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Tumors of the Brain and Spine          Joe Hlavin PA-C, MS      Texas Brain and Spine Institute                Bryan, TX  ...
Introduction/Bio US  Navy – Corpsman – 1984 to 1989 Cuyahoga Comm College – 1991 – surgical PA  ◦ Went right into privat...
Objectives•   For this lecture:    •   Review of the normal brain and spine anatomy and        physiology, including CT an...
AnatomyQuidi Vidi Bay, Newfoundland
The Brain                             some A&P•   Lobes - Supertentorial              UT student????    •   Frontal    •  ...
the brain A&P•   Frontal    •   Reasoning, planning, “personality”    •   Frontal eye fields – Brodman 8       PERSONALITY...
the brain A&P                                                                           Important – Dominant              ...
Spinal Cord•   Anatomy    •   Tracts        •   Ascending            •   sensory        •   Descending            •   Motor
Spinal Cord•   Understanding the medullary    component    •   Simply – relay station for input        and output of trans...
Spinal Cord•   Focusing for function    •   Keys        •   Ascending – sensory            •   Lesions are not as         ...
StudiesSt. John’s Bay – The Narrows
CT• Usually the first study performed  • Fast  • Easy  • Least expensive  • Consists of 60 to 70 – 5mm slices  • Can be do...
MRI    preferred for brain and a must for                   spine•   Most detailed    •   Used with Gadolinium        (“dy...
Lesions
Lesion Types
Lesion Types•   Benign    •   Non-aggressive but can be devastating based on size and        location    •   Meningioma is...
Lesion types•   Metastatic    •   The primary cancer: lung, breast, colon, kidney, or skin        (melanoma), but can orig...
Malignant lesions                          Glial tumors•   World Health Organization grading (WHO) scale    ASTROCYTOMAS, ...
Examples•   Four different astrocytic lesions, four different looksSub-ependymoma                                         ...
Cerebellar Lesions•   Very similar to CEREBRAL lesions•   Have increased risks with compression of    essential component ...
Describing Studies
General Descriptions                         for Brain and Spinal Lesions•   For the brain    •   Extra-axial    •   Intra...
General Descriptions                           for Brain and Spinal Lesions•   Location, location, location    •   For the...
examples
More Examples
Neurological Exam
Neuro Exam•   Tenets of the approach to the NS patient    •   DO NOT BELIEVE ANYONE ELSES EXAM –        •   DO YOUR OWN   ...
Neuro exam•   The mental status    •   “normal” or “Sleeping” is not a good descriptor. Use:        •   Awake/alert/talkin...
Neuro exam•   Glasgow Coma Scale    •   Eyes – 4, spontaneous, 3, to voice, 2, to pain, 1, none    •   Motor – 6, obeys, 5...
Neuro exam•   Cranial nerves    •   LOOK AT THE EYEs        •   Symmetry – light response,            movements, gaze pref...
Neuro exam•   Motor exam    •   Abbreviated evaluation    •   Look for: (KEEP IN MIND – Right cortex = left body)        •...
Neuro exam•   Reflexes    •   Know the difference between UMN and LMN reflex        changes
Neuro exam•       Upper motor neuron reflexes•       Cranial nerve reflexes are considered normal and loss of reflex      ...
Neuro exam•   Lower motor neuron reflexes    •   Spinal reflexes        •   Relay station in the medullary cord        •  ...
Neuro exam•   Cerebellar exam    •   Coordination    •   Rapid movements    •   Finger-to-nose•   KEEP IN MIND – RIGHT cer...
Treatment
Treatment•   Initial treatment plan – generally speaking    •   Dependent on the patient presentation and clinical status ...
Treatment•   The treatment is based on clinical exam, age, comorbidities, and    patient’s/family’s wishes – KNOWING risk/...
Treatment•   Metastatic Lesions    •   Based on original lesion,        location, and clinical picture    •   Surgical res...
Treatment - Survival•   Astrocytomas    •   Grade I – surgery based on clinical picture, location, and        risk but con...
Treatment - Survival•   Astrocytomas    •   Grade III – these are considered malignant and are likely        to convert to...
Treatment - Survival•   Astrocytomas    •   Grade VI – most aggressive, Glioblastoma Multiforme, high mitotic        chang...
Case Studies•   22 y/o WM presents to the ER with focal RUE seizures•   No prior history – very healthy•   Student at loca...
Case 1 DescribeWhat’s next?
Case 1•   Notify the NS service – UNLESS that’s you•   Admit to the hospital•   Start steroids•   Start Dilantin•   Order ...
Case 1                      DescribeIs this extra-axial, intra-axial, infiltrative, edematous?
Case 1•   Next treatment course?•   Surgery?•   Watch?•   Medicine?•   Other studies?
Case 1•   What we did:    •   Continued the steroids and Dilantin    •   Family discussion and surgical planning as outpat...
Case 1•   Final Diagnosis    •   Glioblastoma Multiforme    •   High grade lesion – aggressive•   Oncology and radiation t...
Case 2•   30 y/o female presented to outlying clinic with progressive    thoracic pain – ONLY•   No significant PMHx•   Ex...
Case 2 Describe this MRI  of the Thoracic      spine w/    Gadolinium:Level?Extra-dural?intra-dural?extra-medullary?Intra-...
Case 2•   Treatment    •   Surgical resection?    •   Medications?    •   Radiation?    •   Watch?
Case 2•   What we did:    •   Surgical discussion with patient and husband        •   Remember that patient’s only problem...
Case 2•   Final diagnosis    •   Ependymoma – Grade II        •   High likelihood of future neurological dysfunction    • ...
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, ini...
Case 3Describe
Case 3DescribeExtra or intra axial?Enhancing?Heterogeneous orhomogenous?Location?Mass effect?
Case 3•   Treatment?    •   Steroids?    •   Surgery?    •   Medications?    •   Watch?
Case 3•   This is what we did:    •   Discharged from hospital after recovery from pelvic injury    •   Took to surgery fo...
Case 3•   Diagnosis    •   Meningioma – benign lesion – total resection with        attachment to the dura upon entry    •...
Case 4 – Last one•   50 y/o WF well known to our practice with multiple    intracranial CAVERNOMAs•   In 2008, developed n...
Case 4MRI - Hem   W/ Gad   w/o Gad
Case 4Describe:Location?Extradural/intradural?Extramedullary/intra-medullary?Levels/location?
Case 4•   Treatment?    •   Surgery?    •   watch?    •   Medications?    •   Steroids?    •   Immobilize?
Case 4•   What we did:    •   Surgical decompression    •   Steroids – short term    •   PT    •   F/U w/ serial MRIs    •...
Wrap up
Wrap up•   Tumor types of the CNS are numerous but are categorized    for description, correlation to clinical picture, an...
Wrap up•   The clinical picture of the patient upon presentation    coupled with the studies is paramount to the developme...
Questions?
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Neuro oncology

