The document provides an introduction and background about Joe Hlavin, a physician assistant with extensive experience in neurosurgery. It then outlines the objectives and topics to be covered in a lecture on tumors of the brain and spine, including anatomy, imaging, lesion types, treatment approaches, and case studies. Examples and descriptions of various brain and spinal lesions are also provided.

1. Tumors of the Brain and Spine
Joe Hlavin PA-C, MS
Texas Brain and Spine Institute
Bryan, TX
jhlavin@txbsi.com

2. Introduction/Bio
 US Navy – Corpsman – 1984 to 1989
 Cuyahoga Comm College – 1991 – surgical PA
◦ Went right into private practice neurosurgery
 22 years of neurosurgery experience
 BS in Education – BGSU
 MS in Organizational Learning – TAMU
 PhD Student - Organizational Design - TAMU
 Designer & director of the TAMHSC/TBSI Postgraduate
PA Residency in Neurosurgery

3. Objectives
• For this lecture:
• Review of the normal brain and spine anatomy and
physiology, including CT and MRI
• Review neurological exam
• Discuss selected intracranial and intraspinal lesions
• Provide current treatment schemes
• Discuss reasoning for treatment decisions
• Case studies

4. Anatomy
Quidi Vidi Bay, Newfoundland

5. The Brain
some A&P
• Lobes - Supertentorial UT student????
• Frontal
• Temporal
• Parietal
• Occipital
• Cerebellum - Subtentorial

6. the brain A&P
• Frontal
• Reasoning, planning, “personality”
• Frontal eye fields – Brodman 8 PERSONALITY MOTOR
SENSORY
PLANNING
REASONING
• Visual attention SPEECH VISION
HEARING PROCESSING
• Motor strip SPEECH
MEMORY
• Temporal SMELL
• Speech – dominant
PARIETAL
• Memory – non-dominant
FRONTAL OCCIPITAL
• High Sz region
TEMPORAL TENTORIUM
CEREBELLUM

7. the brain A&P
Important – Dominant
Involves 3 lobes
• Parietal
• Sensory PERSONALITY MOTOR
SENSORY
PLANNING
• Proprioception REASONING
writing SPEECH VISION
HEARING PROCESSING
• Calculia, graphesthesia, left/right – dominant SPEECH
• Occipital MEMORY
SMELL
• Visual cortex – processing/understanding
PARIETAL
• End point of the ocular tracts
FRONTAL OCCIPITAL
• Cerebellum
TEMPORAL TENTORIUM
• Coordination, balance CEREBELLUM

8. Spinal Cord
• Anatomy
• Tracts
• Ascending
• sensory
• Descending
• Motor

9. Spinal Cord
• Understanding the medullary
component
• Simply – relay station for input
and output of transmissions
• Important to know:
• Medial to lateral IS:
• Cervical to Sacral

10. Spinal Cord
• Focusing for function
• Keys
• Ascending – sensory
• Lesions are not as
easily identified due
to subjective nature
• Descending – motor
• Easier to find level
due to objectiveness
of the exam

11. Studies
St. John’s Bay – The Narrows

12. CT
• Usually the first study performed
• Fast
• Easy
• Least expensive
• Consists of 60 to 70 – 5mm slices
• Can be done with dye

13. MRI
preferred for brain and a must for
spine
• Most detailed
• Used with Gadolinium
(“dye”)
• No radiation
• But
• Expensive
• Tight space
• Takes more time
• Cannot do with some
implanted devices

14. Lesions

15. Lesion Types

16. Lesion Types
• Benign
• Non-aggressive but can be devastating based on size and
location
• Meningioma is most common – ARISE FROM?
• less common
• Neuromas – acoustic
• Dermoid
• Pituitary adenomas

17. Lesion types
• Metastatic
• The primary cancer: lung, breast, colon, kidney, or skin
(melanoma), but can originate in any part of the body

18. Malignant lesions
Glial tumors
• World Health Organization grading (WHO) scale
ASTROCYTOMAS, I – VI
• Grade – I – e.g. Pilocytic and Subependymomas
• Grade – II – low grade astrocytoma and
oligodendrocytoma
• Grade – III – medium, anaplastic astrocytoma
• Grade – VI – high, Glioblastoma Multiforme (GBM)

19. Examples
• Four different astrocytic lesions, four different looks
Sub-ependymoma
GBM – grade VI
Oligodendroglioma
Anaplastic
astrocytoma

20. Cerebellar Lesions
• Very similar to CEREBRAL lesions
• Have increased risks with compression of
essential component of CSF drainage
• Primarily noted in children, e.g.
medulloblastoma, PNET (prim. neuroecto.
Tumor)
• Will present in adults as astrocytoma and
cystic
• Common area for metastatic seeding

21. Describing Studies

22. General Descriptions
for Brain and Spinal Lesions
• For the brain
• Extra-axial
• Intra-axial
• For the spinal cord
• Extra-dural vs. Intra-dural
• Extra-medullary vs. Intra-medullar
• For both
• Non-enhancing vs. enhancing (MRI)

