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Parietal lobe tumor

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Parietal lobe tumor

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Parietal lobe tumor

  1. 1. Parietal Lobe Tumors DR V K SAHU RESIDENT PSYCHIATRY INHS ASVINI 1
  2. 2. Aim and Main Headings • Anatomy of Parietal lobe • Functions • Tests • Tumors • Clinical features • Investigations • Management 2
  3. 3. Anatomy 3
  4. 4. Anatomy • Anterior border - Central Sulcus - parietal lobe & frontal lobe • Posterior border - Parieto-occipital Sulcus - parietal & occipital lobes • Ventral border - Lateral Sulcus (sylvian fissure) is the most lateral boundary separating it from the temporal lobe • Medial Longitudinal Fissure divides the two hemispheres. 4
  5. 5. Blood supply • Anterior parietal artery • Posterior parietal artery • Angular artery • Temporaloccipital: The longest cortical artery. 5
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  9. 9.  Body image representation Body in space Tactile discrimination Functions 9
  10. 10.  3 D analysis of body space interactions (body schema) Visual spatial properties Visual attention Motivation and grasping functions. (parietal lobe lesions - there is ‘self grasping’ of forearm opp. the lesion ) mediate influence of emotion, attention and motivation on behavior  INFERIOR PARIETAL LOBULE Last to mature anatomically and functionally. So, the functions are late, to develop b/w 5 and 8 yrs age. ( reading , calculations ) Angular gyrus & Supra marginal gyrus - they have interconnections with visual, auditory, somasthetic, supr. colliculus, Lateral Geniculate Body and other lobes. 10
  11. 11. Parietal lobe function Impairment of parietal lobe function Sensory cortex: (represents similar to motor cortex) ---receives afferent pathways for - appreciation of posture - touch - passive movement Contraleteral disturbances of cortical sensation - postural sensation disturbed - sensation of passive movement disturbed - accurate localization of light touch disturbed - 2 point discrimination disturbed - Asterognosis Supramarginal angular gyrus: (dominant hemisphere) - Wernicke’s language area - receptive area where auditory , visual aspect of comprehension are integrated. Supramarginal angular gyrus: (dominant hemisphere) Gerstmann’s syn -confusion of right & left limb. -Finger agnosia -Acalculia -Agraphia Supramarginal angular gyrus: (non dominant hemisphere) - concept of body image - awareness of external movement - skills of handling numbers/calculation - visual pathway (optic radiation pass through parietal lobe) Supramarginal angular gyrus: (non dominant hemisphere) -Unaware of opposite limbs -Anosognosia -Geographical agnosia -Constitutional apraxia: - cannot copy geometric pattern -Damage of optic radiation: lower homonymous quadranopia 11
  12. 12. 1. Multimodal assimilation – capacity for organizing , labelling and conceptualizing , using all senses. Ex : chair 2. Language capabilities angular gyrus - anomia supramarginal gyrus – conduction aphasia visual cortex to IPL connections – word blindness 12
  13. 13. 3. Agraphia – lt. lobe Engrams for production and perception of written language are stored in IPL . So, misspellings, distorsions, and inversions occur. 4. Temporal sequential functions IPL is the main track of input and output. Therefore, information is organized appropriately into a sequence here. 5. Calculation (Lt.) and computation (Rt.) 13
  14. 14. IPL lesions leads to disruption of visual spatial functioning and temporal sequencing ability (apraxia). i.e either spatial sequential tasks lost - OXOXOX or sequential grammar relations are lost. 14
  15. 15. Cerebral laterality 15
  16. 16. Either hemisphere 1. Cortical sensations. 2. Integration of sensory , motor and attention signals (i.e disengage attention - do other activity - immediately reengage correctly) 3. Optic radiation passes through. 4. Constructional ability – capacity to construct or draw 3D/2D figures or shapes. Lt. – programming of movements necessary for constructional activity. (simplification of complex diagrams) Rt. – related to spatial relationships or imagery. (rotation of diagrams) 16
  17. 17. Right hemisphere 1. Constructional skills 2. Dressing apraxia 3. Calculations – arithmetic concepts of carrying and borrowing spatial alignment of written calculations. (computational difficulty – inability to manipulate no.s in spatial relation, like using decimals,etc – but he is able to do problems in his head ) 4. Perceptual functions (inattention/neglect of lt. hemispace) 17
