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electrical activity or combination Supratentorial tumors FND CL weakness Visual field deficit Headache Seizure Infratentorial tumors Hydrocephalus ICP compression of CN4 headache, n/v, diplopia RARE seizures Cerebellar hemisphere/ brainstem dysfunction Ataxia, nystagmus, CN palsies ALL px suspect for brain tumor MRI (w/ AND w/o gadolinium); evaluation study of choice! Initial Mx: Dexamethasone (if edema) Phenytoin (supratentorial tumors only) Metastatic Tumors In decreasing frequency Lung - more than half Breast Kidney GI Tract Melanoma Travel hematogenously & seed gray-white junction (other locations: cerebellum & meninges w/c can lead to carcinomatous meningitis: Leptomeningeal carcinomatosis) Mx: Depends on primary tumor Tumor burden Px’s medical condition Location & number of metastases Craniotomy is NOT advisable unless ALL detectable metastases can be accessed/resected Surgery SHOULD be followed by whole brain radiation therapy average survival to 8 months Radiation may be delayed until recurrence in low grade tumors Stereotactic surgery (gamma knife) multiple metastases; gross total resection w/o unacceptable devastating neurologic deficit Glial Tumors Glial cells provide the anatomic & physiologic support for neurons & their processes ASTROCYTOMA Most common primary CNS neoplasm “Glioma” Grade: I low grade II low grade Median survival: 8 years III anaplastic astrocytoma Median survival: 2-3 years IV glioblastoma multiforme (GBM) Median survival: 1 year 2/3 of all astrocytomas
Do NOT infiltrate brain: Juvenile pilocytic astrocytoma Pleomorphic xanthoastrocytoma (Both) are circumscribed, low grade & w/ good prognosis Higher grade: Hypercellularity Nuclear atypia Endovascular hyperplasia Necrosis OnLy w/ GBM; required for Dx
OLIGODENDROGLIOMA 10% of gliomas seizures CT/MRI: calcifications & hemorrhages Grade I – IV Prognosis is better than astrocytoma Prognosis: 2-7 years Respond to: Procarbazine Lomustine (CCNU) Vincristine (PCV) EPENDYMOMA Lining of ventricular system: cuboidal/columnar ependymal cells Infratentorial 2/3 adult From floor of 4th ventricle (off the back of the brainstem making gross total resection often impossible) Mx: Suboccipital craniotomy & midline separation of the cerebellar hemisphere Supratentorial pediatric From lateral / 3rd ventricle @ Foramen of Luschka CPA tumor “drop mets” spread @ CSF to spinal cord S/S: Headache, n/v, vertigo 2ndary to ICP from obstruction to CSF flow Histology: Papillary ependymoma Anaplastic ependymoma mitotic activity & areas of necrosis Postop Radiation Therapy CSF spread (documented by LP or CEMRI) w/ whole spine radiation
CHOROID PLEXUS PAPILLOMA Many small vascular tufts covered w/ cuboidal epithelium Part of interface between blood & brain Choroid cells create CSF from blood Choroid plexus CARCINOMAS (rare, pediatric) Occur in infants (supratentorial @ lateral ventricle) … in adults (infratentorial @ 4th ventricle) well circumscribed, extensive vasculature S/S ICP Tx excision DO NOT USE Radiation or Chemotx
Neural Tumors & Mixed Tumors Medulloblastomas PNETS most common; arise from bipotential cells (capable of differentiating into neurons or glial cells) 1st and 3rd decade most common pediatric malignant tumor; usually midline & @ cerebellum S/S ICP Histo: Densely packed small round cells w/ large nuclei & scant cytoplasm NOT encapsulated, frequently disseminated Tx: Surgical resection radiation tx chemotx Ganglioglioma Mixed tumor (neurons & glial cells) First 3 decades Medial temporal lobe seizure Circumscribed masses that may contain cysts/ calcium
Pituitary Adenoma Anterior Pituitary (Adenohypophysis) Microadenoma (<1cm) / Macro Functional (endocrine) / Nonfunctional effect)
Neural Crest Tumor Multipotent Miscellaneous tumors MENINGIOMA From arachnoid cells (arachnoid matter) From dura matter (grossly & MRI) “Dural-based tumors” Locations: Falx Convexities (cerebral hemispheres) Sphenoid wing Less common: Foramen magnum Olfactory groove Inside Lateral ventricle Mostly slow growing, encapsulated, benign If malignant invade adjacent bone or into cortex Previous cranial irradiation increases incidence 10% - multiple Vestibular Schwannoma (Acoustic Neuroma) Arise from the superior half of the vestibular portion of vestibulocochlear nerve (CN 8) S/S: Progressive hearing loss Tinnitus Balance difficulty Large tumors: brainstem compression obstructive hydrocephalus If bilateral NF 2 Chromosome 22 mutation incidence of spinal & cranial meningiomas & gliomas Tx: microsurgical resection or gamma knife Main complication: Damage to CN 7 – Facial Nerve (because it runs through the internal auditory canal w/ CN 8) this risk with tumor diameter
