КУТОВОЙ ИГОРЬ АЛЕКСАНДРОВИЧ: +38 050 300-25-50; +38 098 447-26-32 город Харьков, ул. Акад. Павлова, 46 Государственное учреждение "Институт неврологии, психиатрии и наркологии НАМН Украины"
web: kutovoy.umi.ru
mail: igorKutovoy@gmail.com

Class 3

Class 3

Methodological recommendations on the theme:

Tumours of the brain. Classification, clinical course, pathogenetic mechanisms of formation of general brain and local symptoms. Main principles of diagnostics of tumours of the brain. Clinical course of tumours of the brain of different localization. Significance of additional methods of examination. A surgery of tumours of the brain. Radical and palliative operations. The combined treatment of malignant tumours of the brain.

Hydrocephaly. Pathogenesis. Kinds of hydrocephaly. Clinical course, diagnostics. Modern methods of surgery.

2. Importance of the THEME: Tumours of the brain constitute 9 % of the general number of all human neoplasms and take the fifth place among tumours of other localizations. One case of the brain tumour is registered annually per 15-20 thousand people. Early diagnostics of the brain tumour provides successful in treatment.

3.1.           The practical aims: To give the students an opportunity to consider the basic clinical signs of the brain tumours at the bed side of the patient. They can to consider general brain and focal symptoms on the example of the patients with brain tumour. To learn diagnostic signs of auxiliary methods of inspection in tumours of the brain. To consider the order of making and formulation of the diagnosis. Surgery of tumours of the brain. Radical and palliative operations. The combined treatment of malignant tumours.

3.3.    The EDUCATIONAL AIMS: are connected with formation neurooncologic alertness and feelings of great responsibility for health of the patient and his life in the students.

  1. Materials of independent preparation (interdisciplinary integration)

 

DISCIPLINES

TO KNOW

TO BE ABLE

Nervous diseases

General neurology, methods of examination of the neurologic patient, specific neurology

To carry out the examination of the neurologic patient.

To analyze general brain and local symptoms

Oncology

Clinical, histopathological classification of tumours of the brain, histologic types of tumours, surgical classification

To inspect neurooncologic patient

Radiology

Craniographyc signs of hypertension - liquor syndrome

To consider X-ray images of the patient with brain tumour

 

  1. The contents of the theme

Clinical classification of intracranial tumours

Localization of tumours

Supratentorial

Subtentorial

 

Hemisphere

Midline

Adults

Children

glioblastoma

adenoma of a hypophysis

Angioblastoma

 ependymoma

astrocytoma

Cranyopharyngioma

Metastases

glioma of the brain stem

oligodendroglioma

Pineal tumour

Shwanoma of VIII nerve

astrocytoma of a cerebellum

meningioma

colloidal cyst

meningioma

medulloblastoma

metastases

 

 

 

 

Clinical groups of neurooncological patients

Clinical group

Degrees of malignancy

size of the primary tumour

The fact of metastases

G1

T1

М0

G1

Т 2, Т3

М0

11А

G2

Т1

М0

11В

G2

Т2, Т3

М0

111А

G3

Т1

М0

111В

G3

Т2, Т3

М0

1Y

G1, G2, G3, G4

Any Т

М0, М1

 

5. The contents of the theme of the class

HYDROCEPHALY

Hydrocephaly is an excessive accumulation of a cerebrospinal liquid in the cavity of the skull. The rate of the congenital forms of hydrocephaly reaches 2-5 on 1000 newborns. It is a disease of mainly early children's age, from the birth till the first year of life. It is necessary to distinguish precisely hydrocephaly as the disease having the clinical picture, course, the prognosis, and hydrocephaly as a syndrome in various neurosurgical diseases and traumatic affection of the brain.

