SPACE OCCUPYING LESIONS

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Tumour definition
A brain tumour is a mass of abnormal

tissue growing in any part of the brain. For some unknown reason, some brain cells multiply in an uncontrolled manner and form these tumours.

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 These tumours can arise from any part of the brain, spinal

cord or the nerves

AGE:childhood (3- 12 years)

adult(55- 65years) AETIOLOGY: ILLUNDERSTOOD HEREDITARY ROLE OF ONCOGENES RECENT STUDIES:TISSUE CULTURE IN- VITRO, IN-VIVO -------CELL KINECTICS INVASIVE INDEX-------CHROMOSOME www.similima.com 4 ANALYSIS IN TUMOR TISSUE

Broadly tumours classified:

Slow growth, no spread Increase in size and cause pressure on brain affects the mind and body.

Grow faster Spreading in nature(brain or spinal cord)

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BENIGN: meningiomas, pituitary adenoma, craniopharyngioma, epidermoid cysts, neurocytoma, haemangioma, pilocytic astrocytoma, etc.

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MALIGNANT: Astrocytoma/Glioma ependymoma medulloblastoma lymphoma Germ cell tumours.

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By location and origin of the neoplasm

Primary brain tumours

Secondary brain tumours

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Primary brain tumors Primary neoplasms of the brain are tumors that originate in the intracranial sphere or the central spinal canal, based on the organic tissues that make up the brain and the spinal cord.

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 Secondary brain tumors

Secondary tumors of the brain are metastatic tumors

that invaded the intracranial sphere from cancers primarily located in other organs such as breast, lungs, kidneys,thyroid.

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CLINICAL FEATURES
Mainly depends on Age Location Nature Rate of growth Effect on CSF pathways
ONSET: INSIDIOUS
COURSE: PROGRESSIVE RARELY: stroke,
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haemorrhage,remissions/exacerbations

 HEADACHE:

Intermittent..severe(progressing to sleep disturbance) < morning Throbbing type of headache < stooping, straining, exertion. PAIN: Frontal.retroorbital pain Posterior occipetal pain Foramen herniationsuboccipetal pain with or without neck stiffness. VOMITING: Associated with or without nausea, occuring at peaks of www.similima.com 13 headache.

 PAPILLOEDEMA:(sign of ICP)

The expanding tumors especially in children produce blindness with or without episodesof transitory visual obscurations. OPTIC ATROPHY: Visual loss irreversible ABDUCENS NERVE PALSY: Unilateral or bilateral ,diplopia, squint. FOCAL SYMPTOMS: Compressing Displacing Distorting EPILEPSY: 14 Focalwww.similima.com or generalised seizure.

Some Common Symptoms

Limb weakness and any abnormal sensation in the limbs

can be a symptom of a tumour in and around motor/sensory area of opposite side. Unsteady walking or imbalance (ataxia) may occur if the tumour is in the cerebellum. vision dimness, because of compression, or swollen optic nerve(papilloedema), squint or double vision (diplopia) may develop if the nerves moving the eyes are affected.

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 Speech: Ability to understand (sensory aphasia) or

express (motor aphasia) may be affected by tumours in certain parts of the brain. Sometimes the person is able to understand but is not able to express properly and may not get the right words.
Recent or long term memory loss.

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 Hormonal Effects: Some tumours in and around the

pituitary / hypothalamus region (sellar and suprasellar region) can cause either excess or deficiency of many hormones. This may affect the growth, fertility, libido, body weight, mental functions, etc. Changed behaviour, lethargy, drowsiness, and loss of consciousness are some of the other symptoms of brain tumours.

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CLASSIFICATION
I. Congenital :- Dermoid, Epidermoid, Teratoma.

