Pathology of CNS Tumors

Pathology of Brain tumors (CNS tumors) for undergraduate medical students.

1. CNS TumorsCNS Tumors
CPC-4.3.7 – Jenna 27y teacher.
Jenna is a 27 year old teacher in Ingham who
collapsed in her classroom today. She was seen by
her pupils to ‘shake all over’.
Brought to ED by paramedics, accompanied by
teaching colleague. Collapsed approx 30 mins ago.
(Aim: The aim of this CPC is to get students to
initially look at a broad range of differential diagnoses
for a witnessed, generalized tonic- clonic seizureseizure.
Then get them to focus on idiopathic epilepsyepilepsy,
convulsion secondary to infection (meningitismeningitis), and
convulsion secondary to brainbrain tumourtumour. get them to
discuss ‘what if’ questions; outlined below are a
variety of scenarios for you to draw from.
please remind students re. importance of accurate
collateral history in seizure description

2. CNS TumorsCNS Tumors
CPC-4.3.7 – Differential Diag.
Epileptic seizure
Idiopathic - epilepsy
Secondary:
Stroke - Cerebrovascular accident n.b. sub- arachnoid
haemorrhage in this scenario.
Infection (meningitis,encephalitis)
Tumour: primary or secondary
Drugs: drug or alcohol withdrawal; drug overdose
cocaine; amphetamines; tricyclics, buproprion (Zyban)
Genetic: neurofibromatosis;tuberous sclerosis..
Autoimmune: SLE; Hashimoto’s, encephalitis
Head Injury: Trauma.
Metabolic disorders: uraemia; hypoglycaemia; hypo-+
hypercalcaemia; hypo-+hypernatraemia
Neurodegenerative diseases e.g. Alzheimer’s
Non epileptic events: consider syncope; cardiac
arrythmias; pseudoseizures; TIA…etc

3. CNS TumorsCNS Tumors
Scenario: Epilepsy:
ABC breathing spontaneously rr 14/min; 4l O2 via
mask , sats (O2 Sat study) 96% ; pulse 100 bpm regular
good volume T 36.1 C BP 148/94.
GCS E2V3M4
Detailed check no neck stiffness, no skin lesions/rash
Tongue has been bitten; pupils equal and reactive to
light; fundoscopy normal
Decreased tone R upper limb, ?normal tone other limbs
Reflexes increased on R upper + lower limb; decreased
on L upper +lower;
Plantar reflexes upgoing
Evidence of urinary incontinence
All other systems : nil abnormal
Ix - BSL : 5.1; toxicology screen : negative

4. CNS TumorsCNS Tumors
Scenario: Meningitis
ABC breathing spontaneously rr 18/min 4l O2 via
mask, sats 90%; pulse 110 bpm reg small volume;
BP 90/60 mmHg T39.6C
GCS - E2V3M4
Detailed check - petechiae non blanching rash
trunk, buttocks, Neck stiffness
Small contusion L temperoparietal area
Capillary refill time > 3 secs, peripheral cyanosis+
Brudzinski sign positive
Ixskin scraping from lesion : gram negative
diplococci; CSF gram negative diplococci; FBC
wcc 18 (polymorhic leucocytosis)
Brudzinski sign, Kernig sign, CSF findings

5. CNS TumorsCNS Tumors
Core Learning Issues:
Pathology Major CLI:
Raised ICP – Pathology & Clinical features.
Pathology of common Primary and secondary CNS tumors in
different age groups.
Astrocytoma – grades, clinical types, presentation &
complications.
Pathology & Microbiology of Meningitis – common types
*Bacterial, viral, fungal & others.
Pathology Minor CLI:
Pathology of Epilepsy (note this is major clinical learning issue)
Meningioma, Acoustic neuroma, Craniopharyngioma / pituitary
tumors. Medulloblastoma.
Overview of Pathogenesis of Epilepsy (include theories for
idiopathic epilepsy).
CJD-Creutzfeldt jakob's disease. (Mad cow disease).

6. In every person who comes near you
look for what is good and strong;
honor that; try to learn it, and your
faults will drop off like dead leaves
when their time comes.

--John Ruskin
Look for good in others “No one is without faults and
everyone has some good qualities…!”

7. Pathology of
CNS TumorsCNS Tumors
Dr. Venkatesh M. Shashidhar, MDDr. Venkatesh M. Shashidhar, MD
Associate Professor & Head of Pathology

8. CNS TumorsCNS Tumors
CNS Tumors: General Features
10% of all tumors.
Commonest solid cancers in children.(2
nd
to Leuk
for all malignancies)
Age: double peak 1
st
& 6
th
decade
Adults - 70% supratentorial
Children - 70% infratentorial
No/very rare extraneural
spread.
Metastasis most common.
AdultsAdults
ChildrenChildren

9. CNS TumorsCNS Tumors
Clinical features:
Raised Intracranial Pressure*
Headache (morning), vomiting,
slow pulse, papilloedema.
Local damage:
Nerve & tract deficits, Paralysis,
seizures etc.