23. General Descriptions
for Brain and Spinal Lesions
• Location, location, location
• For the brain
• What lobe? Size? Edema? Shift? Obstructive?
• For spinal cord
• What level? Size? Syrinx?
• Lesion consistency PA circa 1989
• Heterogenous vs. homogenous
• Ring enhancing (w/ cyst) vs. diffuse
enhancement

24. examples

25. More Examples

26. Neurological Exam

27. Neuro Exam
• Tenets of the approach to the NS patient
• DO NOT BELIEVE ANYONE ELSES EXAM –
• DO YOUR OWN
• LOOK at the studies yourself, NOT just the report
• SEE the patient as MORE THAN the studies

28. Neuro exam
• The mental status
• “normal” or “Sleeping” is not a good descriptor. Use:
• Awake/alert/talking
• Less than alert – obtunded
• Unresponsive – comatose, stupor
• In this case, give the Glasgow Coma Scale as
descriptor

29. Neuro exam
• Glasgow Coma Scale
• Eyes – 4, spontaneous, 3, to voice, 2, to pain, 1, none
• Motor – 6, obeys, 5, localizes, 4, w/drawls, 3, flexion
response, 2, extension to pain, 1, none
• verbal – 5, oriented, 4, confused, 3, inappropriate words, 2,
incomprehensible words, 1, none
• PEARL – if pt is brought in by EMS – GET THE GCS NOTED
AT THE SCENE
• Remember, everything has a GCS – even a rock has a GCS of
3

30. Neuro exam
• Cranial nerves
• LOOK AT THE EYEs
• Symmetry – light response,
movements, gaze pref
• LOOK AT THE FACE
• Symmetry – right = left, pay
attention to motor
• LOOK IN THE MOUTH
• Symmetry – tongue and pharynx

31. Neuro exam
• Motor exam
• Abbreviated evaluation
• Look for: (KEEP IN MIND – Right cortex = left body)
• Right vs. left strength – if equal then
• Check individual groups – start with upper extremities
• Keep level of any deficit in mind
• example: bilateral weakness from biceps down = C6 level

32. Neuro exam
• Reflexes
• Know the difference between UMN and LMN reflex
changes

33. Neuro exam
• Upper motor neuron reflexes
• Cranial nerve reflexes are considered normal and loss of reflex
is concerning – e.g. pupillary response
• Primitive Reflexes – found in newborns, but can present in
patients with neurological disease due to loss of blunting of
reflexes.
• Hyper-reflexia and ankle clonus – unsustained/sustained
• Babinski Reflex – blunted by myelination of SC
• Hoffman Reflex – blunted also

34. Neuro exam
• Lower motor neuron reflexes
• Spinal reflexes
• Relay station in the medullary cord
• E.g. knee jerk, triceps jerk
• Loss: indicative of root irritation/compression, e.g. HNP,
tumor
• May be associated with motor group deficit

35. Neuro exam
• Cerebellar exam
• Coordination
• Rapid movements
• Finger-to-nose
• KEEP IN MIND – RIGHT cerebellum = RIGHT body
• Docusates twice – once at peduncle and then medulla

36. Treatment

37. Treatment
• Initial treatment plan – generally speaking
• Dependent on the patient presentation and clinical status
• Steroids – Decadron
• H2 blocker du jour
• Admission to hospital for continued treatment, w/u, and
neurosurgical consultation (UNLESS THAT IS YOU)

38. Treatment
• The treatment is based on clinical exam, age, comorbidities, and
patient’s/family’s wishes – KNOWING risk/complications and
outcomes.
• Benign lesions can be followed, treated with surgical
decompression (if clinically warranted), and/or radio-surgical
techniques, e.g. Gamma knife, Linear accelerator, etc.

39. Treatment
• Metastatic Lesions
• Based on original lesion,
location, and clinical picture
• Surgical resection for
symptomatic lesions AND
diagnosis
• Also based on surgical safety
• Some metastatic lesions are
very hemorrhagic – risk
outweighs reward

40. Treatment - Survival
• Astrocytomas
• Grade I – surgery based on clinical picture, location, and
risk but considered benign and can be followed with serial
MRIs for growth. Stereotactic bx can also be considered or
even total resection
• Survival is quite acceptable and may have complete remission
after surgical removal
• Grade II – Same as above but consider the incidence of
conversion to more aggressive lesion.
• Can consider serial MRIs, bx, surgical resection. Survival
based on diagnosis

41. Treatment - Survival
• Astrocytomas
• Grade III – these are considered malignant and are likely
to convert to higher grade. Clinic picture likely to require
surgical intervention.
• Gross total resection, radiation therapy, possible include
chemotherapy – Tamodar
• Survival is tenuous based on lesion type, resection, and
response to treatment

42. Treatment - Survival
• Astrocytomas
• Grade VI – most aggressive, Glioblastoma Multiforme, high mitotic
changes, low percentage of overall cancers in the US but very
devastating.
• Best quality of life, ~ one (1) year, is w/ gross total resection,
radiation, and Tamodar
• Other treatments have been, or are being, studied:
• Gene therapy
• Immunotherapy
• Novel delivery methods

43. Case Studies
• 22 y/o WM presents to the ER with focal RUE seizures
• No prior history – very healthy
• Student at local university
• Exam – mild “drift” of the RUE and ? Mild weakness, no
UMN findings, gait not tested
• Next step?