  18. 18. Statistics • Estimated 69,720 new cases of primary malignant and non– malignant brain and CNS tumors are expected in 2013. • The incidence rate of all primary malignant and non- malignant brain and CNS tumors is 20.6 cases per 100,000 (7.3 per 100,000 for malignant tumors and 13.3 per 100,000 for non–malignant tumors). The rate is higher in females (22.3 per 100,000) than males (18.8 per 100,000). • Estimated 24,620 new cases of primary malignant brain and CNS system tumors are expected in 2013 ( Central Brain Tumor Registry of the United States ) 18
  19. 19. Primary Brain Tumor Frequency Tumor Frequency (Percent) Meningioma 24 Glioblastoma 23 Astrocytoma 12 Pituitary tumors 10 Nerve Sheath tumors & Primary Acoustic Neuroma 7 Medulloblastoma and Pinealomas 5 Anaplastic Astrocytoma and lymphomas 4 Oligodrogliomas 3 All others 12 19
  20. 20. Most Common Brain Tumor by Age Group Age Range (yr ) Tumor Types 0-9 Primitive Neuroectodermal tumors medulloblastomas 10-19 Astrocytomas 20-34 Pituitary tumors 35-44 Menigiomas 45-75 Glioblastomas 76 and older Meningiomas 20
  21. 21. Anatomic location of Brain Tumors and Frequency of Neuropsychiatric symptoms Anatomic location % of all Brain tumors % with Psychiatric & Behavioral Symptoms Frontal lobes 22 As much as 90 Temporal lobes 22 50-55 Parietal lobes 12 As much as 16 Pituitary 10 As much as 60 Occipital 4 As much as 25 Diencephalic Region 2 50 or more Posterior fossa, Cerebellum and Brainstem 28 Uncertain,Numerous neuropsychiatric symptoms reported 21
  22. 22. General characteristics in Brain Tumors • Only 18 % of Brain tumor psychiatric 1st manifest with behavioral/ Neuropsychiatric symptoms. • When mental disturbance most common pt may first come to psychiatrist • Many patient with cerebral symptoms have some psych symptom during illness • Mental symptoms little guide to location of tumor Vs Neurological signs. 22
  23. 23. General characteristics in Brain Tumors • Tumor material proved to be disappointing for study of cerebral basis of mental symptoms • Depressive symptoms- single most important predictor of quality of life. • Slow growing tumor tumor cause changes of personality , allow premorbid tendencies to manifest themselves • Rapid growing tumors-impairment of consciousness 23
  24. 24. Neuropsychiatric & Behavior associated Symptoms in Parietal lobe tumors • Primarily affective symptoms, depressive > hypomania or mania • Psychotic manifestation Paranoid delusions & Cotard’s syndrome (delusion that they are dead/do not exist/putrefying/lost blood/internal organs,rarely delusion of immortality) 24
  25. 25. Neuropsychiatric & Behavior associated Symptoms (Contd) • Many have imp lateralizing characteristics • Results in Contralateral disturbance in - Two point discrimination - Joint position sense - Stereognosis - Graphesthesia 25
  26. 26. Neuropsychiatric & Behavior associated Symptoms (Contd) • Tumors in Dominant Parietal lobe - difficulties with reading & spelling - receptive aphasias - Gerstmann’s syndrome • Tumors in Non dominant lobe - visuospatial discrimination - anosognosia (lack of awareness, denial or complete neglect of obvious contralateral neurological deficits ) • Various Apraxias 26
  27. 27. Psychiatric & Behavioral Complications of Medical & Surgical Treatment • Therapeutic interventions causing abnormalities • Intraoperative injury to normal brain tissue in resection/debulking. e.g. Nonverbal learning disabilities & psychotic symptoms in children, in frontal lobe –executive dysfunction. • Radiation induced damage – transient & reversible vs Permanent • Chemotherapy causing Delirium • Treatment of ↑ ICT /Cerebral oedema , Corticosteroid result in Psychotic and affective symptoms 27
  28. 28. Contributing factors in development of Neuropsychiatric manifestations • General Considerations - Prevalence more in Psychiatric population - Not commonly the earliest manifestation • Anatomical localization - not sole criteria - lateralization & features not consistent - symptom far away from location of tumor due to diaschisis and connection syndrome esp corpus callosum. - only two mental syndrome consistent – in acute stage clouding of consciousness & chronic amnesic syndrome in chronic stage 28
  29. 29. Contributing factors in development of Neuropsychiatric manifestations (contd) • Tumor growth - Rapidity/extent of spread-type/acuity & severity of symptoms - Rapid growing– acute, significant neurocognitive impairment - Slow growing – more vague & subtle behavioral change - Metastatic lesion & multiple locations • Tumor type - more aggressive tumor (high grade gliomas) - Menigiomas – slow growing & disproportionately in frontal region cause silent growth & vague/subtle change. 29