10. CNS TumorsCNS Tumors
CNS Tum: Clinical Features-Pathogenesis
Headaches (morning)
Papilloedema
Nausea or vomiting
Bradycardia
Seizures (convulsions).
Drowsiness, Obtundation
Personality or memory
Changes in speech
Limb weakness
Balance/Stumbling
eye movements or vision
Increased ICP
Increased ICP
ICP – Medulla ob.
ICP – Parasymp.
Irritation.
Brain Stem compress
Frontal lobe
Temporal lobe
Motor area
Cerebellum
Optic tract, occipital.

11. CNS TumorsCNS Tumors
CNS Anatomy - Clinical Features

12. CNS TumorsCNS Tumors
CNS Tumors Classification:
Primary Tumors:
Meninges – Meningioma
Glial cells: Glioma
Astrocytoma & Glioblastoma. Oligodendroma,
ependymoma.
Nerve sheath – Schwanoma, Neurofibroma.
Embryonal – Medulloblastoma, neuroblastoma,
teratoma.
Blood vessels – angioma, angiosarcoma etc.
* Other Epithelial, Pituitary & Pineal gland tumors.
Secondary Tumors - Metastasis – common
Melanoma, breast, lung, GIT.

13. CNS TumorsCNS Tumors
Adults:
Astrocytoma &
Glioblastoma.
Meningioma
Metastasis.
Children:
Astrocytoma
Medulloblastoma
Common:

14. CNS TumorsCNS Tumors
Meningioma:
Arise from arachnoid granulations of venous
sinuses. Attached to dura.
Common sites: parasagittal (falx), sphenoid
ridge, olfactory groove, cerebellopontine
angle.  specific clinical features.
Females common (2:1)
Slow growth, well differentiated &
demarcated. Does not invade brain (Benign).
Reactive skull Hyperostosis over the tumor.
Microscopy: spindle cells in whorls and
psammoma bodies(microcalcification).

15. Meningioma

16. CNS TumorsCNS Tumors
Meningioma

17. CNS TumorsCNS Tumors
Meningioma

18. CNS TumorsCNS Tumors
Meningioma

19. CNS TumorsCNS Tumors
Meningioma

20. CNS TumorsCNS Tumors
Meningioma

21. CNS TumorsCNS Tumors
Meningioma
•Well demarcated
•Capsulated

22. CNS TumorsCNS Tumors
Meningioma – whorls of clear cells.
Normal
Arachnoid
Granulation

23. CNS TumorsCNS Tumors
Meningioma
NodulesNodules
Psammoma Body

24. Psammoma bodies

25. CNS TumorsCNS Tumors
Glioma:
Gliomas are neoplasms of glial cells.
Commonest both in adults and
children
Benign * to Aggressively malignant.
Astrocytoma (anaplastic & G.B.M)
Ependymoma - Rare, 4th ventricle.
Oligodendroglioma - Benign, adults,
rare

26. CNS TumorsCNS Tumors
Astrocytoma
s
Adults:
Commonest 80%, Supratentorial.
Solid – Fibrillary – low grade*.
Varigated, Hemorrhagic - Malignant,
glioblastoma multiforme.
Children:
Infratentorial (Cerebellum),
Cystic, Low grade*, Pilocytic

27. CNS TumorsCNS Tumors
Astrocytoma-Lowgrade fibrillary

28. CNS TumorsCNS Tumors
Astrocytoma

29. CNS TumorsCNS Tumors
Astrocytoma: * Lat. Vent. *petechial hem.

30. CNS TumorsCNS Tumors
Glioma Brain Stem – note diffuse tumor

31. CNS TumorsCNS Tumors
Glioma Cerebrum cystic degeneration

32. CNS TumorsCNS Tumors
Glioma:

33. CNS TumorsCNS Tumors
Astrocytoma (Glioma)

34. CNS TumorsCNS Tumors
Glioma Brain Normal

35. CNS TumorsCNS Tumors
Astrocytoma

36. CNS TumorsCNS Tumors
Astrocytoma
s
Adults:
Commonest 80%, Supratentorial.
Solid – Fibrillary – low grade*.
Varigated, Hemorrhagic - Malignant,
glioblastoma multiforme.
Children:
Infratentorial (Cerebellum),
Cystic, Low grade*, Pilocytic

37. CNS TumorsCNS Tumors
Glioblastoma Multiforme (GBM):
High grade Astrocytoma - Grade IV
Commonest & malignant brain tumor in adults –
mean survival <1y – cerebral supratentorial.
Loss of heterozygosity on Chromosome 10 (80%)
Most GBMs have lost one entire copy of C – 10
2 types: Primary (worst) or Secondary from low grade
astrocytomas (better prog).
Variants: giant cell GBM, gliosarcoma
Microscopy:
Necrosis, palisading, hypercellularity, nuclear atypia
& vascular proliferation & mitoses.

