|


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iIt is defined as any intracranial tumor caursed by abnormal

and uncontrolled cell division, normally either
- in the brain itself
(neurons, glial cells (astrocytes, oligodendrocytes,
ependymal cells),
lymphatic tissue, blood vessels),
- in the cranial nerves (myelin-producing Schwann cells),
- in the brain envelopes (meninges), skull,
pituitary and pineal gland,
- or metastatic tumors
 |


rimary (true) brain tumors are

commonly located in the
- posterior cranial fossa in children
- anterior 2/3 of the cerebral hemispheres in adults,
although they can affect any part of the brain.
 p


 IMA
- sporadic

Environmentsl risk factor

Smoking
Diet
Occupation
Mobile phone No causative link proven

Immunosupression -

Linked with Genetic abnormalities -

  

 
 
  


  
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i Arises from glial cells
iThe most common site of gliomas is the brain





lassified - by cell type,
- by grade,
- by location.
 |   


  



Astrocytes Astrocytomas
Oligodendrocytes Oligodendrogliomas
Ependymal cells Ependymomas
Different types of glia Mixed gliomas (oligoastrocytomas)
 |  

  


    


 well-differentiated benign better

(not anaplastic)

 undifferentiated malignant worse
(anaplastic)

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Depends on which part of the central nervous system is
affected
     






 




 


 











 
 

 



 
 

  



 



 







   


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‰igh-grade gliomas
ihighly-vascular tumors
itendency to infiltrate
iextensive areas of necrosis and hypoxia
ibreakdown of the blood-brain barrier
ialmost always recur even after complete surgical excision

Low-grade gliomas
igrow slowly
iover many years
ifollowed without treatment unless they grow and cause
symptoms

  
depends on - location,
- cell type
- grade of malignancy

combined approach - Surgery

- adiation therapy
 
  




  
 




 


 

 



- hemotherapy
  
 
 

  



 
iGliomas cannot be cured

‰igh-grade gliomas
ioor prognosis
i50% - 1 year after diagnosis
i25% - 2 years after diagnosis
ianaplastic astrocytoma survive about three years
iGlioblastoma multiforme has a worse prognosis
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iAstrocytomas originate in star-shaped brain cells

called astrocytes
imost common primary NS malignancy
i75% of neuroepithelial tumors

ilow grade - < 6 % of Intracranial tumors

igrade (IV) - 20 % of Intracranial tumors
- survival 3 - 12 months
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iSporadic , without any genetic predisposition
iNo links - smoking,diet, cellular phones, electromagnetic
fields
iSex: male
iAge: over 50 years old
iEthnicity: aucasians, Latinos, Asians
iLinked - low-grade astrocytoma (brain tumor)
- genetic disorder
Neurofibromatosis, Tuberous sclerosis,
Von ‰ippel-Lindau disease,
Li-Fraumeni syndrome, Turcot syndrome
- cytomegalovirus.
- ionizing radiation
- polyvinyl chloride
 

 

a 
idepends highly on the location
iasymptomatic condition
iseizure, nausea and vomiting,
iheadache, and hemiparesis
iprogressive
memory, personality, or neurological deficit
due to temporal and frontal lobe involvement

è
 
iM I ring-enhancing lesions
iDefinitive diagnosis of a suspected GBM on T or M I
stereotactic biopsy or
craniotomy with tumor resection


 

Sagittal M I
with contrast
glioblastoma
W‰O grade IV
in a 15-year-old boy
 

 
  
ipresence of small areas of necrotizing tissue
that is surrounded by anaplastic cells
(pseudopalisading necrosis)
idifferentiates Grade 3 astrocytomas
presence of hyperplastic blood vessels
isecondary GBM
degeneration of lower grade gliomas
more common in younger patients
iIn the cerebral white matter, grow quickly
i 


 





 







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very difficult
iThe tumor cells are very resistant to chemotherapy
and other conventional therapies
iThe brain is susceptible to damage due to therapy
iThe brain has a very limited capacity to repair itself
iMany drugs cannot cross the blood brain barrier
to act on the tumor

 

 


iAnticonvulsants
iorticosteroids - reduce peritumoral edema
 

 


  

ito improve quality of life
ito achieve a longer survival time

a


i1011 cells reduced to 109 cells
iThe greater the extent of tumor removal,
the longer the survival time

ito take a section for a pathological diagnosis

ito remove some of the symptoms of a large mass pressing
against the brain
ito remove disease before secondary resistance to radiotherapy
and chemotherapy
ito prolong survival
 