  30. 30. Contributing factors in development of Neuropsychiatric manifestations (contd) - local effects may be seen e.g. focal cognitive deficits with parietal lobe tumor & focal amnesic syndrome with diencephalic tumors - Hallucination – derive from focal lesions of brain • Intra cranial pressure - focal & nonfocal neurological symptoms/signs ( - diffuse cognitive impairment, - changes in attention & concentration - alteration of level of consciousness - anxiety,agitation,irritability,depression/apathy ) 30
  31. 31. Premorbid Patient characteristics & Psychosocial factors • Depression or preexisting psychiatric illness • Cognitive capacity,coping skills, adaptive/maladaptive behavioral style • Psychosocial support • Challenges by tumor and treatment 31
  32. 32. Diagnostic considerations • Symptoms and signs • High index of suspicion & low threshold for diagnosis in new onset psychiatric symptoms, esp - if negative past/personal history - unexplained personality change - New neurological/neurocognitive dysfn • Family History 32
  33. 33. Symptoms suggestive of Brain tumor in Psychiatric patients • New onset seizure (focal/partial/generalised) in adult • Headache - ↑frequency/severity, persistent & nonmigrainous , nocturnal, present on awakening, worsened by position/Valsalva maneuver • Nausea/Vomiting - esp if nonmigrainous headache • ↓ Visual acuity, field cuts and double vision • Unlilateral High Frequency hearing loss,intermittent tinnitus, vertigo • Focal weakness • Focal sensory loss, paresthesias, and dysyesthesias • Gait disturbances, incoordination, ataxia, and dysarthria 33
  34. 34. Diagnostic studies • Plain Skull X-ray : pituitary adenomas, craniopharyngiomas, intracranial calcification, bony metastasis involving skull ( Bone Scan Preferred ) 1. Calcification - oligodendroglioma - meningioma - craniopharyngioma 34
  35. 35. Diagnostic studies • Signs Of Raised Intracranial Pressure: -suture separation(diastasis) - “beaten brass” appreance • Osteolytic lesion : primary/secondary bone tumour. - dermiod/epidermoid - chordoma - nasopharyngeal carcinoma - myeloma 35
  36. 36. Diagnostic studies (contd) CAT SCAN : • Calcification • erosion of bony intracranial structures • shift in midline cerebral structures • Abnormalties involving venetricular system : Hydorcephalus 36
  37. 37. Diagnostic studies • High definition scan: indication - pituitary - orbital - posterior fossa tumour - tumour of skull base Coronal and sagital reconstruction - diagnosing vertical extent - relationship with other structure • IV Contrast : enhance visibility 37
  38. 38. Diagnostic studies (Contd) • MRI Indication - tumours around the skull base/close to bone - brainstem Advantage of MRI - Multiplanar - exact anatomy - paramagnetic enhancement - ↑ sensitivity & clarifies the site of origin. - delineate border b/w tumour & surrounding edema - more sensitive in identifying - small tumours ( < 0.5 cms diameter) solid or cystic - multiple lesions- metastasis 38
  39. 39. Diagnostic studies • Angiography/ MRA: reveal - tumour ‘blush’ - vessel displacement - preoperative information - for identifying feeding to vascular tumours - tumour involvement and constriction of major vessels. 39
  40. 40. Diagnostic studies (Contd) • CT & MRI Cistenography - evaluation of circulation of CSF - morphology of ventricular system - tumor associated hydeocephalus - CSF leaks - Intraventricular tumors • MRI cisternography is better 40
  41. 41. Diagnostic studies (Contd) • Electroencephalography - Non specific information, no precise location - 10-25 % of undiagnosed tumor has no finding/non diagnostic non specific - useful for tumor causing seizure - Findings more in rapidly growing/aggressive • Lumbar Puncture - may be useful in leukemias,lymphomas & meningeal carcinomatosis ( may be missed othervise ) 41
  42. 42. Diagnostic studies (Contd) • Other diagnostic procedures - Chest x-ray, urinalysis & stool exam ( rule out origination of metastatic tumors) - PET & SPECT - tumor recurrence from radiation necrosis - CNS lymphoma from opportunistic infn - Magnetoencephalography (MEG) -may help in phenomenon of disachiasis & disconnection syndromes 42
  43. 43. Diagnostic studies (Contd) - Visual field assesment By Goldman Kinetic perimetry, Humphries static perimetry - Endocrinological evaluation – hypothalamic-pituitary axis (for regional involvement & pt treated with radiotherapy. - Evoked potentials – role in diagnosis & monitoring of Neurological function during surgical resection. 43
