Medicine 5th year, 1st lecture (Dr. Hassan Al-Jumaily)
د. حسن محمد الجميلي اخصائي طب الجملة العصبية Brain tumorThe brain tumor is either (Primary) that is arise from brain tissue or meninges or (secondary) when metastasisfrom other tissue of the body (metastatic tumor) and they found that metastatic tumor more common thanprimary.The sex ratio for brain tumors is approximately equal, although meningioma & nerve sheath tumor are morecommon in female while glioma more common in male. (3)Aetiology & Pathogenesis: The exact cause of brain tumor is unknown, although genetic factors appear tobe important in some tumors like (neurofibroma, hemangioblastoma & some glioms).Brain intracranial tumors are slow_ growing & with out vascular proliferation, while malignant tumors aremore rapid growing, invaiveness, with vascular proliferation. (2)Types of Intracranial Tumors:1) Gliomas: * Glioblastoma multiforme. * Astrocytoma. * Ependymoma. * Medulloblastoma. * Oligodendroglioma.2) Meningioma.3) Pituitary tumor: * Pituitary adenoma. * Craniopharyngioma.4) Tumors of cranial nerves: * Acaustic shwanoma. * Neurofibroma.5) Metastatic tumors.6) Angioma.7) Sarcoma.8) Primary C.N.S lymphoma.9) Miscellanous (Pinealoma, Chondroma, Granuloma). (4)Clinical Features: The symptoms and signs of tumors depend on their size, site & rate of growth. The generalclinical features for all tumors are: _ 1) Headache characteristically awaked the patient at night and is worse in the morning or it could be recurrent. 2) Vomiting & nausea, result from direct or reflex stimulation of emetic center in the medulla, some time patient vomite without nausea called (projectile vomiting).
3) Papilledema. (swollening of optic disk) due to increased intracranial pressure & occur only in (1/3_1/2) of patients . So abscent papilledema not exclude increase intracranial pressure. 4) Seizures. focal or greneralized seizure could be the first manifestation of brain tumor. 5) Mental changes, as psychomotor retardation, depression, social indifference, forget fullness, sleepiness or confusion. 6) Focal neurological manifestation.this will tell us the site of the tumor:_ • Frontal lobe → Contra lateral hemi paresis, dysphasia. • Parietal lobe → Contra lateral hemianasthesia. • Occipital lobe → Contra lateral hemianopia or quadreanopia. • Temporal → Temporal lobe epilepsy (complex partial seizure) • Posterior fossa → Cranial nerve palsies, ataxia, dysarthria (Brain stem & cerebellum) sever headache & vomiting. • Pituitary gland → Bitemporal hemianopia. (2-3)* Astrocytoma: Tend to occur in adults in their (3rd _ 4th decades, also its more frequent in children &adolescents, & its mostly occurs in cerebrum but could occur in cerebellum, optic nerve & in pons. Its slowlyprogressive tumor & infiltrative & tends to form large cavites or (pseudocyst). (4)* Meningioma: _ its abenign tumor & more common in women than men, & its highest incidence in theseventh decade.It was arise from the dura matter. Most commonly occur in sylvian region, parasagettalsurface, olfactory groove, lesser wing of sphenoid bone & the dorsal surface of the cerebrum. (4)* Pituitary Adenoma: Its bening tumor, patient present with endocrine abnormality, when affect optic chiasmapatient will present with visual failure & characteristic bitemporal hemianopia. (3)* Medulloblastoma: It’s the common tumor in children, arise in the roof of fourth ventricle or posterior part ofthe cerebellum vermis. Child present with ataxia & projectile vomiting, it’s the (only) brain tumormetastasized to lower spinal cord by (seeding) process. (4)* Metastatic Tumors: These are the tumors metastasized from other part of the body to the brain. In male mostcommonly come from lung or colon tumor & in female come from breast & ovary or uterus . The metastatictumor could be single or multiple. Metastasis from carcinoma of kidney & malignant melanoma causeintracerebral haemorrhagic tumor. (3)* Investigations: 1) C.T scan is important to detect the lesion. 2) MRI more sensitive, specially in post , fossa tumors, pituitary tumors & in metastatic tumors. 3) C.X.R to detect the primary tumor of the lung. 4) Ultrasound of abd. For primary tumor of colon, overy & and uterus or other Abd, tumors. 5) C.S.F should be avoided in tumor. 6) Other investigation as haematologic for other primary systemic tumors (Leukaemia).* Management: 1) Symptomatic treatment; • Analgesic for headache. • Anti_emetic for vomiting & nausea. • Anticonvulsant for seizures. • Corticosteroids for increased intracranial pressure and brain edema caused by tumors. (3) 2) Complet surgical removal: used in:
• Benign accessible tumors as (meningioma & acuistic neuroma). • In single lesion of metastatic tumor, either resection of the tumor as hall or even total lobectomy. (3)3) Biopsy: For deep_seated tumors, including some glioma & many lymphomas. (3)4) Radiotherapy: For: _ • Tumor particularly sensitive to it like pineal germinoma. • For tumor unamenable for surgery as (multifocal lymphoma, diffuse brain-- stem glioma). • Following surgery in glioma or metastatic tumor. • In children following surgery for medulloblastoma, as postoperative craniospinal irradiation, because the risk of C.S.F tumor seeding.5) Chemotherapy: • As adjurant therapy in malignant glioma. • In children less than 5 years age in whom. radiotherapy should be avoided as in optic gliomas. • Recurrent medulloblastoma. (3) ………………………………………….