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Seen most frequently in children Generally arises from roof of fourth ventricle and leads to increased intracranial pressure accompanied by brainstem and cerebellar signs May seed subarachnoid space Glioma arising from the ependyma of a ventricle, especially the fourth ventricle; leads to early signs of increased intracranial pressure Arises also from central canal of cord Slow-growing Usually arises in cerebral hemisphere in adults Calcification may be visible on skull x-ray Presents during childhood with cranial nerve palsies and then with long tract signs in the limbs Signs of increased intracranial pressure occur late Presents with disequilibrium, ataxia of trunk or limbs, and signs of increased intracranial pressure Sometimes familial May be associated with retinal and spinal vascular lesions, polycythemia, and renal cell carcinoma Presents with increased intracranial pressure, sometimes associated with impaired upward gaze (Parinaud s syndrome) and other deficits indicative of midbrain lesion
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Ependymoma
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Oligodendroglioma
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Cerebellar hemangioblastoma
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Ventricular decompression by shunting is followed by surgical approach to tumor; irradiation is indicated if tumor is malignant Prognosis depends on histopathologic findings and extent of tumor Treatment is surgical, but total removal may not be possible Radiation may be used for residual tumor Treatment is excision by translabyrinthine surgery, craniectomy, or a combined approach Outcome is usually good
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Craniopharyngioma
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Originates from remnants of Rathke s pouch above the sella, depressing the optic chiasm May present at any age but usually in childhood, with endocrine dysfunction and bitemporal field defects Ipsilateral hearing loss is most common initial symptom Subsequent symptoms may include tinnitus, headache, vertigo, facial weakness or numbness, and long tract signs (May be familial and bilateral when related to neurofibromatosis) Most sensitive screening tests are MRI and brainstem auditory evoked potential Originates from the dura mater or arachnoid; compresses rather than invades adjacent neural structures Increasingly common with advancing age Tumor size varies greatly Symptoms vary with tumor site eg, unilateral proptosis (sphenoidal ridge); anosmia and optic nerve compression (olfactory groove) Tumor is usually benign and readily detected by CT scanning; may lead to calcification and bone erosion visible on plain x-rays of skull Associated with AIDS and other immunodeficient states Presentation may be with focal deficits or with disturbances of cognition and consciousness May be indistinguishable from cerebral toxoplasmosis
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Acoustic neurinoma
Meningioma
Treatment is surgical Tumor may recur if removal is incomplete
Primary cerebral lymphoma
Treatment is high-dose methotrexate followed by radiation therapy Prognosis depends on CD4 count at diagnosis
without actual loss of consciousness Temporal lobe lesions also lead to depersonalization, emotional changes, behavioral disturbances, sensations of d j vu or jamais vu, micropsia or macropsia (objects appear smaller or larger than they are), visual field defects (crossed upper quadrantanopia), and auditory illusions or hallucinations Left-sided lesions may lead to
dysnomia and receptive aphasia, while right-sided involvement sometimes disturbs the perception of musical notes and melodies 3 Parietal lobe lesions Tumors in this location characteristically cause contralateral disturbances of sensation and
CMDT 2008
MRI is of particular value there The characteristic appearance of meningiomas on CT scanning is virtually diagnostic, ie, a lesion in a typical site (parasagittal and sylvian regions, olfactory groove, sphenoidal ridge, tuberculum sellae) that appears as a homogeneous area of increased density in noncontrast CT scans and enhances uniformly with contrast Arteriography may show stretching or displacement of normal cerebral vessels by the tumor and the presence of tumor vascularity The presence of an avascular mass is a nonspecific finding that could be due to tumor, hematoma, abscess, or any space-occupying lesion In patients with normal hormone levels and an intrasellar mass, angiography is necessary to distinguish with confidence between a pituitary adenoma and an arterial aneurysm
may cause sensory seizures, sensory loss or inattention, or some combination of these symptoms The sensory loss is cortical in type and involves postural sensibility and tactile discrimination, so that the appreciation of shape, size, weight, and texture is impaired Objects placed in the hand may not be recognized (astereognosis) Extensive parietal lobe lesions may produce contralateral hyperpathia and spontaneous pain (thalamic syndrome) Involvement of the optic radiation leads to a contralateral homonymous field defect that sometimes consists solely of lower quadrantanopia Lesions of the left angular gyrus cause Gerstmann s syndrome (a combination of alexia, agraphia, acalculia, right-left confusion, and finger agnosia), whereas involvement of the left submarginal gyrus causes ideational apraxia Anosognosia (the denial, neglect, or rejection of a paralyzed limb) is seen in patients with lesions of the nondominant (right) hemisphere Constructional apraxia and dressing apraxia may also occur with right-sided lesions 4 Occipital lobe lesions Tumors of the occipital lobe characteristically produce crossed homonymous hemianopia or a partial field defect With left-sided or bilateral lesions, there may be visual agnosia both for objects and for colors, while irritative lesions on either side can cause unformed visual hallucinations Bilateral occipital lobe involvement causes cortical blindness in which there is preservation of pupillary responses to light and lack of awareness of the defect by the patient There may also be loss of color perception, prosopagnosia (inability to identify a familiar face), simultagnosia (inability to integrate and interpret a composite scene as opposed to its individual elements), and Balint s syndrome (failure to turn the eyes to a particular point in space, despite preservation of spontaneous and reflex eye movements) The denial of blindness or a field defect constitutes Anton s syndrome 5 Brainstem and cerebellar lesions Brainstem lesions lead to cranial nerve palsies, ataxia, incoordination, nystagmus, and pyramidal and sensory deficits in the limbs on one or both sides Intrinsic brainstem tumors, such as gliomas, tend to produce an increase in intracranial pressure only late in their course Cerebellar tumors produce marked ataxia of the trunk if the vermis cerebelli is involved and ipsilateral appendicular deficits (ataxia, incoordination and hypotonia of the limbs) if the cerebellar hemispheres are affected 6 False localizing signs Tumors may lead to neurologic signs other than by direct compression or infiltration, thereby leading to errors of clinical localization These false localizing signs include third or sixth nerve palsy and bilateral extensor plantar responses produced by herniation syndromes, and an extensor plantar response occurring ipsilateral to a hemispheric tumor as a result of compression of the opposite cerebral peduncle against the tentorium
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