  44. 44. Management of Brain tumors • Medical Management (Pharmacological) -Acute treatment/Psychiatric sequelae • Non pharmacological management • Management of tumor - Chemotherapy/Surgery/Radiotherapy • New Therapeutic Modalities 44
  45. 45. Acute Medical Management – Stablise patient with peritumoral oedema/↑ ICT/seizure/Delirium. – Cognitive impairment (slowing of mental performance ,sedation & fatigue )may result from antiepileptics drugs. – Dexamethasone (low mineralocorticoid activity & possibly lesser risk of infn & cognitive impairment(but can cause delirium/psychosis, sleep disturbance & osteopenia ) – Risk of Opportunistic infn – Risk of thromboemolism – Identify hypothalamic-pituitary abnormality 45
  46. 46. Managing Psychiatric Sequalae • Treatment of Anxiety & Depression - SSRI drug of choice • Supportive psychotherapy & CBT recommended • Cognitive deterioration early marker of progression (serial neuropsychiatric testing recommended) • Methylphenidate may improve cognition. • Palliative care – for disabling neurological symptoms ( e.g. dysphagia) 46
  47. 47. Managing Tumor • Chemotherapy : Medulloblastoma, lymphomas, oligodendriomas & germ cell tumor –Highly sensitive • Neurotoxicity is troublesome s/e esp if intrathecal chemotherapy • Intrathecal Methotrexate can cause necrotising encephalopathy. • Cisplatin cause encephalopathy & peripheral neuropathy • Risk of toxicity increases with associated radiotherapy 47
  48. 48. Managing Tumor • Radiotherapy - Cognitive deficits reported in children (RT to brain for acute leukemia),adults in gliomas, brain metastasis, nasopharyngeal malignancies, small lung carcinoma. - Vascular & endothelial damage main features of radiation damage. - Demyelination may happen subsequently - Acute radiation encephalopathy (within 2 weeks) - About 1-6 months after RT may develop radiation encephalopathy 48
  49. 49. Managing Tumor - Late-delayed encephalopathy is serious & irreversible - Memory, attention & new learning are sensitive to RT. - Common neurological sequelae include urinary incontinence, ataxia, pyramidal as well as extrapyramidal signs. - Intensity modulated radiation therapy (IMRT) attack from various angles in 3 dimensional manner. - Gamma knife uses emitted photons that are precisely directed - Cyber knife has compact light weight linear accelerator on a robotic arm 49
  50. 50. New Modalities (a) Gene therapy – Viral genes to malignant cells (b) Signal Transduction Inhibitors – aim to reverse the abnormal activation/suppression responsible for resistance to radiotherapy (c) Immunotherapy – monoclonal antibody against antigens expressed by glioma cells - Interferons also being used (d) Tamoxifen (modulated Protein Kinase C-involved in cellular signal transduction) –may have a role. (e) Stem Cell Therapy- aim to deliver molecules capable of enhancing antitumor immunity/altering their gene structure 50
  51. 51. Main points • Disturbance of affect/personality is not specific to specific portion of brain. • Fast growing tumors cause acute changes , slow growing tumors results in changes in personality. • Neurological symptoms/signs has more localising value. • Depressive symptoms- single most important predictor of quality of life. • Premorbid cognitive capacity/coping skills important in degree of dysfunction. 51
  52. 52. Main points • Treatment can also result in Neuropsychiatric abnormalities. • Identify patient having suicidal tendencies • Avoid drugs at risk of inducing seizure in patient with past h/o of seizure (Bupropion,Lithium carbonate) • Adopt active “here & now” therapeutic psychoeducational approach along with pharmacotherapy 52
  53. 53. • CANCERS SO LIMITED It can't cripple love It can't shatter hope It can't corrode faith It can't eat away peace It can't destroy confidence It can't kill friendship It can't shut out memories It can't silence courage It can't invade the soul It can't reduce eternal life It can't quench the Spirits It can't lessen the power of the resurrection. CANCER IS SO LIMITED It can't cripple love It can't shatter hope It can't corrode faith It can't eat away peace It can't destroy confidence It can't kill friendship It can't shut out memories It can't silence courage It can't invade the soul It can't reduce eternal life It can't quench the Spirits It can't lessen the power of the resurrection. 53
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  55. 55. References • (http://www.cbtrus.org/factsheet/factsheet.h tml ( Central Brain Tumor Registry of the United States ) • Comprehensive Textbook of Psychiatry (Kaplan & Sadock’s) – Ninth Edition • Lishman’s Organic Psychiatry – Fourth Edition 55

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