Tumors of the Brain and Spine

Joe Hlavin PA-C, MSTexas Brain and Spine Institute

Bryan, TXjhlavin@txbsi.com

Introduction/Bio

US Navy – Corpsman – 1984 to 1989Cuyahoga Comm College – 1991 – surgical PA

◦Went right into private practice neurosurgery22 years of neurosurgery experienceBS in Education – BGSUMS in Organizational Learning – TAMUPhD Student - Organizational Design - TAMUDesigner & director of the TAMHSC/TBSI Postgraduate PA Residency in Neurosurgery

Objectives• For this lecture:

• Review of the normal brain and spine anatomy and physiology, including CT and MRI

• Review neurological exam

• Discuss selected intracranial and intraspinal lesions

• Provide current treatment schemes

• Discuss reasoning for treatment decisions

• Case studies

AnatomyQuidi Vidi Bay, Newfoundland

The Brainsome A&P

• Lobes - Supertentorial

• Frontal

• Temporal

• Parietal

• Occipital

• Cerebellum - Subtentorial

UT student????

the brain A&P• Frontal

• Reasoning, planning, “personality”

• Frontal eye fields – Brodman 8

• Visual attention

• Motor strip

• Temporal

• Speech – dominant

• Memory – non-dominant

• High Sz region

PERSONALITYPLANNINGREASONING

MOTORSENSORY

SPEECHHEARING

SPEECH

MEMORYSMELL

VISIONPROCESSING

FRONTAL

PARIETAL

TEMPORAL

OCCIPITAL

CEREBELLUM

TENTORIUM

the brain A&P• Parietal

• Sensory

• Proprioception

• Calculia, graphesthesia, left/right – dominant

• Occipital

• Visual cortex – processing/understanding

• End point of the ocular tracts

• Cerebellum

• Coordination, balance

PERSONALITYPLANNINGREASONING

MOTORSENSORY

SPEECHHEARING

SPEECH

MEMORYSMELL

VISIONPROCESSING

FRONTAL

PARIETAL

TEMPORAL

OCCIPITAL

CEREBELLUM

TENTORIUM

writing

Important – DominantInvolves 3 lobes

Spinal Cord

• Anatomy

• Tracts

• Ascending

• sensory

• Descending

• Motor

Spinal Cord

• Understanding the medullary component

• Simply – relay station for input and output of transmissions

• Important to know:

• Medial to lateral IS:

• Cervical to Sacral

Spinal Cord

• Focusing for function

• Keys

• Ascending – sensory

• Lesions are not as easily identified due to subjective nature

• Descending – motor

• Easier to find level due to objectiveness of the exam

StudiesSt. John’s Bay – The Narrows

CT

• Usually the first study performed• Fast• Easy• Least expensive• Consists of 60 to 70 – 5mm slices• Can be done with dye

MRIpreferred for brain and a

must for spine• Most detailed

• Used with Gadolinium (“dye”)

• No radiation

• But

• Expensive

• Tight space

• Takes more time

• Cannot do with some implanted devices

Lesions

Lesion Types

Lesion Types• Benign

• Non-aggressive but can be devastating based on size and location

• Meningioma is most common – ARISE FROM?

• less common

• Neuromas – acoustic

• Dermoid

• Pituitary adenomas

Lesion types•Metastatic

• The primary cancer: lung, breast, colon, kidney, or skin (melanoma), but can originate in any part of the body

Malignant lesionsGlial tumors

• World Health Organization grading (WHO) scale ASTROCYTOMAS, I – VI

• Grade – I – e.g. Pilocytic and Subependymomas

• Grade – II – low grade astrocytoma and oligodendrocytoma

• Grade – III – medium, anaplastic astrocytoma

• Grade – VI – high, Glioblastoma Multiforme (GBM)

Examples

• Four different astrocytic lesions, four different looks

Sub-ependymoma Oligodendroglioma

Anaplastic astrocytoma

GBM – grade VI

Cerebellar Lesions

• Very similar to CEREBRAL lesions

• Have increased risks with compression of essential component of CSF drainage

• Primarily noted in children, e.g. medulloblastoma, PNET (prim. neuroecto. Tumor)

• Will present in adults as astrocytoma and cystic

• Common area for metastatic seeding

Describing Studies

General Descriptionsfor Brain and Spinal Lesions

• For the brain

• Extra-axial

• Intra-axial

• For the spinal cord

• Extra-dural vs. Intra-dural

• Extra-medullary vs. Intra-medullar

• For both

• Non-enhancing vs. enhancing (MRI)

General Descriptionsfor Brain and Spinal Lesions

• Location, location, location

• For the brain

• What lobe? Size? Edema? Shift? Obstructive?

