This is a short review of brain tumors for medical school students.

1. DR. FARRUKH JAVEED
CONSULTANT NEUROSURGEON
JPMC, Karachi.

2. LOBES OF THE
CEREBRUM
PARIETAL
LOBE
TEMPORAL LOBE
FRONTAL LOBE
LIMBIC LOBE
OCCIPITAL LOBE

3. FRONTAL LOBE
The frontal lobe is the area of
the brain responsible for higher
cognitive functions.
Problem solving
• Memory
• Language
• Motivation
• Judgment
• Impulse control
• Social and sexual behavior.

4. TEMPORAL LOBE
The temporal lobe plays
a role in emotions, and
is also responsible for
smelling, tasting,
perception, memory,
understanding music,
aggressiveness, and
sexual behavior.
The temporal lobe also
contains the language
area of the brain.

5. PARIETAL LOBE
The parietal lobe plays a role in
our sensations of touch, smell,
and taste.
It also processes sensory and
spatial awareness, and is a key
component in eye-hand co-
ordination and arm movement.
The parietal lobe also contains a
specialized area called
Wernicke’s area that is
responsible for matching written
words with the sound of spoken
speech.

6. OCCIPITAL LOBE
The occipital
lobe is at the
rear of the brain
and controls
vision and
recognition.

7. LANGUAGE
Wernicke’s area is a
specialized portion of the
parietal lobe that recognizes
and understands written and
spoken language.
Wernicke’s area surrounds
the auditory association
area.
Damage to this part of the
brain can result in someone
hearing speech, but not
understanding it.
Wernicke’s
Area
Auditory Association
Area

8. HEARING
There are two auditory
areas of the brain:
• The primary auditory area
(brown circle) is what
detects sounds that are
transmitted from the ear. It
is located in the sensory
cortex.
• The auditory association
area (purple circle) is the
part of the brain that is
used to recognize the
sounds as speech, music,
or noise.

9. SPEECH
Broca’s area is where we
formulate speech and the
area of the brain that
sends motor instructions
to the motor cortex.
Injury to Broca’s area can
cause difficulty in
speaking. The individual
may know what words he
or she wishes to speak,
but will be unable to do
so.
Broca’s Area

10. MOTOR CORTEX
The motor portion of the
cerebrum is illustrated here. The
light red area is the premotor
cortex, which is responsible for
repetitive motions of learned
motor skills. The dark red area is
the primary motor area, and is
responsible for control of skeletal
muscles.
Different areas of the brain are
associated with different parts of
the body.
Injury to the motor cortex can
result in motor disturbance in the
associated body part.

11. SENSORY CORTEX
The sensory portion of the
cerebrum is illustrated here.
Different areas of the brain
are associated with different
parts of the body, as can be
seen below.
Injury to the sensory cortex
can result in sensory
disturbance in the associated
body part.

12. CEREBELLUM
The cerebellum is connected
to the brainstem, and is the
center for body movement
and balance.

13. INCIDENCE OF CNS
TUMORS
 One-third of CNS tumors
are metastatic lesions
 One third are gliomas
and
 One-third is of nonglial
origin.

14. World Health Organization
(WHO) Classification
Categorized & considered by cell layer of origin
 Tumors of Neuroepithelial tissue
 Tumors of Meninges
 Tumors of Craniospinal Nerves
 Hematopoietic Neoplasms
 Germ Cell Tumors
 Sellar Tumors
 Metastatic Tumors

15. Brain Tumors in General
 Presentation – Headache, seizure, neurological
deficit, visual loss, personality changes, etc
 History – Progressive onset of symptoms
(weeks to months)
 Physical Exam – Depends upon brain region
affected

16. HEADACHE
ONSET
• ABRUPT(waking from sleep)
• Triggered by exertion or Valsalva
CHANGE
• First or worst
• Change or progression in pattern
• New headache >50yrs
• New headache in cancer or AIDS pts
ASSOCIATED
• Abnormal neurological exam
• Neurological symptoms > 1 hours
• Associated with altered / loss of consciousness