 

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iradiotherapy after surgery
reduce the tumor size to 107 cells
iA total radiation dose of 60±65 Gy - optimal

 

istandard of care for glioblastoma is
chemotherapy during and after radiotherapy
ichemotherapy after surgery and radiotherapy
reduce the tumor size to 106 cells
iTemozolomide
during radiotherapy
for six months post radiotherapy
 

 

 

iMedian survival time

from the time of diagnosis without any treatment
- 3 months

iglioblastoma multiforme prognosis depends on

- Karnofsky erformance Score (KS)
- age of the patient
- treatment
  
a type of glioma that are believed to originate
from the oligodendrocytes of the brain
or from a glial precursor cell.

 

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They occur primarily in adults

(9.4% of all primary brain )
in children
(4% of all primary brain tumors)
The average age at diagnosis is 35 years

etiology of oligodendrogliomas is unknown

linked - viral cause
- irradiation of pituitary adenoma
 
first symptom - seizure
frontal lobe - affecting personality
‰eadaches combined with increased intracranial pressure
Depending on the location of the tumor,
any neurological deficit

(T) or (M I) scan is necessary to characterize the anatomy

of this tumor (size, location, heter/homogeneity)

final diagnosis of this tumor,

relies on histopathologic examination
(biopsy examination).
  
 p



 
characteristic À
-like cells, with clear cytoplasm and
well-defined cell borders. ‰ E stain.

composed of cells with small to slightly enlarged round nuclei

with dark, compact nuclei and a small amount of eosinophilic
cytoplasm









  







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iIncurable
islowly growing with prolonged survival
imedian survival times
-11.6 years for grade II
-3.5 years for grade III
ivery high (almost uniform) rate of recurrence
igradually increase in grade over time

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- Temozolomide
standard dosing schedule
5 consecutive days of daily dosing
during 28 day cycles

 
iBecause of their diffusely infiltrating nature,
oligodendrogliomas cannot be completely resected
inot curable by surgical excision
i       



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ia tumor that arises from the ependyma,
a tissue of the central nervous system
ilocation in children - intracranial
in adults - spinal
common intracrania location
- fourth ventricle
can occur in - pelvic cavity
iSyringomyelia can be caused by an ependymona
iEpendymomas are also seen with Neurofibromatosis Type
II
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by obstructing the flow of cerebrospinal fluid
headache, nausea and vomiting
hydrocephalus
Other symptoms
loss of appetite,
difficulty sleeping,
temporary inability to distinguish colors,
uncontrollable twitching,
seeing vertical or horizontal lines when in bright light,
temporary memory loss
 " 

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iwell-differentiated ependymomas
radiation therapy only
iother ependymomas
total surgical removal is the preferred treatment
cannot be totally removed - require radiation therapy
imalignant (anaplastic) varieties of this tumor
imalignant ependymoma
iEpendymoblastoma - treated similarly to medulloblastoma
combination of radiation therapy and chemotherapy
iin infants and children younger than 5 years of age,
may spread through the cerebrospinal fluid
usually require radiation therapy
 
(  
ia variant of the ependymoma
iarise in the fourth ventricle
in the septum pellucidum
cervical spinal cord
iover 40 years of age
imen > women

isubependymal giant-cell astrocytoma, (giant-cell glioma)

is typically associated with tuberous sclerosis
but can occur independent of that condition
iArising in the walls of the lateral ventricles
over the basal ganglia - cause obstruction
iwell-encapsulated tumor
igenerally has a very benign course
 "     ""

ialso known as 



 
,
imay be an unusual form of teratoma or
imay be confused with a sacrococcygeal teratoma
  






  


 

 


 
 

 


 


 
   
  
irare,
islow-growing,
ihistologically benign intracranial tumor

icommonly located
in the ventricular system of the choroid plexus

iobstruct the cerebrospinal fluid flow

causing increased intracranial pressur
  
ineuroectodermal in origin
isimilar in structure
to a normal choroid plexus
imay be created by
epithelial cells of choroid plexus

D *
     
i0.4-0.6% of all intracranial neoplasms
imost commonly affects young children under the age of 5
imean patient age of 5.2 year