• For spinal cord

• What level? Size? Syrinx?

• Lesion consistency

• Heterogenous vs. homogenous

• Ring enhancing (w/ cyst) vs. diffuse enhancement

PA circa 1989

examples

More Examples

Neurological Exam

Neuro Exam

•Tenets of the approach to the NS patient

• DO NOT BELIEVE ANYONE ELSES EXAM –

• DO YOUR OWN

• LOOK at the studies yourself, NOT just the report

• SEE the patient as MORE THAN the studies

Neuro exam

• The mental status

• “normal” or “Sleeping” is not a good descriptor. Use:

• Awake/alert/talking

• Less than alert – obtunded

• Unresponsive – comatose, stupor

• In this case, give the Glasgow Coma Scale as descriptor

Neuro exam• Glasgow Coma Scale

• Eyes – 4, spontaneous, 3, to voice, 2, to pain, 1, none

• Motor – 6, obeys, 5, localizes, 4, w/drawls, 3, flexion response, 2, extension to pain, 1, none

• verbal – 5, oriented, 4, confused, 3, inappropriate words, 2, incomprehensible words, 1, none

• PEARL – if pt is brought in by EMS – GET THE GCS NOTED AT THE SCENE

• Remember, everything has a GCS – even a rock has a GCS of 3

Neuro exam• Cranial nerves

• LOOK AT THE EYEs

• Symmetry – light response, movements, gaze pref

• LOOK AT THE FACE

• Symmetry – right = left, pay attention to motor

• LOOK IN THE MOUTH

• Symmetry – tongue and pharynx

Neuro exam• Motor exam

• Abbreviated evaluation

• Look for: (KEEP IN MIND – Right cortex = left body)

• Right vs. left strength – if equal then

• Check individual groups – start with upper extremities

• Keep level of any deficit in mind

• example: bilateral weakness from biceps down = C6 level

Neuro exam

• Reflexes

• Know the difference between UMN and LMN reflex changes

Neuro exam• Upper motor neuron reflexes

• Cranial nerve reflexes are considered normal and loss of reflex is concerning – e.g. pupillary response

• Primitive Reflexes – found in newborns, but can present in patients with neurological disease due to loss of blunting of reflexes.

• Hyper-reflexia and ankle clonus – unsustained/sustained

• Babinski Reflex – blunted by myelination of SC

• Hoffman Reflex – blunted also

Neuro exam• Lower motor neuron reflexes

• Spinal reflexes

• Relay station in the medullary cord

• E.g. knee jerk, triceps jerk

• Loss: indicative of root irritation/compression, e.g. HNP, tumor

• May be associated with motor group deficit

Neuro exam

• Cerebellar exam

• Coordination

• Rapid movements

• Finger-to-nose

• KEEP IN MIND – RIGHT cerebellum = RIGHT body

• Docusates twice – once at peduncle and then medulla

Treatment

Treatment

• Initial treatment plan – generally speaking

• Dependent on the patient presentation and clinical status

• Steroids – Decadron

• H2 blocker du jour

• Admission to hospital for continued treatment, w/u, and neurosurgical consultation (UNLESS THAT IS YOU)

Treatment• The treatment is based on clinical exam, age,

comorbidities, and patient’s/family’s wishes – KNOWING risk/complications and outcomes.

• Benign lesions can be followed, treated with surgical decompression (if clinically warranted), and/or radio-surgical techniques, e.g. Gamma knife, Linear accelerator, etc.

Treatment• Metastatic Lesions

• Based on original lesion, location, and clinical picture

• Surgical resection for symptomatic lesions AND diagnosis

• Also based on surgical safety

• Some metastatic lesions are very hemorrhagic – risk outweighs reward

Treatment - Survival• Astrocytomas

• Grade I – surgery based on clinical picture, location, and risk but considered benign and can be followed with serial MRIs for growth. Stereotactic bx can also be considered or even total resection

• Survival is quite acceptable and may have complete remission after surgical removal

• Grade II – Same as above but consider the incidence of conversion to more aggressive lesion.

• Can consider serial MRIs, bx, surgical resection. Survival based on diagnosis

Treatment - Survival

• Astrocytomas

• Grade III – these are considered malignant and are likely to convert to higher grade. Clinic picture likely to require surgical intervention.

• Gross total resection, radiation therapy, possible include chemotherapy – Tamodar

• Survival is tenuous based on lesion type, resection, and response to treatment

Treatment - Survival• Astrocytomas

• Grade VI – most aggressive, Glioblastoma Multiforme, high mitotic changes, low percentage of overall cancers in the US but very devastating.

