Medical Neuroscience Quiz 9

NEURO-ONCOLOGY

1. Background:

1. 50% of neoplasms originate from CNS tissue (primary tumors)

2. 50% represent a metastatic source (However, more common than primary tumors

NEURO-ONCOLOGY

1. Background:

   1. Neuroanatomical region:

1. Adults= two thirds arise from SUPRA-tentorium (supratentorial)

2. Children= two thirds arise from BELOW-tentorium (infratentorial)

   1. Second only to leukemia for pediatric cancer

NEURO-ONCOLOGY

1. Background:

   1. 4 most common types of primary CNS tumors (95% of all primary tumors)

1. Giloma

2. Meningioma

3. Pituitary adenoma

4. Acoustic neuroma

NEURO-ONCOLOGY

1. What is Etiology and risk factors:

1. Most CNS neoplasms are thought to arise from individual cell mutations.

2. A few inherited diseases, such as neurofibromatosis, tuberous sclerosis, multiple endocrine neoplasia (type 1), and retinoblastoma, increase the predilection to develop CNS tumors.

3. Primary CNS lymphoma is a relatively frequent occurrence in HIV patients.

4. A prior history of irradiation to head for reasons other than treatment of the present tumor may increase the chance of primary brain tumor

NEURO-ONCOLOGY

1. What is Etiology and risk factors: (continued…)

1. The most common tumors originating from the cerebellopontine angle are acoustic neuroma and meningioma.

2. Metastatic tumors reach the brain via hematogenous dissemination through the arterial system.

   1. Lung cancer—especially small cell lung cancer—is by far the most solid tumor disseminating to the brain, followed by breast cancer, melanoma, and colon cancer.

   2. Less common sources of metastasis are testicular cancer and renal cell cancer

   3. Prostate, uterine, and ovarian cancers are unlikely sources of brain metastasis

NEURO-ONCOLOGY

1. Signs and symptoms:

1. Insidious onset (however, if with bleeding or obstruction to ventricles can have “acute” manifestations.

2. Primary vs Metastasis differentiation cannot be done with symptoms

3. Nonspecific manifestations:

   1. Headache

   2. Altered mental status

   3. Ataxia

   4. Nausea

   5. Vommiting

   6. Weakness

   7. Gait disturbance

NEURO-ONCOLOGY

1. CNS neoplasms also may manifest as follows:

1. Focal seizures

2. Fixed visual changes

3. Speech deficits

4. Focal sensory abnormalities

NEURO-ONCOLOGY

1. Headache associated with intracranial neoplasms have the following characteristics:

1. Often is a late complaint

2. Usually not an isolated finding

3. The worst symptom is only one half of patients

4. Usually nonspecific and resembles tension-type headaches

5. in patients with established headache, may manifest as a change in the headache pattern

6. New onset of headaches in the midlle-aged or older patients is worrisome

NEURO-ONCOLOGY

1. Headache associated with intracranial neoplasms have the following characteristics: (continued..)

1. The location of the headache reliably indicates the side of the head affected, but it does not indicate the precise site of the tumor

2. Headaches are more common with posterior fossa tumors

3. Headache is a more frequent symptom of intracranial tumor in pediatric patients

4. Accompanied by nausea and/or vomiting up to 40% of the time

NEURO-ONCOLOGY

1. Location dictates generalized or focal deficit:

1. Papilledema,(higher pediatric incidence)= increase in intracranial pressure (ICP) of several days or longer

2. Diplopia = displacement or compression of the sixth cranial nerve at the base of the brain

3. Impaired upward gaze (Parinaud syndrome)= pineal tumors

4. Homonymous hemianopia or partial visual field deficits = Tumors of the occipital lobe

5. Anosmia = frontal lobe tumors

6. Cranial nerve palsies, ataxia, incoordination, nystagmus, pyramidal signs, and sensort deficits on one or both sides of the body = Brainstem and cerebellar tumors

NEURO-ONCOLOGY

1. What are the roles of CT scans ?

1. FIrst, Start with history, physical (focused approach)

2. Then, Obtain regular bloodwork (CBC, coagulation, electrolytes, metabolic panel)

3. Get CT if any of these:

   1. Acute mental status changes

   2. New-onset seizures

   3. Focal motor or sensory deficits, including gait disturbance

   4. Suspicious headache

   5. Signs of elavated ICP (eg,papilledema)

*Definitve diagnosis requires tissue biopsy performed by a qualified neurosurgeon

