6th cranial nerve compression
Horizontal diplopia, convergent squint
Posterior cerebral artery compression
Occipital infarction Cortical blindness
Cerebral peduncle compression
Upper motor neurone signs
Brainstem compression and haemorrhage
Decerebrate posture Cardiorespiratory failureDeath
Foramen magnum
Brainstem compression and haemorrhage
Decerebrate posture Cardiorespiratory failure Death
Acute obstruction of CSF pathway
Decerebrate posture Cardiorespiratory failureDeath
CNS TumorsCNS Tumors
Decorticate posturing, with elbows, wrists and fingers flexed, and legs extended and rotated inward.
Look for good in others… no one is without faults and everyone has some good qualities!
BK.
CNS TumorsCNS Tumors
52y, F, CNS tumor: ? diagnosis
1 2 3 4 5
0%
10%
90%
0%0%
1.1. Glioblastoma m.Glioblastoma m.
2.2. AstrocytomaAstrocytoma
3.3. MetastasesMetastases
4.4. Medulloblastoma Medulloblastoma
5.5. MeningiomaMeningioma
CNS TumorsCNS Tumors
52y, F, CNS tumor: ? diagnosis
1 2 3 4 5
4%
90%
6%0%0%
A.A. Glioblastoma m.Glioblastoma m.
B.B. AstrocytomaAstrocytoma
C.C. MeningiomaMeningioma
D.D. EpendymomaEpendymoma
E.E. MedulloblastomaMedulloblastoma
CNS TumorsCNS Tumors
52y, F, CNS tumor: ? diagnosis
1 2 3 4 5
95%
2% 2%0%0%
A.A. Glioblastoma m.Glioblastoma m.
B.B. AstrocytomaAstrocytoma
C.C. MeningiomaMeningioma
D.D. EpendymomaEpendymoma
E.E. MedulloblastomaMedulloblastoma
CNS TumorsCNS Tumors
52y, F, parasagittal tum attached to falx: ? diagnosis
1 2 3 4 5
6% 8% 10%4%
71%
1.1. Glioblastoma m.Glioblastoma m.
2.2. AstrocytomaAstrocytoma
3.3. MeningiomaMeningioma
4.4. EpendymomaEpendymoma
5.5. Medulloblastoma Medulloblastoma
CNS TumorsCNS Tumors
Commonest primary CNS tumor in Adults ?
1 2 3 4 5
15%
73%
0%0%
12%
A.A. Glioblastoma m.Glioblastoma m.
B.B. AstrocytomaAstrocytoma
C.C. MeningiomaMeningioma
D.D. EpendymomaEpendymoma
E.E. MedulloblastomaMedulloblastoma
CNS TumorsCNS Tumors
52y, F, CNS tumor: ? Arrow Feature
1 2 3 4 5
0%
98%
0%2%0%
1.1. Necrosis.Necrosis.
2.2. Psammoma bodyPsammoma body
3.3. CalcificationCalcification
4.4. Blood vesselBlood vessel
5.5. Epithelial pearlEpithelial pearl
60y smoker, chronic bronchitis complains of difficulty walking. PE: stiff, expressionless face. A tremor of his fingers is apparent but ceases when he tries to reach for something. Image shows brain
stem . Diagnosis?
1 2 3 4 5
0%4% 2%
92%
2%
1.1. Alzheimers diseaseAlzheimers disease2.2. Lacunar infarctsLacunar infarcts3.3. Picks diseasePicks disease4.4. Parkinsons diseaseParkinsons disease5.5. Durett hemorrhagesDurett hemorrhages
CNS TumorsCNS Tumors
Commonest primary CNS tumor in Children?
1 2 3 4 5
0%
67%
28%
4%0%
A.A. Glioblastoma m.Glioblastoma m.
B.B. AstrocytomaAstrocytoma
C.C. MeningiomaMeningioma
D.D. EpendymomaEpendymoma
E.E. MedulloblastomaMedulloblastoma
CNS TumorsCNS Tumors
Commonest Location of CNS tumor in Children?
