BRAIN TUMORS - Schwartz  Do NOT infiltrate brain:

Intracranial Tumors  Juvenile pilocytic astrocytoma

 Cause mass effect, dysfunction/destruction of adjacent  Pleomorphic xanthoastrocytoma
neural structures, swelling, abnormal electrical activity  (Both) are circumscribed, low grade & w/
or combination good prognosis
 Higher grade:
 Supratentorial tumors  Hypercellularity
 FND  Nuclear atypia
 CL weakness  Endovascular hyperplasia
 Visual field deficit  Necrosis  OnLy w/ GBM; required for Dx
 Headache
 Seizure  OLIGODENDROGLIOMA
 Infratentorial tumors  10% of gliomas
 Hydrocephalus   ICP  compression of CN4    seizures
headache, n/v, diplopia  CT/MRI:  calcifications &  hemorrhages
 RARE seizures  Grade I – IV
 Prognosis is better than astrocytoma
 Cerebellar hemisphere/ brainstem dysfunction  Prognosis: 2-7 years
 Ataxia, nystagmus, CN palsies  Respond to:
 ALL px suspect for brain tumor  MRI (w/ AND w/o  Procarbazine
gadolinium); evaluation study of choice!  Lomustine (CCNU)
 Initial Mx:  Vincristine (PCV)
 Dexamethasone (if edema)
 Phenytoin (supratentorial tumors only)  EPENDYMOMA
 Lining of ventricular system: cuboidal/columnar
Metastatic Tumors ependymal cells
 In decreasing frequency  Infratentorial  2/3 adult
 Lung - more than half  From floor of 4th ventricle (off the back of the
 Breast - brainstem  making gross total resection often
 Kidney impossible)
 GI Tract  Mx: Suboccipital craniotomy & midline
 Melanoma separation of the cerebellar hemisphere
 Travel hematogenously & seed gray-white junction  Supratentorial  pediatric
(other locations: cerebellum & meninges  w/c can  From lateral / 3rd ventricle
lead to carcinomatous meningitis: Leptomeningeal
carcinomatosis)  @ Foramen of Luschka
 Mx:  CPA tumor
 Depends on primary tumor  “drop mets”  spread @ CSF to spinal cord
 Tumor burden
 Px’s medical condition  S/S: Headache, n/v, vertigo  2ndary to  ICP
 Location & number of metastases from obstruction to CSF flow
 Craniotomy is NOT advisable unless ALL detectable  Histology:
metastases can be accessed/resected  Papillary ependymoma
 Surgery SHOULD be followed by whole brain radiation  Anaplastic ependymoma   mitotic activity &
therapy   average survival to 8 months areas of necrosis
 Radiation may be delayed until recurrence in low   Postop Radiation Therapy
grade tumors  CSF spread (documented by LP or CEMRI)  w/
 Stereotactic surgery (gamma knife)  multiple whole spine radiation
metastases; gross total resection w/o unacceptable
devastating neurologic deficit  CHOROID PLEXUS PAPILLOMA
 Many small vascular tufts covered w/ cuboidal
Glial Tumors epithelium
 Glial cells  provide the anatomic & physiologic  Part of interface between blood & brain
support for neurons & their processes  Choroid cells  create CSF from blood
 ASTROCYTOMA  Choroid plexus CARCINOMAS (rare, pediatric)
 Most common primary CNS neoplasm
 “Glioma”  Occur in infants (supratentorial @ lateral ventricle)
 Grade:  … in adults (infratentorial @ 4th ventricle)
 I  low grade  well circumscribed, extensive vasculature
 II  low grade  S/S  ICP
 Median survival: 8 years  Tx excision
 III  anaplastic astrocytoma  DO NOT USE Radiation or Chemotx
 Median survival: 2-3 years
 IV  glioblastoma multiforme (GBM)
 Median survival: 1 year
 2/3 of all astrocytomas