38. CNS TumorsCNS Tumors
Genetic abnormalities in Glioma:
Low grade  Anaplastic  GBM

39. CNS TumorsCNS Tumors
Glioma: high grade

40. CNS TumorsCNS Tumors
Glioma:
Enhanceme
nt with
peritumoral
edema.

41. CNS TumorsCNS Tumors
Glioblastoma:

42. CNS TumorsCNS Tumors
GBM:
+ glioma
Enhancement
with peritumoral
edema.

43. CNS TumorsCNS Tumors
Glioblastoma – high grade Astrocytoma

44. CNS TumorsCNS Tumors
Glioblastoma – high grade Astrocytoma

45. CNS TumorsCNS Tumors
Glioblastoma Multiforme (high grade Astrocytoma)

46. CNS TumorsCNS Tumors
Glioblastoma Cerebrum

47. CNS TumorsCNS Tumors
Glioblastoma Cerebrum

48. CNS TumorsCNS Tumors
Glioblastoma Multiforme
PalisadingPalisading
NecrosisNecrosis

49. CNS TumorsCNS Tumors
Glioblastoma Multiforme
NecrosisNecrosis
PalisadingPalisading

50. CNS TumorsCNS Tumors
Glioblastoma Multiforme
Palisading
B.V
Necrosis

51. CNS TumorsCNS Tumors
Glioblastoma Multiforme
Palisading
Necrosis

52. CNS TumorsCNS Tumors
Glioblastoma Multiforme

53. A Astrocytoma Low grade
B Glioblastoma Multiforme(GBM)
C Necrosis with
pseudopalisading in GBM.

54. CNS TumorsCNS Tumors
Astrocytoma
s
Adults:
Commonest 80%, Supratentorial.
Solid – Fibrillary – low grade*.
Varigated, Hemorrhagic - Malignant,
glioblastoma multiforme.
Children:
Infratentorial (Cerebellum),
Cystic, Low grade*, Pilocytic

55. CNS TumorsCNS Tumors
Pilocytic astrocytoma
Common in childhood
Most slow growing of the gliomas
Sites: cerebellum, around 3
rd
Ventricle. optic
nerve.
Grossly cystic with mural nodule
Microscopic
elongated hair-like (pilocytic) elongated
cells & Rosenthal fibers.

56. CNS TumorsCNS Tumors
Pilocytic Astrocytoma - children

57. CNS TumorsCNS Tumors
Pilocytic Astrocytoma - children

58. CNS TumorsCNS Tumors
Pilocytic astrocytoma
Mural nodule

59. CNS TumorsCNS Tumors
Pilocytic Astrocytoma: Microscopy
Palisading pilocytic astrocytes – note plenty of Rosenthal fibres between cells.

60. CNS TumorsCNS Tumors
Medulloblastoma:
Children.
Cerebellum – vermis.
Primitive neuroectodermal tum.
Blast cells – round scanty cytoplasm.
4
th
ventricle Obstruction – hydrocephalus.
CSF seeding and Meningeal infiltration is
common.
Rosettes & neuronal or glial differentiation
rarely seen.

61. CNS TumorsCNS Tumors
Medulloblastoma:
Primitive neuroectodermal tumor:
Children, vermis of cerebellum.
Origin
Spread

62. CNS TumorsCNS Tumors
Medulloblastoma

63. CNS TumorsCNS Tumors
Medulloblastoma

64. CNS TumorsCNS Tumors
Youtube Videos:
Glioblastoma Multiforme:
http://www.youtube.com/watch?v=idSos1XOi7A
http://www.youtube.com/watch?v=bGawC2RJ-Sc
Meningioma:
http://www.youtube.com/watch?v=ddEB5ITx2fw
Pyogenic Meningitis:
http://www.youtube.com/watch?v=L9jpjxTSLws

65. CNS TumorsCNS Tumors
Most common CNS Tumors:
Glioblastoma MF

66. CNS Tumors: Summary
Adults:Adults:
Secondary commonSecondary common
Lung, Skin, breast..Lung, Skin, breast..
Primary - SupratentorialPrimary - Supratentorial
Astrocytoma / Astrocytoma /
glioblastoma.glioblastoma.
MeningiomaMeningioma
Children:Children:
22
ndnd
common (leuk / lymph) common (leuk / lymph)
InfratentorialInfratentorial
Astrocytoma (cystic Astrocytoma (cystic
cerebellar)cerebellar)
MedulloblastomaMedulloblastoma
Hydrocephalus.Hydrocephalus.
Meningeal spread.Meningeal spread.

