Neurology - Week 7 - Brain tumour & Stroke

STROKE: Sudden loss of neurological function due to interruption of blood supply
1. Ischaemia - blockage of a blood vessel (85%)
  1. THROMBOSIS: Stroke due to clot which has arised from within the arteries of the brain Atherosclerosis = in the blood vessil itself
    1. May be caused by blood disorders that promote clotting like Sickle cell disease , Thrombophilia
  2. EMBOLISM: Clot that travels from the heart, blocking brain circulation
    1. May be caused by damaged heart vavles, artificial valves, disorders of rhythm
  3. TIA: Transient Ischaemic Attack - temporary and reverseable loss of function within 24 hours
    1. Sometimes known as 'mini' stroke
    2. Speedy attention to prevent major stroke
    3. Can do doppler ultrasound to assess the state of arteries in the neck may need Endarterectomy to open up blocked blood vessil.
  4. Fatal up to 30% for first month
2. Haemorrhage - rupture of blood vessel (15%)
  1. Less common
  2. Normally blood - brain barrier separates blood from brain. Once blood in contact with brain tissue quite toxic
  3. Ischaemic stroke tend to survive better
  4. fatal in up to 50% of victims in the first month
3. SYMPTOMS - weakness arm or leg, sensory impairment, visual on one side…
  1. RISK FACTORS
    1. Hypertension: Should be treated as precipitates hardening of the arteries making them easy to block or rupture
      1. Diabetes and hypertension go hand in hand - one cause of hypertension is renal / kidney cause
    2. Age
    3. Smoking - can also lead to can lead to atherosclerosis (artery hardening)
    4. High cholesterol - fuzzing of arteries
    5. Family history / genetic pre-disposition
    6. Heart problems, e.g. Atrial fibrillation : disturbance in heart rhythm leading to clot
4. 2:1000 new cases ever year
5. 3rd major cause of death after cancer and heart disease
6. Major cause of disability
7. DIAGNOSIS
  1. Brain CT or Brain MRI used to image brain. MRI more detailed but CT more readily available.
  2. Can have coloured scans for the blood vessels if diagnosis is not straight forward.
  3. Manifestation depends on area of brain affected
  4. Described as Anterior circulation or posterior circulation infarction depending on whcih affected
  5. May be called: severe, mild, moderate are 3 classifications etc…
  6. ANTERIOR circulation infarction features (affect opp side of body)
    1. Hemiplegia: weakness of upper and lower limbs
    2. Hemianesthesia: lack of sensation
    3. Hemianopia: Loss vision one side field
    4. Dysphasia: Inability to express self or understand others
    5. Inattention: Unable to pay attention to one side of body / environment
    6. More able to treat this kind of infarct - e.g. if in the neck
      1. Posterior surgery more risky and less rewarding
  7. POSTERIOR circulation infarction
    1. Vertigo / unsteadiness
    2. Loss of vision / double vision
    3. Upper and lower limb weakness
    4. Dysarthric speech
    5. Receptive dyspasia
ACUTE STROKE MANAGEMENT
1. 1. Confirm diagnosis of stroke
  1. 2. Confirm whether ischaemic or haemorhaggic
    1. 3. Maintain: airway, circulation, hydration, skin, bladder and bowel function
      1. 4. If catch them in a 4 hour window the patient may be entitled to Thrombolysis – has to be ischaemic not heamorrhagic- give them a drip to dissolve a clot. (About 20%)
        4. If haemorrhage is superficial chance you can take the clot out, reduce pressure in the skull ' surgical evacuation'
        e.g. young people with deteriorating level of consciousness or Cerebellar haematoma
        5. Prevent complications like: Aspiration Pneumonia / Deep vein thrombosis which can lead to pulmonary embolism
        6. Secondary PREVENTATIVE TREATMENT
        Anti-platelets therapy like Aspirin
        Lipid lowering / statins lowers further hardening of the arteries (as result of cholesterol).
        Full anti-coagulation like giving Warfarin - have to monitor
        Diabetes / hypertension mangement
        Stop smoking
        Healthier life style
        Major risk of this haemorrhage however. 1/8 full recovery. 1/17 bleeding.
        4. Endarterectomy: Opening up a narrowed artery by surgical operation if there is 70% blockage when the pt suffers a small stroke