1
traboco
Neural Tumors & Mixed Tumors  Pituitary Adenoma
 Medulloblastomas  Anterior Pituitary (Adenohypophysis)
 PNETS  most common; arise from bipotential cells  Microadenoma (<1cm) / Macro
(capable of differentiating into neurons or glial  Functional (endocrine) / Nonfunctional (mass
cells) effect)
 1st and 3rd decade
 most common pediatric malignant tumor; usually  Endocrine Dysfunction
midline & @ cerebellum  Cushing’s disease  ACTH secretion
 S/S  ICP  Forbes-Albright syndrome  PRL secretion
 Histo:  Tx: Dopamine
 Densely packed small round cells w/ large  Sx if persistent mass effect
nuclei & scant cytoplasm  Acromegaly  Growth hormone secretion
 NOT encapsulated, frequently disseminated  S/S
 Tx:  Visual field defects  compression of optic
 Surgical resection  radiation tx  chemotx chiasm
 Panhypopituitarism  compression of entire
 Ganglioglioma gland
 Mixed tumor (neurons & glial cells)  Hemorrhage  Pituitary apoplexy
 First 3 decades  Headache
 Medial temporal lobe  seizure  Visual disturbance
 Circumscribed masses that may contain cysts/   mental status
calcium  endocrine disfunction
 Mx: Transphenoidal Sx (through the nose)
Neural Crest Tumor
 Multipotent
 Hemangioblastoma
Miscellaneous tumors  @ Posterior fossa
 MENINGIOMA  20%  Von Hippel-Lindau disease
 From arachnoid cells (arachnoid matter)  multisystem neoplastic d/o
 From dura matter (grossly & MRI)  “Dural-based  also assoc w/:
tumors”  Renal cell CA
 Locations:  Pheochromocytomas
 Falx  Retinal angiomas
 Convexities (cerebral hemispheres)  Appear as cystic w/ mural nodule (enhancing tumor
 Sphenoid wing @ cyst wall)
 Less common:  Mx: En bloc resection of mural nodule alone is
 Foramen magnum sufficient
 Olfactory groove  Sx resection is curative for sporadic (non-VHL)
 Inside Lateral ventricle tumors
 Mostly slow growing, encapsulated, benign  Patho:
 If malignant  invade adjacent bone or into  Thin walled vascular channels (internal
cortex debulking may be bloody)
 Previous cranial irradiation increases incidence
 10% - multiple  Lymphoma
 Primarily @ CNS or 2ndary to systemic disease
 Vestibular Schwannoma (Acoustic Neuroma)  Incidence:
 Arise from the superior half of the vestibular  Transplant px
portion of vestibulocochlear nerve (CN 8)  AIDS
 S/S:  S/S:
 Progressive hearing loss  Mental status changes
 Tinnitus  Headache   ICP
 Balance difficulty  CN palsy  lymphomatous meningitis
 Large tumors: (~carcinomatous meningitis)
 brainstem compression  Hyperdense on CT (dense cellularity)
 obstructive hydrocephalus  Sx excision: little role
 If bilateral  NF 2  Tx: steroids, whole brain radiation, chemotherapy
 Chromosome 22 mutation (intrathecal methotrexate)
  incidence of spinal & cranial meningiomas &
gliomas
 Tx: microsurgical resection or gamma knife
 Main complication: Damage to CN 7 – Facial Nerve
(because it runs through the internal auditory canal
w/ CN 8)  this risk  with  tumor diameter

2
traboco
Embryologic Tumors BRAIN ABSCESS
 Failure to involute or differentiate properly  Encapsulated infection w/in brain parenchyma
 Spread hematogenously in px w/
 Craniopharyngioma  endocarditis
 Benign, cystic lesions in children  intracardiac
 2nd peak of occurrence (50 y/o)  intrapulmonary RL shunts
 All pediatric & 50% of adult craniopharyngiomas  migration from sinuses or ear
calcify  direct seeding by penetrating trauma
 S/S:  Disorganized cerebritis  preceedes abscess formation
 Compression of adjacent structures (optic  S/S:
chiasm)  Headache
 Pituitary/ hypothalamic dysfunction or  Nausea
hydrocephalus may develop  Lethargy
 Sx:  FND (hemiparesis)
 Excision is easier in children (soft & suckable  Extremis (???)  if abscess ruptures into ventricular
tumor) system
 Adult tumors (firm & adherent to adjacent vital  CT/MRI: Well demarcated, ring enhancing, thin walled
structures) lesions w/ assoc edema & mass effect
 Complications from Sx:  Blood & CSF cultures: rarely give definitive diagnosis
 Visual loss
 Pituitary endocrine hypofunction
 Diabetes insipidus
 Cognitive impairment (basal frontal injury)

