BRAIN TUMOURS

Classification

Ahmed Kareem

Presentation
one or more features belonging to three
cardinal categories:
1.seizure,
2.raised ICP
3.focal neurological deficit
*Pituitary adenomas may also present with
endocrine disturbance.
Neurosurgery‫د محمود شكري‬

Brain tumors BT
Are an intracranial neoplastic mass that because of size or location cause
symptoms of mass effect or neurological deficit.
BT classified into primary and secondary
1-primary BT: primary intracranial tumors that arise from cells of brain
parenchyma or from its intracranial lining.
2-secondary BT: secondary intracranial tumors that arise in the skull or
neighboring structures and extent through the skull or cranial foramina, or
they may arise at distant sites and spread hematogenously to the brain and
dura.
In both primary and secondary may be intra-axial or extra-axial or both.
Intra-axial tumors are located primarily within brain parenchyma or
ventricular system; where as extra-axial tumors are located in the
subarachnoid space or meninges.

Primary brain tumors:

1-Glioma:
Tumors arise from neuroglial cell, are the most common primary BT,
comprising 50-60%, they are diverse in pathology, location, and prognosis.
Astrocytoma are the most common glioma consist of 4 main grade 1,2,3,4 of
these grade 4 which called glioblastoma multiformi is the most aggressive
astrocytic tumors associated with poorer prognosis with high mortality rate.
2-Ependymoma:
Are glial neoplasm arising from ependyma and constitute approximately 5%
of all gliomas.approximately two-third of ependymomas occur in the
infratentorial compartment and the most of these present in children,
adolescents and young adults. The supratentorial ependymomas occur
mostly in adult.
3-Oligodendroglioma:
Comprise 4% of all glioma, occur in adult patient and it’s unlike the
astrocyte group, most oligodendrogliomas are well differentiated.
Calcium deposits are found in up to 90% of oligodendrogliomas.

4-Meningioma:
Originate from the arachnoid layer of the meninges, principally the
arachnoid villi and granulation.
Meningiomas are the most common of the benign brain tumours and
constitute about 15% of all intracranial tumours, with a mean age of
incidence 45 years, females have meningioma often than male since
meningioma exhibit hormonal factor(progesterone, estrogen) in their genesis
,thus explaining the higher incidence of these tumours in women, their
accelerated growth during pregnancy.
The most common location is in the parasagittal region or in the convexity
of the cranial vault others include sphenoid wing meningioma,olfactory
groove, suprasellar and posterior fossa meningioma.

Clinical presentation of BT:

Initial interaction with a patient with an intracranial mass is a careful review
of patient history and a thorough physical examination. Many patient
develop symptoms months to years before diagnosis with exception of
hemorrhagic tumors.
Headache, nausea, vomiting, decline in memory, sensory &/or motor deficit,
visual &/or auditory changes, loss of appetite or depression.
Early onset of seizure or focal deficit in an adult is suggestive of an
intracranial mass until proven otherwise.
History of endocrine dysfunction such as cold or heat intolerance, changes in
body weight or habits, abnormal thirst or urination may be indicative of
pathology near or within third ventricle or hypothalamus. History of familial
syndrome such as neurofibromatosis may also suggestive.
Other sign and symptoms will depend on location of mass, for example
frontal lobe tumor present with decreased mental status, Cerebellopontine
angle mass may cause lower cranial nerve deficits, upper or lower extremity
weakness may be secondary to a parietal mass, hydrocephalus may occur on
lesion near brain stem or any lesion that interfere with CSF flow.

Diagnosis:
1. Skull x-ray:
Although its not an useful first line in diagnosis of BT ,but can give clue to
the pathological changes result of BT for example ,calcification that seen in
meningioma of craniopharyngioma, osteolytic or osteosclerosis that seen in
some metastatic BT.

2. CT-scan:
CT scan are rapid method of initial screening for a suspected intracranial
lesion, they are useful for identifying bony anatomy, tumor calcification,
presence of a mass effect and assessing for acute changes such as
hemorrhage, edema and hydrocephalus.
CT scan usually done without and with contrast study if indicated
accordingly depending on pathology type.
3. Brain MRI (magnetic resonance imaging):
Give a better and good visualization of a lesion since it’s a method of choice
for soft tissue lesion study. Different views can be taken including axial,
coronal and sagittal allowing details study of a brain lesion.
4. Angiography:
Cerebral angiography is useful in study of a vascular tumor study as
 Glioma
Subtypes
1.Astrocytoma
-the most common primary CNS neoplasm
-The term “glioma” often is used to refer to astrocytomas specifically

2.Oligodendroglioma
-accounts for approximately 10% of gliomas.
-often present with seizures.
-Calcifications and hemorrhage on CT or MRI suggest the diagnosis.
-Prognosis is better overall than for astrocytomas.