II. Traumatic :- Subdural & Extradural haematoma III. Inflammatory :- Abscess, Tuberculoma, Syphilitic gumma,fungal Granulomas. IV. Parasitic :- Cysticercosis, Hydratid cyst, Amoebic abscess, Schistosoma japonicum. V. Neoplasms

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 a) Tumors arising from neural structures: Gliomas

astrocytoma, ependymoma, oligodendroglioma, germinoma, medulloblastoma. b) Tumors arising from appendages: Meningioma, schwannoma, chondroma, osteoma. c) Pituitary lesions : Pituitary adenoma, Craniopharyngioma. d) Vascular lesions : Angioma, Hemangioblastoma, Papilloma of choroid plexus. e) Secondary neoplasms.

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SITES OF LESIONS

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Cerebellum Ataxia Intention tremor is worst at the end of a movement and leads to past-pointing. Ask the patient to first touch his nose with his index finger, and then your index finger, held about 50cm away and back to his nose again. A positive sign is when he tends to point beyond your finger. Dysdiadochokinesis is tested by asking the patient to hold up his hands and rapidly pronate and supinate repetitively. Ask him to tap the back of his hand as fast as possible. Nystagmus.. Cerebellar speech is described as staccato.
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 Cerebral lobes and some functions

1. Frontal lobe - voluntary movement, personality, memory, speech 2. Parietal - general senses, taste 3. Occipital - vision 4. Temporal - hearing, smell, taste, language, speech, past memories

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 Temporal lobe

psychological problems.
There may be depersonalisation, emotional changes, and

disturbances of behaviour. There can be hallucinations of smell, taste, sound and sight. There may be Dja vu in which there is a feeling of familiarity as if the present has happened before. Dysphasia Visual field defects There may be convulsions. Other psychological problems include forgetfulness, fugue (a disturbed state of consciousness in which the patient seems to perform acts in full awareness but upon recovery www.similima.com 25 cannot recollect them), functional psychosis and fear or

 Frontal lobe

anosmia. This is especially significant if it is unilateral.

There may be a change in personality with the person

becoming indecent, indiscreet or dishonest. Dysphasia can occur if Broca's area is involved. Hemiparesis or fits may affect the contralateral side.

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 Parietal lobe

neurological picture. There may be hemisensory loss. Decreased two-point discrimination. Astereognosis is the inability to recognize a familiar object placed in the hand. APRAXIA: Extinction can be demonstrated by asking the patient to close his eyes and touch one side of his body. Ask him to point to where you touched. Repeat this but touching both sides simultaneously. He will acknowledge only one side. The patient may systematically ignore one side of his body, called sensory inattention. If you ask him to draw a clock face, he omits the half contralateral to the lesion. www.similima.com 27 Dysphasia may occur.

 Occipital lobe Visual field defects A lesion in front of the optic chiasma will affect just

one eye. A lesion at the optic chiasma, such as a pituitary adenoma, classically causes a bitemporal hemianopia

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 Cerebellopontine angle

The commonest pathology here is an acoustic neuroma.

Common features include: Ipsilateral deafness Tinnitus Nystagmus Reduced corneal reflex Facial and trigeminal nerve palsies Ipsilateral cerebellar signs

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 Corpus callosum

This is an interesting part of the brain that communicates

between the two sides. Lesions usually cause severe rapid intellectual deterioration with focal signs of adjacent lobes. There may be signs of loss of communication between the lobes such as inability of the left hand to carry out verbal commands.

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Midbrain The following features suggest a midbrain lesion: Unequal pupils Inability to direct the eyes up or down Amnesia for recent events with confabulation Somnolence

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 Pituitary tumours

If they are large they can cause homonymous

hemianopia but the most obvious presenting features may be related to their endocrine effects

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Methods of detecting a brain tumour

Most of the symptoms described above are

non-specific and can be caused by many other diseases. A detailed history and medical examination is first done by the doctor and if a brain tumour is suspected then further tests like CT or MRI scan, angiogram, CSF test, hormonal blood test or EEG may be done.
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 CT or MRI Scan , To get a clearer picture,

Iodine or Gadolinium contrast dyes are given intravenously. Some people can develop an allergic reaction to the iodine contrast agent and you should always tell the doctor if you have any allergies. The more expensive non-ionic contrast agents reduce the risk of allergic reaction

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 Angiogram is an X-ray taken after injecting an

iodine dye through catheters placed into the arteries. This shows the details of the blood supply to the tumour. For vascular malformation like AVM it is essential to plan embolisation, surgery or stereotactic radiation.