1 2 3 4 5
4%
37%
4%2%
53%
A.A. SupratentorialSupratentorial
B.B. Cerebellum Cerebellum
C.C. InfratentorialInfratentorial
D.D. Cerebrum.Cerebrum.
E.E. Brain stemBrain stem
CNS TumorsCNS Tumors
7y, F, CNS tumor: ? diagnosis
1 2 3 4 5
8%
46% 46%
0%0%
A.A. Glioblastoma m.Glioblastoma m.
B.B. AstrocytomaAstrocytoma
C.C. MeningiomaMeningioma
D.D. EpendymomaEpendymoma
E.E. MedulloblastomaMedulloblastoma
CNS TumorsCNS Tumors
55y Female. Died following car crash. Coroners autopsy Image shows Brain stem- What is the likely cause of death?
1 2 3 4 5
20% 20% 20%20%20%
1.1. Herniation of cerebral tonsil Herniation of cerebral tonsil
2.2. Intracerebral hemorrhage.Intracerebral hemorrhage.
3.3. Subdural hemotomaSubdural hemotoma
4.4. Subarachnoid hemorrhage.Subarachnoid hemorrhage.
5.5. Glioblastoma multiforme.Glioblastoma multiforme.
CNS TumorsCNS Tumors
56y, F Rapidly growing parietal lobe tumor:? diagnosis
1 2 3 4 5
88%
0%6%6%
0%
A.A. Glioblastoma m.Glioblastoma m.
B.B. AstrocytomaAstrocytoma
C.C. MeningiomaMeningioma
D.D. EpendymomaEpendymoma
E.E. MedulloblastomaMedulloblastoma
CNS TumorsCNS Tumors
49y, M, CNS tumor: ? diagnosis
1 2 3 4 5
0% 0%
20%
80%
0%
A.A. MetastasesMetastases
B.B. Astrocytoma sy.Astrocytoma sy.
C.C. MeningiomatosisMeningiomatosis
D.D. NeurofibromatosisNeurofibromatosis
E.E. LipomatosisLipomatosis
54y woman dies 48 hours after suffering severe head injuries in an automobile accident. Just before her death, her left pupil becomes fixed and dilated. An inferior view of the patient's brain at autopsy is shown.
Most likely cause of death?
A. B. C. D. E.
2% 0%
9%
89%
0%
A.A. Diffuse axonal shearingDiffuse axonal shearing
B.B. Laminar necrosisLaminar necrosis
C.C. Thrombosis of sagittal sinusThrombosis of sagittal sinus
D.D. Transtentorial herniationTranstentorial herniation
E.E. Watershed infarctWatershed infarct
CNS TumorsCNS Tumors
1 2 3 4 5
20% 20% 20%20%20%
48y male, Frontal lobe tum, What is the most likely diagnosis?
1.1. Glioblastoma m.Glioblastoma m.
2.2. AstrocytomaAstrocytoma
3.3. MeningiomaMeningioma
4.4. EpendymomaEpendymoma
5.5. Medulloblastoma Medulloblastoma
CNS TumorsCNS Tumors
SAQ / KFP Should seizure patients have
imaging done immediately? Personality changes indicate
which location? Differentials for young adult
with insidious symptoms, seizures and decreased signal on T1 and increased signal on T2 weighted MRI?
What is the treatment and prognosis for someone with a low-grade astrocytoma?
How should the symptoms be treated?
What tests could have been done in the absence of neuroimaging?
Yes, 10-20% tumors. Frontal lobe Other gliomas Conservative – Poor Steroids, anti
epileptic, symptomatic.
EEG
CNS TumorsCNS Tumors
SAQ / KFP Why was the child hitting his
head? Why did the child have a
headache? If the child does have
hydrocephalus, at what level is the ventricular system being obstructed at?
Should a lumbar puncture be performed?
Where in the cerebellum is the lesion located?