 Epidermoid
 Cystic lesions w/ stratified squamous epithelial
walls from trapped ectodermal cell rests
 Grow slow & linearly by desquamation into cyst
cavity
 Contain:
 Keratin
 Cholesterol
 Cellular debris
 CPA Angle
 Mollaret’s Meningitis  recurrent bouts of aseptic
meningitis due to release of irritating cyst contents
into subarachnoid space

 Dermoid
 Less common than epidermods
 Contain hair follicles, sebaceous glands, squamous
epithelium
 Midline structures
 Bacterial meningitis if associated with skin sinus
tract

 Teratoma
 Midline (often @ pineal region  area behind 3rd
ventricle, above midbrain & cerebellum)
 Contain elements from all 3 germ layers: endo,
meso & ectoderm
 Contain skin, cartilage, GI glands, teeth
 If w/ more pirimitive structures = more malignant

3
traboco
CEREBROVASCULAR DISEASE - Schwartz  Majority enter: Anterior carotid circulation

 Most frequent case of new rapid-onset, nontraumatic  Common types:

neurologic deficit ACA stroke Medial frontal, CL leg wkness
 More common than seizures or tumors Parietal lobes,
 Risk factors: (motor strip)
 Diabeters MCA stroke Lateral frontal, CL face & arm
  cholesterol Parietal lobes, wkness
  BP Temporal lobes
 Smoking Dominant Language deficits
 Vascular damage by: hemisphere
 Atheroma deposition  luminal stenosis Proximal MCA Mass effect &
 Endothelial damage  thrombogenesis (ischemia & midline shift
 Weakening of vessel wall  aneursym swelling)
formation/dissection PCA stroke Occipital lobe CL homonymous
hemianopsia
Ischemic Diseases PICA stroke Lateral medulla, N/V, dysphagia,
 85% of acute cerebrovascular events Inferior half of IL Horner’s,
 Complete occlusion of the carotid artery the cerebellar IL limb ataxia
 Can be asymptomatic because of CL carotid & hemispheres
basilar artery *Lateral
 However! Px can have variable anatomy of the Circle Medullary
of Willis Syndrome*
 Some may have a hypoplastic/ missing OR
communicating artery, dominant artery, one origin, *Wallenberg’s
etc.. syndrome*

TIA  Transient ischemic Sudden onset focal  Mx:

