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Surgery 5th year, 1st lecture/part one (Dr. Khalid Shokor Mahmood)


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The lecture has been given on May 23rd, 2011 by Dr. Khalid Shokor Mahmood.

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Surgery 5th year, 1st lecture/part one (Dr. Khalid Shokor Mahmood)

  1. 1. Intracranial Tumors<br />Dr. Khalid S. Mahmood<br />F.I.C.M.S. (Neurosurgery)<br />
  2. 2. Any mass lesion within the skull is a threat to the integrity of brain function and therefore even histologically benign tumours can threaten life. <br />The incidence varies with age.<br />The classification of brain tumors is determined by their cell of origin. <br />
  3. 3. Etiology<br />• The etiology of brain tumors is still not clearly understood. <br />Chromosomal abnormalities: this is noted in many CNS tumors. Oncogenesisinvolves both the addition of oncogene to the genome and the loss of normally occurring tumor suppressor genes. <br />Immunosuppression<br />Chemicals <br />Radiation<br />Occupation<br />Mobile phones<br />Diet<br />
  4. 4. Clinical Features<br />There will be different combination of the followings: <br />•Features of raised ICP <br />• Focal neurological signs<br />Motor and sensory area<br />Dominant hemisphere near the speech area<br />Optic pathways posterior to the chiasm<br />Anterior frontal lobe<br />Sellar tumors<br />Tumors in relation to the CSF pathways<br />Cerebellarvermis<br />Cerebellar hemisphere<br />• Seizures<br />Late-onset epilepsy, particularly over the age of 25, should prompt investigation to exclude an intracranial neoplasm. <br />Endocrine dysfunction<br />
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  7. 7. Gliomas<br />Gliomas form about 50% of adult primary intracranial tumors. They are usually supratentorial.<br />They arise from the glial cells of which there are four types: astrocytes, oligodendrocytes, ependymal, and microglial cells. <br />The most common primary CNS tumor is astrocytoma.<br />Diagnosis <br />• CT scan with and without contrast.<br />• MRI will show more details and in multiplanar views.<br />Treatment <br />• Dexamethasone<br />• Surgery: its aim is to obtain pathological diagnosis and grading, and to debulk the tumor.<br />• Radiotherapy: <br />• External beam <br />• Stereotactic focal irradiation [Gamma Knife (GK)]<br />• Brachytherapy (implantation of radioactive source) <br />• Chemotherapy<br />
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  11. 11. Meningiomas<br />Most of them are benign. They are uncommon in children. There is slight female predominance, and their incidence peaks in middle age. <br />They originate from the meningothelial cells of arachnoidvilli. <br />They classically arise from a broad base along the dura and may invade the bone. <br />Diagnosis <br />CT scan and MRI. <br />Treatment <br />• Total surgical excision wherever possible with trying to preserve neurological function. Total resection of the tumor with its dural attachment is usually curative. <br />• Perioperativedexamethasone. <br />• Radiotherapy is reserved for aggressive tumors, recurrent tumors or subtotally removed tumors. <br />
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  14. 14. Acoustic Neuromas<br />They are benign nerve sheath tumors arising from Schwann cells of the 8th cranial nerve within the internal acoustic meatus. <br />As the tumor grows, it will extend into the cerebellopontine angle (CPA) compressing the pons, cerebellum, and cranial nerves. <br />Bilateral acoustic schwannomas are diagnostic of Neurofibromatosis type 2. <br />Unilateral hearing loss occurs early. <br />CT and MRI will provide the diagnosis. <br />Treatment <br />Total surgical removal is usually aimed. Patients may sustain postoperative 7th nerve palsy. <br />GK radiosurgery is recently used for small tumors.<br />
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  16. 16. Metastatic tumors<br />Of those who die with cancer, 25% have brain metastases at autopsy. <br />Origin of cerebral metastasis: <br />Lung: 40%; Breast: 20%; Kidney: 11%; Melanoma: 11%; Colon: 8%; unknown primary: 5%<br />It's diagnosed by CT scan and MRI<br />General investigation must be done searching for the primary tumor (chest radiography, ultrasound, ESR, etc.)<br />Treatment<br />• Steroids<br />• anticonvulsant<br />• Surgery<br />• Radiotherapy. More recently, GK.<br />
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  18. 18. Pituitary Tumors<br />They account for about 8% of all brain tumors. <br />Classified as the following: <br />• According the size:<br />microadenomas (<10 mm)<br />mesoadenomas (10-20 mm)<br />macroadenomas (>20 mm) <br />• According to the hormone secreted by the adenoma: <br />Growth hormone (GH) <br />Adrenocorticotrophic hormone (ACTH) <br />Prolactin (PRL), prolactinoma<br />Thyroid-stimulating hormone (TSH) <br />Non-functioning adenomas <br />
  19. 19. Clinical features<br />Pituitary tumors arise in the sellaturcica and can compress the optic chiasm resulting in visual field defects<br />They may invade laterally into the cavernous sinuses compressing the 3rd to 6th cranial nerves. <br />Endocrine disturbance is due to either hypopituitarism or excess secretion of a particular pituitary hormone: <br />Prolactinomas: usually in younger women and cause loss of libido, infertility, amenorrhea, and galactorrhea. <br />ACTH secreting adenomas: cause Cushing's disease.<br />GH secreting adenomas: cause: <br /><ul><li>Acromegaly in adults.
  20. 20. Gigantism in children.</li></ul>pituitary apoplexy<br />Diabetes insipidus<br />
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  22. 22. Investigations<br />Neuroradiological imaging: MRI and CT scan<br />Hormonal assessment <br />Visual assessment: VA and VF (visual acuity and field) <br />Treatment<br />Conservative: in prolactinomas, bromocriptine(a dopamine agonist) or octreotide are useful. <br />Surgical: either through trans-sphenoidal approach to the sellaturcica, or transcranial (subfrontal) approach. Surgery is indicated in: <br />Lesions compressing the surrounding structures <br />Inappropriate hormone production, which cannot be controlled by the drugs <br />Replacement of the pituitary hormones is usually needed postoperatively. <br />Radiotherapyis used for subtotal resection and for persistent hypersecretion of pituitary hormones.<br />
  23. 23. Thank you<br />