What is the radiolucent area visible along the antero-superior aspect of the radiograph?
Indicating headache. Increased ICP, tum. 4th ventricle. No – coning…* Central – vermis Separation/malfusion of
anterior frontoparietal suture due to hydrocephalus.
CNS TumorsCNS Tumors
50y Female smoker - Headache.This 50 year-old female smoker known for hypertension and diabetes mellitus type 2 was in her usual state of health until 2 years ago, when she began to have morning headaches that would usually go away by themselves. Year later began to have hearing problem on her left side. Recently, she noticed intermittent loss of sensation of the left side of her face. She is taking a thiazide diuretic, captopril, glyburide, and metformin. She has no known allergies.
Physical exam: Slight drooping in the left mouth and lower eyelid. Incomplete closure of the left eyelid with corneal touch. Reduced pain and light touch on the left side. Fundoscopic exam revealed bilateral papilledema.
CNS TumorsCNS Tumors
50y Female smoker - Headache.
CNS TumorsCNS Tumors
50y Female smoker - Headache.
CNS TumorsCNS Tumors
1.1. Glioblastoma m.Glioblastoma m.
2.2. AstrocytomaAstrocytoma
3.3. MeningiomaMeningioma
4.4. EpendymomaEpendymoma
5.5. Medulloblastoma Medulloblastoma
What is the most likely diagnosis?
CNS TumorsCNS Tumors
SAQ / KFP Name the location of
tumor? What cranial nerves
are involved? List differential
diagnosis Explain pathogenesis
of headache and papilledema?
What does the histological pattern represent in slide 1? slide 2?
Cerebellopontine angle Cranial Nerves 5,7 & 8 Teratoma, meningioma,
acoustic neuroma. Increased intracranial
tension. Tumor attempting to form
Arachnoid grannulations. Origin of tumor.
CNS TumorsCNS Tumors
35y Male, depression2-year history of loss of initiative, depression. He had slowly lost his drive to win all the big deals he always done so well at work. 3 months ago he began to experience headache, which did not respond to acetaminophen or aspirin. His wife noticed that his lethargic state had increased in the past few months. 3 days ago his right arm began to convulse uncontrollably for 1 minute. 1 day ago the patient began again violently shaking his right arm, and the right side of face began to twitch at the dinner table. No fever.
Physical exam: Bilateral papilledema, increased deep tendon reflexes of the right bicep, tricep, +ve babinski sign on the right foot, reduced leg strength on the right.
CNS TumorsCNS Tumors
35y Male, depression
Axial T1 weighted MRI
Axial T2 weighted MRI
CNS TumorsCNS Tumors
35y Male, depression
Coronal T1 weighted MRI
Coronal T2 weighted MRI
CNS TumorsCNS Tumors
3y Male, constant cry….
Constant crying and not interacting with other children at daycare since 1m. Mother noticed that he was pointing to his head often. Family physician who stated that he was developing normally, and that the “ terrible two’s” are difficult period for parents. Recently started vomiting on a daily basis and started wobbling even though he learned to walk 6 months ago.
Physical: Bilateral papilledema and gait ataxia was noted on the physical exam.
CNS TumorsCNS Tumors
Axial T1 weighted MRI Axial T2 weighted MRI
3y Male, constant cry….
CNS TumorsCNS Tumors
Coronal T1 weighted MRI
3y Male, constant cry….
CNS TumorsCNS Tumors
1.1. Glioblastoma m.Glioblastoma m.
2.2. AstrocytomaAstrocytoma
3.3. MeningiomaMeningioma
4.4. EpendymomaEpendymoma
5.5. Medulloblastoma Medulloblastoma
What is the most likely diagnosis?