67. CNS TumorsCNS Tumors
Learning Medicine...!
Learning medicine should be a JOY, not an ordeal.
Everybody learns according to their own best style.
The Hippocratic oath issues of patient privacy,
compassion, and FREE sharing of knowledge have to
be honored.
Exam and grade anxieties are the CANCERS of
medical education.
If your school admitted students which they feel need to
be whipped, the SCHOOL has failed, not YOU!
If you claim you NEED to be pushed, I do not want you
as my doctor.
John R. Minarcik, MD (http://www.medicalschoolpathology.com)

68. CNS TumorsCNS Tumors
Pathology of Pathology of
Increased Intracranial PressureIncreased Intracranial Pressure

69. CNS TumorsCNS Tumors
Pathogenesis:
Increased intracranial pressure (ICP): - if >
40 mm Hg  cerebral hypoxia, cerebral
ischemia, cerebral edema, hydrocephalus, and
brain herniation.
Cerebral edema: Edema - Disruption of the
blood brain barrier – vasodilatation – swelling.
Hydrocephalus  communicating type
common in Total Body Irradiation.

70. CNS TumorsCNS Tumors
Pathogenesis:
Brain herniation: Supratentorial herniation common.
3 sub types
Subfalcine herniation: The cingulate gyrus of the frontal
lobe (commonest)
Central transtentorial herniation: displacement of the
basal nuclei and cerebral hemispheres downward
Uncal herniation: Medial edge of the uncus and the
hippocampal gyrus
Cerebellar herniation: infratentorial herniation -
tonsil of the cerebellum is pushed through the
foramen magnum and compresses the medulla,
leading to bradycardia and respiratory arrest.

71. CNS TumorsCNS Tumors
Common CNS Herniations:
Subfalcine:

72. CNS TumorsCNS Tumors
Subfalcine Herniation: in brain trauma.
Contusion of the inferior temporal
lobe (blue arrow) has resulted in
diffuse edema. (compressed and
flattened gyri on the right).
This has resulted in subfalcine
herniation of the cingulate gyrus
(red arrow), with a secondary
hemorrhagic infarction above that
(black arrow). A midline shift from
right to left is also present, as is
uncal herniation (yellow arrow).

73. CNS TumorsCNS Tumors
Uncal Herniation:
Inferior view, The
herniated uncus is
bulging over the position
of the tentorium (black
arrows) and
compressing the
midbrain. The two
mammillary bodies (blue
arrows) have been
shifted to the patients
right due to the
pressure.

74. CNS TumorsCNS Tumors
Uncal Herniation:

75. CNS TumorsCNS Tumors
acute brain swelling + Uncal
Herniation
Swelling of the left
cerebral hemisphere
has produced a shift
with herniation of the
uncus of the
hippocampus through
the tentorium, leading
to the groove seen at
the white arrow.

76. CNS TumorsCNS Tumors
Cerebellar Tonsil - Herniation
Note the cone shape of the
herniated tonsils around the
medulla in this cerebellum
specimen.
Results in compression and
Duret hemorrhages in the
pons.

77. CNS TumorsCNS Tumors
Transtentorial herniation:
Transtentorial herniation
at the base of the brain. A
prominent groove
surrounds the displaced
parahippocampal gyrus
(arrow). The adjacent 3rd
nerve (N) is compressed
and distorted and the
ipsilateral cerebral
peduncle (P) is distorted
with small areas of
haemorrhage.

78. CNS TumorsCNS Tumors
Cerebral Herniation: Pathogenesis
Decerebrate posture
Cardiorespiratory failure
Death
Acute obstruction of CSF
pathway

Decerebrate posture
Cardiorespiratory failure Death
Brainstem compression and
haemorrhage
Foramen
magnum
Decerebrate posture
Cardiorespiratory failure
Death
Brainstem compression and
haemorrhage

Upper motor neurone signsCerebral peduncle
compression

Occipital infarction Cortical blindnessPosterior cerebral artery
compression

Horizontal diplopia, convergent
squint
Ipsilateral 6th cranial nerve
compression

Ipsilateral fixed dilated pupilIpsilateral 3rd cranial nerve
compression
Transtentorial
Clinical consequenceClinical consequenceEffectEffect
Site of Site of
herniationherniation

79. CNS TumorsCNS Tumors
Decorticate posturing, with elbows, wrists and
fingers flexed, and legs extended and rotated
inward.

