NEUROLOGIC SYMPTOMSNEUROLOGIC SYMPTOMS– BRAIN TUMORS– BRAIN TUMORS

INTP - PPO, PHO, IAP.P2 – 27 slides

Topic IncludesTopic Includes

Clinical history Presentation / signs Diagnosis Classification Treatment overview Management of common tumors

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Pediatric Brain Pediatric Brain TumorsTumors

Commonest Solid Tumors Symptoms mimic other conditions Delay in diagnosis possible High index of suspicion necessary Long term survivors more than 60%

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Clinical Summary: 06 year, female child Complaints – Headache, vomiting Unsteadiness of gait / difficulty in

walking/ swaying visual deterioration

Case –1

Clinical signs

No cranial nerve palsy

No sensory / Motor deficit

Conscious / cooperative

Reflexes (N)

Rhomberg’s sign absent

Bilateral papillodema (+)

Broad based gait

Falls on either side (Lt) > (Rt)

(Lt) cerebellar signs positive

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Case – 2Clinical summary: 07 year male child complaints difficulty in

swallowing/speech weakness (Rt) side of body, double vision, altered sensorium.

Case – 3Clinical summary: 14 year male child, complaints headache,

seizures, memory loss

Possible diagnosis: Brain tumor/neoplasmINTP - PPO, PHO, IAP.P2 – 5/27

Normal Anatomy Normal Anatomy of Brain (MRI)of Brain (MRI)

Supratentorial compartment: Cerebral hemispheres Basal ganglia Thalamic nuclei Lateral ventricles Hypothalamus Corpus callosum

Infratentorial compartment: Cerebellum Brain stem (MB/P/MO) 4th ventricle

Sagittal

AxialINTP - PPO, PHO, IAP.P2 – 6/27

Clinical SymptomsClinical Symptoms Location / age Non localised / raised intracranial pressure Localised

Nonlocalised Tumor mass Blockage of CSF pathways

Weight loss, listlessness, irritability, decreased appetite, lethargy / withdrawn behaviour, headache, vomiting, double vision.

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Clinical SymptomsClinical Symptoms

Infratentorial tumors Symptoms of ICP Imbalance / Swaying Diplopia, swallowing

difficulty

Intrinsic brain tumors Diplopia, swallowing and

breathing difficulty, weakness limbs, swaying ICP

Supratentorial tumors

Weakness of limbs, loss of sensation, abnormal vision, learning difficulty, memory loss,

Deep midline tumors

Obesity, visual complaints, growth abnormalities.

Localised

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Clinical Signs

Non-localisedPapillodema, head circumference, malaligned eyes, cranial nerve palsy (6th)

LocalisedInfratentorial tumorsAtaxia, defects in co-ordination, nystagmus, abnormal speech.Intrinsic brain tumorsCranial neuropathy, long tract signs, ataxia.Supratentorial tumors Hemiparesis, hemisensory, visual field abnormalities, cognitive/learning difficulties, seizures.Deep midline tumorsEndocrinopathies, visual acuity and visual, field abnormalities, Parinaud’s syndrome.

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Pediatric Brain TumorsPediatric Brain TumorsDiagnosisDiagnosis

ImagingCT scan (plain + contrast)

MRI with Contrast (Gd) MRI preferred sensitivityresolution three planer views

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Pediatric Brain TumorsPediatric Brain Tumors

Posterior fossa neoplasm – MedulloblastomaINTP - PPO, PHO, IAP.P2 – 11/27

Intrinsic pontine glioma

Pediatric Brain TumorsPediatric Brain Tumors

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Pediatric Brain TumorsPediatric Brain Tumors

Supratentorial tumors – Astrocytoma & ependymoma

Pinealoblastoma & craniopharyngioma INTP - PPO, PHO, IAP.P2 – 13/27

Histologic: Craniotomy / Tumor resection CT/MRI / STB Exception Pontine glioma

Pediatric Brain TumorsPediatric Brain TumorsDiagnosisDiagnosis

Classification: Histology Location – Differs from adult brain neoplasms

Low grade Infratentorial

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Common Brain TumorsCommon Brain Tumors

Location Percentage

Infratentorial 45-60

Supratentorial Hemispheric

Midline – Suprasellular / Pineal region

25-40

15-20

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Medulloblastoma undifferentiated, barophilic round to oral nuclei with minimal perceptible cytoplasm