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This is a presentation that I gave to first year PA students

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Neuro oncology

  1. 1. Tumors of the Brain and Spine Joe Hlavin PA-C, MS Texas Brain and Spine Institute Bryan, TX jhlavin@txbsi.com
  2. 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. 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. 4. AnatomyQuidi Vidi Bay, Newfoundland
  5. 5. The Brain some A&P• Lobes - Supertentorial UT student???? • Frontal • Temporal • Parietal • Occipital• Cerebellum - Subtentorial
  6. 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. 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. 8. Spinal Cord• Anatomy • Tracts • Ascending • sensory • Descending • Motor
  9. 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. 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. 11. StudiesSt. John’s Bay – The Narrows
  12. 12. CT• Usually the first study performed • Fast • Easy • Least expensive • Consists of 60 to 70 – 5mm slices • Can be done with dye
  13. 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. 14. Lesions
  15. 15. Lesion Types
  16. 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. 17. Lesion types• Metastatic • The primary cancer: lung, breast, colon, kidney, or skin (melanoma), but can originate in any part of the body
  18. 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. 19. Examples• Four different astrocytic lesions, four different looksSub-ependymoma GBM – grade VI Oligodendroglioma Anaplastic astrocytoma
  20. 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. 21. Describing Studies
  22. 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. 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. 24. examples
  25. 25. More Examples
  26. 26. Neurological Exam
  27. 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. 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. 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. 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. 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. 32. Neuro exam• Reflexes • Know the difference between UMN and LMN reflex changes
  33. 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. 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. 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. 36. Treatment
  37. 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. 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. 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. 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. 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. 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. 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. 44. Case 1 DescribeWhat’s next?
  45. 45. Case 1• Notify the NS service – UNLESS that’s you• Admit to the hospital• Start steroids• Start Dilantin• Order MRI w/ GAD
  46. 46. Case 1 DescribeIs this extra-axial, intra-axial, infiltrative, edematous?
  47. 47. Case 1• Next treatment course?• Surgery?• Watch?• Medicine?• Other studies?
  48. 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. 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. 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. 51. Case 2 Describe this MRI of the Thoracic spine w/ Gadolinium:Level?Extra-dural?intra-dural?extra-medullary?Intra-medullary?Enhancing?
  52. 52. Case 2• Treatment • Surgical resection? • Medications? • Radiation? • Watch?
  53. 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. 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. 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. 56. Case 3Describe
  57. 57. Case 3DescribeExtra or intra axial?Enhancing?Heterogeneous orhomogenous?Location?Mass effect?
  58. 58. Case 3• Treatment? • Steroids? • Surgery? • Medications? • Watch?
  59. 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. 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. 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. 62. Case 4MRI - Hem W/ Gad w/o Gad
  63. 63. Case 4Describe:Location?Extradural/intradural?Extramedullary/intra-medullary?Levels/location?
  64. 64. Case 4• Treatment? • Surgery? • watch? • Medications? • Steroids? • Immobilize?
  65. 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. 66. Wrap up
  67. 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. 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. 69. Questions?

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