80. Look for good in others…
no one is without faults and
everyone has some good
qualities!
BK.

81. CNS TumorsCNS Tumors
52y, F, CNS tumor: ? diagnosis
1 2 3 4 5
0%
10%
90%
0%0%
1.1.Glioblastoma m.Glioblastoma m.
2.2.AstrocytomaAstrocytoma
3.3.MetastasesMetastases
4.4.Medulloblastoma Medulloblastoma
5.5.MeningiomaMeningioma

82. CNS TumorsCNS Tumors
52y, F, CNS tumor: ? diagnosis
1 2 3 4 5
4%
90%
6%
0%0%
•Glioblastoma m.Glioblastoma m.
•AstrocytomaAstrocytoma
•MeningiomaMeningioma
•EpendymomaEpendymoma
•MedulloblastomaMedulloblastoma

83. CNS TumorsCNS Tumors
52y, F, CNS tumor: ? diagnosis
1 2 3 4 5
95%
2% 2%
0%0%
•Glioblastoma m.Glioblastoma m.
•AstrocytomaAstrocytoma
•MeningiomaMeningioma
•EpendymomaEpendymoma
•MedulloblastomaMedulloblastoma

84. CNS TumorsCNS Tumors
52y, F, parasagittal tum attached to falx: ? diagnosis
1 2 3 4 5
6%
8%
10%
4%
71%
1.1.Glioblastoma m.Glioblastoma m.
2.2.AstrocytomaAstrocytoma
3.3.MeningiomaMeningioma
4.4.EpendymomaEpendymoma
5.5.Medulloblastoma Medulloblastoma

85. CNS TumorsCNS Tumors
Commonest primary CNS tumor in Adults ?
1 2 3 4 5
15%
73%
0%0%
12%
•Glioblastoma m.Glioblastoma m.
•AstrocytomaAstrocytoma
•MeningiomaMeningioma
•EpendymomaEpendymoma
•MedulloblastomaMedulloblastoma

86. CNS TumorsCNS Tumors
52y, F, CNS tumor: ? Arrow Feature
1 2 3 4 5
0%
98%
0%
2%
0%
1.1.Necrosis.Necrosis.
2.2.Psammoma bodyPsammoma body
3.3.CalcificationCalcification
4.4.Blood vesselBlood vessel
5.5.Epithelial pearlEpithelial pearl

87. 60y smoker, chronic bronchitis complains of
difficulty walking. PE: stiff, expressionless face. A
tremor of his fingers is apparent but ceases when
he tries to reach for something. Image shows brain
stem . Diagnosis?
1 2 3 4 5
0%
4%
2%
92%
2%
1.1.Alzheimers diseaseAlzheimers disease
2.2.Lacunar infarctsLacunar infarcts
3.3.Picks diseasePicks disease
4.4.Parkinsons diseaseParkinsons disease
5.5.Durett hemorrhagesDurett hemorrhages

88. CNS TumorsCNS Tumors
Commonest primary CNS tumor in Children?
1 2 3 4 5
0%
67%
28%
4%
0%
•Glioblastoma m.Glioblastoma m.
•AstrocytomaAstrocytoma
•MeningiomaMeningioma
•EpendymomaEpendymoma
•MedulloblastomaMedulloblastoma

89. CNS TumorsCNS Tumors
Commonest Location of CNS tumor in Children?
1 2 3 4 5
4%
37%
4%
2%
53%
A.A.SupratentorialSupratentorial
B.B.Cerebellum Cerebellum
C.C.InfratentorialInfratentorial
D.D.Cerebrum.Cerebrum.
E.E.Brain stemBrain stem

90. CNS TumorsCNS Tumors
7y, F, CNS tumor: ? diagnosis
1 2 3 4 5
8%
46% 46%
0%0%
•Glioblastoma m.Glioblastoma m.
•AstrocytomaAstrocytoma
•MeningiomaMeningioma
•EpendymomaEpendymoma
•MedulloblastomaMedulloblastoma

91. CNS TumorsCNS Tumors
55y Female. Died following car crash. Coroners
autopsy Image shows Brain stem- What is the
likely cause of death?
1 2 3 4 5
20%20% 20%20%20%
1.1.Herniation of cerebral tonsil Herniation of cerebral tonsil
2.2.Intracerebral hemorrhage.Intracerebral hemorrhage.
3.3.Subdural hemotomaSubdural hemotoma
4.4.Subarachnoid hemorrhage.Subarachnoid hemorrhage.
5.5.Glioblastoma multiforme.Glioblastoma multiforme.

92. CNS TumorsCNS Tumors
56y, F Rapidly growing parietal lobe tumor:? diagnosis
1 2 3 4 5
88%
0%
6%6%
0%
•Glioblastoma m.Glioblastoma m.
•AstrocytomaAstrocytoma
•MeningiomaMeningioma
•EpendymomaEpendymoma
•MedulloblastomaMedulloblastoma

93. CNS TumorsCNS Tumors
49y, M, CNS tumor: ? diagnosis
1 2 3 4 5
0% 0%
20%
80%
0%
A.A.MetastasesMetastases
B.B.Astrocytoma sy.Astrocytoma sy.
C.C.MeningiomatosisMeningiomatosis
D.D.NeurofibromatosisNeurofibromatosis
E.E.LipomatosisLipomatosis