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 Cerebro Spinal Fluid (CSF) Study is

done after removing the CSF from the spine by a long needle (lumbar puncture). This is done in certain tumours which have a high chance of spreading to the spine or to rule out infections or bleeding.

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 Hormonal Blood Tests are done for tumours

like pituitary adenoma, craniopharyngioma, optic chiasmal or hypothalamic glioma.

Electroencephalogram (EEG) is occasionally

done to study the pattern of seizures.

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treatment
Treatment depends upon the tumour

type, patient's age and general condition Surgery Radiation Therapy Chemotherapy

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if the tumour is very deep-seated or is in a very critical area. Therefore a tumour may be either completely or partially removed or only a biopsy may be taken. Highpowered operating microscopes make it easier to see and remove tumours while sparing the normal brain.
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 The various Neurosurgical approaches are:

Craniotomy - This is the commonest approach which allows maximum tumour removal. To reach the tumour, a window is created by cutting the skull bone and after the operation this bone is replaced. Trans Sphenoidal approach is used for removing tumours in the pituitary region by going through the nose and opening a key hole in the sphenoid sinus / base skull.
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 Skull Base or Craniofacial approach

is used for removing tumours in and around the base of the skull. Usually a team of neurosurgeons and ENT or Head & Neck surgeons perform this operation together. Stereotactic Biopsy is done for deepseated or critically situated tumours where open biopsy is thought to be www.similima.com more risky.

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 . A CT or MRI scan is done with the patient wearing a

stereotactic head frame. Using computers for accurate localisation, a needle is inserted through a small opening in the skull bone to take small piece of tumour tissue (biopsy) for pathological examination. VP or VA Shunt operation is done when the tumour is blocking the flow of the cerebrospinal fluid (CSF). A long tube is inserted under the skin to divert the CSF flow from the brain ventricles to the peritoneal or atrial cavity

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MATERIA MEDICA
Sepia (Cuttlefish)

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Onchorynchus (Salmon) Ambra grisea (Whale ambergris) Serum angulara (Ichthyotoxinum, Eel serum) Asteria (Starfish) Limulus (King crab) Lac del-phinum (Dophin milk) Murex (Purple fish)
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Oleum

morrhua, (Cod liver oil, which also has restored menses) Spongia (toasted Sea sponge) Homarus, (Lobster) Corallium rubrum (Red coral)

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 Apomorphinum hydrochloricum

[APOMORPHINUM] - An alkaloid obtained from Morphia The peculiarity of the vomiting is its suddenness, completeness, and the absence of pain or continued nausea. - It has been used with success in cases of sympathetic vomiting, and from pressure of a tumour on the brain.
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 Mercurius corrosivus sublimatus.

Syphilitic tumours of brain.

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ARNICA MONTANA
Haematoma , head injury.

Meningitis from injury to head.

strokes

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BARYTA CARB
Mental disabilities.

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NAPHTHOQUINONE
Rapidly growing tumors

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Conium maculatum
Headache, stupefying with nausea and

vomiting of mucus With a feeling of foreign body under the skull

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GLONINE
Cerebral congestion

Throbbing and bursting headaches

Head heavy, cant lay on the pillow Threatened strokes

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GRAPHITIS
Headache in the morning while

waking, mostly on one side with inclination to vomit.

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KALI- IODATUM
Bilateral headaches

Violent headaches
Hard painful lumps on cranium with

headache. Brain feels as if enlarged.

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THUJA, PLUMBUM, CHAMOMILLA, SULPHUR HYDRASTIS, BELLADONNA, MERC-SOL, SILICEA,CALCAREA FLOUR

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