CNS TumorsCNS Tumors
65y Fem morning headache.Morning headache 2y, Progressive right upper limb weakness. She woke up this morning obtunded, and did not initially respond to her husband’s cries. She screamed to her husband that she could not see anything to her right, and that she that her left arm and leg were very weak. At this point her husband rushed her to the nearest hospital.Physical Exam: left lid ptosis, left-pupillary dilation, and failure of her left eye to constrict to light directly or consenually. Patient had bilateral lower limb weakness, with increased deep tendon reflexes on the left side, and a +ve babinski on the left side. Bilateral Papilledema. Homonymous hemianopia of the right side. Visual acuity was corrected to 20/20 with glasses.
CNS TumorsCNS Tumors
65y Fem morning headache.
CNS TumorsCNS Tumors
Brain Metastasis: Lung, Breast, Skin,
Kidney, GIT. Prostate – never..! Well demarcated,
usually multiple with surrounding rim of inflammation.
Carcinomatosis: Meningeal CSF spread of malignant cells.
CNS TumorsCNS Tumors
Metastatic Melanoma: multiple
CNS TumorsCNS Tumors
Brain Metastases: Surrounding edema.
CNS TumorsCNS Tumors
1.1. Glioblastoma m.Glioblastoma m.
2.2. AstrocytomaAstrocytoma
3.3. MeningiomaMeningioma
4.4. EpendymomaEpendymoma
5.5. Medulloblastoma Medulloblastoma
What is the most likely diagnosis?
CNS TumorsCNS Tumors
SAQ / KFP Are there clinical signs of
nerve compression? What is the most likely cause
of the homonymous hemianopia?
Why does the patient have progressive right upper limb weakness, and paroxysmal left upper and lower limb weakness?
Should a lumbar puncture be performed?
Why was the patient obtunded?
Why was an-x-ray taken?
Yes, ptosis, pupils 3rd Optic pathway -
occipital. Motor cortex
compression – tum. Risky. Brainstem
compression. Meningioma
hyperostosis.
CNS TumorsCNS Tumors
CPC-3.7– KFP Questions: Meningitis Types, classification & comparison. Septic, Viral & TB meningitis. Morphology, complications. Laboratory diagnosis, CSF findings. CNS tumours: common features. Adult and childhood CNS tumors. Common Types & features. Increased intracranial pressure – Pathologic
basis of clinical features.
It has been my philosophy of life that difficulties vanish
when faced boldly.
--Isaac Asimov
Other CNS tumors
CNS TumorsCNS Tumors
Neuroectodermal Tumors
Origin from primitive blast cells. Rosettes - attempted nerve formation.
1. Medulloblastoma – Cerebellum
2. Retinoblastoma - Retina
3. Neuroblastoma – Adrenal glands
4. Ganglioneuroma - Mediastinum
CNS TumorsCNS Tumors
Medulloblastoma
CNS TumorsCNS Tumors
Ependymoma-hemorrhage
CNS TumorsCNS Tumors
Ependymoma 4th Ventricle
CNS TumorsCNS Tumors
Ependymoma 4th Ventricle
Ependymoma
CNS TumorsCNS Tumors
Nerve Sheath Tumors:
Neurofibroma: Epi & endoneurial fibroblasts. Form whorls of fibroblasts with nerves Well differentiated, benign, capsulated.
Schwannoma: Schwann cells, elongated form whorls Nuclear palisading
CNS TumorsCNS Tumors
Schwannoma / Neurofibroma
CNS TumorsCNS Tumors
Schwannoma 8th Nerve:
CNS TumorsCNS Tumors
Bilateral 8th nerve schwannomas.
CNS TumorsCNS Tumors
Schwannoma:
Schwannoma
Neurofibromatosis:
Neurofibromatosis:
Café-au-lait spot
CNS TumorsCNS Tumors
Schwannoma
CNS TumorsCNS Tumors
Schwannoma
CNS TumorsCNS Tumors
Summary: Children – 70% INFRAtentorial Adults – 70% SUPRAtentorial Common Malignant - adults, metastatic tumors (Lungs) Common - adults – glioblastoma multiforme
Intracerebral Common Benign - children – cerebellar astrocytoma. Common Mal - children – cerebellar medulloblastoma Very rare – meninges and schwann cells (meningiomas
and schwannomas) – usu. found in adults
CNS TumorsCNS Tumors
A 26-year old femaleHeadache,vomiting, an epileptic attack, weakness of legs. Now drowsy. Two weeks before admission she gave her second birth.