94. 54y woman dies 48 hours after suffering severe head
injuries in an automobile accident. Just before her death,
her left pupil becomes fixed and dilated. An inferior view
of the patient's brain at autopsy is shown.
Most likely cause of death?
A. B. C. D. E.
2%
0%
9%
89%
0%
A.A.Diffuse axonal shearingDiffuse axonal shearing
B.B.Laminar necrosisLaminar necrosis
C.C.Thrombosis of sagittal sinusThrombosis of sagittal sinus
D.D.Transtentorial herniationTranstentorial herniation
E.E.Watershed infarctWatershed infarct

95. CNS TumorsCNS Tumors
1 2 3 4 5
20%20% 20%20%20%
48y male, Frontal lobe tum,
What is the most likely diagnosis?
1.1.Glioblastoma m.Glioblastoma m.
2.2.AstrocytomaAstrocytoma
3.3.MeningiomaMeningioma
4.4.EpendymomaEpendymoma
5.5.Medulloblastoma Medulloblastoma

96. CNS TumorsCNS Tumors
SAQ / KFP
Should seizure patients have
imaging done immediately?
Personality changes indicate
which location?
Differentials for young adult
with insidious symptoms,
seizures and decreased signal
on T1 and increased signal on
T2 weighted MRI?
What is the treatment and
prognosis for someone with a
low-grade astrocytoma?
How should the symptoms be
treated?
What tests could have been
done in the absence of
neuroimaging?
Yes, 10-20% tumors.
Frontal lobe
Other gliomas
Conservative – Poor
Steroids, anti
epileptic,
symptomatic.
EEG

97. CNS TumorsCNS Tumors
SAQ / KFP
Why was the child hitting his
head?
Why did the child have a
headache?
If the child does have
hydrocephalus, at what level
is the ventricular system
being obstructed at?
Should a lumbar puncture be
performed?
Where in the cerebellum is
the lesion located?
What is the radiolucent area
visible along the antero-
superior aspect of the
radiograph?
Indicating headache.
Increased ICP, tum.
4
th
ventricle.
No – coning…*
Central – vermis
Separation/malfusion of
anterior frontoparietal
suture due to
hydrocephalus.

98. CNS TumorsCNS Tumors
50y Female smoker - Headache.
This 50 year-old female smoker known for hypertension
and diabetes mellitus type 2 was in her usual state of
health until 2 years ago, when she began to have
morning headaches that would usually go away by
themselves. Year later began to have hearing problem
on her left side. Recently, she noticed intermittent loss
of sensation of the left side of her face. She is taking a
thiazide diuretic, captopril, glyburide, and metformin.
She has no known allergies.
Physical exam: Slight drooping in the left mouth and
lower eyelid. Incomplete closure of the left eyelid with
corneal touch. Reduced pain and light touch on the left
side. Fundoscopic exam revealed bilateral papilledema.

99. CNS TumorsCNS Tumors
50y Female smoker - Headache.

100. CNS TumorsCNS Tumors
50y Female smoker - Headache.

101. CNS TumorsCNS Tumors
1.1.Glioblastoma m.Glioblastoma m.
2.2.AstrocytomaAstrocytoma
3.3.MeningiomaMeningioma
4.4.EpendymomaEpendymoma
5.5.Medulloblastoma Medulloblastoma
What is the most likely diagnosis?

102. CNS TumorsCNS Tumors
SAQ / KFP
Name the location of
tumor?
What cranial nerves
are involved?
List differential
diagnosis
Explain pathogenesis
of headache and
papilledema?
What does
the histological pattern
represent in slide 1?
slide 2?
Cerebellopontine angle
Cranial Nerves 5,7 & 8
Teratoma, meningioma,
acoustic neuroma.
Increased intracranial
tension.
Tumor attempting to form
Arachnoid grannulations.
Origin of tumor.

103. CNS TumorsCNS Tumors
35y Male, depression
2-year history of loss of initiative, depression. He had
slowly lost his drive to win all the big deals he always
done so well at work. 3 months ago he began to
experience headache, which did not respond to
acetaminophen or aspirin. His wife noticed that his
lethargic state had increased in the past few months. 3
days ago his right arm began to convulse uncontrollably
for 1 minute. 1 day ago the patient began again violently
shaking his right arm, and the right side of face began to
twitch at the dinner table. No fever.
Physical exam: Bilateral papilledema, increased deep
tendon reflexes of the right bicep, tricep, +ve babinski
sign on the right foot, reduced leg strength on the right.

