INTRACRANIAL TUMORS

Benign brain tumors:

• Benign brain tumors do not contain cancer cells:

usually, benign tumors can be removed, and they
seldom grow back.

• The border or edge of a benign brain tumor can be

clearly seen. Cells from benign tumors do not invade
tissues around them or spread to other parts of the
body.
However, benign tumors can press on sensitive areas of
the brain and cause serious health problems.

• Unlike benign tumors in most other parts of the body,

benign brain tumors are sometimes life threatening.

• Very rarely, a benign brain tumor may become malignant.

Malignant brain tumors

• Malignant brain tumors are generally more serious

and often is life threatening. It may be primary (the
tumor originate from the brain tissue) or secondary
(metastasis from others tumor elsewhere in the
body).

• They are likely to grow rapidly and invade the

surrounding healthy brain tissue.
 Risk factors of the brain tumor
• Male
• Race
• Age
• Family history
• Being exposed to radiation or
certain chemicals at work
Increased intracranial pressure

• Decrease in level of
consciousness such as confusion
and lethargy.

• Headache most common in the

early morning and made worse by
coughing or straining
• Vomiting
• Papilledema and visual
disturbance
• Alteration in mental status.
• Aphasia
• Personality changes as in case
of frontal lobe tumor
• Sensory defects ( smell,
hearing).
• Seizures.
• Motor abnormalities
Diagnosis of brain tumor

• Physical exam
• Neurological examination
• Brain CT scan
• MRI on brain
• Angiogram
• Spinal tap
• Biopsy
Treatment of brain tumor

•A variety of medical treatment

modalities, including chemotherapy
and radiotherapy, are used alone or in
combination with surgical resection.
• Supportive care include:
• Steroids
• Anticonvulsant drugs
Secondary brain tumors
• Metastasis
• Most common
• 25-45% of cancer patients
• Lung: >50% of all; most common in men
• Breast: Most common in women
• Melanoma: Highest propensity for brain
• 50% of melanoma patients develop brain mets
• Renal Cell
• Colorectal

• Any primary can metastasize to the brain

 Primary brain tumors Skin

Skull
• Meningioma (35%)
Meninges
• Glioma (30%)
• Astrocytoma Brain
• Glioblastoma
• Oligodendroglioma
• Oligoastrocytoma Neuron

• Ependymoma Astrocyte
• Pituitary Adenoma (13%) Oligodendrocyte

• Within skull Ependyma

• Beneath brain
 Benign Malignant

• Slow growing • Fast growing

• Non-invasive • Aggressively invasive
• Does not spread • May spread distantly
• Less likely to recur • More likely to recur
• Mass effect
• Tumor pushes on normal brain

• Local invasion
• Tumors invade normal brain
• Microscopic

• Edema
• Swelling of normal brain
Presentation
• Generalized symptoms and signs
→ Elevated intracranial pressure

• Headaches (50%) • Personality change (25%)

• New or different
• Nausea/vomiting (15%)
• Worsening over time
• Blurred vision/papilledema
• Worse on awakening, them
improve • Lethargy
• Other symptoms
• Seizures (30%)
• Cognitive change (30%)
Presentation
• Focal symptoms and signs
→ site specific to location
 Presentation
• Focal symptoms and signs
• → site specific to location;

Weakness
Incoordination
Personality
Cognitition
Expressive
language
Vision

Incoordination
Receptive Balance
language
What are our options?
• Surveillance
• Serial MRI scans

• Surgery
• Biopsy
• Diagnose the tumor
• Resection
• Diagnose the tumor
• Remove as much of tumor as possible
Surgery
• Where is the tumor?
• What bone is in the way?
• What brain is involved?
• What does that brain do?
• What arteries/veins are involved?
X
X
Transnasal
Trans-
sphenoidal
Biopsy
 Surgical tools - Microscope
• Improves visualization
• Increased light
• Increased magnification

• Improves surgeon comfort

• Adjust scope angle,
instead of bending/twisting
 Surgical tools - Robotics
• Navigation systems with built in
surgical assistant
• Pre-plan surgical approach
• Utilize the robot to align the
instruments