In the majority of cases we deal with a congenital hydrocephaly, with violet progressing of hydrocephalus of the brain already in the first months and even days after birth. It is considered, that in development of hydrocephaly the birth trauma, asphyxia and hypoxia during delivery have essential value. However the given literatures of last years and our investigations show, that the major importance in development of hydrocephaly has infectious affection of the fetus, it is more often virus, during pregnancy of the mother. Probably there may be intranatal infection of the fetus during delivery, as a result of contact with causative agents in the area of generic duct, most often with a virus of a genital herpes and chlamydia.

There are a lot of classifications of hydrocephaly (A.A.Arendt, 1948; Matson, 1960; B.P.Simernitsky, 1989; Raimondi and Mori, 1991, etc.). The basis of the majority of classifications is division of hydrocephaly into open and closed, hypertensive and hyporesorptive (disresorbtive); internal, external, mixed, congenital, posttraumatic, postinflammatory, tumoral, vascular, idiopathic, etc. By localization of the is liquid hydrocephaly is divided into external (the liquid accumulates in ventricles of the brain); by character of functioning of liquor system – into open (circulation of the cerebrospinal liquid is not disturbed) and occlusive, or closed (disorders of circulation at different levels of liquor system). In its turn, the open hydrocephaly can be aresorptive (slow absorption of the cerebrospinal liquid), hypersecretory intensification of secretion in constant resorption and mixed. The occlusive hydrocephaly can be caused by impairment of liquid outflow at the level of interventricular apertures (Monroe), III ventricles, a waterpipe of the brain, IV ventricles, median and lateral apertures of IV ventricles, cerebellar – medulla oblongata tanks. By time of development there are congenital and acquired hydrocephalies, by course acute and chronic, by stages – progressing and stabilized, compensated. The analysis of our own material and the literature data show, that the above-stated classifications insufficiently adequately reflect essence of the pathological process. Besides, the widespread classifications are not always convenient for use in practical work. The retrospective analysis of results of investigation and treatment of 1200 patients with hydrocephaly who had undergone 2000 various operations was made. Evaluation of hydrocephaly was carried out by means of investigation of cephaloventricular factors, viscous - elastic properties, a ratio of "pressure - volume" of craniospinal systems and dynamics of perfusion pressure of the brain, rate of production and resistance of cerebrospinal liquid (CSL) resorption.

Results of our own research were compared with the data of the literature. It has been established, that in some part of patients with the connected hydrocephaly on the background of liquor hypertension, the transitional occlusion of liquor ways develops which is spontaneously eliminated after removing CSL and normalization of liquor pressure. In ¼ of patients with hydrocephaly interoscopy reveals signs of occlusion of one of lateral sinuses. This occlusion in 2/3 cases is transitional, it is observed on the background of ventriculomegaly and liquor hypertension it is spontaneously eliminated after normalization of liquor pressure. Besides in 2/3 of patients with hydrocephaly on the background of liquor hypertension decrease in perfusion pressure of the brain is marked. Study of viscous - elastic properties of cranio-spinal system in patients with hydrocephaly reveals reduction in elasticity of the brain, combined with "S" shaped form of a curve "P-V" ratio pressure - volume in partial removal of CSL. In 2/3 of patients with occlusive hydrocephaly there is disturbance of resorption. The analysis of evolution of hydrocephaly reveals, that more often it has the following orientation: an external hydrocephaly ® mixed (external and internal) hydrocephaly ® internal hydrocephaly. Presence of the mechanism of "a transitional occlusion» of the liquor ways and sinuses of the dura mater membrane provides transformation of the occlusive hydrocephaly into hyporesorptive and vice versa.

Thus, with development of the disease in patients with hydrocephaly the pathological system whose structure can be presented as follows is formed: disturbance of liquorocirculation excessive accumulation of CSL, expansion of the liquor cavities, increase in pressure of CSL ® transitional occlusion of liquor ways and sinuses of the dura mater membrane, decrease in the perfused pressure and ischemia of the brain, reduction in elasticity of the brain, obliteration of the subarachnoidal fissures ® the further increase of disturbance of liquorocirculation. This pathological system can be self preserved and provide the further progressing of the disease together with assumed etiologic factor or together with it.

