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Monroe-Kelly doctrine: the summarized volume of the intracranial components (brain tissue, blood, CSF) is constant. Inrease of any of them is possible only at the expense of the other two, and inceases the intracranial pressure. Normal CSF pressure: 100-170 mmH2O (by lumbar puncture in a lying position)
Changes in CSF
subarachnoideal hemorrhage, meningitis, hindered resorbtion of CSF.
Circulatory disturbances
extremely high arterial blood pressure, thrombosis of the
cerebral veins or venous sinuses.
Brain oedema
A common consequence of several different pathological processes, a general reaction of brain tissue for diverse harmful effects
Herniations
Shifting of brain tissue from one intracranial compartment to another, as a consequence of mass lesions. Importance: emergency, life threatening condition.
Types
1. Trantentorial (uncus of the temporal lobe into the opening of the tentorium). Symptoms: Oculomotor nerve palsy ipsilaterally. Ipsilateral hemiparesis due to the compression ot the contralateral midbrain by the edge of the tentorium. Cortical blindness due to bilateral occipital infarction resulted from compression of both posterior cerebral arteries. Decreased level of consciousness, coma, respiratory problems (Cheyne-Stokes) after severe damage of the midbrain.
1.
Herniations
2. Cerebellar- foramen magnum herniation (the cerebellar tonsils impacted into the foramen magnum, compressing the medulla oblongata). Causes: mass in the posterior fossa, great supratentorial mass lesion or general brain swelling. Symptoms: episodic tonic extensions-abduction ot the limbs. respiratory disturbances, cardiac irregularity (causes of death) paresis of all limbs, bilateral pyramidal signs. Neck stiffness, head tilt. Consciosusness relatively preserved, but finally coma.
Herniations
3. Subfalcial (lateral) herniation (the cingulum shifted under the falx cerebri to the other side) Cause: great, unilateral space-occupiing.
Herniations
Angiography. Disclosing of the blood supply of some hypervascularized tumors (e.g. angiomas, meningiomas)
Neuroepithelial tumors
Astrocytomas Graded from A 1 to A 4. The most malignant form is anaplastic astrocytoma, Glioblastoma multiforme (A3-4) In older patients. Localized in the hemispheres. High malignancy, rapid growth, infiltrative spreading. Butterfly tumor, transcallosal propagation. Symptoms: seisures, focal signs, elevated intracranial pressure, headache, psychiatric disorders (depression, behavioural, personality changes) Dg: CT, MR. Necrotic, irregular tumor mass, marginal enhancement, widespread perifocal oedema. Brain biopsy. Treatment: surgical: total removal is not possible. Irradiation and chemotheraby mav be added. High rate of recurrence, poor survival (maximum 1,5 year, average a few months)
Glioblastoma multiforme
Astrocytoma
Neuroepithelial tumors
Oligodendroglioma. Rare, hemispherial tumor. Usually calcificated. Slow propagation, not very malignant, but sometimes transfers to malignancy, to Glioblastoma multiforme. Highly epileptogenic. Symptoms: seisures, focal signs. Dg: CT, MR. Calcificated, circumscribed mass, slight perifocal oedema. Brain biopsy is diagnostic. Treatment: surgical: total removal. Antiepileptic medication. Ependymal tumors
Chorioid plexus tumors within ventricles, may lead to increased CSF production.
Pineal tumors. - Parinaud syndrome.
Neuroepithelial tumors
Embryonic tumors Most important: Medulloblastoma. The most malignant childhood brain tumor, originated from the vermis of the cerebellum. Invasive, infiltrating growth, high risk of recurrence, metastatizes by CSF. Symptoms: headache, nausea, vomiting, dysbalance, frequent falling. Brainstem symptoms. Dg: CT, MR. Enhancing, space occupying mass in the posterior fossa, causing CSF circulatory block, hydrocephalus. Treatment: surgical + Chemotherapy. Recently long (5-7 years) Others: teratomas
Medulloblastoma, CT with CM
Histology
Meningioma
Pituitary tumors
Pituitary adenomas. Originated from endocrine gland cells of the pituitary glands. Micro or macro-adenomas. Intra or suprrasellar masses. Hormonally active or inactive. Symptoms: local signs (visual field defect, etc.), hormonal dysfunction Hyperfunction hyperprolactinaemia (galactorrhoea, amenorrhoea) GH overproduction (acromegaly, giant growth) ACTH overproduction (Cushing disease) TSH overproduction (central hyperthyreoidism) Hypofunction: decrease of one or all the upper hormones (panhypopituitarism) Caused by compression of the functioning normal gland tissue.
Pituitary tumors
Dg: CT, MR. Microadenomas are non enhancing foci within the normal gland Tissue. Macroadenomas are usually enhancing, irregular, masses, with extrasellar propagation.
CT with CM
Treatment: surgical: transsphenoidal or by craniotomy. Irradiation. Hormonal treatment: bromocriptine may decrease the tumor size and normalize the hormonal dysfunction.
CT, no CM
CT, with CM
CT, with CM
Treatment: if solitary is the metastasis surgical removal is possible. In multiple cases irradiation ot chemotherapy. Outcome is dependent on the general oncologic state of the patient.
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