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Distribution of common brain tumors in children Distribution of common brain tumors in children – location and histologic appearance– location and histologic appearance

Infra-tentorial % of all brain tumors

PNET (Medulloblastoma) 20-25

Low grade astrocytoma cerebellar

12-18

Ependynoma 4-8

Malignant glioma, brain stem 3-6

Other 2-5

Total 45-60INTP - PPO, PHO, IAP.P2 – 17/27

Supratentorial % of all brain tumors

Low grade astrocytoma 8-20

Malignant glioma 6-12

Ependymoma 2-5

Mixed glioma 1-5

Ganglioglioma 1-5

Oligodendroglioma 1-2

Chorioid plexus tumor 1-2

PNET 1-2

Meningioma 0.5-2

Other 1-3

Total 25-40

Distribution of common brain tumors in children Distribution of common brain tumors in children – location and histologic appearance– location and histologic appearance

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Supratentorial midline % of all brain tumors

Suprasellar

Craniopharyngioma 6-9

Low grade glioma, chasmatic hypothalamic 4-8

Germ cell tumor 1-2

Pituitary adenoma 0.5-2.5

Pineal region

Low grade glioma 1-2

Germ cell tumor 0.5-2

Pineal parenchymal tumor 0.5-2

Total 15-20

Distribution of common brain tumors in children Distribution of common brain tumors in children – location and histologic appearance– location and histologic appearance

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Staging Work upStaging Work up

Dissemination extraneurally rare – staging work up seldom indicated

Spinal MRI/CSF cytology – mandatory Medulloblastoma, PF ependymoma, Germ cell tumor

Blood / CSF - FP, Hcg – Germ cell tumors

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TreatmentTreatment General principlesGeneral principles

Surgery Diagnosis Tumor burden is decreased/reduced CT/MRI Guided STB Open biopsy / extensive microsurgical

resectionINTP - PPO, PHO, IAP.P2 – 21/27

Problem Associated tumors Peri / intraoperative Management

Postop management

Odema Large tumors small tumors in critical areas

Corticosteroids Dexona

0.1mg/kg Q6h

Corticosteroids tapered

Obstructive hydrocephalus

Intra and periventricular tumors

External ventricular drain placement or VP shunt

Closure or permanent

Seizures Tumors of cerebral hemispheres

Anticonvulsant phenytoin

Stopped in follow-up

Hypothalamic Pituitary hormonal insufficiency

Tumors close to hypothalamus

Endocrine Evaluation, Steroids fluid and electrolyte balance

Hormone replacement

Perioperative ManagementPerioperative Management

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Radiotherapy High energy machines Volume – Craniospinal irradiation, localised

irradiation Dose – 50-60 Gy / 24-36 Gy, 180-200 Gy / # STRS/STRT – Interstitial brachytherapy /

conformal and intensity modulated treatment Delay/defer irradiation for children younger than

3 years

TreatmentTreatment General principlesGeneral principles

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Useful and standard

Medulloblastoma, malignant astrocytomas, optic pathway / hypothalamic gliomas, malignant tumors in children less than 3 years of age.

Upfront CT / neo-adjuvant CT, HD CT - BMT

Useful drugs: CCNU/VCR/Prednisalone, Procarbazine, Carboplatinum, Vincristine, Temozolamide

TreatmentTreatment General principlesGeneral principles

ChemotherapyChemotherapy

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Infratentorial TumorsInfratentorial Tumors

High risk M1

>1.5 cms residual tumor <3 years RT + CT

Standard risk RT ?CT

Medulloblastoma Sx Adjuvant Treatment

Cerebellar Astrocytoma Ependymomas Brain stem glioma

Sx alone ?RT (adjuvant) Sx Adjuvant RT RT alone

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Supratentorial TumorsSupratentorial TumorsHemispheric tumors:

Gliomas: Low grade: Sx alone

High grade: Sx RT + CT (adjuvant)

Ependymomas: Sx RT (adjuvant)

Optic pathway/ Sx CT RT

Hypothalamic

Gliomas Craniopharyngioma Sx RT Pineal region tumors Individualized

treatment

Midline Supratentorial Tumors

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