Endocrine Dysfunction Cushing’s disease ACTH secretion Forbes-Albright syndrome PRL secretion Tx: Dopamine Sx if persistent mass effect Acromegaly Growth hormone secretion S/S Visual field defects compression of optic chiasm Panhypopituitarism compression of entire gland Hemorrhage Pituitary apoplexy Headache Visual disturbance mental status endocrine disfunction Mx: Transphenoidal Sx (through the nose)
Hemangioblastoma @ Posterior fossa 20% Von Hippel-Lindau disease multisystem neoplastic d/o also assoc w/: Renal cell CA Pheochromocytomas Retinal angiomas Appear as cystic w/ mural nodule (enhancing tumor @ cyst wall) Mx: En bloc resection of mural nodule alone is sufficient Sx resection is curative for sporadic (non-VHL) tumors Patho: Thin walled vascular channels (internal debulking may be bloody) Lymphoma Primarily @ CNS or 2ndary to systemic disease Incidence: Transplant px AIDS S/S: Mental status changes Headache ICP CN palsy lymphomatous meningitis (~carcinomatous meningitis) Hyperdense on CT (dense cellularity) Sx excision: little role Tx: steroids, whole brain radiation, chemotherapy (intrathecal methotrexate)
Embryologic Tumors Failure to involute or differentiate properly Craniopharyngioma Benign, cystic lesions in children 2nd peak of occurrence (50 y/o) All pediatric & 50% of adult craniopharyngiomas calcify S/S: Compression of adjacent structures (optic chiasm) Pituitary/ hypothalamic dysfunction or hydrocephalus may develop Sx: Excision is easier in children (soft & suckable tumor) Adult tumors (firm & adherent to adjacent vital structures) Complications from Sx: Visual loss Pituitary endocrine hypofunction Diabetes insipidus Cognitive impairment (basal frontal injury) Epidermoid Cystic lesions w/ stratified squamous epithelial walls from trapped ectodermal cell rests Grow slow & linearly by desquamation into cyst cavity Contain: Keratin Cholesterol Cellular debris CPA Angle Mollaret’s Meningitis recurrent bouts of aseptic meningitis due to release of irritating cyst contents into subarachnoid space Dermoid Less common than epidermods Contain hair follicles, sebaceous glands, squamous epithelium Midline structures Bacterial meningitis if associated with skin sinus tract Teratoma Midline (often @ pineal region area behind 3rd ventricle, above midbrain & cerebellum) Contain elements from all 3 germ layers: endo, meso & ectoderm Contain skin, cartilage, GI glands, teeth If w/ more pirimitive structures = more malignant
BRAIN ABSCESS Encapsulated infection w/in brain parenchyma Spread hematogenously in px w/ endocarditis intracardiac intrapulmonary RL shunts migration from sinuses or ear direct seeding by penetrating trauma Disorganized cerebritis preceedes abscess formation S/S: Headache Nausea Lethargy FND (hemiparesis) Extremis (???) if abscess ruptures into ventricular system CT/MRI: Well demarcated, ring enhancing, thin walled lesions w/ assoc edema & mass effect Blood & CSF cultures: rarely give definitive diagnosis
CEREBROVASCULAR DISEASE - Schwartz Most frequent case of new rapid-onset, nontraumatic neurologic deficit More common than seizures or tumors Risk factors: Diabeters cholesterol BP Smoking Vascular damage by: Atheroma deposition luminal stenosis Endothelial damage thrombogenesis Weakening of vessel wall aneursym formation/dissection Ischemic Diseases 85% of acute cerebrovascular events Complete occlusion of the carotid artery Can be asymptomatic because of CL carotid & basilar artery However! Px can have variable anatomy of the Circle of Willis Some may have a hypoplastic/ missing communicating artery, dominant artery, one origin, etc.. TIA Transient ischemic attack RIND Reversible ischemic neurologic deficit CVA Cerebrovascular accident Sudden onset focal neurologic deficit that resolves w/in 24 hrs Resolves 24 hrs – 1 wk Permanent deficits “complete stroke” ;
Majority enter: Anterior carotid circulation CL leg wkness CL face & arm wkness Language deficits Mass effect midline shift &
Common types: ACA stroke Medial frontal, Parietal lobes, (motor strip) MCA stroke Lateral frontal, Parietal lobes, Temporal lobes Dominant hemisphere Proximal MCA (ischemia & swelling) PCA stroke Occipital lobe PICA stroke Lateral medulla, Inferior half of the cerebellar hemispheres
CL homonymous hemianopsia N/V, dysphagia, IL Horner’s, IL limb ataxia *Lateral Medullary Syndrome* OR *Wallenberg’s syndrome*
Thrombotic Diseases Most common area of neurologically significant vessel thrombosis CAROTID ARTERY (@ bifurcation) chronic narrowing by atheroma More common concern THROMBOEMBOLUS No tx Emergency endarterectomy carotid
Mx: Complete occlusion of CA w/o referable neurologic deficit New neurologic deficit & angiographically demonstrated complete CA occlusion CL to the s/s
