SOL%20Neuro%20874%20W3%202009

SOL%20Neuro%20874%20W3%202009 - Space Occupying Lesions...

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Unformatted text preview: Space Occupying Lesions General ' Incidence Brent Gordon There are 2 broad categories of brain tumours: ‘ - 6 persons per l00.000 per year primary brain tumours. B.Mcd.5e(}-Ians)( CLUnL) ' r M Chin}. (Macq. HI.) 1. Primary CNS tumours ‘ ~l in 12 primary brain tumours in chliclren <15 years. 2. Metastatic tumours SHIRLEY RD H C oPRAcrrc it E? R x a l m we i Q m. WWW" a. m Mme u. I mm mm a“. mm i . . . . . Site ; lntracranlal Neoplasms E Site 13"” onumom Eaton! I - In adults, most lie in the supratentorial compartment Glloma l ' 1“ aduksu the “105‘ common tumours are gllomai mmmmmlmm m - In children. the reverse is true and. most lie in the metaStfies and meninglomasi Mmymmusmmmd .1, .0 infratentorial compartment — compression of the 4!“ ventricle . - In children. medulloblastomas and cerebellar astrocytomas ‘2’ : tends to lead to hydmmphalus 1 . | predommate' l wwwmg‘mm" 1 - medulloblastomas and cerebellar astrocytomas predominate ‘ mama plexus papliluma l “Id 3 Metastases 23 in c I fen r Meningloma l 7 Adul'la Children ‘ Pituitary adennma 5 1 . 1 I Schwannorn'a. 5 ‘ ‘ 5H5“ 5“P’“‘°M°'i" m g l r l Lymphoma 3 ‘ .mu r ‘ r max 80% - Em Miscellaneous 7 %m j “mum M chm-M“ 1 Wm”, .. “mm, uqun mm m... m, “mm. 3 umuymizmlcnl'A-uu. m. «mm m WWW infirm. n m. “m. Cemifmé flew: Su Jraor Interior Canned-mu resumian ammo“ I l gland c0 iculus muiwiais [wraiin (Seaman ——-—— :3— LAIEPAE vammcws lN iEHVEN i'Hii'Lll N! f-OLr‘i‘ifH FOIWJE‘N ‘ wmmcm xx mm ‘ A Canadian: K. vEm‘rmme w Cfiflhfifim. L-‘lTEF-léi. ‘ e --H_ AQUEDL’C‘. .r-iPIZ-Hlufil- r _. .. m ileum: —-----— d V 1 Fourth 4 : '1'?an -r 77 rfimmmwm- I i . . .J u H4 «chfi‘iufz‘ r : CENTRAL CANAL W V r lee...‘..fl_fl....__.__——— surrrslcmi 1 J n - Cerebeiinm w P Ad- . 1 u r . ' ‘ J1 ‘ {h‘e’i‘WHE-e’ The ventricular system www.mmm “MW mmmmmmwmmMm 9mm." Bum M1 i-i -l -l -r Pathology - a brain tumour is considered "benign" ifit does not infiltrate or disseminate widely through the nervous system. May still have devastating effects if allowed to expand within the rigid confines of the skull. - a "malignant" intracranial tumour implies potential to spread (Le. rapid growth, poor differentiation. Increased cellularity. mitosis, necrosis and vascular proliferation). z Em c lee-l mun... Clinical Features ‘ insidious symptoms - Over a few weeks - +/- headaches - Occasionally present acute due to.- - haemo rrhage i «hydrocephalus ‘ - Raised ICP - aggravated by caughing or straining 3,“ Signs 8: Symptoms of raised ICP - Headache that is often worse in the morning, with brain oedema increasing overnight and gravity effects - Altered mental status (irritable and i alertness) “ - Nausea and vomiting (projectile) (mechanism notunderstood) - Papliloedema (obstruction of venous return and axonal transport In optic nerve due to TlCP transmitted through subararhnnld space to the optic nerve sheath; often not present in acute setting and can rake hours to days to develop). - Diplopia due to downward traction on CN VI. causing ull or bfl abducen paisies. nil-«n (min I - Aetiology Causes of most intracranial tumours is unknown Some predisposing factors; -Cranial irradiation -e.g. astrocytoma -lmmuno-suppressive therapy oe.g. lymphoma - Neu rofibromatosis -increased risk of optic nerve glioma and meningion‘ifia {re “mm-m Clinical Features H/A's will be present if the mass distorts or irritates blood vessels. -May not be severe -early a.m. «aggravated by strain or dehydration Pain is due to displacement and stretching of lntracranial tissues. t Presentations Cerebral tumours will usually present with one of the foiiowing: - Overactivity of the brain (seizures) - Underactivity of the brain (infarction) - Evidence of raised intracranial pressure ([CP) I Evidence of tumour elsewhere in the body Unlike vascular accident and demyelination. symptoms usually appear insidiously. Clinical Features Site of original H/A may indicate approximate location of tumour.