• Generalized or focal disturbance of cerebral function (or both)
• Increased ICP in some pts
  • ↑ quicker if lesion is in anterior portion
  • late finding if in posterior portion
• Imaging evidence of space-occupying lesion

Most common are: 

1. Astrocytoma
2. Medulloblastoma
3. Ependymoma (epithelial cells that line the ventricles)

• 50% are Gliomas
• Rest are: 
  • Meningiomas
  • Pituitary adenomas
  • Neurofibromas
  • Other tumors

• indicates the degree of malignancy
• based on the tumor's tendency to spread (infiltrate), its growth rate, and its similarity to normal cells
• exact system used to grade tumors varies with each specific family of tumors
• Tumors often contain several grades of cells: most malignant grade found determines the grade (even if most of the tumor is made of a lower grade)

• Distinct borders (circumscribed)
• sometimes referred to as benign or mildly malignant
• either do not grow or grow slowly

• tend to grow into surrounding tissue
• low-grade, mid-grade, and high-grade 

• Neurofibromas (Type 1 & 2)
• Hemangioblastomas
• Retinoblastomas
• Craniopharyngiomas

• Type of congenital tumor
• Cystic tumors (very well defined borders, therefore less aggressive)
• Often in the cerebellum

• type of congenital tumors 
• Cafe-au-lait spots
• pts develop neruofibromas: benign tumors usually located just under skin, also develop in nerves near spinal cord or along other nerves
• Can develop cancerous tumors that grow along nerve (malignant peripheral nerve sheath tumors)

• Type of congenital tumors
• most commonly associated with vestibulocochlear (CN8) schwannoma tumor
  • affects hearing

• type of congenital tumor
• rapidly developing cancer in the cells of the retina

• type of congenital tumor
• grows into ventricles 
• causes severe headaches

• Generalized disturbance of cerebral fxn
• s/s of ICP
• Personality changes
• Intellectual decline
• emotional instability 
• seizures (acute development)
• Headache, Nausea, malaise

• If P ↑ in one cranial compartment, brain tissue can herniate into a compartment with ↓ P
• Ex: herniation of temporal lobe thru tentorial hiatus: compresses 3rd CN, midbrain, PCA
• Same side pupil dilation, stupor, coma, decerebrate posturing, resp. arrest

Presents with...

• unable to cross midline when looking to side of tumor
• unable to open ipsilateral eyelid (ptosis)
• eye will be dilated
• often vascular due to DM, HTN or atherosclerosis

• Displacement of cerebellar tonsils through the foramen magnum ("my brain fell out"): worst kind of herniation
• Compression of medulla (a very bad thing)
• Causes:
  • Circulatory collapse
  • apnea
  • death

• Intellectual decline (progressive)
• slowing of mental activity
• Personality changes
• Contralateral grasp reflexes
• Left side: expressive aphasia: if in Broca's area
• Anosmia: if pressure placed on olfactory nerve
• If in central frontal area: focal Motor seizures or contralateral pyramidal (motor) deficits

Occurs if lesion occurs in Broca's area:

Inferior frontal gyrus of cerebrum

• stroke palm or sole: fingers or toes will flex in grasping motion
• normal only in infants
• Pathology in others

• Seizures with hallucinations of smells or taste
• Motor abnormalities: licking or smacking lips
• impairment of external awareness (no loss of consciousness)
• Depersonalization 
• Emotional changes
• Behavioral disturbances
• "Deja vu or jamais vu" (feeling like a stranger when your with familiar people or in familiar place)
• visual field defects
• auditory hallucinations
• Left side: receptive aphasia (Wernicke's area)
• Right sided: problems with perception of music

• often seen with temporal lobe lesions
• feeling of unreality concerning oneself... who am I?...I feel strange in this body... with these people
• Uncomfortable with those close to them

 Visual field loss depends on location of lesion: 

distal to optic chiasma: unilateral field loss: ie optic neuritis

At chiasma: Bitemporal Hemianopsia 

Proximal to Chiasma: Homonymus hemianopsia 

[image]

• Contralateral disturbances of sensation
• Sensory seizures or loss
• Loss sense of posture, tactile discrimination
• Objects placed in the hand may not be recognized
• Extensive tumor: produce thalamic syndrome
• Involvement of optic radiation: contralateral homonymous field defect
• Right sided tumor: contralateral anosognosia, ipsilateral constructional apraxia

• Due to extensive parietal lobe lesions
• Cause spontaneous pain

Loss of vision in 1/2 the visual fields of both eyes, opposite the side of the lesion

Ex: if tumor is on right, the left 1/2 of the visual fields of both eyes os impaired

Due to right sided parietal lobe lesions (contralaterally)

denial, neglect or rejection of paralyzed limb

Due to right sided parietal lobe lesions (ipsilaterally)

cant copy drawings 

• Crossed homonymous hemianopsia or a partial field defect
• Left sided/bilateral lesions: visual agnosia for objects/colors
• Irritative lesions on either side: unformed visual hallucinations
• Bilateral involvement: cortical blindness
  • Pupil responses to light are preserved
  • Pt not aware of defect
• Inability to identify a familiar face may be present

• Temporal: contralateral homonymous hemianopsia
• Parietal: Contralateral homonymous hemianopsia
• Occipital: crossed homonymous hemianopsia or partial field deficit
  •  if left sided or bilateral: visual agnosia for objects/colors
  •  with irritative lesions: unformed visual hallucinations
  • Bilateral: cortical blindness
• Pituitary: bitemporal hemianopsia (most common cause)
• Craniopharyngioma: bitemporal hemianopsia

