CNS Tumors CNS 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 seizure seizure. Then get them to focus on idiopathic epilepsy epilepsy, convulsion secondary to infection ( meningitis meningitis), and convulsion secondary to brain brain tumour tumour. 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
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
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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
hypercalcaemia; hypo-+hypernatraemia Neurodegenerative diseases e.g. Alzheimer’s
Non epileptic events: consider syncope; cardiac arrythmias; pseudoseizures; TIA…etc
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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
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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
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
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)
tonsil of the cerebellum is pushed through the foramen magnum and compresses the medulla, leading to bradycardia and respiratory arrest.
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Common CNS Herniations: Subfalcine:
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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).
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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.
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Uncal Herniation:
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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.
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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.
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.
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Cerebral Herniation: PathogenesisSite of Site of herniationherniation EffectEffect Clinical consequenceClinical consequenceTranstentorial Ipsilateral 3rd cranial nerve
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.
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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
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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
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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
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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
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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
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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
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
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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.
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
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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.
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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.
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50y Female smoker - Headache.
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50y Female smoker - Headache.
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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?
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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?
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.
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35y Male, depression
Axial T1 weighted MRI
Axial T2 weighted MRI
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35y Male, depression
Coronal T1 weighted MRI
Coronal T2 weighted MRI
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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.
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Axial T1 weighted MRI Axial T2 weighted MRI
3y Male, constant cry….
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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.
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65y Fem morning headache.
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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.
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Metastatic Melanoma: multiple
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Brain Metastases: Surrounding edema.
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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?
It has been my philosophy of life that difficulties vanish
when faced boldly.
--Isaac Asimov
Other CNS tumors
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Neuroectodermal Tumors
Origin from primitive blast cells. Rosettes - attempted nerve formation.
1. Medulloblastoma – Cerebellum
2. Retinoblastoma - Retina
3. Neuroblastoma – Adrenal glands
4. Ganglioneuroma - Mediastinum
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Medulloblastoma
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Ependymoma-hemorrhage
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Ependymoma 4th Ventricle
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Ependymoma 4th Ventricle
Ependymoma
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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
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Schwannoma / Neurofibroma
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Schwannoma 8th Nerve:
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Bilateral 8th nerve schwannomas.
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Schwannoma:
Schwannoma
Neurofibromatosis:
Neurofibromatosis:
Café-au-lait spot
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Schwannoma
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Schwannoma
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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
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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.
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Histopathology:
Bifrontal parasagittal tumor, craniectomy and tumor was totally removed.
Well demarcated, firm white lobular.
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Fibrous – spindle cells.
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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
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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.
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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.
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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).