   

iSigns of increased intracranial pressure - 91%

icommon symptoms -
vomiting,
homonymous visual field defects
and headache


    
ibenign tumors
iusually cured by surgery
imalignant progression has been rarely reported
 

arise from specialized cells of pineal gland -ineocytes
ineocytoma - also known as a pinealocytoma
- benign, slowly-growing tumor
- low grade tumor
- well-differentiated
- areas of neutropil + tumor cells
with small round nuclei
- no mitoses or necrosis
ineoblastoma - high grade tumor
- densely packed small cells
- necrosis and mitoses
- spread through SF
- more common in children
- may occur in etinoblastoma patients
 


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itumour that arises from ganglion cells in NS

itemporal lobe
ican occur anywhere in the brain, or in the spinal cord
ioften associated with seizures

isecond most common cause of spinal cord tumors in children

imature ganglion cells clustered with neoplastic glial cells

 

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imost common extracranial solid cancer in childhood

imost common cancer in infancy
i50 % of neuroblastoma
children < 2 years old

ineuroendocrine tumor,
arising from any neural crest element
of the sympathetic nervous system

imost frequently originates in one of the adrenal glands

but can also develop in nerve tissues
in the neck, chest, abdomen, or pelvis
  


ione of the few human malignancies

known to demonstrate spontaneous regression
from an undifferentiated state
to a completely benign cellular appearance

ithree risk categories: - low

- intermediate
- high risk
iLow-risk disease is most common in infants
highly curable with observation only or surgery
ihigh-risk disease is difficult to cure
even with the most intensive multi-modal therapies
available
 "

inot well understood

ilinked to genetics
iFamilial neuroblastoma
very rare germline mutations
in the anaplastic lymphoma kinase (ALK) gene
 " 
i6-10% of all childhood cancers
i15% of cancer deaths in children

iannual mortality rate

10 per million in 0 ± 4 year old age group
4 per million in 4 ± 9 year old age group

ihighest incidence - first year of life

isome cases are congenital

i 10% > 5 years of age

i < 2% > 18 years of age
  
 
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 German physician
udolf Virchow
the first to describe an abdominal tumor
in a child as a "glioma"
   

 


   
 

 
 

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iFatigue, loss of appetite, fever, and joint pain

idepend on primary tumor locations and metastases if
present
i50 to 60% cases - present with metastases
iA tumor in the abdomen, may cause
swollen belly and constipation.
iA tumor in the chest may cause
breathing problems.
iA tumors pressing on the spinal cord may cause
weakness and thus an inability to stand, crawl, or walk.
iBone lesions in the legs and hips may cause
pain and limping.
iA tumor in the bones around the eyes or orbits may cause
distinct bruising and swelling
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ioften spreads to other parts of the body
before any symptoms are apparent
i50 - 60% - present with metastases
imost common location of 
 adrenal glands
40% of localized tumors
60% of cases of widespread disease
ican also develop anywhere along the SNS chain

    

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usually confirmed by a surgical pathologist
iclinical presentation,
imicroscopic findings,
iother laboratory tests

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iurine or blood
ielevated levels of catecholamines or its metabolites
- dopamine,
- homovanillic acid (‰VA),
- vanillylmandelic acid (VMA)
i90% of cases of neuroblastoma
  
imIBG scan (meta-iodobenzylguanidine)
imIBG-avid
i90 to 95% of all neuroblastomas

à 
imIBG is taken up by sympathetic neurons
functioning analog of neurotransmitter norepinephrine
iWhen it is radio-ionated with I-131 or I-123
(radioactive iodine isotopes)
very good radiopharmaceutical for diagnosis and
monitoring of response to treatment for this disease
ihalf-life of I-123 - 13 hours,
preferred isotope for imaging sensitivity and quality.
ihalf-life of I-131 - 8 days
higher doses is an effective therapy as targeted
radiation
against relapsed and refractory neuroblastoma
 ‰

microscopic view of
stroma-rich ganglioneuroblastoma

tumor cells are typically described as

ismall, round and blue,
iand rosette patterns (‰omer-Wright pseudo-rosettes)
   


ione of the peripheral neuroblastic tumors (pNTs)

iwide pattern of differentiation
benign ganglioneuroma
stroma-rich ganglioneuroblastoma
highly malignant neuroblastoma
iimportant prognostic factor
with - age and
- mitosis-karyorrhexis index (MKI)
ipathology classification system
iInternational Neuroblastoma athology ommittee
(IN, also called Shimada system)
- Favorable
- Unfavorable
  