• Temporal: smells or tastes with seizures, auditory
• Irritative occipital lesions: unformed visual 

• Lead to cranial nerve palsies
• Ataxia, incoordination
• Nystagmus (usually vertical)
• Pyramidal (motor) and sensory deficits in limbs
  • 1 sided (ipsilateral) if cerebellar
  • 2 sided if brainstem is involved
• Rise in ICP comes late in the course if brainstem tumors are contained within
• Cerebellar tumors: marked ataxia of trunk or limbs

• Tumors can cause neuro signs in other ways besides direct compression or infiltration
• You can make a mistake localizing the tumor because of this

• 3rd or 6th nerve palsy 
• Bilateral, extensor plantar responses (Babinski sign)

• with gadolinium may pinpoint a tumor
  • can determine location, shape and size
  • can tell whether it has distorted normal anatomy
  • tell how much cerebral edema or mass effect is present
• For tumors in posterior fossa: use MRI (CT will not image these)

• On CT have a characteristic appearance:
  • lesion in a particular site 
  • homogeneous increased density in non-contrast CT
  • enhances uniformly with contrast
• Appearance is Diagnostic
• must still bx

• only do if MRI is not definitive
• provides supporting info on cerebral fxn
• can show focal disturbance because of tumor
• Diffuse change throughout the EEG reflects altered mental status

Rarely necessary

may cause brain herniation (never do if ICP is ↑)

• Depends on type, location and condition of pt
• May include complete:
  • surgical removal or palliative removal (surgery confirms dx)
  • Surgical shunting
  • Radiation
  • Chemo

If tumor not inside brain (meningioma, acoustic neuroma), or is not in a critical Inaccessible region of the brain (cerebral hemangioblastoma)

• Partial removal of tumor
• may reduce ICP and relieve symptoms
• improves pts quality of life
• complete cure not achieved

• CSF shunted from CNS to abdomen
• relieves hydrocephalus
• produces dramatic benefit

• Radiation plus Chemo even without surgery greatly increases survival time
• Usually start Steroids before surgery to reduce cerebral edema

• Give following 3 drugs emergently: 
• IV dexamethasone (10-20 mg bolus; then 4 mg q6hr)
• IV Mannitol (20% solution; 1.5g/kg over 30 min)
• Anticonvulsants given in standard doses

• Malignant, rapidly growing tumor
• Pulpy, cystic tumor (not well circumscribed)
• Spreads with pseudopod-like projections
• Butterfly appearance on CT scan
• Poor prognosis
• cant totally surgically remove
• Mix of monocytes, pyriform (pear shaped) cells, astrocytes and fibrous processes

• nonspecific complaints
• ↑ ICP
  
• as it grows: focal deficits
• rapidly progressive

• sxs a lot like glioblastoma, but course is much longer, drawn out (several years)
• If it is on cerebellum: more benign course
• Variable prognosis
• Total removal usually not possible (palliative removal often is)
• Tumor not sensitive to radiation

• Seen most frequently in children
• arises from roof of 4th ventricle
• ↑ ICP
  
• Brainstem/cerebellar signs
• Surgery + radiation and chemo

• Glioma arising from ependymal (epithelial layer) of a ventricle (esp 4th)
• ↑ ICP: early 
• Treat surgically
• radiation does not work

• Slow growing
• In cerebral hemisphere of adults
• Calcification visible on skull Xray
• surgical tmt
• usually successful
• oligodendrocytes help maintain myelin covering of nerve axons; source of cells

• In childhood with cranial nerve palsies
• Develops in childhood, but can be very slow growing and not present until adulthood
• Then long tract signs in limbs (ie corticospinal tract: spastic paralysis)
• Late > ICP
• Inoperable tumor
• Radiate and shunt for ↑ ICP

• Dysequilibrium
• Ataxia of trunk/limbs
• > ICP
• can be familial 
• retinal/spinal vascular lesions
• polycythemia; renal cell CA (always do CBC and renal fxn panel)
• surgical tmt

• Lies below the corpus callosum
• Produces the hormone melatonin
• Can be a source of cancerous cells

• ↑ ICP
• Impaired upward gaze
• Midbrain lesion
• Tmt: shunting then surgery
  • if tumor malignant: radiate

• Originates above sella turcica (bone in the sphenoid that houses the pituitary gland)
• Depresses optic chiasm
• Usually in kids (but can be any age)
• Endocrine dysfunction
• Bitemporal field defects 
• Tmt: surgery: total removal (may not be possible)

• Ipsilateral hearing loss most common 1st symptom
• Later: tinnitus, AH, vertigo
• Facial weakness/numbness can occur if 7th CN is compressed
• If large enough can also compress the cerebellum and pons
• Evaluation: MRI; auditory evoked potentials
• Surgery: good outcome

• From dura matter or arachnoid
• Compresses neural structures
• Increasingly common as one gets older
• Size varies greatly 
• symptoms vary depending on location
• Tumor usually benign
• Easy to see on CT
• May lead to calcification and bone erosion seen on plain Xrays
• Tmt: surgery
• If incompletely removed: may come back

• Associated with AIDS/immunodeficiency
• Presents wit focal signs or
• disturbance of thinking and consciousness
• Hard to distinguish from cerebral toxoplasmosis (which may also develop in HIV pts)
• Tmt: Whole brain radiation/chemo