bms.25. neurologi_brain tumor.ppt

7/27/2019 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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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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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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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

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bms.25. neurologi_brain tumor.ppt