Urine catecholamine level
can be elevated in pre-clinical neuroblastoma
1980s - Japan, anada, and Germany
asymptomatic infants at three weeks, six months, 1
year

homovanillic acid and vanilmandelic acid

1984 - Japan
six-month olds

Screening was halted

2004 - anada and Germany
- no reduction in deaths due to neuroblastoma,
- increase in diagnoses
that would have disappeared without treatment,
unnecessary surgery and chemotherapy.

  
localized lesion - generally curable

long-term survival for children

with advanced disease > 18 months of age is poor
despite aggressive multimodal therapy
- intensive chemotherapy
- surgery
- radiation therapy
- stem cell transplant
- differentiation agent isotretinoin
also called 13-î
-retinoic acid
- immunotherapy with
anti-GD2 monoclonal antibody
therapy
Treatment options - different
according to different risk categories


  
 







isk assesment
   


 




 
 


 

 

 
 
 








  

 



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ihighly malignant primary brain tumor

originates in the cerebellum or posterior fossa
ifamily of cranial primitive neuroectodermal tumors (NET)
iInfratentorial
iinfratentorial NET
imost common NET originating in the brain

iAll NET tumors of the brain are invasive and rapidly

growing tumors
iunlike most brain tumors
spread through SF
metastasize to different locations in brain and spine
  
iBrain tumors
second most common malignancy < 20 years of age
iMedulloblastoma
in children most common malignant brain tumor
14.5%
in adults 2% of NS malignancies

ihigher in males (62%) than females (38%)

imore prevalent in younger children
iDiagnostic age
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iusually form in the fourth ventricle,
between the brainstem and the cerebellum
iexact cell of origin "medulloblast³

imay be arised from cerebellar "stem cells"

prevented from dividing and differentiating of normal cell types

ihighly characteristic of medulloblastoma

perivascular pseudorosette and
‰omer-Wright rosette formation
seen in up to half of the cases

iMolecular genetics
iloss of genetic information on the
distal part of chromosome 17, distal to the ½
gene
ineoplastic transformation of the undifferentiated cerebellar cells

imay be associated with

- Gorlin syndrome
- Turcot syndrome
- J virus, the virus that causes multifocal leukoencephalopathy.
      
i1 to 5 months before diagnosis
iincreased intracranial pressure
blockage of the fourth ventricle
i
,
irepeated episodes of 3



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- facial sensory loss or motor weakness
iLate - decerebrate attacks

iExtraneural metastases to the rest of the body is rare

- only after craniotomy
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distinctive on T1 and T2-weighted M I
- with heterogeneous enhancement
- typical location
- adjacent to and
- extension into the fourth ventricle

‰  
 


isolid
ipink-gray in color
iwell circumscribed
ivery cellular
imany mitoses
ilittle cytoplasm
ihas tendency to form clusters and rosettes

  
maximal resection of the tumor
to increase the disease-free survival




 to the entire neuraxis
- chemotherapy
Increased I - corticosteroids or
- ventriculoperitoneal shunt

  
combination therapy
5 year survival in > 80% of cases
better prognosis
presence of desmoplastic features
- connective tissue formation
poor prognosis
- less than 3 years old
- inadequate degree of resection
- any SF, spinal, supratentorial or systemic spread
 



  

   
 

 


 
      


  
 
  

 4 
iNeurilemmoma
ibenign nerve sheath tumor
icomposed of Schwann cells
which normally produce the insulating myelin sheath
covering peripheral nerves
ivery homogeneous tumors
iconsisting only of Schwann cells
itumor cells always stay on the outside of the nerve
ibut the tumor itself may either push the nerve against a bony structure
thereby possibly causing damage
irelatively slow growing
imostly benign
i< 1% become malignant
idegenerating into a form of cancer known as neurofibrosarcoma
ican arise from a genetic disorder called neurofibromatosis
ican be removed surgically
but can then recur
Tumours of the cranial and paraspinal nerves


  



 

 
 

 


  




 
  
 
    


W‰O classification


  





 


 



 

 

 






 

 

 
 

 

  

 
 

 

 
 
  
isecond most common primary tumor
of the central nervous system

iarising from the arachnoid

i"cap" cells of the arachnoid villi in the meninges

iusually - benign
- can be malignant


imost - sporadic
isome - familial
irisk factor - radiation to the scalp
igenetic mutations - inactivation mutations
in the neurofibromatosis 2 gene (merlin)
on chromosome 22q
   