• Minimally invasive
• Single stitch incision
• Maximizing precision
 Surgical tools – Laser Ablation
• Minimally invasive
• Single stitch incision

• Pass a probe into the tumor

• Reduced risk to normal brain

Pre-op
• Utilize heat to destroy tumor
cells
1 year
post-op
 Radiation Therapy
• No clean margins
• Whole brain radiation
• Multiple small doses to entire brain

• Stereotactic radiosurgery (SRS)

• High dose to a small area
• Limits exposure to normal brain
INCREASED INTRACRANIAL
PRESSURE
Causes of Increases ICP
• Intracranial hemorrhage
• Traumatic brain injury
• Ruptured aneurysm
• Arteriovenous malformation
• Other vascular anomalies
• Central nervous system infections
• Neoplasm
• Vasculitis
• Ischemic infarcts
• Hydrocephalus
• Pseudotumor cerebri
MONRO-KELLIE DOCTRINE
• Brain parenchyma—80%
• Cerebrospinal fluid—10%
• Blood—10%
• Monro-Kellie doctrine: Because the overall
volume of the cranial vault cannot change, an
increase in the volume of one component, or
the presence of pathologic components,
necessitates the displacement of other
structures, an increase in ICP, or both
Effects of trauma
• Increase in volume of any or all of the intracranial
components
• Uncoupling of Cerebral Blood Flow and metabolic
activity (loss of autoregulation) which can lead to
excessive CBF
• Increased CSF production in response to
cerebral hyperemia
• Hypercapnia or hypoxia, which may cause
vasodilation and increase CBF
• Herniation, brain swelling, or subarachnoid
hemorrhage, which may obstruct the flow of CSF
Effects of trauma
• Combination of these changes can rapidly
exceed the limits of intracranial compensation
• Leading to an increase in ICP and subsequent
herniation or ischemia (focal or global)
• Intracranial hypertension may manifest immediately, but
more often occurs in the first few days and peaks at day
three to five after trauma
• The elevation of ICP may fluctuate in waves that can be
triggered by blood pressure changes, hypoventilation,
hypoxia, change of head position, hyperthermia, seizures,
or simply cerebrovascular instability
Herniation Syndromes
• Herniation of brain tissue can cause injury by
compression or traction on neural and vascular
structures
• Herniation results when there is a pressure
differential between the intracranial
compartments, and can occur in four areas of the
cranial cavity
• Transtentorial (2)
• Subfalcian (1)
• Foramen magnum (3)
Presentation: Symptoms
• Global symptoms of elevated ICP
• Headache
• Depressed global consciousness
• Due to either the local effect of mass lesions or pressure on the
midbrain reticular formation
• Vomiting
• Focal symptoms
• May be caused by local effects in patients with mass lesions or
herniation syndromes
Presentation: Symptoms
• Additional features of traumatic head injury
• Decreased level of consciousness
• Pain coming in waves
• Visual changes
• Alterations in vital signs
• Infants may present with less specific symptoms
• Irritability
• Bulging fontanel
• Lethargy
• Flat affect
• Poor feeding
Presentation: Symptoms
• Nontraumatic
• Headache
• Nocturnal awakening
• Worsening by cough, micturition, or defecation
• Recurrent and localized
• Progressive increase in frequency or severity
• Growth abnormalities
• Nuchal rigidity
• Focal neurologic deficit
• Persistent vomiting
• Known risk factor for intracranial pathology
• (eg, neurocutaneous syndrome, macrocephaly, hormonal abnormalities)
• Lethargy
• Personality change
Presentation: Signs
• Papilledema
• If present can confirm
the diagnosis
• Papilledema may be
absent in acute ICP
elevations because it
takes several days to
become apparent
• Is not invariably
present in patients with
intracranial
hypertension
Presentation: Signs
• Retinal hemorrhages
• may be present in
patients with increased
intracranial pressure,
and should raise the
suspicion of
nonaccidental head
trauma
Presentation: Signs
• Infants may develop
• Macrocephaly
• Split sutures
• Bulging fontanel
• Hydrocephalus
• “Sun setting"
appearance of the
eyes may appear
Presentation: Signs
• Dilated pupil
• Usually on the side of the
lesion
