Increased intracranial pressure' Brain tumors'

1
Increased intracranial pressure. Brain tumors.

• Dr. Ilniczky Sándor

2
Intracranial compartments, intracranial pressure

• Monroe-Kelly doctrine the summarized volume of
  the intracranial components (brain tissue, blood,
  CSF) is constant. Inrease of any of them is
  possible only at the expense of the other two,
  and inceases the intracranial pressure.
• Normal CSF pressure 100-170 mmH2O (by lumbar
  puncture in a lying position)

3
Symptoms of increased intracranial pressure

• Headache (diffuse, continuus, progressive in
  character)
• Nausea, vomitus (mainly in the morning)
• Disturbances of consciousness level
• Cushing phenomenon bradycardia, bradypnoe,
  increased systolic blood pressure
• Bilateral edema of the optic disc
• Diplopia (due to bilateral abducent nerve palsy)

4
Causes of increased intracranial pressure

• Space-occupying lesions
• tumors, brain oedema, inflammation, abscess,
  haemorrhage (intracerebral, epidural, subdural),
  brain infarction, brain contusion, occlusive
  hydrocephalus, parasites.
• Changes in CSF
  subarachnoideal hemorrhage, meningitis,
  hindered resorbtion of CSF.
• Circulatory disturbances
• extremely high arterial blood pressure,
  thrombosis of the cerebral veins or venous
  sinuses.

5
Brain oedema

• A common consequence of several different
  pathological processes, a general reaction of
  brain tissue for diverse harmful effects
• 
  Cytotoxic (intracellular). Disfunction of the
  proton pump of the cell membranes, water
  accumulation within brain cells
  
  (anoxia, ischaemic damage, metabolic diseases)
• Vasogenic (extracellular). Breakdown of the
  blood-brain-barrier. Fluid extravasation.
• (hypertensive crisis, inflammations, contusion,
  tumors.
• Interstitial (in hydrocephalus, around ventricles)

6
Herniations

• Shifting of brain tissue from one intracranial
  compartment to another, as a consequence of mass
  lesions. Importance emergency, life threatening
  condition.
• Types
  1. 1. Trantentorial (uncus of the temporal
  lobe into the opening of the tentorium).
• Symptoms
• Oculomotor nerve palsy ipsilaterally.
• Ipsilateral hemiparesis due to the compression ot
  the contralateral midbrain by the edge of the
  tentorium.
• Cortical blindness due to bilateral occipital
  infarction resulted from compression of both
  posterior cerebral arteries.
• Decreased level of consciousness, coma,
  respiratory problems (Cheyne-Stokes) after severe
  damage of the midbrain.

7
Herniations

• 2. Cerebellar- foramen magnum herniation (the
  cerebellar tonsils impacted into the foramen
  magnum, compressing the medulla oblongata).
  Causes mass in the posterior fossa, great
  supratentorial mass lesion or general brain
  swelling.
• Symptoms
• episodic tonic extensions-abduction ot the limbs.
• respiratory disturbances, cardiac irregularity
  (causes of death)
• paresis of all limbs, bilateral pyramidal signs.
• Neck stiffness, head tilt.
• Consciosusness relatively preserved, but finally
  coma.

8
Herniations

• 3. Subfalcial (lateral) herniation (the cingulum
  shifted under the falx cerebri to the other side)
  Cause great, unilateral space-occupiing.

9
Herniations
10
Brain tumors - symptoms

• Insidous development of symptoms is typical for
  brain tumors.
• Sudden worsening or onset ot new symptoms may be
  a consequence ot intratumoral haemorrhage, or
  herniation.

11
Brain tumors - symptoms

• 1. Focal signs. Direct effect of the tumor
  itself.
• Damaged function (e. g. paresis, hypaesthesia,
  visual field defect, etc.)
• Positive symptoms - focal or secondarily
  generalized epileptic seisures, helpful in
  localizing the tumor.
• 2. Compression signs - on surrounding structures,
  tracts, cranial nerves, CSF pathways resulting in
  hydrocephalus.
• 3. General symptoms caused by the increased
  intracranial pressure, mass effect of the tumor,
  independent from its nature.
• 4. Psychic signs -cognitive, behavioural or
  personality changes (sometimes leading or only
  features of the tumor.)
• 5. Hormonal changes - result of disfunction of
  the pituitary gland.
• (hyper or hypofunction)
  