- -Supratentoriai — in front of the ear -lnFratentorial — behind the ear Tumour may be a metastasis -investigate the general health of patient increased ESR? i. -Screen chest, breast, liver and glands is 0 Am“ mm... is n Nun‘tniln a. word All-law new ' Mmu’l‘nlnml Clinical Features - Supratentorial Frontal lobe - c/l face, arm or leg weakness - expressive dysphasia (dominant hemisphere) - personality changes antisocial behaviour -loss of inhibitions -loss of initiative -intellectual impairment 3. An Isolated hornonymnus hemlanopia usually Indicaies an occipital lesion is Helium Visual field defects and their significance A: Blindness In one eye B: Bilempolal hemlampla C: Homunyrnous hemlanopla D: Quadranlanopia E: Homonymous hemlanopla The findings aid localisation of the lesion: 1. Impairment ofvislon + Impaired pupil response imileair's a lesion anterior to {he LGN 2. A homonymaus hemlanopla + receptive dysphasla indicates a parietoslempolai lulgtn in n mm mm DD of Intracranial mass lesion Vascular uhaematoma Agiant aneurysm -AVM ninfarct with oedema -venous thrombosis Trauma -haematoma —contusion infection —abscess —tuberculoma -sarcoiciosis -encephalltis Cysts —arachnoid —parasitic (hydatid) ; Clinical Features - Supratentorial Parietal lobe Dominant hemisphere -rlghi,'left confusion disturbed sensation -localisation of touch finger agnusia -passwe movement flaw,“ 'astereognosis -agraphla sensory inattention _Non—melnant hezmspi'iene. -lower homonymous quadrantanopia Clinical Features —- 1 lnfratentorial Mldbrain I Brainstern -cranial nerve lesions lll—Xll -long tract signs -deterioratlon of conscious level «vomiting, hiccup (medulla) Halihlwllrln ma 1mm: alumnae»). Classification according to site Ell-um rum-vi Dam: in cur-um, my. mummy mm Nllrwlpal' ennui-a. o limit-mum “I” I I I“ I Clinical Features - Supratentorial Temporai lobe -receptive dysphasia (dominant hemisphere) (difficulty in comprehension) upper homonymous quadrantanopia Occipltal lobe -homonymous hemianopia Cerebellum -ataxic gait intention tremor -dysmetria -dysarthria -ny5tagmus mum Limb-r. um I Llllamkr, 1m Hulda“ and llwrmurvflrillurlmu‘) a‘ . . gas a MunC‘nmn Pathological Classification 1979 WHO Classification - Neuroeplthellal ~Astrocyte5 oollgodendrocytes - Ependymal cells and choroid plexus 'Neurons ‘Pineal cells ~Poorly differentiated and embryonic cells - Meninges - Nerve sheath cells - Blood vessels - Tumours of maldevelopmental origin - Anterior pituitary gland - Local extension from adjacent tumours - Metastatlc tumours E on... hymn ,— L Pathological Classification Neuroepithellal -A5trocytes » astrocytorna -most common primary brain tumour -4 histologimJ grades -most common grade IV (anaplastic astrocytoma) «widely infiltrates :1 Iran we.» -often precludes surgery ' Neuroeplthellal -Poorly differentiated and embryonic cells — Glioblastoma 3. Medulloblastoma Glloblastoma -hlgh]y malignant tumour -poorly differentiated prevents identification of cell tissue orig! n Pllhulur [1995: suuns 1. Law: ouau ml Meninges -meningioma from arachnoid granulations -compresses rather than invades -often occur in the spine -most are benign Pathological Classification i - Neuroepithelial -Oligodendrocytes - oligodendroglloma -slow growing -sharply