      2. Control of circulation: If haemorrhagic keep low, ischaemic keep high or likely to make it worse
BRAIN TUMOUR: New growth of cells which form lesion / lump
1. BENIGN Neoplasm: Does not infiltrate normal tissue or metastesize
  1. Removed with out recurrance
2. Malignant Neoplasm / cancer: Has aggressive characteristics – multiplies rapidly, doesn’t usually have a capsule – unlike benign
  1. Metastasis to other areas of body
  2. Recurrence after removal
3. CLINICAL FEATURES
  1. Raised ICP: If increase by 30ml (one tenth can of coke) you will have problems.
  2. Affects on local tissue
  3. Headache: Worse in morning, better as day goes on
  4. Vomiting
  5. Bradycardia: Slow heart rate
  6. Hypertension
  7. Impairment on concious level
  8. Papilloedema: swelling of the cranial nerves. You can see the selling of optic nerve through the eye….
  9. Epilepsy
4. WHO CLASSIFICATION
  1. 1. Tumours of Neuro-epithelial origin (Gliomas)
    1. Astrocytoma: Most common form of Glioma in children and adults - develop from astrocytes (neurones)
      1. High / low grade (slow or rapid) growth
      2. 3 Subtypes
        a. Localised - less malignant
        b. Diffuse - more malignant
        c. Anaplastic - very bad news
      3. Glioma = arising from the BRAIN TISSUE and supporting structures itself
      4. Oedema around the glioma shows multiplying and dying very quickly
        Midline shifted left
    2. Oligodendroglioma: from oligodendrocytes that make myelin
      1. 3% of brain tumours
      2. Slow growing - doesn't have such an effect on surrounding structures till gets big
      3. Cerebral hemisphere
      4. Adults
    3. Medulloblastoma
      1. Most common in childhood
      2. Coz at base of the brain, can block flow of CSF.
      3. Agressive
      4. In Posterior Fossa
        Can be removed
  2. 2. Tumours of cranial and paraspinal nerves
    1. Vestibular schwannomas
      1. Arise location: Schwann cells on VIII cranial nerve
      2. Slow growing - benign
      3. Older people
      4. Rarely spread
      5. Loss of hearing
      6. Unilateral / bilateral
      7. Rarely associated with Neurofibromatosis type 2
        Can remove, but risk damage to facial nerve VII
        Presses on the cerebellar pontine angle – dangerous to press on the Pons – heartrate, CSF flow etc… so needs to go.
      8. Lack of balance
    2. Spinal cord tumours
      1. 20% CNS tumours
      2. Meningiomas
      3. Neurofibromas
      4. Cordomas
  3. 3. Tumours of the meninges
    1. Meningiomas - 25% adult brain tumours
    2. Older people
    3. Arise Location : cerebrum, cerebellum
    4. Meningeal tail' - tumour blends with meninges
  4. 4. Tumours of the haematopoetic system
    1. Lymphomas affecting brain or spinal cord
    2. 5% CNS tumours
    3. Arise: Diffuse large B-cells non Hodgkin lymphoma
  5. 5. Tumours of the sellar region
    1. Craniopharyngiomas
      1. Rare benign tumours
      2. Base of brain, close to pituaitary
        Can cause impaired vivsion
      3. Children and young adults
    2. Pituitary tumours
      1. Benign
      2. 8% of tumours
      3. Can be functioning (release hormones) or non - functioning
      4. Grow slowly
      5. Don't spread
      6. Can affect Thyroid & hormone secretions
      7. Can effect blood pressure
  6. 6. Metastatic Tumours
    1. Colour under dye (like Lymphomas)
  7. Grades of tumour 1-4: 1 benign 2 partly benign 3 low malignancy 4 high malignancy
    1. Analysis of mitotic division under microscope… Histological grading = specimin of tumour, section, stain, and histopathologist examine through microscope. (Histo = tissue)
5. ASSESSMENT: CT scan, MRI
  1. Angiogram for surgeons – to see where blood is coming from in the blood vessels & where to stop the bleeding in advance etc.
6. MANAGEMENT
  1. Palliative like reduction of ICP
  2. Surgery: Partial or total excision
  3. Anti epilepsy drugs
  4. Steroids - reduce swelling
  5. Grade tumour directs what best form of Chemo / radio therapy
  6. New biologic / targeted therapies - less harmful, halt tumour growth
  7. CHEMOtherpay: Medulloblastoma
  8. RADIOtherapy: Ependymoma / Lymphoma

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Neurology - Week 7 - Brain tumour & Stroke

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	Created by Heather Snaith about 8 years ago