12
Brain tumors - diagnostics

• Sometimes tumor may be exactly localized by the
  findings of the physical examination.
• In the suspicion of brain tumor imaging methods
  are indicated.
• Brain CT. Administration of contrast media
  (containing iodine) is necessary. Some tumors are
  isodense and indetectable on non-contrast scans.
  Most tumors enhance CM, may contain central
  necrosis (most malignant ones). Prifocal oedema
  indicates a primary or metastatic malignant
  tumor. CT is not proper for small tumors, mainly
  in the posterior fossa (bony artefacts). CT is
  prior to MR in evaluation of intratumoral
  calcification an bone destruction.
• Some tumors have characteristic CT features (e.g.
  meningiomas)

13
Brain tumors - diagnostics

• Brain MR. The proper method of diadnostics of
  brain tumors. More detailed spatial resolution,
  multi-planar imaging, all parts of the brain are
  well visualized.
• Special tchniques (diffusion, perfusion MR,
  MR-angiography, MR spectroscopy, functional MRI,
  contrast enhanced MR)
• The best method for surgical planning.
• Angiography. Disclosing of the blood supply of
  some hyper-vascularized tumors (e.g. angiomas,
  meningiomas)

14
Brain tumors - diagnostics

• Brain SPECT and PET. Evaluation of circulation
  and metabolism of tumors.
• Differentation between tumors and lesions of
  other nature in in contraversary cases.
• Brain biopsy. CT assisted, stereotaxic
  procedure. Exact histological classification of
  tumors. Grading.
• Additional tests.
• CSF examination.
• EEG
• Evoked potentials.
• Hormonal tests.
• Genetics.

15
Brain tumors - classification

• Neuroepithelial tumors
• Tumors of the peripheral nerves
• Tumors originated from the meninges
• Tumors of the hemopoietic system, affecting
  nervous system
• Germinal tumors
• Sellar tumors
• Tumors, spreading from the surounding structures
  to the brain
• Metastatic tumors

16
Neuroepithelial tumors

• Astrocytomas Graded from A 1 to A 4. The most
  malignant form is anaplastic astrocytoma,
  Glioblastoma multiforme (A3-4)
• In older patients. Localized in the hemispheres.
  High malignancy, rapid growth, infiltrative
  spreading. Butterfly tumor, transcallosal
  propagation.
• Symptoms seisures, focal signs, elevated
  intracranial pressure, headache, psychiatric
  disorders (depression, behavioural, personality
  changes)
• Dg CT, MR. Necrotic, irregular tumor mass,
  marginal enhancement, widespread perifocal
  oedema. Brain biopsy.
• Treatment surgical total removal is not
  possible. Irradiation and chemotheraby mav be
  added. High rate of recurrence, poor survival
  (maximum 1,5 year, average a few months)

17
Glioblastoma multiforme
18
Astrocytoma
19
Neuroepithelial tumors

• Oligodendroglioma. Rare, hemispherial tumor.
  Usually calcificated. Slow propagation, not very
  malignant, but sometimes transfers to malignancy,
  to Glioblastoma multiforme. Highly epileptogenic.
  
• Symptoms seisures, focal signs.
• Dg CT, MR. Calcificated, circumscribed mass,
• slight perifocal oedema. Brain biopsy is
  diagnostic.
• Treatment surgical total removal.
• Antiepileptic medication.
• Ependymal tumors
• Chorioid plexus tumors within ventricles, may
  lead to increased CSF production.
• Pineal tumors. - Parinaud syndrome.

20
Neuroepithelial tumors

• Embryonic tumors
• Most important Medulloblastoma. The most
  malignant childhood brain tumor, originated from
  the vermis of the cerebellum.
• Invasive, infiltrating growth, high risk of
  recurrence, metastatizes by CSF.
• Symptoms headache, nausea, vomiting, dysbalance,
  frequent falling. Brainstem symptoms.
• Dg CT, MR. Enhancing, space occupying mass in
  the posterior fossa, causing CSF circulatory
  block, hydrocephalus.
• Treatment surgical Chemotherapy. Recently
  long (5-7 years)
• Others teratomas

21
Medulloblastoma, CT with CM
Histology
22
Tumors of peripheral nerves

• Schwannoma. Originated from the sheet of the
  intracranial segment of cranial nerves,
  especially VIII (vestibulo-cochlear, vestibular
  part) - Acustic neurinoma Cerebello-pontine
  angel tumor.
• Usually localized to the intra-canalicular part
  of the nerve, later growing out, compressing
  brainstem. Slow growth, benign tumor.
• May be bilateral, esp. in m. Recklinghausen.
• Symptoms worsening hearing loss, tinnitus
  (usually unilateral), vertigo, later, peripheral
  facial nerve palsy, after growing out the canal,
  brainstem or other cranial nerve signs.
• Dg MR. Enhancing, round, circumscribed tumor
  along the course of the VIII. nerve. BAEP.
• Treatment surgical or chemotherapy (for smaller
  tumors). Total recovery may be achieved.