NEURO-ONCOLOGY

1. CT findings (not pathognomonic):

1. most tumors demonstrate enhancement with contrast material administration

2. Tumors may appear hypodense, or hyperdense or have mixed density

3. Metastases to the brain tend to be multiple, but certain tumors (l,e., renall cell carcinomas) tend to produce solitary metastatic brain lesions

NEURO-ONCOLOGY

1. The role of MRI:

1. MRI is most helpful for identifying tumors in the posterior fossa (including acoustic neuromas) and hemorrhagic lesions

2. MRI is useful in patients with an allergy to iodinated contrast material or renal insufficiency

3. Drawbacks to MRI include incompatibility with certain medical equipment, longer imaging times (increased risk of motion artifact), and poor visualization of the subarachnoid space

4. Neither CT nor MRI can be used to differentiate tumor recurrence from radio-necrosis

NEURO-ONCOLOGY

1. Management:

1. Acute treatment for cerebral edema from intracranial neoplasms:

   1. Corticosteroids may dramatically reduce signs and symptoms, bringing relief within a few hours

   2. Dexamethasone is the agent of choice (4-24 mg/d)

2. Definitive treatment is as follows:

   1. Multidisciplinary: neurosurgeon, an oncologist, a radiologist, and radiation theropist

   2. Varies greatly depending on tumor location, tissue type, and comorbid conditions

   3. Surgical treatment options:

      1. Tumor removal or debulking, instalation of a ventricular shunt, and/or placement of radioactive implants

NEURO-ONCOLOGY

1. Prognosis

1. Tumor resectability, tumor location, age of the patient, and tumor histology are the primary determination of survival.

2. Without radiation therapy, the mean life expentancy of a patient with brain metastases is 1 month. Radiation therapy may extend survival to 4-6 months.

3. Patients with seizures secondary to brain tumor generally experience obvious neurologic deterioration over a 6-month course.

4. Most patients with brain metastases die from progression of their primary malignancy rather than from brain damage

HEADACHE

1. International classification of headache disorders:

1. Primary Headache(main focus for our conversation next..)

   1. Tension Headache

   2. Migraine

   3. Cluster headache

2. And Secondary headache (not the main focus of our conversation)

HEADACHE

1. Tension Headache: Clinical Presentation:

1. Throbbing in quality and is usually more gradual than the onset in migraines.

2. Compared with migraines, tension-type headaches are more variable in duration, more constant in quality, and less severe.

HEADACHE: TENSION HEADACHE

1. IHS diagnostic criteria for tension-type headaches states that two of the following characteristics must be present:

1. Pressing or tightening (nonpulsatile quality)

2. Frontal-occipital location

3. Bilateral - Mild/moderate intensity

4. Not aggravated by physical activity

HEADACHE: TENSION HEADACHE

1. Tension-type heache history is as follows:

1. Duration of 30 minutes to 7 days

2. No nausea or vomiting (anorexia may occur)

3. Photophobia and/or phonophobia

4. Minimum of 10 previous headache episodes; fewer than 180 days per year with headache to be considered “infrequent”

5. Bilateral and occipitonuchal or bifrontal pain

6. Pain described as “fullness, tightness/squeezing, pressure,”or “bandlike/viselike”

7. May occur acutely under emotional distress or intense worry

HEADACHE: TENSION HEADACHE

1. History (continued..)

1. Insomnia

2. Often present upon rising or shortly thereafter

3. Muscular Tightness or stiffness in neck, occipital, and frontal regions

4. Duration of more than 5 years in 75% of patients with chronic headaches

5. Difficulty concentrating

6. No prodrome

*New headache onset in elderly patients should suggest etiologies other than tension headache.

HEADACHE: TENSION HEADACHE

1. work-up for Tension headache:

1. Laboratory work should be unremarkable

2. Specific tests should be obtained if the history or physical examination suggest another diagnostic possibility

3. Head CT scan or MRI is necessary only when the headache pattern has changed recently, the headache cannot be clearly defined by the clinician as a common primary headache disorder(that is not a cluster, migraine, or tension-type of headache), or neurologic examination reveals abnormal findings.

HEADACHE: TENSION HEADACHE

1. General Management of Tension Headache:

1. Hot or cold packs, ultrasound, electrical stimulation, Improvement of posture, trigger point injections, occipital nerve blocks, stretching, and relaxation techniques.