• Best quality of life, ~ one (1) year, is w/ gross total resection, radiation, and Tamodar

• Other treatments have been, or are being, studied:

• Gene therapy

• Immunotherapy

• Novel delivery methods

Case Studies

• 22 y/o WM presents to the ER with focal RUE seizures

• No prior history – very healthy

• Student at local university

• Exam – mild “drift” of the RUE and ? Mild weakness, no UMN findings, gait not tested

• Next step?

Case 1Describe

What’s next?

Case 1

• Notify the NS service – UNLESS that’s you

• Admit to the hospital

• Start steroids

• Start Dilantin

• Order MRI w/ GAD

Case 1

Is this extra-axial, intra-axial, infiltrative, edematous?

Describe

Case 1

• Next treatment course?

• Surgery?

• Watch?

• Medicine?

• Other studies?

Case 1

• What we did:

• Continued the steroids and Dilantin

• Family discussion and surgical planning as outpatient

• Craniotomy for biopsy and debulking

• Initial postoperative course was uneventful

• Awaited final diagnosis

Case 1

• Final Diagnosis

• Glioblastoma Multiforme

• High grade lesion – aggressive

• Oncology and radiation therapy involved

• Family made one trip to MD Anderson for second opinion

• Started treatment – We will be following up this month

Case 2

• 30 y/o female presented to outlying clinic with progressive thoracic pain – ONLY

• No significant PMHx

• Exam was essentially normal

• What would be your initial study if conservative medical treatment failed?

Case 2

Describe this MRI of the

Thoracic spine w/ Gadolinium:Level?Extra-dural?intra-dural?extra-medullary?Intra-medullary?Enhancing?

Case 2

• Treatment

• Surgical resection?

• Medications?

• Radiation?

• Watch?

Case 2

• What we did:

• Surgical discussion with patient and husband

• Remember that patient’s only problem was pain

• Thoracic laminectomy for partial resection and biopsy

• Steroid treatment in post op phase

• Stable post op exam w/ minor sensory changes

Case 2

• Final diagnosis

• Ependymoma – Grade II

• High likelihood of future neurological dysfunction

• Completed radiation treatment and first post radiation MRI was stable – exam also stable

• Due for f/u with new MRI of the Tspine

Case 3

• 63 y/o BM presented after struck in the head and pelvis by a toolbox

• w/u by ER and trauma service was, initially, just the abd and pelvis

• Head CT done as inpatient to complete work up

• No neurological complaints or exam findings

Case 3

Describe

Case 3

DescribeExtra or intra axial?Enhancing?Heterogeneous or homogenous?Location?Mass effect?

Case 3

• Treatment?

• Steroids?

• Surgery?

• Medications?

• Watch?

Case 3

• This is what we did:

• Discharged from hospital after recovery from pelvic injury

• Took to surgery for craniotomy and excision of the tumor

• Excellent postoperative course with discharge w/ in 3 days to home – no loss of function

Case 3

• Diagnosis

• Meningioma – benign lesion – total resection with attachment to the dura upon entry

• No need for aggressive post op treatment

• Follow up MRI in 6 months

• Return to normal activity

Case 4 – Last one

• 50 y/o WF well known to our practice with multiple intracranial CAVERNOMAs

• In 2008, developed new symptoms of neck and arm pain that progressed to gait instability

• Her exam fits with parasthesias and UMN findings in extremities

• What is the next step? Medications, studies?

Case 4

MRI - Hem W/ Gad w/o Gad

Case 4

Describe:Location?Extradural/intradural?Extramedullary/intra-medullary?Levels/location?

Case 4

• Treatment?

• Surgery?

• watch?

• Medications?

• Steroids?

• Immobilize?

Case 4

• What we did:

• Surgical decompression

• Steroids – short term

• PT

• F/U w/ serial MRIs

• Last study in Sept. 2012 – stable

• Very mild neurologic sequelae

Wrap up

Wrap up

• Tumor types of the CNS are numerous but are categorized for description, correlation to clinical picture, and treatment strategies

• Current imaging techniques are quite useful in identifying and predicting CNS lesions

• Take the time to gather a history, obtain your own exam, and look at the actual studies (use the radiology report as reference)

Wrap up

• The clinical picture of the patient upon presentation coupled with the studies is paramount to the development of a treatment strategy

• Studies and new treatments of aggressive CNS lesions, e.g. GBMs, remain at the forefront of cancer research

• Finally, all of you should endeavor to be neurosurgical PAs

Questions?