23
Acustic neurinoma, MR with CM
24
Tumors originated from the meninges.

• Meningiomas. In any age, but mainly in older
  persons, more frequent in females. Very slow
  growth (20-30 years), but may reach extreme
  sizes. Rarely turns into malignancy. May destroy
  bones of skull.
• Originated from cells of the arachnoidea.
• May be anywhere on meninges, but there are
  typical sites
• Fronto-basal (olfactory groove, Foster-Kennedy
  syndrome)
• Convexity. Sphenoid bone. Parasellar. Falx
  cerebri. Tentorium. Clivus.
• Spinal.
• Symptoms depending on localisation. Epileptic
  seisures may occur. Dg CT, MR. Strong CM
  enhancement, well circumscribed, calcificated,
  highly vascularized tumor, with no or sligh
  oedema.
• Widely attached to the meninges.
• Treatment surgical, total removal if possible.
  Total recovery may be achieved.

25
Meningeoma
MR with CM
CT with CM
26
Meningioma
27
Tumors of the hemopoietic system, affecting
nervous system

• Primary nervous system lymphomas. B-cell,
  non-Hodggkin lymphoma. In immunsuppressed
  patients, mainly in AIDS.
• Dg MR. Round-like, sometimes multiple lesions,
  usually close to CSF. Brain biopsy is necessary.
  
• Treatment corticosteroids decrease the size of
  the tumors.

28
Pituitary tumors

• Pituitary adenomas. Originated from endocrine
  gland cells of the pituitary glands.
• Micro or macro-adenomas. Intra or suprrasellar
  masses.
• Hormonally active or inactive.
• Symptoms local signs (visual field defect,
  etc.),
• hormonal dysfunction -
• Hyperfunction
• hyperprolactinaemia (galactorrhoea, amenorrhoea)
• GH overproduction (acromegaly, giant growth)
• ACTH overproduction (Cushing disease)
• TSH overproduction (central hyperthyreoidism)
• Hypofunction decrease of one or all the upper
  hormones (panhypopituitarism) Caused by
  compression of the functioning normal gland
  tissue.

29
Pituitary tumors

• Dg CT, MR. Microadenomas are non enhancing foci
  within the normal gland Tissue.
• Macroadenomas are usually enhancing, irregular,
  masses, with extrasellar propagation.
• Treatment surgical transsphenoidal or by
  craniotomy.
• Irradiation.
• Hormonal treatment bromocriptine may decrease
  the tumor size and normalize the hormonal
  dysfunction.

CT with CM
30
Metastatic brain tumors (from other parts of the
body)

• In many cases the brain metastasis is diagnosed
  before the recognition of the primary tumor.
  Sometimes the origin is not found at all.
• Metastatis brain tumors, in order of frequency
• Lung 64
• Breast 14
• Unknown origin 8
• Malignant melanoma 4
• Colorectal 3
• Kidney 2
• Others 5

31
Metastatic brain tumors

• Symptoms nott differing from the general
  tumor-symptoms.
• Focal epileptic seizures are quite frequent.
• Dg CT, MR often multiple, round like,
  enhancing lesions with large perifocal oedema.
• Lumbar puncture (for diagosing meningeal
  spreading of the tumor carcinous meningitis)
• Brain biopsy. May provide information about the
  origin of the tumor.
• Investigation of the primary tumor.
• Treatment if solitary is the metastasis surgical
  removal is possible. In multiple cases
  irradiation ot chemotherapy. Outcome is dependent
  on the general oncologic state of the patient.

CT, no CM
CT, with CM
CT, with CM
32
Meaning of the lecture

• - Brain tumors are not frequent, but we have to
  consider them.
• - The symptoms of brain tumors are not specific.
• - New onset headache or epileptic seisures always
  indicate a search for brain tumor.
• _ Some types of brain tumors recognized in time
  have good outcome.

33
Thank you!