defined tumour -anaplastic variants {malignant} Em: ‘ ammo-dw- —Mallgnant tumour -cnmmon in chlldhood ' -arlses In the cerebellum ornay seed through the CSF pathways - ID year survival rate >50% ‘ ' ' " " Plillfllaw (199: til-mucu- on... man i Pathological Classification 1 . Neuroepithelia] I v Ependymal cells - ependyrnoma anywhere throughout ventricular system or spinal canal .common in 4th ventricle and cauda equlna in o um gm... Medulloblastoma um. Destruction of the cerebellar vennis causes truncal and gait ataxia -may present with raised lCP due to blockage of CSF drainage "timiqu unwamuuw).u.m.uaunmwi emu-mm nun...” CAVANAGH. MERRILYN I “2751 7-1 é‘i’LDv‘i 1402mm ,mr 3I'IMZBI'2'O 4 ‘ g? g Emma-"m. I {HAG}! HBEEIL‘K’II THE!qu PRIVATE mm I r3117: FJ'SDy E‘hili Stallian 5 I15: -007 MI: | ; Ill-“19 mu RV. 50am a "‘ i 0.0 mm 3 1 CE 5 i“ 2“" r . r 50 132-12 3531‘ ", ' . ' ' DOB! 15 Apr 1556 -" W - ua l-eh anm 5:2 MEL?! c mmwum Nerve sheath cells vNeurilemmoma (acoustic neuroma} -non invasive I -s|0wly growing oin close apposition to the nerve of origin e.g. VIII nerve l .l' ' I " .‘i l -i -. - Pathological Classification " Pathological Classification 3 Pathological Classification Nerve sheath cells . Blood vessel . ll -Anterlor pituitary gland hNeumfibmma ' -haemangioblastoma ‘ 'Pimtary adenoma -tumour of schwann cells -benlgn -lnvoives spinal nerve roots or peripheral nerves occurs within cerebellar parenchyma -increases secretion of: I -spina.l cord -greater tendency to undergo malignant change than -‘ ,prolacfin schwannoma -GH -associated with Von Recklinghausen's disease ‘ j . ACTH _ ' a L l a o o - l v o o . Cushing's Syndrome 1 Pathological Classrflcation r Pathological Classification Characteristic features of Cushing's syndrome: : i Local extension from adlacent tumours r Metastatic tumours -rnoun face -Chordorna ': I _ame ‘ . ware «may arise from any «hirsutlsm (abnormal hairlness) and baldness primary site buffalo type obesity -may occur anywhere from sphenoid to cpccyx .purple striae OVer flanks and abdomen .most common in ba5§_oc,jpital and sacrococcygea] -most common from bruising area bronchus, breast or -musde weakness and wasting ‘ Skin osteoporosis -invades and destroys bone at these sites -hypertenslon ' : . ’ ' . _ .lncreased susceptibility to infection " r E mu. ' = (ltlflulliaull niggf HNLNK I. ' ' Vi -iatent diabEtes mellitus I “mm” [Health-h". me nun-roar rim run-mu um Italian-1m rimmed) um mm“ ‘ nn-mbwlal alarm.»- s f h i t' Tentorial herniation i ' ' ff f b ~ hm ummary 0 cm a ions 5 . CIII‘IICBI «3 acts 0 rain 5 l Win r r r __ , ,,_ r s an; m a. w; I | Tim-uan “mum” _ 5,“... Diensflnhllunllld midhrlln dlmnn- horn hflnIIllnu am. / ' = ' mu aimlnn and matching nfplrlorlllnu van-I. veluicl: - 5 gal..." dun-nauuun nl . r l I. I wnnpemnqm ' Rmsed [CF P n I E If" lllI-ll" rI area 0! Gel ml 0 I 5"" -H/A‘s ammo; Ind "p.39. unillculil l ’ arm-3m: nun \ in light imp-in w: movements v upwud uarall iultllliylusl . -vomiting -papiiloedema : i - Brain shift Wm. -deterioration of consciousness (ret. Formation) r Lfllgbeili ‘\ F ‘ I dnate (3rd Ennlrllllniurial ‘ hamlatlnn my pruoru: Duwnw-mtr-mionon ullulllrv l l r - W“ I» ' I I wronaiil lhlrniuilnn - mlkanfl hvn lhlllm “my . a —-—__ . u u "WMN‘M , . ‘ EpilePsy - cum auburn-1pm: l _ "reentry _ V ' . __ l N" A' ‘ ‘ I Illuliunflm.wmlauilam:‘ us; 7 Murmur mnlwrn‘um‘ry Iiwmw: “I” lfliwn-om Pallev U995) snuns I Law. Clinical effects of brain shift ‘ TENTDII-ll HEMIATIDN - LIWII Prlawr. Iglinll Illa lullwlll rnrmannn In m- mldbmln causes \ dclon'aulian m'aunscl‘nul but \ Prciiurl Irnm mud" nl ma llnlnrium wrubllil on Illa appmiu corabrll pudflnnll :Karnnhall’. nolohl