The document discusses intracranial neoplasms (brain tumors). It defines them as abnormal masses of tissue within the cranial cavity that grow and multiply uncontrollably. The causes are mostly unknown, but some environmental and genetic factors are associated with increased risk. Brain tumors are broadly classified by the WHO based on cell type and location. They are also graded based on how abnormal the cells appear, with higher grades generally growing more quickly. Symptoms vary depending on the tumor location but can include headaches, seizures, vomiting, and signs of increased intracranial pressure.

1. INTRACRANIAL
NEOPLASM
S AYA L I G U JJ E WA R
M P T I I

2. DEFINITION OF INTRACRANIAL NEOPLASM
• A brain tumor, known as an intracranial tumor/ intracranial neoplasm, is an abnormal
mass of tissue within the cranial cavity, in which cells grow and multiply uncontrollably,
seemingly unchecked by the mechanisms that control normal cells.

3. CAUSES & RISK FACTORS OF INTRACRANIAL NEOPLASM
• The cause of most brain tumors is unknown.
• Exposure to vinyl chloride or ionizing radiation, are the known environmental factors
associated with brain tumors.
• Mutations and deletions of so-called tumor suppressor genes, such as P53, are
thought to be the cause of some forms of brain tumor.
• Inherited conditions, such as Von Hippel–Lindau disease, multiple endocrine neoplasia,
and neurofibromatosis type 2 carry a high risk for the development of brain tumors.
• People with celiac disease have a slightly increased risk of developing brain tumors.
• Although studies have not shown any link between cell phone or mobile phone
radiation and the occurrence of brain tumors, the World Health Organization has
classified mobile phone radiation possibly carcinogenic.

4. CLASSIFICATION OF INTRACRANIAL NEOPLASM
• Diffuse astrocytic and oligodendroglial
tumours
• Other astrocytic tumours
• Ependymal tumours
• Other gliomas
• Choroid plexus tumours
• Neuronal and mixed neuronal-glial
tumours
• Tumours of the pineal region
• Embryonal tumours
• Tumours of the cranial and paraspinal
nerves
According to WHO (2016), tumours are broadly classified as:
• Meningiomas
• Mesenchymal, non-meningothelial
tumours
• Melanocytic tumours
• Lymphomas
• Histiocytic tumours
• Germ cell tumours
• Tumours of the sellar region
• Metastatic tumours

5. GRADING SYSTEM OF INTRACRANIAL NEOPLASM

6. TUMOUR GRADES
The grade of a tumor refers to the way the cells look under a microscope:
• Grade I: The tissue is benign. The cells look nearly like normal brain cells, and they grow
slowly.
• Grade II: The tissue is malignant. The cells look less like normal cells than do the cells in a
Grade I tumor.
• Grade III: The malignant tissue has cells that look very different from normal cells. The
abnormal cells are actively growing (anaplastic).
• Grade IV: The malignant tissue has cells that look most abnormal and tend to grow quickly.
quickly.
Cells from low-grade tumors (grades I and II) look more normal and generally grow more
slowly than cells from high-grade tumors (grades III and IV).
Over time, a low-grade tumor may become a high-grade tumor. However, the change to a
high-grade tumor happens more often among adults than children.

7. PATHOPHYSIOLOGY OF INTRACRANIAL NEOPLASM

8. CLINICAL FEATURES OF INTRACRANIAL NEOPLASM
Tumors of the brain often exist with hardly any symptoms.
• A slight confused, slowness in comprehension, or loss of capacity for sustained mental
activity may be the only deviations from normal, and signs of focal cerebral disease are
wholly lacking.
• In some patients, on the other hand, there is early indication of cerebral disease in the
form of a progressive hemiparesis, a seizure occurring in a previously well person.
• In a third group, the existence of a brain tumor can be assumed because of the
presence of increased intracranial pressure with or without localizing signs of the
tumor.
• In yet another group, the symptoms are so definite as to make it likely that not only is
there an intracranial neoplasm but that it is of a certain type and is located in a
particular region. These localized growths create certain syndromes seldom caused by
any other disease.
Further, intracranial tumors are considered in relation to these common modes of clinical
presentation:
1. Patients who present with focal cerebral signs and general impairment of cerebral
function, headaches, or seizures
2. Patients who present with evidence of increased intracranial pressure