2. Regular exercise, stretching, balanced meals, and adequate sleep

HEADACHE: TENSION HEADACHE

1. Medications available for Tension Headache:

1. NSAIDs

2. Acetylsalicylic acid

3. Barbiturates

4. Analgesics

5. Ergot alkaloids/derivatives

HEADACHE: TENSION HEADACHE

1. Considerations for medication usage in Tension headache:

1. Avoid repeated use of OTC pain relievers as these can cause medication overuse headaches

2. Opiods nor barbiturates should be used in TTH when better options (eg, simple analgesics and combination analgesics containing caffeine) are available.

3. Barbiturates may be used when all other treatment options have failed.

HEADACHE: CLUSTER HEADACHE

1. What is a Cluster Headache:

1. Also reffered to as a trigeminal autonomic cephalalgia

   1. Primary neurovascular headache disorder characterized by recurrent, stricly unilateral attacks of severe pain in the orbital, supraorbital, or temporal regions

   2. These attacks are often accompanied by ipsilateral autonomic symptoms, including conjunctival injection, lacrimination, nasal congestion, rhinorrhea, ptosis, or miosis. The attacks last between 15 and 180 minutes and occur from once every other day up to eight times daily.

HEADACHE: CLUSTER HEADACHE

1. What is Etiology:

1. Unknown origin

2. Precipitating factors include:

   1. Stress, allergens, seasonal changes, nitroglycerin and alcohol

HEADACHE: CLUSTER HEADACHE

1. Diagnosis is ______

2. Workup______

1. Diagnosis is highly clinical (imaging only if other causes suspected)

2. Workup unremarkable

HEADACHE: CLUSTER HEADACHE

1. What is the Management :

1. Abortive/symptomatic agents:

   1. Oxygen, triptans, ergot alkaloids, and anesthetics.

2. Preventive/prophylactic agents:

   1. Calcium channel blockers, mood stabilizers, and anticonvulsants

HEADACHE: MIGRAINE

1. What are General considerations:

1. Complex disorder characterized by recurrent episodes of headache,

2. Most often unilateral and in some cases associated with visual or sensory symptoms—collectively known as an aura.

3. Migraine is most common in women and has a strong genetic component

HEADACHE: MIGRAINE

1. What are some Clinical characteristics:

1. Throbbing or pulsatile headache, with moderate to severe pain that intensifies with movement or physical activity

2. Unilateral and localized pain in the frontotemporal and ocular area, but the pain may be felt anywhere around the head or neck

3. Pain builds up over a period of 1-2 hours, progressing posteriorly and becoming diffuse

4. Headache lasts 4-72 hours

5. Nausea (80%) and vomiting(50%), including anorexia and food intolerance, and light-headedness

6. Sensitivity to light and sound

HEADACHE: MIGRAINE

1. Features of migraine aura:

1. May precede or accompany the headache phase or may occur in isolation

2. Usually develops over 5-20 minutes and lasts less than 60 minutes

3. Most commonly visual but can be sensory, motor, or any combination of these

4. Visual symptoms may be positive or negative

5. The most common positive visual phenomenom is the scintillating scotoma, an arc or band of absent vision with shimmering or glittering zigzag border

HEADACHE: MIGRAINE

1. Any of the folowing features suggest secondary headache disorder and warrant further investigation: First 6

1. The first or worst headache of the patient’s life, especially if rapid in onset

2. A change in frequency, severity, or clinical features of the attack

3. New progressive headache that persists for days

4. Precipitation of headache with Valsalva maneuvers (i.e., coughing,sneezing, bearing down)

5. The presence of associated neuroligic signs or symptoms (i.e., diplopia, loss of sensation, weakness, ataxia)

6. Onset of headaches after the age of 55 years

HEADACHE: MIGRAINE

1. Any of the following features suggest secondary headache disorder and warrant further investigation: Last 5

1. Headache developing after head injury or major trauma

2. Persistent, 1-sided throbbing headaches

3. Headache accompanied by stiff neck or fever

4. Atypical history or unusual character that does not fulfill the criteria for migraine

5. Inadequate response to optimal therapy

HEADACHE: MIGRAINE

1. What are Management considerations:

1. Do not administer opiate analgesics in the ED until after evaluated ny neurologist

2. Acute management

3. Preventive management