18. TYPES OF BRAIN
HERNIATION

19. DIAGNOSIS
 Imaging Studies – CT, MRI, PET
 Laboratory Studies – Important for
systemic tumors and metastasis, e.g.
leukemia •
Treatment & Prognosis
 Varies per histology of specific tumors

20. CARE OF THE BRAIN TUMOR
PATIENT
Steroids
 Help resolve edema and symptoms
associated with it
 Can confuse the issue of lymphoma,
because rapid “disappearance” is seen for
lymphoma, followed by recurrence
Anti-convulsants
 Recommended particularly for supra
tentorial & epileptogenic areas, e.g. mesial
temporal lobe, and with past h/o seizures

21. Treatment Options in general
for Intracranial Tumors
 Need Biopsy for definitve identification…
then one or combination of the following:
 Surgery
 Radiation Therapy
 Whole brain
 Focused beam
 Gamma Knife Stereotactic Radiosurgery
 Chemotherapy
 Systemic
 Local

22. COMMON INTRAAXIAL TUMORS IN
ADULTS
Supratentorial Infratentorial
Metastasis Metastasis
Gliomas
Fibrillary Astrocytoma
Anaplastic Astrocytoma
Glioblastoma Multiforme
Oligodendroglioma
Hemangioblastoma

23. COMMON INTRAAXIAL TUMORS
IN PEDIATRICS
Supratentorial Infratentorial
Astrocytoma Juvenile Pilocytic Astrocytoma
Pleomorphic Xanthoastrocytoma PNET (Medulloblastoma)
PNET Ependymoma
DNET Brainstem Astrocytoma
Ganglioglioma
Although cancer is rare in children, brain tumors are the most
common type of childhood cancer after leukemia and
lymphoma.

25. SIGNS OF EXTRA AXIAL
LOCATION
 CSF cleft
 Displaced subarachnoid vessels
 Cortical gray between mass and white matter
 Displaced and expanded subarachnoid
spaces
 Broad dural base
 Bony reaction

26.  The T2W-images show a schwannoma located
in the cerebellopontine angle (CPA).
 CSF Cleft (yellow arrow)
 Displaced subarachnoid Space (blue arrow)
 Gray Matter between mass and White matter
(curved arrow)
 Wide CSF spaces (long arrow)

27. Meningioma (Enplaque variety)
 broad dural base and a dural tail of enhancement(blue
arrow)
 There is hyperostosis in the adjacent bone (yellow arrow)
 lesion enhances homogeneously

28.  A hyperintense contrast enhancing lesion
with extension to the prepontine area (blue
arrows) and into the foramen magnum (red
arrow).
 This Lesion proved to be Ependymoma

29.  Above image shows a diffusely infiltrating intra-axial tumor
occupying most of the right hemisphere with only a minimal
mass effect.
 Low-grade astrocytoma.

30. Midline Crossing Tumors
 Glioblastoma multiforme (GBM) frequently
crosses the midline by infiltrating the white
matter tracts of the corpus callosum.
 Radiation necrosis can look like recurrent GBM
and can sometimes cross the midline.
 Meningioma is an extra-axial tumor and can
spread along the meninges to the contralateral
side.
Continued

31. GBM Radiation Necrosis Meningioma

32. CALCIFICATIONS
Intraaxial
Tumors
Extraaxial
Tumors
Astrocytomas (20%) Meningiomas (25%)
Craniopharyngiomas (90%)
Oligodendrogliomas (80%)
Chordomas
Metastasis
Chondrosarcomas
Ependymomas (50%)
Choroid plexus papilloma
(25%)
Ganglioglioma (40%)

33.  The CT shows a
mass with
calcifications, which
extends all the way
to the cortex.
 The most likely
diagnosis is
Oligodendroglioma.

