bms.25. neurologi_brain tumor.ppt
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BRAIN TUMOR
YUNELDI ANWAR
DEPARTMENT NEUROLOGY MEDICALFACULTY UNIVERSITY OF NORTH
SUMATERA
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INTRODUCTION
BRAIN TUMOR INTRA KRANIAL, MED
SPINALIS AND MENINGES
TWO TYPE PRIMER AND SECUNDER PRIMER TUMOR ASTROCYTE,
OLIGODENDROCYTE, EPENDEMOCYTE,
ARACHNOID, NEUROBLAST ANDMEDULLUBLAST
SEKUNDER TUMOR METASTATIK FROMLUNG, BREAST, COLON AND SKIN
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ETIOLOGY
GENETIC GENE DEVIATION
CONGENGITAL TERATOMA, CHORDOMA
AGE PINEALOMA, MEDULLOBLASTOMA(< 20 yr). MENINGIOMA (> 50yr)
CARSINOGEN HYDROCARBON,
NITROSAMIN
HEAD INYURY, INFECTION, TOKSIN,RADIATION, VIRUS
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Risk factors related to CNS tumorDefinitiveionizing radiation immune supression (HIV infection)
Possible
Electromagnetic field (high tension wires, cellular telepon)Diets (N-nitroso compounds, Aspartame)Occupation (petroleum industry, agricultural pesticides)Household chemicals (hairdyes and sprays, household
pesticides)Head injuryMedication (vitamin)Infections (Cysticercosis, varicella zoster, SV 40
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CONCEPT OF PATOGENESISPRIMER TUMOR
HISTOGENIC THEORY (Bayley &Cushing) EMBRIOLOGICAL OF NERVE CELL AND GLIA
RECENT THEORY TUMOR ARISES FROMTRANSFORMATION OF ASTROCYTE,OLIGODENDROCYTE, MICROGLIOCYTE,
EPENDYMOCYTE NEOPLASM CELL MULTIPLICATION AND DIFFRENTIATION
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PATHOFISIOLOGY
NORMAL CAVUM CRANII CONSIST OF
Brain tissue ( 1400 gr )
Cerebro spinal fluid ( 75 cc )
Blood ( 75 cc )
these component any time stabil
Brain tumor increase intracranial pressure
Brain tumor cerebral edema cerebralherniation
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NORMAL BRAIN
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Cerebral herniation cause by brain tumor
A. Subfacial/cingulate hern
B. Uncal herniation
C. Transtentorial/central hern
D. External herniation
E. Tonsillar herniation
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CLASSIFICATION HISTOPATOLOGICAL PATTERNPrimary brain tumorhistological
benign or malformative meningioma
pituitary adenoma, acustic neuroma,craniopharyngioma, pilocytic astrocytomahemangioblastomahistological malignant glioma (anaplas
tic astrocytoma, glioblastoma multiform),ependymoma, oligodendroglioma, medulloblastoma, pineal cell tumor, chroid plexus carcinoma
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MENINGIOMA
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GLIOBLASTOMA
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CLASSIFICATION CONT
METASTATIC BRAINTUMORS
BREAST
LUNG
GI TRACT
PROSTAT
SKIN
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INTRA CRANIAL METASTASIS
Brain parenchyma breast, lung,melanoma
Pituitary gland breast, melanoma,germ cell
Dural based lung, prostat, breast
Leptomeningeal disease breast, lung
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SKULL METASTASIS
Skull base breast, prostat,osteosarcoma of skull, head and neck
cancer Calvarium breast, prostat
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SPINE METASTASIS
Epidural lung, breast, prostat,neuroblastoma, lymphoma. Leukemia
Leptomeningeal breast, lung Intramedullary breast, colon, lung,
prostat
Brachial plexus lung, breast, lymphoma
Lumbosacral plexus pelvic tumor
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CLASSIFICATION BASED ONTOPOGRAPHY (LOCATION)
SUPRA TENTORIAL TUMORS
Cerebral lobe and deep hemispheric
glioma, meningioma, metastatic tumor
Sella turcica tumor pituitary tumor,
craniopharyngiomas
INFRATENTORIAL TUMOR
MEDULLASPINALIS TUMOR
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INFRATENTORIAL TUMORS
ADULTS
Cerebellopontine angel acoustic
schwannoma
Others sites brainstem gliomas, metastase,
hemangioblastoma, ependymoma
CHILDRENS
Midline tumors medulloblastomas
Cerebellar lobes astrocytomas
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MEDULLA SPINALIS TUMORS
EKSTRA DURAL Metastatic tumor
INTRA DURAL
Ekstra medulla meningioma neurofibromas
Intra medulla ependymoma
astrositoma
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SYMPTOMS AND SIGNS
Generalized symptoms caused by raised
intracranial pressure
Focal symptoms caused by invasion,ischemia and compression
False localizing symptoms caused by shifts
of cerebral structures
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GENERALIZED SYMPTOMS ANDSIGNS
HEADACHE
VOMITING
DROWSINESS ( VERTIGO AND DIZZINESS)VISUAL OBSCURATION
PERSONALITY CHANGE
CONFUSION PAPILEDEMA
APATHY
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MECHANISM HEADACHEASSOCIATED WITH BRAIN TUMOR
1.Traction on venous sinuses
2.Traction on meningeal arteries
3.Traction on large arteries at base of the
brain
4.Pressure on cranial and cervical pain sensi
tive structure
5.Dilatation of intracranial arteries
6.Inflamation of pain-sensitive structures
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FOCAL SYMPTOMS AND SIGNS
FRONTAL LOBE
Generalized seizure
Focal motor seizure (contra lateral)
Expressive aphasia (dominant size)
Behavioral changes
Dementia
Gait disorders, incotinence
Hemiparese
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Frontal lobe tumor
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FOCAL SYMPTOMS & SIGNS
BASAL GANGLIA