• Cranial nerve palsies of
the third, fourth, and sixth
cranial nerves can occur
• 3rd nerve palsy most
common
• May cause double vision or
abnormal head posture
Presentation: Signs
• Level of consciousness
• Can range from irritability to obtundation or coma
• Hemiparesis, hyperreflexia, and hypertonia
• Cushing triad
• Systemic hypertension, bradycardia, and respiratory
depression
Presentation: Herniation
• Earliest clinical
signs of
transtentorial
herniation
• Headache and
altered level of
consciousness
• Followed by pupillary
changes
• Bradycardia is
another early sign
in children
Presentation: Herniation
• Foramen magnum herniation
• May have downbeat nystagmus, bradycardia,
bradypnea, and hypertension
• These findings may be exacerbated by neck flexion and improve
with neck extension
• Subfalcian herniation
• Unilateral or bilateral weakness, loss of bladder control,
and coma
Initial Stabilization: Airway
• A definitive airway must be established
• endotracheal intubation
Initial Stabilization: Breathing
• Ventilation should be provided as necessary to maintain a
PaCO2 in the low- to mid-30s
• Mild hyperventilation causes hypocapnia
• Results in cerebral vasoconstriction and reduced CBF
• Decrease in CBF is accompanied by a decrease in cerebral blood
volume, which in turn decreases ICP
Initial Stabilization: Circulation
• Cerebral perfusion must be maintained to prevent
secondary ischemic injuries
• Hypovolemia should be treated with hypertonic fluids with
a goal of attaining a state of normal volume
• Excess intravascular volume may exacerbate the
development of cerebral edema
Evaluation: Neuroimaging
• Head CT may demonstrate:
• Underlying etiology of elevated ICP (eg, mass lesion, hemorrhage)
• Findings consistent with elevated ICP (eg, midline shift, effacement
of the basilar cisterns And/or effacement of the sulci)
Evaluation: Neuroimaging
• Other studies have shown that up to one-third of
patients with initially normal scans developed CT
scan abnormalities within the first few days after
closed head injury
Together, these findings demonstrate that ICP
can be elevated even in the setting of a normal
initial CT, highlighting the role of follow-up
imaging in patients who develop clinical evidence
of increased ICP during hospitalization
Evaluation: Lumbar Puncture
• LP, if necessary, should be deferred until after
head CT scan in any patient in whom intracranial
hypertension is suspected
• In patients in whom central nervous system
infection is a strong consideration, deferral of
lumbar puncture should not delay the initiation of
empiric antibiotic therapy
Management
• Goals of therapy
• Minimize ICP elevation
• Maintain adequate cerebral perfusion pressure to prevent
secondary ischemic injury
Management
• The best therapy for elevated ICP is resolution of
the underlying cause
• Regardless of the cause, ICH is a medical
emergency, and treatment should be undertaken
as expeditiously as possible
• Early neurosurgical consultation should be
obtained
Management
• Rapid treatment of hypoxia, hypercarbia, and
hypotension
• Fluids (eg, normal saline or 3% NaCl)
• If this fails, infusions of epinephrine can be initiated
• Elevation of the head of the bed from 15 to 30
degrees
Management
• Aggressively treating fever with antipyretics and cooling
blankets
• Hyperpyrexia increases cerebral metabolism and increases CBF,
further elevating ICP
• Controlling shivering in intubated patients with muscle relaxants
Management
• Administering prophylactic phenytoin or phenobarbital to
patients who are at high risk of developing seizures
Management: Mannitol
• Establishes an osmotic gradient between plasma
and parenchymal tissue, resulting in a net
reduction in brain water content
• Rapid onset of action and maintains its effect for
a period of hours
Management: CSF Drainage
• In cases of uncontrolled intracranial hypertension, an
intracranial drain can be placed to remove CSF and
monitor ICP
• As the ICP increases, the compliance of the brain decreases, and
small changes in volume (eg, the removal of as little as 1 mL of
CSF) can significantly reduce ICP