34.  A calcified mass seen in the
suprasellar region, causing
obstructive hydrocephalus.
 Craniopharyngiomas are slow
growing,calcified, cystic
tumors arising from remnants
of Rathke's cleft.
 They are located in the
suprasellar region and
primarily seen in children with
a small second peak incidence
in older adults.

35.  On the coronal and sagittal TW1I there is a large
mass centered around the sella with a broad dural
base. & extension into the sella.
 CT shows densely calcified tumor.

36. Melanoma GBM PNET

37. DIFFUSION WEIGHTED
IMAGING
 Normally water protons have the ability to diffuse
extracellularly and loose signal.
 High intensity on DWI indicates restriction of the
ability of water protons to diffuse extracellularly.
 Restricted diffusion is seen in abscesses,
epidermoid cysts and acute infarction
 In most tumors there is no restricted diffusion -
even in necrotic or cystic components. This
results in a normal, low signal on DWI.

38.  We see restriction in above left extreme image
as it is hyperintense, while lower extreme left
image shows no restriction.

39.  Schwannoma extending into the middle cranial
fossa with homogeneous enhancement (right).
 Primary Lymphoma shows vivid enhancement (left).

40. Contrast Enhancement
Meningioma Schwannoma Lymphoma Choroid Plexus
Papilloma

41. Contrast Enhancement
Hemangioblastoma Pilocytic Astrocytoma Ganglioglioma

42.  Above image shows glioblastoma multiforme (GBM).
 The enhancement indicates that this is a high-grade tumor
 There is also a cystic component with ring enhancement..

43. RING ENHANCEMENT
1. Metastasis
2. Glioblastoma Multiforme
3. Tuberculoma
4. Abscess,
5. Infectious disease Toxoplasma
6. Multiple Sclerosis
7. Chronic hematoma

44. Contrast Enhancement

45.  Many non-
tumorous
lesions can
mimic a
brain
tumor.

46.  Infections and vascular lesions can also
mimic a CNS tumor.

47. METASTATIC BRAIN
TUMOR
 History – Rapidly
progressive onset of
symptoms (weeks vs.
months)
 Most common sources
are LUNG, BREAST (in
women), Thyroid,
RENAL, & G.I. tract

48. DIAGNOSIS
Imaging Studies –
 MRI: Tumor at grey-white
matter junction, usually
associated with edema
Systemic work-up includes
 CT scan of chest, abdomen
and pelvis
 Mammography
 Bone scan
Diagnostic Laboratory Studies
 CBC, ESR, LFTs,

50. TREATMENT
 For solitary lesion or less
than 4 lesions all < 3 cm. –
biopsy if undiagnosed, plus
Gamma Knife
 For > 3 cm. tumor, surgery
followed by WBRT
 For > 4 lesions, biopsy for
diagnosis, plus whole brain
radiation therapy
 Prognosis: 7 – 12 mos.

51. GLIOMAS
Presentation
 Depends upon brain
location, usually H/A over
several weeks, seizure,
vomiting, visual chages or
word finding difficulty
Physical Exam –
 Depends upon brain region
affected
Diagnostic Imaging Studies –
 CT, MRI

53. Treatment
 Surgery, Radiation, Chemotherapy (varies with
age group & type)
Survival depends on pathology: –
 Pilocytic astrocytoma: resection Æ cure; Grade
1 Astrocytoma (nuclear atypia) – 8-10 yrs;
 Grade 2 Anaplastic astrocytoma (+endothelial
proliferation) – 2 yrs
 Grade 3 (+necrosis) GBM – 11 months

54. MENINGIOMA
Presentation
 Meningiomas occur in
middle aged females more
frequently
History
 Meningiomas are usually
slow-growing (months to
years)
 CT/MRI: Show meninges-
based tumor (usually), with
variable amount of edema

57. TREATMENT
 Meninigiomas: Gross total resection curative
 Need for radiation therapy depends on grade
Prognosis
 – Meningiomas: Can be cured with gross
total resection with favorable prognosis