3.Ependymoma
-Arise from the lining of the ventricular system
-The most common symptoms are headache, nausea, vomiting, or vertigo
(raised ICP)
-may spread through the CSF to form “drop mets” in the spinal canal
-two main histologic subtypes (papillary and anaplastic)

4.Choroid Plexus Papilloma

-usually occur in infants
-well circumscribed and vividly enhance due to extensive vasculature.
-usually present with symptoms of increased ICP

Diagnosis
-The diagnosis is histological, but imaging often predicts both a glial origin and the
grade of tumour
-MRI (with or without contrast)
-CT of the chest/abdomen/pelvis (exclude an extracranial primary)

Management
-high-dose steroids + proton pump inhibitor
-Antiepileptics (presenting with seizure or temporal location)
Active treatment consists of:
-maximal resection,
-high-dose focused radiation therapy
-chemotherapy (local “carmustine wafers” or systemic “temozolomide”)
Oligodendroglioma (the tumor is partly calcified)

Choroid plexus papilloma

 Meningioma
-usually benign, slow-growing lesions Originate from the arachnoid layer of the meninges,
-typically present due to mass effect principally the arachnoid villi and granulation.
-obstructive hydrocephalus
-Imaging will demonstrate a contrast-enhancing mass distinct from the brain
with a dural base

Management
-Most are amenable to curative resection
-Smaller lesions, detected incidentally —> ‘watch-and-wait’ approach
-large or impinge on key structures —> steroids and early surgery
-difficult to approach surgically —> radiotherapy or stereotactic radiosurgery (SRS)

= mean age of incidence 45 years,

= females have meningioma often than male since meningioma exhibit hormonal
factor(progesterone, estrogen) in their genesis ,thus explaining the higher incidence of these
tumours in women, their accelerated growth during pregnancy.

= The most common location is in the parasagittal region or in the convexity of the cranial vault
others include sphenoid wing meningioma,olfactory groove, suprasellar and posterior fossa
meningioma.
 Vestibular schwannoma
-nerve sheath tumours arising in the cerebellopontine angle
-present with hearing loss, tinnitus and balance problems
-Facial numbness and weakness are less common,
-large tumours —> features of brainstem compression or hydrocephalus

Management
-Small intracanalicular tumours—> surveillance.
-intermediate size tumours —> radiosurgery.
-Large lesions (>4 cm), especially with brainstem compression —>
excision+ventriculoperitoneal shunt
 Brain tumours in children
Neonates (supratentorial)
-teratoma;
-primitive neuroectodermal tumour (PNET);
-high-grade astrocytoma;
-choroid plexus papilloma/carcinoma.

Older children (infratentorial)

-medulloblastoma (an infratentorial PNET);
-ependymoma;
-pilocytic astrocytoma.

Medulloblastoma

Supratentorial PNET
hemangioblastoma.

Treatment:
I. Medical.
II. Surgical.
III. Radiotherapy.
IIII. Chemotherapy.

-medical treatment:
Are measures taken to reduce what associated sign of raised ICP like (head
elevation, hyperventilation, hypothermia, hyperosmolar drugs as mannitol,
steroid drugs as dexamethasone, barbiturate, and furosemide).
Drugs therapy to control symptoms like antiepileptic to treat seizures, other
medication to treat hormonal disturbance that may occur as in pituitary
tumors.
-surgery:
A biopsy or surgical resection is usually indicated to obtain definitive
diagnosis.
The primary role of surgery is to provide tissue for histopathological
Diagnosis, to alleviate elevated ICP as a result of tumor mass&/or
hemorrhage, and to achieve maximal excision of neoplastic tumor.
Tumor biopsy can be carried out by burrhole while tumor removal can be
done through craniotomy.
-Radiotherapy:
Either wholly brain radiation or by gamma knife.
Indication:
• Resected tumor in which malignant changes been supported by
histopathological study
• Incomplete resected tumor.
• Inoperable tumor near vital centers.
-chemotherapy:
Numerous chemotherapy regimes have been reported, including the use of
Intravenous or intrathecal therapies in chemosensitive tumors.
Secondary brain tumors
Are the most common intracranial neoplasm in adult, they are account for
30% of brain tumor.
Five sources are responsible for most cerebral metastases which include:
• Carcinoma of lung.
• Carcinoma of breast.
• Metastatic melanoma.
• Carcinoma of kidney.
• Gastrointestinal carcinoma.
In 15% a primary origin is never found.
Most metastatic tumors are multiple and one-third are solitary. the incidence
of tumor in cerebrum relative to the cerebellum is 8 th 1, and most occur in
the distribution of the middle cerebral artery.metastatic tumors are often
surrounded by intense cerebral edema.
Clinical features &diagnosis:
Same as for primary brain tumors.

Treatment:
• Medication.
• Surgery.
• Radiotherapy.
• Chemotherapy.
Steroid medication e.g. dexamethasone will control cerebral edema and
should be commenced immediately if there is raised intracranial pressure.
Surgery to remove the metastasis is indicated if:
-there is a solitary metastasis in a surgically accessible position.
-there is no systemic spread.
Removal of a solitary secondary is preferable only if the primary site of
origin has been, or will be controlled. However, excision of a single
metastasis will provide excellent symptomatic relief.
Radiotherapy, together with steroid medication to control cerebral edema, is
used to treat patients with multiple cerebral metastases and may be advisable
following excision of a single metastasis.
Recently stereotactic radio surgery (gamma knife) utilizing highly focused
beam of radiation has been used to treat single and multiple cerebral
metastases.
Chemotherapy used widely in metastatic chemo sensitive tumors.
 Cerebral metastases
-the most common intracranial tumours
-usually travel to the brain hematogenously
-frequently seed the gray-white junction, cerebellum, meninges
-These lesions are typically well circumscribed, round, and multiple

Diagnosis
-MRI pre- and postcontrast administration is the study of choice
-CT scan of the chest, abdomen, and pelvis
-bone scan.
*Occasionally, diagnostic biopsy may be warranted where the primary is
unknown

Management
-largely depends upon the primary tumor, overall tumor burden, patient’s
medical condition, and location and number of metastases
-Craniotomy plus whole-brain radiation therapy (WBRT) or stereotactic
radiosurgery (SRS)