9. PATIENTS PRESENTING WITH GENERAL IMPAIRMENT OF CEREBRAL
FUNCTION, HEADACHES AND SEIZURES
A. Changes in Mental Function
• A lack of persistent application to everyday tasks, undue irritability, emotional liability,
mental inertia, faulty insight, forgetfulness, reduced range of mental activity, indifference
common social practices, lack of initiative and spontaneity.
• Excessive drowsiness or apathy may be prominent.
• There is both a reduction in the amount of thought and action and a slowing of reaction
time.
• When the patient is questioned, a long pause precedes each reply (abulia); at times the
patient may not respond at all. Or, at the moment the examiner decides that the patient
not heard the question and prepares to repeat it, an appropriate answer is given, usually
few words. Moreover, the responses are often more intelligent than one would expect,
considering the patient's inactive mental state.
• Many of these features will be recognized as components of a frontal lobe syndrome, but
the tumor is often situated elsewhere, or is diffusely infiltrative.
• There are, in addition, patients who are overtly confuse or demented.

10. B. Headache
• This is an early symptom in fewer than 25% of patients with brain tumor and are variable in nature.
• In some, the pain is slight, dull, and episodic; in others, it is severe and either dull or sharp but also
intermittent.
• If there are any characteristic features of the headache, they would be its nocturnal occurrence or
on first awakening and perhaps its deep, nonpulsatile quality.
• However, these are not specific attributes, as migraine and hypertensive vascular headaches may also
in the early morning hours or upon awakening. But if vomiting occurs at the peak of the head pain, tumor
more likely.
• Occipitonuchal headache with vomiting is indicative of a tumor in or near the cerebellum and foramen
magnum and is one typical presentation in children.
• Patients with brain tumors do not always complain of head pain even when it is present, but they may
its existence by placing their hands to their heads and looking distressed.
• In the majority of instances, the CSF pressure is normal during the first weeks when the headache is
and one can attribute it only to local swelling of tissues and to distortion of blood vessels in the dura
overlying the tumor.
• Later, the headache may be related to increases in intracranial pressure, thus the early morning occurrence
after recumbency and vomiting.
• Tumors above the tentorium cause headache on the side of the tumor and in its vicinity, in the
temporal, or parietal region; tumors in the posterior fossa usually cause ipsilateral retroauricular or
headache.

11. C. Vomiting & Dizziness
• Vomiting appears in a relatively small number of patients with a tumor syndrome and
usually accompanies the headache when the latter is severe.
• It is more frequent with tumors of the posterior fossa.
• The most persistent vomiting (lasting several weeks) is observed in patients with low
brainstem gliomas, fourth ventricular ependymomas, and subtentorial meningiomas.
• Some patients may vomit unexpectedly and forcibly without preceding nausea
("projectile vomiting"), a sign that is fairly specific to tumor in children, but others
suffer nausea and severe discomfort.
• Usually the vomiting is not related to the ingestion of food, and, often, it occurs
breakfast.
• No less frequent is the complaint of dizziness. It consists of an unnatural sensation in
the head, coupled with feelings of strangeness and insecurity when the position of
head is altered.
• Positional vertigo can be a symptom of a tumor in the posterior fossa affecting
vestibular structures.

12. D. Seizures
• The occurrence of focal or generalized seizures is the other major manifestation of
brain tumor.
• Convulsions have been observed in 20 to 50 percent of all patients with cerebral
tumors.
• A first seizure during adulthood is always suggestive of brain tumor and has been the
most common initial manifestation of primary and metastatic neoplasm.
• Seizures caused by brain tumor most often have a focal onset and may secondarily
generalize.
• There maybe one seizure or many, and they may follow the other symptoms or
precede them by weeks or months or exceptionally, in patients with low-grade
astrocytoma, oligodendroglioma, or meningioma-by several years.
• Status epilepticus as an early event from brain tumor is rare but has occurred.