Thus, probably, the following classification is useful: the initial stage of development of hydrocephaly ® late stage of hydrocephaly ® hydrocephaly after liquoroshuntins operations.

All above-named forms and kinds of hydrocephaly belong to a progressing active hydrocephaly when due to disbalance between production, circulation and resorption of CSL intracranial pressure raises, ventricles of the brain extend, the brain tissue become squeezed and atrophied. But ventricles of the brain and subarachnoid space can extend passively during progressing of atrophy of the brain tissue, for example, after intranatal hypoxia of the brain, a severe craniocerebral trauma, an ischemic insult of the brain. Such hydrocephaly recently has been called normotensive as intracranial pressure does not raise in this case.

In case of a progressing hydrocephaly in newborns such external signs, as progressing change of the size and form of the head are the main ones. The circumference of it can reach 70 cm and more in newborns at the age of 6-7 months. The size of the head is increased in the sagittal direction therefore the frontal bone swells and hangs above rather tiny skeleton of the face. The skin of the head is thinned, atrophic, a venous network is compensatory expanded. Bones of the skull are thinned, their edges go apart, forming significant intervals, especial by along coronal and sagittal sutures. The anterior and posterior vertex are expanded, tensed, sometimes swell, there is not pulsation. If hydrocephaly starts to develop in children after a year expansion of cranial sutures progresses, the sound changes on percussion of the skull (a sound of cracked pot).

Neurologic symptoms in hydrocephaly are various and are a heritage both of the basic process which has caused development of hydrocephaly, and chronic increase of the intracranial pressure caused by it. Affections of the cranial nerves, motor and cerebellar systems, spasms, mental disorders can be observed. Babies have a characteristic sign of move of the eyeballs from top to bottom (a symptom of "sunset"). Visual acuity is reduced even to blindness. There is often dysfunction of abducent nerves therefore there may be a converging squint.

Disorders of movement have various characters; there may be different pareses, sometimes in a combination with hyperkinesias. Cerebellar dysfunctions are manifested by disturbance of statics and coordination of movements. Children often cannot go, stand, and even sometimes sit and hold the head. There can be a significant retardation in the intellectual development, hypererethism and irritability or weakness and adynamia, indifference to everything.

Hydrocephaly which develops in adults, is characterized by a syndrome of a progressing intracranial hypertension: a headache, especially in the morning, nausea and vomitting at the height of headache, edema of disks of the optic nerves, hypertension changes of the bones of the skull and a turkish saddle.

For adequate treatment it is necessary to specify character and a degree of hydrocephaly, a level of occlusion of the liquor ways. For this purpose there are used radiological methods of investigation, radionuclide ventriculography, axial computer tomography.

Conservative methods of treatment in hydrocephaly are ineffective and can be used during limited time at early stages of its development as a course of dehydration therapy. In occlusive hydrocephaly surgical methods of treatment are widely used directed at formation of collateral ways of outflow of CSL beyond the central nervous system and normalization of intracranial pressure. The main indication to operation is progressing of hydrocephaly in absence of inflammation of the brain membranes.

Depending on a kind of hydrocephaly methods of surgery are divided into used in case of an open hydrocephaly, occlusive and universal methods. In case of an open hydrocephaly the operation results constant in removal of CSL beyond the central nervous system into some cavity of the organism where it can be absorbed or removed outside. For this purpose there is widely used the operation of lumbar subarachnoidal-peritoneal shuntings – maintenance of constant outflow of CSL from a terminal ventricle of the spinal cord into abdominal cavity. It is possible to use valvular systems for the regulated decrease in the intracranial pressure.

There is a modification of puncture introductions of the subarachnoidal - lumbar end of the shunt.

In case of occlusive hydrocephaly in children over 3 years and in adults when it is impossible to remove the direct cause of the occlusion by the surgical way the operation of ventriculocysternostomy was suggested by Torkildsen in 1993. The essence of operation is that with the help of a catheter the connection between a lateral ventricle and cerebellar – medulla oblongata tank is formed.