attack neurologic deficit that  Goals:
resolves w/in 24 hrs  Reopen occluded vessel
RIND  Reversible ischemic Resolves 24 hrs – 1 wk  Recombinant tPA
neurologic deficit  W/in 3 hrs of onset of neurologic
CVA  Cerebrovascular Permanent deficits ; deficit (improves outcome @ 3
accident “complete stroke” months)
 Contraindications:
 ICH
Thrombotic Diseases  Majory surgery in the previous 2
 Most common area of neurologically significant vessel wks
thrombosis  CAROTID ARTERY (@ bifurcation)  Platelet (<100K/L)
  chronic narrowing by atheroma  SBP >185mmGg
 Maintain blood flow to borderline ischemic
 More common concern  THROMBOEMBOLUS tissues (ischemic penumbra)
 Head CT Scan  differentiate Ischemic from
 Mx: Hemorhagic
Complete occlusion of CA No tx  Allow BP to run high to maximize cerebral perfusion
w/o referable neurologic  SBP > 180mmHg may require tx
deficit  NSS w/o glucose (glucose injures neurons in
New neurologic deficit & Emergency carotid penumbra)
angiographically endarterectomy  Swelling typically peaks 3-5 days after the stroke
demonstrated complete CA  Significant swelling may require:
occlusion CL to the s/s  Hemicraniectomy
 Suboccipital craniectomy
 Surgery should NOT be done on obtunded &
comatose px Hemorrhagic Diseases
 Surgery SHOULD be done w/in 2 hrs of symptom  15% of acute cerebrovascular events
onset  HTN & amyloid angiopathy  account for most ICH
 Other causes
Embolic Diseases  AVM
 From…  Aneurysms
 Left atrium  atrial fibrillation  Venous thrombosis
 Hypokinetic Left ventricular wall segment  Tumors
 Valvular vegetations  Hemorrhagic conversion of ischemic infarct
 Atheromatous aortic arch  Fungal infections
 Stenosed carotid bifurcations
 Systemic venous sys (RL shunt like patent
foramen ovale)
4
traboco
 ICH  intracranial/ intraparenchymal hemorrhage
 Causes local/global neuronal injury/dysfunction
 Mass effect
 AVM / aneurysm  SAH (subarachnoid hemorrhage)
 Major cerberal & cortical blood vessels travel
between the pia & arachnoid membrane (@
subarachnoid space)
 SAH 
 Exposure of brain to intra-arterial pressure
pulsations
 Delayed ischemia  cerebral arterial
vasospasm
 Meningeal linings of the brain are sensitive 
sudden, severe, “thunderclap” headache
 “worst headache of my life!” 
 CT immediately!
 Acute SAH  bright signal
 Rapid, non invasive, 95% sensitive
 LP
 Suspicious symptoms but negative CT
 SAH: do not decrease from test tubes 1-4
 Xanthochromia
  RBC (100K/L)
 4 vessel angiography
 w/in 24 hrs, assess for aneurysm, other
vascular malformation, etc
 Catheter angiography  GOLD standard
 Hunt Hess classification:
 Grade 4-5  intubation/ hemodynamic
monitoring & stabilization
 Vasospasm
 cerebral arteries constrict 
ischemia/stroke (4-21 days) after SAH
 prophylaxis:
 maintain HTN & mild hypovolemia
(optimize perfusion)
 Nimodipine  CCB,  spasm
 Neurointerventional: (Vasospasm)
 Intra-arterial papverine
 Balloon angioplasty
 More likely to present lethargic or obtunded
 Mass effect (acutely)  Brain shift & herniation 
Depressed mental status
 Hypertension
 Chronic degenerative vasculopathy   ICH risk 4x
 Locations:
 Basal Ganglia
 Thalamus
 Pons
 Result from breakage of small perforating arteries
that branch off of much larger vessels
 Medical Mx:
 Blood dissects through & along neural tracts 
intact, salvageable neurons!!
 Moderate BP control
 Normalize platelet & clotting fxn
 Phenytoin
 Electrolyte Mx
 Intubate  prevent aspiration & hypercarbia
 Surgical:
 Superficial clot location
 Young age
 Non-dominant hemisphere
 Rapid deterioration
 Significant mass effect
 Amyloid Angiopathy
 Amyloid deposition in the media of small cortical
vessels 
 Compromise vessel integrity
 Superficial (lobar) hemorrhages
 Surgical evacuation less morbid
 Multiple hemorrhages
 Medical Mx!!
 Cerebral Aneurysm
 Focal dilatation of the vessel wall
 Balloon-like outpouching, or fusiform
 Thin walled, risk for rupture (lie @ subarachnoid
space)  SAH
 @ branch points of major vessels
 ICA bifurcation
 @ origin of smaller vessels
 PICA
 Opthalmic artery
 85% from anterior circulation (carotid)
 15% from posterior circulation (vertebrobasilar)
 Mx: early aneurysmal occlusion
 Craniotomy w/ microsurgical dissection &
placement of a titanium clip across the
aneurysm neck
 Exclude aneursym from from circulation
 Definitive cure
 young age
 good medical condition
 broad aneurysm necks
 Endovascular placement of looped titanium
coils inside the aneurysm dome
 Coils support thrombosis & prevent blood
flow to aneurysm
 Coils can move and compact over time
(repeat! )
 Old, medically frail px
 Narrow aneurysm necks
 Mortality rate of 50% in the first month
 Most require rehabilitation
 AVM
 Abnormal dilated arteries & veins w/o an
intervening capillary bed
 Nidus   tangles mass of vessels but  neural
tissue!
 Small AVM  hemorrhage
 Large AVM  seizure
 Mx:
 Definitive tx  delayed 3-4 wks
 Allow the brain to recover from acute
injury!
 Hypertension & hypervolemia NOT beneficial
 Because the adjacent brain may be
hyperemic after removal of the high flow
AV shunt

5
traboco
 Tx:
 Microsurgical excision
 Endovascular glue embolization
 Reduces flow through AVM
 Usually considered as adjunctive tx
 Steriotactic radiosurgery
 Lesions < 3 cm
  2 yr time lag (AVM may bleed in the
interval)

 High grade AVM  difficult to resect w/o

causing significant neurologic deficit;
radiosurgery can tx this
 Large
 Near eloquent cortex
 Drain to deep venous structures

Les

6
traboco