13. PATIENTS WHO PRESENT WITH EVIDENCE OF INCREASED INTRACRANIAL
PRESSURE
Headache, papilloedema and vomiting are the classical triad of symptoms of increased intracranial
pressure.
A. Headache
• The headache of intracranial tumor is mainly due to compression or distortion of the dura and of the
intracranial blood vessels.
• It is often paroxysmal.
• Throbbing or bursting pain.
• Worst in the early morning.
• Often the patients awakens with a headache which lasts from few minutes to a few hours and then
passes off, to recur the next day.
• With gradual enlargement of the growth, headache becomes more prolonged and is ultimately
continuous.
• It is generally intensified by activities which raise the intracranial pressure, such as exertion, excitement,
coughing, sneezing, vomiting, stooping, coitus or straining at stool.
• It may be influenced by posture, being worse when lying down, or lying on one side and may be
relieved by sitting.

14. B. Papilloedema
• It usually develops in tumors of the cerebellum, fourth ventricle and temporal lobes.
• A tumor arising sufficiently near the optic canal to occlude the subarachnoid space of
the optic nerve causes primary optic atrophy on the affected side and ocassionally
contralateral papilloedema results from the general effect of the tumor.
• The changes in the visual fields due to papilloedema consist of enlargement of the
blind spot with peripheral concentric constriction.
• Severe papilloedema may be present without impairment of visual acuity but
episodes of unilateral or bilateral visual blurring or even blindness, sometimes
precipitated by coughing, straining, or stooping, may warn of impending irreversible
visual failure due to occlusion of one or both central retinal arteries.
C. Vomiting
• Vomiting due to intracranial tumor usually occurs in the early morning when
is severe.
• In children, it is associated with nausea.

15. C. Epilepsy
• In intracranial tumor, epileptic fits are usually due to the direct effect of the neoplasm
upon the surrounding or underlying brain.
• Such attacks are common when the tumor involves the cortex rather than deeper
structures.
• The incidence of tumor rises to about 30-40 percent in patients with focal rather than
generalized fits.
D. Vertigo
• Relatively uncommon.
• Severe vertigo induced by change in posture is an important manifestation of
ependymomas or metastases in or near the fourth ventricle and vertigo is also a rare
manifestation of temporal lobe tumor.
E. Disturbances of Pulse Rate & Blood Pressure
• An acute or subacute rise of intracranial pressure, often causes slowing of pulse rate,
usually between 50-60 beats / minute.
• If pressure continues to increase, the pulse rate becomes extremely rapid.
• In either case it will be irregular.
• A rapid rise of intracranial pressure usually causes an increase in blood pressure.
• With slowly growing tumors, the pressure is more often normal or subnormal.

16. F. Respiratory Rate
• A gradual rise in intracranial pressure does not at first affect the respiratory rate.
• A rapid and sustained rise causing loss of consciousness usually leads at first to slow
and deep respirations.
• Later, the respiratory rate may become irregular.
• In the terminal stages the respirations are rapid and shallow.
• These manifestations are due to compression or distortion of the brainstem especially
the medulla, where the respiratory centres lie.
G. Hypopituitarism
• Any chronic state of increased intracranial pressure with hydrocephalus may produce
manifestations of hypopituitarism, such as, adiposity and genital atrophy in some
or loss of body hair and hypoadrenalism or hypothyroidism in others.
• This is due to the downward pressure upon hypothalamic nuclei in the floor of the
distended third ventricle, sometimes with erosion of the clinoid processes and
diaphragm sellae and compression of the pituitary.
• These symptoms are most common in cases of cerebellar tumor in children or a
pituitary or suprasellar tumor.

17. H. Somnolence
• Hypersomnia may occur in severe hydrocephalus and with tumors near the
hypothalamus.
I. Mental Symptoms
• If the pressure rises sufficiently, this leads to coma, and the more rapid the rise the
more likely is this to occur.
• An acute or subacute rise insufficient to produce coma usually leads to a confusional
state.
• Frontal meningioma can lead to progressive dementia, with disintegration of intellect,
emotional apathy, carelessness with regard to the person, and incontinence of urine
and faeces.
• Less often, marked disturbances of mood are conspicuous, with episodes of
or of depression.
• In some cases impairment of memory and of concentration with irritability, may be
only mental symptom.