may premium limb minnrsurl the um- :15; nlhu union i.n. ‘ralu imilglng I slfin‘ :rrnrn nuns-m BunEA winner. ml Tn. puminr :Illhral mm in Inmutlmu occluded lmulra mulum hamunymnul nmrnnuni. iu rarulv demand in 0.. Icull tinge Buiinr Incl-y flu - r I m nerve lOplir: nlrvos and chiulmi are rIDI illuslul-di lnlllllul :urolid numer an! Nlulmlgfl Ilrur 'nr. rm ol wmploln puny-«Inn l. mlntnd in the ram 0! Inslan expulsion, mu] Comprollhm mm ul mm: Ind culamnlur nulllul in flu miuhlain mnepuplmuaurlnn and, failurna run! la flgh "my l‘PtoflIami lawman mavnmm if! lull luv to dulld dun In lh “loci-Ind dupranalnn nl conscious Iwai. . Raised intracranial pressure - Interrelationships l annml “noun wns’um (Imp-mu mun "mu m. a. windy. real 7 Neuraiugy-ewm-ingiilée lullnnulllinnj rr llmur m, I Tonsillar herniation - Upward cerebellar herniation - Impaction In foramen magnum head tilt - neck stiffness - Depression of conscious level - Respiration irregularities lntracranial haemorrhage Can be traumatic or atraumatlc. I. Epidural (extradural) haematoma (EDI-l) 2. Subdural haematoma (SDH) 3. Subarachnoid haemorrhage (SAH) 4. lntracerebral or intraparenchymal haemorrhage (ICH). my; film“ am 7 Jrlchnald (5‘ ‘ ‘7 Mann: pl: ' human,“ bum scalp lknil dun - sknu mangle - ' helm-n C9 - ‘ man P“ ' - -~~ men-n;an m" "[er ““H a, cumin ral ham mm «murmur. Fillifliunl' (1995] Slavens a Low: 5 nl‘cl‘slii’l'nasslnd hwfl IM Ilium llrwa-Iy‘ mm s Llilum'xi ml Number m Nlmnmfirr" lllmhund] E TUNSILLAH “WHOM A dam» of upward ureballnr Marni-lion I; usually prosenl ~_ _. Brainsiem aressum results in: _ 7 dapmuion almawiaus lava}. — Nflif‘lflm‘y irregulamlu u—n rupiralmy "raft Tonsillar impaction Inlhl "- - i—r for-marl magnum producu curmrrnum Dara! layers Dun: Arldmuid Suhdulal space Subarachnuld[ space , ail Intracerabrai curler ' l I . lr-nnrnnauy, IHIlI-‘Alimniflr ml leululnwand unnmrm Illuulllnll) Extradan A skull fmnure luring {he middlemeniugal vase]: bleed: ian are cur-de mm. This unruly occur: in Iii: lemporal m- ranpmopmml raglan Ocarina-11y umdunl hem-mums it: fluid by :lnlpmltd ngiml or Innsvcrse Illllll. lllnuuhfl 1: lubdural (bunt lube) Cnnluaionl in Ilse front-l uni lunponl Job on“ load In bleeding inm nu brain Iubmncr, nnuuy mud-m with In “MI-n! Mcrlying nubdun] Juemlmm. 1n Inm=pllieuu impact ‘Bnm lobe' is I run lamb mly rupture Lin:ch ulndlndacrih: rhpr helium:an liar-um peanut: nlinmnhni. Ibrunmn Iinmapmducin‘ hem-mm.- mind. with I [111: lubdlml hlcmllmnu nacmlchn‘m linue, mun-s- in. out iulu Ill: sllhdunl spacer willing =vidnc: nl'umtu- lying tnm'ul contusion nr llcerll'iunr “man Winn-n [def-rod (ms: :maam Nuruamomr Thank firi'rirdurrrl .iiimamiunza (I III ll ; ram: ides téidlirze it: Subarachnoid haemorrhage - Non—traumatic (spontaneous) or traumatic. - Present with sudden headache “worst headache of my life”. - in 75—80% of cases occurs as a result of rupture of an arterial aneurysm in the subarachnold space. Berry aneurysms commonly arising From arterial branch points near the circle of Willis. - 25% of SAH patients die immediately. 50% overall mortality. ta - Less commonly from bleeding of an arteriovenous malformation (AVM). Epidural (extradural) haemotoma in the tight potential space between the dura and the skull. Usually caused by mpture of the middle meningeal artery due to fracture of the temporal bone. Normally within a few hours the haematoma begins to compress the brain. These patients "walk and talk again and then die!" l Surgical treatment is life saving. ...
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SOL%20Neuro%20874%20W3%202009 - Space Occupying Lesions...

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