In case of occlusion at the level of IV ventricle and its apertures, and also aqueduct of the brain it is possible to make unilateral ventriculocysternostomy. However, taking into account the possibility of displacement of a catheter and stop of functioning of the shunt, it is worth to make bilaterial shunting at such levels of occlusion. If there is occlusion at the level of the interventricular aperture or III ventricle, bilaterial shunting is obligatory as lateral ventricles can be divided.

Universal operations can be used in a case of both open, and occlusive hydrocephaly. The most widespread are two kinds of such operations – valvular ventriculo-diostomy and ventriculoperitoneostomy. During the first operation excess of CSL is removed from the ventricles for regulation of outflow of liquid to avoid sharp decrease in the intracranial pressure. Each type of valves is designed for a certain pressure of CSL, below which the valve is closed and ceases to function.

The success of surgery in hydrocephaly depends on the approach to a choice of a kind of the operation (it should be individual), skills to define precisely optimum term of intervention and to provide such system with dosed removal of CSL which would form the best conditions for its circulation. Some surgeons make subarachnoidal-sinus shunting when one end of the shunt is introduced in the subarachnoid space, and another – in the nearest sinus.

2. A place of carrying out the class a class-room, wards, diagnostic consultation rooms.

3. Duration of the class: 2,7 hours.

5. Materials of methodological maintenance of the class.

5.1. Situational TASKS FOR CHECKING THE LEVEL OF KNOWLEDGE OF STUDENTS WITH STANDARD ANSWERS.

 

№ 1. The patient of 34 years old had disorder of the menstrual cycle, and in a year there has come amenorrhea which was regarded by doctors as an early climax. Then sight reduced, the patient was treated at in- and out-patient departments for 2 years, but sight was progressively reducing. In 2 years visual acuity on the right eye was 0.03, left 0.02, at the expense of primary atrophy of the optic nerves. Moderate headaches which worsened in the morning have developed. It is necessary to make the preliminary diagnosis and to define the plan of examination.

ANSWER. The preliminary diagnosis: a tumour in the hypophysis area. With the greatest probability of adenoma of the hypophysis. For specification of the diagnosis ophthalmologic study is indicated, with specification of the field of vision, carrying out of target roentgenogram of the turkish saddle. Echoencephalography, EEG, RHEOENCEPHALOGRAPHY, CT-SCAN.

 

№ 2. The patient of 62 years old developed, the limited immovable swelling 4х4 cm 2 months ago which was firmly adherent to the adjacent tissues in the parietal area. The patient consulted the local surgeon who tried to remove soft tissue tumour of the parietal area in the clinic. The tumour was removed in part, the patient was brought take neurosurgical clinic. What mistake was made by the doctor on inspection and treatment of the patient?

ANSWER. A mistake is insufficient primary examination of the patient craniograme was not made. Attempt of removal of the tumour intimately adherent to bones of the arch of the skull has led to that the tumour was not removed radically that could lead to the deterioration of the general condition of the patient and possibility of bleeding as a complication during and after operation (early complication) and edema of the brain.

 

№ 3. The patient of 38 years old vision in the right eye began to reduce. She was treated under supervision of the oculist, but the sight was progressively reduced at the expense of primary atrophy of the right optic nerve; the diverticulum of the right eyeball developed 4 months ago and increased. On inspection the exophthalm on the right, visual acuity of the right eye – 0.05, left – 1.0 are marked. There is a primary atrophy of an optic nerve, stagnation of the disk of the optic nerve on the left on the eye fundus. Determine the topical diagnosis, apply auxiliary methods of investigation.

ANSWER. The patient has affection of basal part of the right frontal particle with a great probability of a tumour. It is necessary to use auxiliary methods of investigation –Echoencephalography, CT-SCAN, a carotid angiography on the right, craniograms .