104. CNS TumorsCNS Tumors
35y Male, depression
Axial T1 weighted MRI
Axial T2 weighted MRI

105. CNS TumorsCNS Tumors
35y Male, depression
Coronal T1 weighted MRI
Coronal T2 weighted MRI

106. CNS TumorsCNS Tumors
3y Male, constant cry….
Constant crying and not interacting with other
children at daycare since 1m. Mother noticed
that he was pointing to his head often. Family
physician who stated that he was developing
normally, and that the “ terrible two’s” are difficult
period for parents. Recently started vomiting on
a daily basis and started wobbling even though
he learned to walk 6 months ago.
Physical: Bilateral papilledema and gait ataxia
was noted on the physical exam.

107. CNS TumorsCNS Tumors
Axial T1 weighted MRI Axial T2 weighted MRI
3y Male, constant cry….

108. CNS TumorsCNS Tumors
Coronal T1 weighted MRI
3y Male, constant cry….

109. CNS TumorsCNS Tumors
1.1.Glioblastoma m.Glioblastoma m.
2.2.AstrocytomaAstrocytoma
3.3.MeningiomaMeningioma
4.4.EpendymomaEpendymoma
5.5.Medulloblastoma Medulloblastoma
What is the most likely diagnosis?

110. CNS TumorsCNS Tumors
65y Fem morning headache.
Morning headache 2y, Progressive right upper limb
weakness. She woke up this morning obtunded, and did
not initially respond to her husband’s cries. She
screamed to her husband that she could not see
anything to her right, and that she that her left arm and
leg were very weak. At this point her husband rushed
her to the nearest hospital.
Physical Exam: left lid ptosis, left-pupillary dilation, and
failure of her left eye to constrict to light directly or
consenually. Patient had bilateral lower limb weakness,
with increased deep tendon reflexes on the left side,
and a +ve babinski on the left side. Bilateral
Papilledema. Homonymous hemianopia of the right
side. Visual acuity was corrected to 20/20 with glasses.

111. CNS TumorsCNS Tumors
65y Fem morning headache.

112. CNS TumorsCNS Tumors
Brain Metastasis:
Lung, Breast, Skin,
Kidney, GIT.
Prostate – never..!
Well demarcated,
usually multiple with
surrounding rim of
inflammation.
Carcinomatosis:
Meningeal CSF spread
of malignant cells.

113. CNS TumorsCNS Tumors
Metastatic Melanoma: multiple

114. CNS TumorsCNS Tumors
Brain Metastases: Surrounding edema.

115. CNS TumorsCNS Tumors
1.1.Glioblastoma m.Glioblastoma m.
2.2.AstrocytomaAstrocytoma
3.3.MeningiomaMeningioma
4.4.EpendymomaEpendymoma
5.5.Medulloblastoma Medulloblastoma
What is the most likely diagnosis?

116. CNS TumorsCNS Tumors
SAQ / KFP
Are there clinical signs of
nerve compression?
What is the most likely cause
of the homonymous
hemianopia?
Why does the patient have
progressive right upper limb
weakness, and paroxysmal
left upper and lower limb
weakness?
Should a lumbar puncture be
performed?
Why was the patient
obtunded?
Why was an-x-ray taken?
Yes, ptosis, pupils 3
rd

Optic pathway
-occipital.
Motor cortex
compression – tum.
Risky.
Brainstem
compression.
Meningioma
hyperostosis.

117. CNS TumorsCNS Tumors
CPC-3.7– KFP Questions:
Meningitis Types, classification & comparison.
Septic, Viral & TB meningitis.
Morphology, complications.
Laboratory diagnosis, CSF findings.
CNS tumours: common features.
Adult and childhood CNS tumors.
Common Types & features.
Increased intracranial pressure – Pathologic
basis of clinical features.

118. It has been my philosophy of
life that difficulties vanish
when faced boldly.
--Isaac Asimov

119. Other CNS
tumors

120. CNS TumorsCNS Tumors
Neuroectodermal Tumors
Origin from primitive blast cells.
Rosettes - attempted nerve formation.
3.Medulloblastoma – Cerebellum
4.Retinoblastoma - Retina
5.Neuroblastoma – Adrenal glands
6.Ganglioneuroma - Mediastinum

121. CNS TumorsCNS Tumors
Medulloblastoma

122. CNS TumorsCNS Tumors
Ependymoma-hemorrhage

123. CNS TumorsCNS Tumors
Ependymoma 4
th
Ventricle

124. CNS TumorsCNS Tumors
Ependymoma 4
th
Ventricle

125. Ependymoma

126. CNS TumorsCNS Tumors
Nerve Sheath Tumors:
Neurofibroma:
Epi & endoneurial fibroblasts.
Form whorls of fibroblasts with nerves
Well differentiated, benign, capsulated.
Schwannoma:
Schwann cells, elongated form whorls
Nuclear palisading