CT and NMR revealed a huge parasagittal tumor (80x67x65 mm), enhanced by contrast, compressed corpus callosum and ventricles.
CNS TumorsCNS Tumors
Histopathology:
Bifrontal parasagittal tumor, craniectomy and tumor was totally removed.
Well demarcated, firm white lobular.
CNS TumorsCNS Tumors
Fibrous – spindle cells.
CNS TumorsCNS Tumors
37 yr FemaleSerious automobile accident and sustained a close head injury,she does not immediately seek medical attention, but is brought to the emergency room two hours later by her brother,on physical examination there is mydriasis and loss of pupillary light reflex,several hours later she is unable to follow a flash light with her eyes,which of the following herniation is most likely occuring in this patient????
A)cerebellar tonsils into the forman magnum B)cerebellum upward past the tentorium C)singulate gyrus under the falx D)medulla into the foramen magnum E)temporal lobe under the tentorium
CNS TumorsCNS Tumors
32y Female Fleshy pappules: Several fleshy papules
on face, trunk, and upper extremities.
Since 10y of age. Increased & Irritation over the past 5 y.
Previous excision have recurred.
No other significant history.
CNS TumorsCNS Tumors
Neurofibromatosis: Autosomal dominant, NF1- Peripheral/Von Recklinghausen’s NF2- known as central NF. However, NF1 may cause central characteristics. About 50% familial, 50% sporadic gene mutation. NF1/ von Recklinghausen disease, gene mutation on
chromosome 17, 1 in every 3000-4000 births. Diagnosis of NF1 if > 2 of 6 or more café au lait spots (irregularly shaped, evenly
pigmented, brown macules), 2 or more neurofibromas, axillary or inguinal freckling, Lisch nodules on the iris or optic glioma, various types of osseous lesions, a first-degree relative with the condition.
CNS TumorsCNS Tumors
Neurofibromatosis: NF2 – Gene mutation chromosome 22. 1 in every 33,000-40,000 births Typically present with acoustic neuromas or vestibular
schwannomas. Tinnitus, balance disorders, and progressive hearing loss May also have meningiomas and juvenile cataracts. First-degree relative and on any 2 of the conditions listed for NF1. Patients with NF1 are at increased risk of malignancy. Annual ocular examinations are recommended. Genetic testing is
also advocated in patients with NF who wish to have children. Surgery has been a successful treatment for the lesions
themselves; however, recurrence often occurs, and nerve damage is a risk when tumors are located along neural pathways
(National Institute of Neurologic Disorders and Stroke, 2006).
CNS TumorsCNS Tumors
7th nerve palsy: Cerebellopontine angle
tumours. Acoustic neuroma,epidermoid cysts, medulloblastomameningioma
Affected cranial nerves:5 trigeminal - masticatio7 facial –face muscles8 auditory – hearing
CNS TumorsCNS Tumors
Brudzinski Sign of Meningitis:
CNS TumorsCNS Tumors
Scenario: Brain Tumor ABC as for scenario 1 GCS E3V4M5 Detailed check no neck stiffness, no rash Tongue has been bitten; small contusion L
temperoparietal area PEARL fundoscopy normal L sided weakness arm >
leg with increased tone and reflexes L plantar reflex equivocal; R plantar reflex downgoing
Evidence urinary incontinence All other systems : no abnormalities Ix - as per scenario 1; MRI scan ?gliobalstoma multiforme R fronto-parietal region
CNS TumorsCNS Tumors
GBM: Glomeruloid bodies:
CNS TumorsCNS Tumors
Normal Fundus - Papilledema
CNS TumorsCNS Tumors
Normal vs Glaucoma