Mx: Goals: Reopen occluded vessel Recombinant tPA W/in 3 hrs of onset of neurologic deficit (improves outcome @ 3 months) Contraindications: ICH Majory surgery in the previous 2 wks Platelet (<100K/L) SBP >185mmGg Maintain blood flow to borderline ischemic tissues (ischemic penumbra) Head CT Scan differentiate Ischemic from Hemorhagic Allow BP to run high to maximize cerebral perfusion SBP > 180mmHg may require tx NSS w/o glucose (glucose injures neurons in penumbra) Swelling typically peaks 3-5 days after the stroke Significant swelling may require: Hemicraniectomy Suboccipital craniectomy
Surgery should NOT be done on obtunded & comatose px Surgery SHOULD be done w/in 2 hrs of symptom onset
Embolic Diseases From… Left atrium atrial fibrillation Hypokinetic Left ventricular wall segment Valvular vegetations Atheromatous aortic arch Stenosed carotid bifurcations Systemic venous sys (RL shunt like patent foramen ovale)
Hemorrhagic Diseases 15% of acute cerebrovascular events HTN & amyloid angiopathy account for most ICH Other causes AVM Aneurysms Venous thrombosis Tumors Hemorrhagic conversion of ischemic infarct Fungal infections
ICH intracranial/ intraparenchymal hemorrhage Causes local/global neuronal injury/dysfunction Mass effect AVM / aneurysm SAH (subarachnoid hemorrhage) Major cerberal & cortical blood vessels travel between the pia & arachnoid membrane (@ subarachnoid space) SAH Exposure of brain to intra-arterial pressure pulsations Delayed ischemia cerebral arterial vasospasm Meningeal linings of the brain are sensitive sudden, severe, “thunderclap” headache “worst headache of my life!” CT immediately! Acute SAH bright signal Rapid, non invasive, 95% sensitive LP Suspicious symptoms but negative CT SAH: do not decrease from test tubes 1-4 Xanthochromia RBC (100K/L) 4 vessel angiography w/in 24 hrs, assess for aneurysm, other vascular malformation, etc Catheter angiography GOLD standard Hunt Hess classification: Grade 4-5 intubation/ hemodynamic monitoring & stabilization Vasospasm cerebral arteries constrict ischemia/stroke (4-21 days) after SAH prophylaxis: maintain HTN & mild hypovolemia (optimize perfusion) Nimodipine CCB, spasm Neurointerventional: (Vasospasm) Intra-arterial papverine Balloon angioplasty More likely to present lethargic or obtunded Mass effect (acutely) Brain shift & herniation Depressed mental status Hypertension Chronic degenerative vasculopathy ICH risk 4x Locations: Basal Ganglia Thalamus Pons Result from breakage of small perforating arteries that branch off of much larger vessels Medical Mx: Blood dissects through & along neural tracts intact, salvageable neurons!! Moderate BP control Normalize platelet & clotting fxn Phenytoin Electrolyte Mx Intubate prevent aspiration & hypercarbia Surgical: Superficial clot location Young age Non-dominant hemisphere
Rapid deterioration Significant mass effect Amyloid Angiopathy Amyloid deposition in the media of small cortical vessels Compromise vessel integrity Superficial (lobar) hemorrhages Surgical evacuation less morbid Multiple hemorrhages Medical Mx!! Cerebral Aneurysm Focal dilatation of the vessel wall Balloon-like outpouching, or fusiform Thin walled, risk for rupture (lie @ subarachnoid space) SAH @ branch points of major vessels ICA bifurcation @ origin of smaller vessels PICA Opthalmic artery 85% from anterior circulation (carotid) 15% from posterior circulation (vertebrobasilar) Mx: early aneurysmal occlusion Craniotomy w/ microsurgical dissection & placement of a titanium clip across the aneurysm neck Exclude aneursym from from circulation Definitive cure young age good medical condition broad aneurysm necks Endovascular placement of looped titanium coils inside the aneurysm dome Coils support thrombosis & prevent blood flow to aneurysm Coils can move and compact over time (repeat! ) Old, medically frail px Narrow aneurysm necks Mortality rate of 50% in the first month Most require rehabilitation
AVM Abnormal dilated arteries & veins w/o an intervening capillary bed Nidus tangles mass of vessels but neural tissue! Small AVM hemorrhage Large AVM seizure Mx: Definitive tx delayed 3-4 wks Allow the brain to recover from acute injury! Hypertension & hypervolemia NOT beneficial Because the adjacent brain may be hyperemic after removal of the high flow AV shunt
Tx: Microsurgical excision Endovascular glue embolization Reduces flow through AVM Usually considered as adjunctive tx Steriotactic radiosurgery Lesions < 3 cm 2 yr time lag (AVM may bleed in the interval) High grade AVM difficult to resect w/o causing significant neurologic deficit; radiosurgery can tx this Large Near eloquent cortex Drain to deep venous structures
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