Small tumors (e.g., < 2.0 cm)
- usually incidental findings at autopsy
- without having caused symptoms

Larger tumors
- symptoms depending on the size and location

?î 
?
 eventually occurs
but is less frequent than in gliomas

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arise from arachnoidal cells
most of which are near the vicinity of the venous sinuses
(site of greatest prevalence for meningioma formation)

most frequently attached to the dura

over the superior parasagittal surface of frontal and parietal
lobes
along the sphenoid ridge,
in the olfactory grooves, the sylvian region,
superior cerebellum along the À
î 
,
cerebellopontine angle, and the spinal cord

Tumour - gray, well-circumscribed, and space occupies

dome-shaped, with the base lying on the dura

ells - relatively uniform, (histologically)

with a tendency to encircle one another
- forming whorls and psammoma bodies
(laminated calcific concretions)
- have a tendency to calcify and are highly vascularized
 $ 
ivisualized with - contrast T
- M I with gadolinium
- arteriography
i lumbar puncture
protein is usually elevated

A contrast enhanced T scan

of the brain
demonstrating
the appearance of a Meningioma
 



based upon the W‰O classification system

majority of meningiomas are benign

some - malignant

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iObservation with close imaging follow-up

can be used in select cases
if a meningioma is small and asymptomatic

iObservation is not recommended in

tumors that are already causing symptoms

 
 



 
  

 
    
can usually be surgically resected with permanent cure
if the tumor is - superficial on the dural surface
- and easily accessible

Transarterial embolization
standard preoperative procedure in the preoperative
management

If invasion of the adjacent bone occurs

total removal is nearly impossible

Malignant transformation is rare

probability of tumor recurrence

estimated - by the tumor's W‰O Grade and
- by the extent of surgery by the Simpson riteria

      


  

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10 ± 50 % of all cranial tumour

Majority - benign
Metastasis - may occur
especially in elderly

One type of sellar region tumour

Differential diagnosis of sellar region mass
- craniopharyngioma
- meniongioma
- aneurysm
- athke¶s cleft cyst
 

 

Mass effect - bitemporal hemianopia

- pressure on optic chiasma
- cranial nerve III, IV, VI disorder
Endocrine disturbance

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 Galactorrhoea
Amenorrhoea (¶,2¶)

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Type of Secretion Staining athology %
adenoma

î 
î  ½
î (AT‰) basophilic ushing's disease 15 %

(OM)



  ½
î (G‰) acidophilic Acromegaly 20 %
(gigantism)

thyrotrophi (TS‰) basophilic hyperthyroidism 1%

 
  ½
î (L‰) basophilic 1- 2 %
(FS‰)


î  ½
î / prolactin acidophilic galactorrhea, hypogonadism, 40 %
½ 
î


 amenorrhea,infertility,impotence

î Į subunit synaptophysin 20 %


  
 



  





 

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‰emorrhagic infarction of pituitary tumour

resentations - sudden onset of - headache
- visual loss
- opthalmoplegia
- altered concious level
Sudden onset of headache meningism similar to SA‰
Management
- preoperative resuscitation
- urgent decompression
  

Formal visual field acuity test
Imaging - M I scanof pituitary region
Baseline assesment of pituitary function
- prolactin
- fasting serum
- urinary cortisol
- Growth hormopne
- Insulin like growth factor 1
- Folicular stimulating hormone
- Leutinizing hormone
- Thyroid function
  


Essential assesment - endocrine status

- AT‰ cortisol axis
- ortisol deficiency must be corrected (pre-
op)
- Diagnosis of AT‰ secreting tumour is difficult
- etrosal sinus sampling
- Dexamethasone supression test

- rolactin
- high rolactin level - rolactinoma
- preclude the need for surgery
(ituitary stalk compression -
moderately elevate prolactin
level)
 


AIM
- to alleviate mass effect
- restore or replace endocrine function
- prevent recurrence
lose co-operation of - Neurosurgeon
- Endocrinologist

rolactinoma
- initial treatment - medically - Dopamine agonist
- abergoline
- Bromocryptine
Growth hormone secreting tumour
- medically - Somatostatin
analogues
- Octreotide
- Dopamine agonist
 
 

Transsphenoidal Surgery - operating microscope
- endoscope assisted
Large tumour with suprssellar extension - raniotomy
Transsphenoidal Surgery omplication
     
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- pituitary stalk manipulation - Diabetes insipidus

Determination of surgical success (transient)













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iincidence increased over time