18. J. False Localizing Signs
• Sixth-nerve palsy
• Third-nerve palsy
• Bilateral extensor plantar responses or grasp reflexes
• Hypopituitarism
• Kernohan’s sign : an extensor plantar response occurring on the same side as a
of one cerebral hemisphere produced by compression of the opposite cerebral
peduncle against the tentorium.
• Cerebellar dysfunction due to tumors of the frontal lobe.
• Fixed dilated pupils produced by a tumor of the cerebellar vermis.

19. GLIOMA
• The gliomas are tumors derived from
glial cells.
• They are of epiblastic origin.
• There are different types of cell in a
single tumor.
• Tumors which are histologically
identical may behave quite differently.
• Sometimes a glioma seems to arise
diffusely or from multiple centres at
the same time.

21. CLASSIFICATION OF GLIOMA
Medulloblastoma
• Third commonest glioma, about 11%.
• These are rapidly growing tumors which most often occur in the cerebellum in
children, where they arise in the region of the roof of the fourth ventricle.
• Rarely seen in adults.
• Composed of masses of rounded undifferentiated cells and often disseminate
the subarachnoid space both of the brain and the spinal cord.
• It may metastasize outside the cranial cavity giving secondary deposits especially in
spinal canal and bone, particularly after partial operative removal or after a shunting
operation carried out to relieve hydrocephalus.

22. • Second commonest, about 34%.
• This is an extremely malignant glioma
arising in middle life.
• Found in the cerebral hemispheres.
• Infiltrates the brain extensively and
often attains an enormous size.
• It is a reddish, highly vascular tumor,
and often exhibits haemorrhages and
areas of necrosis.
Glioblastoma multiforme

23. • Most commonest glioma, about 36%.
• They are usually white, infiltrating
growths which may occur at any age,
and in either the cerebral or the
cerebellar hemispheres.
• They grow slowly and are relatively
benign.
• They are particularly liable to undergo
cystic transformation.
Astrocytoma

24. • Uncommon, slowly growing, and
usually relatively benign tumor
occurring in the cerebral
hemispheres in young adults.
• Often calcify, giving a fine punctate
or stippled pattern.
Oligodendroglioma

25. • This is a firm, whitish tumor,
sometimes pedunculated, arising
from the ependyma, frequently in
the roof of the fourth ventricle and
sometimes from the walls of the
other ventricles or from the central
canal of the spinal cord.
Ependymoma

26. • These rare tumors contain
ganglion cells.
• The neuroblastoma is
predominantly made up of
neuroblasts.
• The ganglioglioma shows
abnormal ganglion cells lying
among proliferating astrocytes or
astroblasts.
• The gangliocytoma contains not
only ganglion cells and astrocytes
but also nerve fibres, usually
unmyelinated.
Neuroblastoma, ganglioglioma,
gangliocytoma

27. MENINGIOMA
• Arise from the arachnoid cells and have slow growth rate.
• It is a single, large, more or less irregularly lobulated growth, but less
frequently it may form a flat plaque spreading over the inner surface of the
dura.
• A distinctive feature is the relationship of meningiomas to the bones of the
skull.
• These tumors invade bone in about 20% of cases, resorption of bone and new
bone formation occurring simultaneously.
• Meningioma cells fill the haversian canals and spaces.
• Rarely, a meningioma perforates the skull and infiltrates the extracranial
tissues.
• The meningioma, which is of mesodermal origin, does not usually invade the
brain but compresses it, resulting in disturbance of cerebral function.
• They may also arise from tentorium or torcula. Occasionally, they are found
within the lateral ventricles.
• Common in women.

28. ACOUSTIC NEUROMA
• Usually unilateral.
• Eighth cranial nerve is the commonest
site.
• Other sites are optic and trigeminal
nerves, upon spinal nerve roots,
usually the dorsal, and upon peripheral
nerves.
• Arise from the vestibular division of
the acoustic nerve within the porus
acousticus.