127. CNS TumorsCNS Tumors
Schwannoma / Neurofibroma

128. CNS TumorsCNS Tumors
Schwannoma 8
th
Nerve:

129. CNS TumorsCNS Tumors
Bilateral 8
th
nerve schwannomas.

130. CNS TumorsCNS Tumors
Schwannoma:

131. Schwannoma

132. Neurofibromatosis:

133. Neurofibromatosis:
Café-au-lait spot

134. CNS TumorsCNS Tumors
Schwannoma

135. CNS TumorsCNS Tumors
Schwannoma

136. CNS TumorsCNS Tumors
Summary:
Children – 70% INFRAtentorial
Adults – 70% SUPRAtentorial
Common Malignant - adults, metastatic tumors (Lungs)
Common - adults – glioblastoma multiforme
Intracerebral
Common Benign - children – cerebellar astrocytoma.
Common Mal - children – cerebellar medulloblastoma
Very rare – meninges and schwann cells (meningiomas
and schwannomas) – usu. found in adults

137. CNS TumorsCNS Tumors
A 26-year old female
Headache,vomiting, an
epileptic attack, weakness
of legs. Now drowsy. Two
weeks before admission
she gave her second birth.
CT and NMR revealed a
huge parasagittal tumor
(80x67x65 mm), enhanced
by contrast, compressed
corpus callosum and
ventricles.

138. CNS TumorsCNS Tumors
Histopathology:
Bifrontal
parasagittal
tumor,
craniectomy
and tumor
was totally
removed.
Well
demarcated
, firm white
lobular.

139. CNS TumorsCNS Tumors
Fibrous – spindle cells.

140. CNS TumorsCNS Tumors
37 yr Female
Serious automobile accident and sustained a close
head injury,she does not immediately seek medical
attention, but is brought to the emergency room two
hours later by her brother,on physical examination
there is mydriasis and loss of pupillary light
reflex,several hours later she is unable to follow a
flash light with her eyes,which of the following
herniation is most likely occuring in this patient????
A)cerebellar tonsils into the forman magnum
B)cerebellum upward past the tentorium
C)singulate gyrus under the falx
D)medulla into the foramen magnum
E)temporal lobe under the tentorium

141. CNS TumorsCNS Tumors
32y Female Fleshy pappules:
Several fleshy papules
on face, trunk, and upper
extremities.
Since 10y of age.
Increased & Irritation
over the past 5 y.
Previous excision have
recurred.
No other significant
history.


142. CNS TumorsCNS Tumors
Neurofibromatosis:
Autosomal dominant,
NF1- Peripheral/Von Recklinghausen’s
NF2- known as central NF.
However, NF1 may cause central characteristics.
About 50% familial, 50% sporadic gene mutation.
NF1/ von Recklinghausen disease, gene mutation on
chromosome 17, 1 in every 3000-4000 births.
Diagnosis of NF1 if > 2 of
6 or more café au lait spots (irregularly shaped, evenly
pigmented, brown macules),
2 or more neurofibromas,
axillary or inguinal freckling,
Lisch nodules on the iris or optic glioma,
various types of osseous lesions,
a first-degree relative with the condition.

143. CNS TumorsCNS Tumors
Neurofibromatosis:
NF2 – Gene mutation chromosome 22.
1 in every 33,000-40,000 births
Typically present with acoustic neuromas or vestibular
schwannomas.
Tinnitus, balance disorders, and progressive hearing loss
May also have meningiomas and juvenile cataracts.
First-degree relative and on any 2 of the conditions listed for NF1.
Patients with NF1 are at increased risk of malignancy.
Annual ocular examinations are recommended. Genetic testing is
also advocated in patients with NF who wish to have children.
Surgery has been a successful treatment for the lesions
themselves; however, recurrence often occurs, and nerve
damage is a risk when tumors are located along neural pathways
(National Institute of Neurologic Disorders and Stroke, 2006).

144. CNS TumorsCNS Tumors
7
th
nerve palsy:
Cerebellopontine angle
tumours.
Acoustic neuroma,
epidermoid cysts,
medulloblastoma
meningioma
Affected cranial nerves:
5 trigeminal - masticatio
7 facial –face muscles
8 auditory – hearing

145. CNS TumorsCNS Tumors
Brudzinski Sign of Meningitis:

146. CNS TumorsCNS Tumors
Scenario: Brain Tumor
ABC as for scenario 1
GCS E3V4M5
Detailed check no neck stiffness, no rash
Tongue has been bitten; small contusion L
temperoparietal area
PEARL fundoscopy normal L sided weakness arm >
leg with increased tone and reflexes L plantar reflex
equivocal; R plantar reflex downgoing
Evidence urinary incontinence
All other systems : no abnormalities
Ix - as per scenario 1; MRI scan
?gliobalstoma multiforme R fronto-parietal region

147. CNS TumorsCNS Tumors
GBM: Glomeruloid bodies:

148. CNS TumorsCNS Tumors
Normal Fundus - Papilledema

149. CNS TumorsCNS Tumors
Normal vs Glaucoma