 

№ 4. The patient of 52 years old consulted the doctor because of attacks of spasms in the right extremitys which developed 2 years ago. During the 1-st year there were 3 attacks after which there was a headache, weakness in the right hand for 30 minutes after the attack. The last 0.5 years he has attacks with spasms and loss of consciousness which are preceded by numbness and spasms in the right hand. On examination the patient has insignificant lag in the right hand by the test of Barra, prevalence of tendon reflexes by hemitype on the right, reduction of pain sensitivity. Diagnose and determine treatment.

ANSWER. The patient has a tumour of frontal-temporal part on the left. It is recommended: osteoplastic trepanation, removal of the tumour after inspection. In malignant character application of chemotherapy and radiation therapy is indicated.

 

№ 5. The patient is 62 years old. His condition is severe marked headache, vomiting in the mornings, the limited movements in the left extremities. The patient considers himself ill for 2 weeks, the condition progressively worsens. The patient has been smoking since from 20-years of age. For the last year he has constant cough. The patient is under nourished, integuments are pale - grey, memory is reduced. Make the plan of examination of the patient; determine character of the pathology, examination and treatment.

ANSWER: The patient has a great probability – cancer of the lungs with metastasises in the brain. It is necessary to carry out general somatic and oncological inspection of the patient, roentgenography of organs of the thorax. In detection single metastasis in the right hemisphere of the brain and in absence of contra-indications on the part of lungs removal of this metastasis with the subsequent chemotherapy and radiation therapy is indicated after angiography. Symptomatic treatment. If there are multiple metastasises operative treatment is not indicated. Chemotherapy and symptomatic treatment are administered.

 

№ 6. The patient of 42 years old was admitted to the clinic with complaints of headaches which worsen in the mornings and are accompanied by vomitting, unsteadiness of walking, absence of hearing in the right ear. When the position of the body is changed he has “a veil” before the eyes. He has been ill for about 5 years. Noise in the right ear developed first. He was examined and treated by the OTORHINOLARYNGOLOGISTs, improvement has not been noted, the hearing in the right ear started to reduce. Two years ago complete deafness developed in the right ear. Headaches at dawn started to disturb him during the last year. At present headaches are constant. Determine character of affection of the brain.

ANSWER: The patient with a great probability has neurinoma of the right acoustic nerve.

 

6. The literature which is recommended on the theme of the class.

The basic

  1. Иргер И.Н. Нейрохирургия, М., Медицина, 1982
  2. Самойлов В.И. Диагностика опухолей головного мозга (общая частичная, дифференциальная), Л., Медицина, 1985

 

Additional

  1. Бротман М.К. и соавт., Ранние проявления нейрохирургических заболеваний, К., Здоровье, 1984
  2. Ромоданов А.П. и соавт., Оперативные вмешательства при заболеваниях головного мозга, К., Здоровье, 1986
  3. Гусев Э.К., Коновалов.Н. Неврология и нейрохирургия: Учебник.-Г.: Медицина. 2000.-656с.
  4. Тиглиев Г.С., Олюшин В., Кондратьев А.Н. Внутричерпные менингиомы.- СПб.: РНХИ им. проф. А.Л.Поленова., 2002.- 560 с.
  5. Никифоров Б.М., Мацко Д.Е. Опухоли главного мозга.– СПб: Питер.– 2002.–320 с.
  6. Практическая нейрохирургия: Руководство для врачей \ Под ред. Б.В.Гайдара.- СПб.: Гиппократ, 2002.- 648 с.
  7. Schiffer D. Brain tumors. Pathology and its Biological Correlation //Springer Verlas. —Berlin Heidelberg, 1993.— 595 p.
  8. Burger S.H., Scheithaner B.W., Atlas O.F., Tumor pathology // Tumors of the central nervous system.– Washington: Armed Forces Inst. Pathol., 1994.– P. 45–66.
  9. Grossman R.G., Loftus C.M. Principles of Neurosurgery, 2nd ed. Philadelphia  Lippincott-Raven, 1999.

 

7. The theme of the next class: «Tumours of the spinal cord. Clinical course of tumours of the spinal cord. Principles of surgery. Traumatic damages of spine and spinal cord. Classification. Rendering urgent aid at stages of medical evacuation ».