58. PITUITARY ADENOMA
Presentation
 Headache, visual defect
(classically bitemporal
hemianopsia), endocrine
abnormalities (dependent
upon hormone secreted) –
 Prolactinoma most common
 ACTH with Cushing’s
disease (w/hypertension,
stria, buffalo hump, morbid
obesity);
 GH with acromegaly

60. History
 Slow-growing, over months to
years
 Headache with progressive
visual loss
 Most common presentation is
bitemporal hemi anopia
Diagnostic Laboratory Studies
 Endocrine panel
 Test IGF-1 for GH-secreting
tumor;
 Use dexamethasone
suppression test for Cushing’s
disease vs. ectopic Cushing’s
syndrome

62. Treatment
 Medical treatment for Prolactinoma only
with dopamine antagonists
 Surgical excision usually initial treatment
(usually transnasal approach), with
Gamma Knife for recurrence vs. local
focused radiation
Prognosis
 Generally benign, so proportional to gross
total resection & control of endocrine
effects;

63. Vestibular schwannoma
Presentation
 Hearing difficulty in
affected ear, vertigo,
headache/facial
weakness/facial
numbness if large
tumor compressing
trigeminal nerve

64. Physical Exam
 Evaluate facial
weakness & hearing
ability
Diagnostic Imaging
Studies
 MRI Brain with
MRA/MRV
OTHERS
 Audiometry

65. NEURO FIBROMOTOSIS

66. Treatment
 Surgical resection if >3 cm. or causing
excessive mass effect, brainstem
compression; GK for smaller lesions (<3 cm.)
Prognosis
 Benign tumor, so good with total excision and
lack of recurrence

67. Lymphoma
Presentation
 Sporadic, more common in
immunosuppresed or
immunocompromised
patients (e.g. HIV+); may or
may not be systemic @
presentation.
 Spinal cord (epidural)
compression or
carcinomatous meningitis
 Multiple cranial nerve deficits

69. Diagnostic Imaging
Studies
 CT / MRI Brain
Treatment
 Biopsy for establishing
diagnosis, followed by
radiation; chemotherapy
(intra thecal
methotrexate) has
shown increased
survival

70. PROGNOSIS
 No treatment 2.5 months.;
 XRT 10 months
 Intraventricular methotrexate 41 months.
 Prognosis worse in AIDS pts. (4 months)

71. Pineal Region Tumors
Presentation
 Headache,
Hydrocephalus (if large)
Physical Exam
 May develop Perinaud’s
syndrome (up gaze
palsy, convergence, and
accomodation
impairment)

72. Diagnostic Imaging
Studies
 MRI
Diagnostic Laboratory
Studies
 CSF can be sent for
markers – AFP, HCG,
PLAP

73.  Tumor located in the pineal region with calcifications.
 This is most likely a germinoma.

74. Treatment
 Depends upon histology:
 Germinoma – biopsy & irradiate;
 Pineoblastoma: resect & irradiate
Prognosis
 Depends upon histology: Pineocytoma
better than germinoma, pineoblastoma

75. Lymphoma Meningioma GBM

76. Meningioma Lymphoma GBM

77. Multifocal Disease
 Multiple tumors in the brain usually indicate
metastatic disease.
 Primary brain tumors are typically seen in a
single region

78.  Some tumors can be multifocal as a
result of seeding metastases: this can
occur in medulloblastomas (PNET-MB),
ependymomas, GBMs and
oligodendrogliomas.
 Meningiomas and schwannomas can be
multiple, especially in neurofibromatosis
type II.

79. Metastasis Neurofibromatosis II

80. COMMON CP ANGLE
TUMORS
Schwannoma
Meningioma
Epidermoid
Arachnoid cyst
Paraganglioma
Metastasis

81.  Cystic schwannoma of Left CP Angle.

84. LOW GRADE
ASTROCYTOMA

93. CYSTIC TUMORS WITH MURAL
NODULE