- advances in neuroimaging procedures
- improvements in treatment of primary tumour and systemic disease
imedian survival - approximately one month without any treatment
two months with corticosteroids
three to six months with cranial irradiation
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iperceptual or behavioral impairments

which are caused by lesions in a particular area
of the central nervous system.
idisease process is focal rather than diffuse
iFocal disease processes include
tumors or infarctions;
iDiffuse disease processes include
meningitis or encephalitis
 D  ( 
usually involve the motor system,
and may include many special types of deficit,
depending on which part of the frontal lobe is affected
iunsteadiness in walking
imuscular rigidity, resistance to passive movements of the
limbs (hypertonia)
iparalysis of a limb (monoparesis)
or a larger area on one side of the body (hemiparesis)
iparalysis head and eye movements
iinability to express oneself linguistically,
described as an expressive aphasia (Broca's aphasia)
ifocal seizures which can spread to adjacent areas
(Jacksonian seizure)
igrand mal or tonic-clonic seizure
 D  ( 

ichanges in personality
disinhibition,
inappropriate jocularity,
rage without provocation;
loss of initiative and concern,
apathy,
akinetic mutism,
general retardation
i"frontal release" signs,
i.e. reappearance of primitive reflexes
snout reflex, the grasp reflex, palmar-mental reflex
iunilateral loss of smell (anosmia)
     ( 
iusually involve somatic sensation
iimpairment of tactile sensation
iimpairment of proprioception, i.e. postural sensation and
sensation of passive movement
isensory and visual neglect syndromes, i.e. inability to pay
attention to things in certain parts of the person's sensory or
spatial environment.
This can be as extreme as denial of a limb.
iloss of ability to read, write or calculate
(dyslexia, dysgraphia, dyscalculia)
iloss of ability to find a defined place (geographical agnosia)
iloss of ability to identify objects based on touch
(astereognosia)

  ( 

iusually involve auditory sensation and memory

ideafness without damage to the structures of the ear,
described as cortical deafness
itinnitus, auditory hallucinations
iloss of ability to comprehend music or language, described as
a sensory aphasia (Wernicke's aphasia)
iamnesia, memory loss (affecting either long- or short-term
memory or both)
iother memory disturbances such as deja vu
icomplex, multimodal hallucinations
icomplex partial seizures (temporal lobe epilepsy)
   ( 
iusually involve visual sensation
itotal loss of vision (cortical blindness)
iloss of vision with denial of the loss (Anton's syndrome)
iloss of vision on one side of the visual field of both eyes
(homonymous hemianopsia)
ivisual agnosias, i.e. inability to recognize familiar objects,
colors, or faces
ivisual illusions such as micropsia (objects appear
smaller)
and macropsia (objects appear larger)
ivisual hallucinations, displaying elementary forms, such as
zig-zags and flashes, in one half of the visual field only
for each eye.
(In contrast, temporal lobe visual hallucinations
display
complex forms, and fill the entire visual field.)
   (   
iinvolve balance and coordination
iunsteady and clumsy motion of the limbs or torso
(ataxia)
iinability to coordinate fine motor activities
(intention tremor)
e.g. "past-pointing"
(pointing beyond the finger in the finger-nose test)
iinability to perform rapid alternating movements
(dysdiadochokinesis),
e.g. inability to rapidly flip the hands
iinvoluntary left-right eye movements
(nystagmus)
 |   

specific sensory and motor abnormalities

depending on which fiber tracts
and cranial nerve nuclei are affected

   

generally involve unilateral paralysis

with contralateral loss of pain sensation
 a 
  



iThe first stereotactic frame is attributed to

‰orsley and lark
iprinciple of stereotaxy is that described by
Descartes;
iany point in space can be identified in
relation to three planes running perpendicular
to each other
 

  

a device is fixed to the head,
so that the co-ordinates of any point within the confines of the
frame itself
or an imaginary extension of it can be accurately localised.
This requires T or M I to be per-formed
after the frame has been applied to the head,
so that the position of the region of interest can be related to
the frame

iused not only for tumour biopsy

ibut also for localising cranio-tomies
for minimally invasive excision of tumours
ifor catheter placement,
ifor drug or isotope delivery or
icyst drainage
 
   


An extension of the stereotactic process is

to obtain a preoperative scan
without the use of a frame
and then use a mathematical algorithm
to correlate with the surface markings of the skull
at the time of surgery
less clumsy and time consuming