Hemiparesis (contralateral)
Movement disorders (rare) PARIETAL LOBE
Receptive aphasia (dominant size)
Spatial disorientation (non dominant)
Cortical sensory dysfungtion (contralat)
Agnosias
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Metastase parietal lobe tumor
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FOCAL SYMPTOMS & SIGNS
OCCIPITAL LOBE Hemiparesis (contralateral) Visual disturbance
TEMPORAL LOBE Complex partial (psychomotor) seizures Generalized seizures Behavioral changes Olfactory and complex seizures Visual auras Visual field defect
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Occipital lobe tumor
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Temporal lobe tumor
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FOCAL SYMPTOMS & SIGNS
CORPUS COLLOSUM
Dementia (anterior)
Behavioral changes Memory loss (posterior)
Asymptomatic (mid)
THALAMUS
Sensory loss (contralateral) Behavioral changes (posterior)
Languange disorders (dominant size)
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FOCAL SYMPTOMS & SIGNS
MIDBRAINS/PINEAL Paresis of vertical eyemovement Pupillary abnormalities
Precocious puberity (boys) SELLA/OPTIC NERVE/PITUITARY Endocrinopathy Bitemporal hemianopia Monocular visual defectOpthalmoplegia (cavernous sinus)
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Pineal tumor
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Pituitary tumor
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FOCAL SYMPYOMS & SIGNS
PONS/MEDULLA
Cranial nerve dysfungtion
Ataxia, nystagmus, spasticity
Weakness, sensory loss CERBELLO PONTINE ANGLE
Deafness (ipsilateral)
Loss of facial sensation (ipsilateral)
Facial weakness (ipsilateral), ataxia
CEREBELLUM
Ataxia (ipsilateral)
Nystagmus
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Cerebellum tumor
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FALSE LOCALIZING SIGNS
CRANIAL NERVE
Anosmia
Diplopia, ptosis, anisocoria
Face pain, numbness, and weakness
Tnnitus, hearing loss
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FALSE LOCALIZING SIGNS
PARENCHYMAL SIGNS
Ipsilateral hemiparesis
Ipsilateral gaze palsy
Visual field defect, cortical blindness
Ataxia
OTHER SIGNS
Nuchal rigidity
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SYMPTOM AND SIGN SPINALCORD TUMOR
INTRAMEDULLARY
Sensory loss
Early spinchter dysfungtion
Pain +
Decreased rectal tone
spasticity
upper motor neuron signs
Common tumor -> Ependymoma, astrositoma
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INTRA MEDULLARY TUMOR
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Symptom and signs spinal cordtumor
Intradural and extramedullary
Pain +++, metastase
Pain +, primary tumor
Radicular or local sensory loss
Radicular or segmental weakness and
sensory loss
Upper motor neuron signs
Common tumors
Meningioma
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INTRA DURAL EXKTAMEDULLA TUMOR
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Symptom and sign spinal cordtumor
EPIDURAL
Pain +++
Radicular or local pain
Common tumors Metastasis
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EXTRA DURAL TUMOR
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DIAGNOSIS BRAIN TUMOR
HISTORY
GENERAL PHYSICAL EXAMINATION
NEUROLOGIC EXAMINATION
LABORATORY FINDING, ESPECIALLYIMAGING
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Laboratory findings
IMAGING
CT Scan
MRI
Magnetic resonance spectroscopy (MRS)
Fungtional MRI
BIOPSY Defenitive diagnosis
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DIFFRENTIAL DIAGNOSIS OFBRAIN TUMORS
HEMATOMA
ABCESS
GRANULOMA
PARASITIC INFECTION CYSTYCIRCOSIS
VASCULAR MALFORMATION
MULTIPLE SCLEROSIS
CEREBRAL INFARCS
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Therapy of Intra Cranial Tumors
Definitive therapy
Surgery Biopsi, resection
Radiation External beam Streotactic radiosurgery
Heavy particles
Brachytherapy
Chemotherapy Parentral, lokal
Experimental modalities
Supportive therapy
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Experimental modalities
Angiogenesis inhibitor
Growth factor inhibitor
Diffrentiating agents
Immunotherapy
Gene therapy
Antisense oligonucleotide
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Supportive Therapy
Anticonvulsant
Corticosteroids
Anti-thrombosis agent
Psychotropic agents
Physical therapy
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Goals of Surgery
Establish the diagnosis
Cure the patient
Decrease tumor burden
Relieve symptoms
Improve neurologic fungtion
Extend duration and quality of live
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Basic concepts in cancerchemotherapy
Chemotherapeutic agent kill only apercentage of cancer cell
Some drugs kill only dividing cells Multiple drugs with differing site of action
are better than a single drugs
High dosee are better than low doses
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Brain tumors anticonvulsant
Prophylaxis
-- does not prevent first seizure
-- probably useful in perioperative period Treatment
-- efficacy unclear
-- side effects more commons-- hard to control levels
-- best drug unknown
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Advantages and Disadvantagesof corticosteroid
Advantages
-- control neurologic symptom by reduce
edema-- decrease acute RT toxicity
-- relieve emesis from chemotherapy
-- oncolytic (lymphoma) Disadvantages
-- side effects common