44. Case 1
Describe
What’s next?

45. Case 1
• Notify the NS service – UNLESS that’s you
• Admit to the hospital
• Start steroids
• Start Dilantin
• Order MRI w/ GAD

46. Case 1
Describe
Is this extra-axial, intra-axial, infiltrative, edematous?

47. Case 1
• Next treatment course?
• Surgery?
• Watch?
• Medicine?
• Other studies?

48. Case 1
• What we did:
• Continued the steroids and Dilantin
• Family discussion and surgical planning as outpatient
• Craniotomy for biopsy and debulking
• Initial postoperative course was uneventful
• Awaited final diagnosis

49. Case 1
• Final Diagnosis
• Glioblastoma Multiforme
• High grade lesion – aggressive
• Oncology and radiation therapy involved
• Family made one trip to MD Anderson for second opinion
• Started treatment – We will be following up this month

50. Case 2
• 30 y/o female presented to outlying clinic with progressive
thoracic pain – ONLY
• No significant PMHx
• Exam was essentially normal
• What would be your initial study if conservative medical
treatment failed?

51. Case 2
Describe this MRI
of the Thoracic
spine w/
Gadolinium:
Level?
Extra-dural?
intra-dural?
extra-medullary?
Intra-medullary?
Enhancing?

52. Case 2
• Treatment
• Surgical resection?
• Medications?
• Radiation?
• Watch?

53. Case 2
• What we did:
• Surgical discussion with patient and husband
• Remember that patient’s only problem was pain
• Thoracic laminectomy for partial resection and biopsy
• Steroid treatment in post op phase
• Stable post op exam w/ minor sensory changes

54. Case 2
• Final diagnosis
• Ependymoma – Grade II
• High likelihood of future neurological dysfunction
• Completed radiation treatment and first post radiation
MRI was stable – exam also stable
• Due for f/u with new MRI of the Tspine

55. Case 3
• 63 y/o BM presented after struck in the head and pelvis by a
toolbox
• w/u by ER and trauma service was, initially, just the abd and
pelvis
• Head CT done as inpatient to complete work up
• No neurological complaints or exam findings

56. Case 3
Describe

57. Case 3
Describe
Extra or intra axial?
Enhancing?
Heterogeneous or
homogenous?
Location?
Mass effect?

58. Case 3
• Treatment?
• Steroids?
• Surgery?
• Medications?
• Watch?

59. Case 3
• This is what we did:
• Discharged from hospital after recovery from pelvic injury
• Took to surgery for craniotomy and excision of the tumor
• Excellent postoperative course with discharge w/ in 3 days
to home – no loss of function

60. Case 3
• Diagnosis
• Meningioma – benign lesion – total resection with
attachment to the dura upon entry
• No need for aggressive post op treatment
• Follow up MRI in 6 months
• Return to normal activity

61. Case 4 – Last one
• 50 y/o WF well known to our practice with multiple
intracranial CAVERNOMAs
• In 2008, developed new symptoms of neck and arm pain that
progressed to gait instability
• Her exam fits with parasthesias and UMN findings in
extremities
• What is the next step? Medications, studies?

62. Case 4
MRI - Hem W/ Gad w/o Gad

63. Case 4
Describe:
Location?
Extradural/intradural?
Extramedullary/intra-
medullary?
Levels/location?

64. Case 4
• Treatment?
• Surgery?
• watch?
• Medications?
• Steroids?
• Immobilize?

65. Case 4
• What we did:
• Surgical decompression
• Steroids – short term
• PT
• F/U w/ serial MRIs
• Last study in Sept. 2012 – stable
• Very mild neurologic sequelae

66. Wrap up

67. Wrap up
• Tumor types of the CNS are numerous but are categorized
for description, correlation to clinical picture, and treatment
strategies
• Current imaging techniques are quite useful in identifying
and predicting CNS lesions
• Take the time to gather a history, obtain your own exam,
and look at the actual studies (use the radiology report as
reference)

68. Wrap up
• The clinical picture of the patient upon presentation
coupled with the studies is paramount to the development
of a treatment strategy
• Studies and new treatments of aggressive CNS lesions, e.g.
GBMs, remain at the forefront of cancer research
• Finally, all of you should endeavor to be neurosurgical PAs

69. Questions?