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Parietal Lobe Tumors

DR V K SAHURESIDENT PSYCHIATRYINHS ASVINI

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Aim and Main Headings

• Anatomy of Parietal lobe• Functions • Tests• Tumors• Clinical features• Investigations• Management

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Anatomy

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Anatomy• Anterior border - Central Sulcus - parietal lobe & frontal lobe• Posterior border - Parieto-occipital Sulcus - parietal & occipital

lobes• Ventral border - Lateral Sulcus (sylvian fissure) is the most

lateral boundary separating it from the temporal lobe• Medial Longitudinal Fissure divides the two hemispheres.

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Blood supply

• Anterior parietal artery• Posterior parietal artery• Angular artery • Temporaloccipital: The longest cortical artery.

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Body image representation Body in space Tactile discrimination

Functions

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3 D analysis of body space interactions (body schema) Visual spatial properties Visual attention Motivation and grasping functions. (parietal lobe lesions - there is ‘self grasping’ of forearm opp. the

lesion ) mediate influence of emotion, attention and motivation on behavior

INFERIOR PARIETAL LOBULE Last to mature anatomically and functionally. So, the functions are late, to develop b/w 5 and 8 yrs age. ( reading ,

calculations ) Angular gyrus & Supra marginal gyrus - they have

interconnections with visual, auditory, somasthetic, supr. colliculus, Lateral Geniculate Body and other lobes.

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Parietal lobe function Impairment of parietal lobe function

Sensory cortex: (represents similar to motor cortex)---receives afferent pathways for - appreciation of posture - touch - passive movement

Contraleteral disturbances of cortical sensation - postural sensation disturbed - sensation of passive movement disturbed - accurate localization of light touch disturbed - 2 point discrimination disturbed - Asterognosis

Supramarginal angular gyrus: (dominant hemisphere) - Wernicke’s language area - receptive area where auditory , visual aspect of comprehension are integrated.

Supramarginal angular gyrus: (dominant hemisphere)Gerstmann’s syn-confusion of right & left limb.-Finger agnosia -Acalculia-Agraphia

Supramarginal angular gyrus: (non dominant hemisphere) - concept of body image - awareness of external movement - skills of handling numbers/calculation - visual pathway (optic radiation pass through parietal lobe)

Supramarginal angular gyrus: (non dominant hemisphere)-Unaware of opposite limbs-Anosognosia-Geographical agnosia-Constitutional apraxia: - cannot copy geometric pattern-Damage of optic radiation: lower homonymous quadranopia

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1. Multimodal assimilation – capacity for organizing , labelling and conceptualizing , using all senses.

Ex : chair

2. Language capabilities angular gyrus - anomia supramarginal gyrus – conduction aphasia visual cortex to IPL connections – word

blindness

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3. Agraphia – lt. lobe Engrams for production and perception of

written language are stored in IPL . So, misspellings, distorsions, and inversions occur.

4. Temporal sequential functions IPL is the main track of input and output. Therefore, information is organized appropriately

into a sequence here.

5. Calculation (Lt.) and computation (Rt.)

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IPL lesions leads to disruption of visual spatial functioning and temporal sequencing ability (apraxia).

i.e either spatial sequential tasks lost - OXOXOX or sequential grammar relations are lost.

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Cerebral laterality

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Either hemisphere

1. Cortical sensations.2. Integration of sensory , motor and attention signals (i.e

disengage attention - do other activity - immediately reengage correctly)

3. Optic radiation passes through. 4. Constructional ability – capacity to construct or draw

3D/2D figures or shapes. Lt. – programming of movements necessary for

constructional activity. (simplification of complex diagrams)

Rt. – related to spatial relationships or imagery. (rotation of diagrams)

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Right hemisphere

1. Constructional skills2. Dressing apraxia3. Calculations – arithmetic concepts of carrying and borrowing spatial alignment of written calculations. (computational difficulty – inability to manipulate no.s

in spatial relation, like using decimals,etc – but he is able to do problems in his head )

4. Perceptual functions (inattention/neglect of lt. hemispace)

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Statistics• Estimated 69,720 new cases of primary malignant and non–

malignant brain and CNS tumors are expected in 2013.

• The incidence rate of all primary malignant and non-malignant brain and CNS tumors is 20.6 cases per 100,000 (7.3 per 100,000 for malignant tumors and 13.3 per 100,000 for non–malignant tumors). The rate is higher in females (22.3 per 100,000) than males (18.8 per 100,000).

• Estimated 24,620 new cases of primary malignant brain and CNS system tumors are expected in 2013

( Central Brain Tumor Registry of the United States )

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Primary Brain Tumor Frequency Tumor Frequency (Percent)

Meningioma 24

Glioblastoma 23

Astrocytoma 12 Pituitary tumors 10

Nerve Sheath tumors & Primary Acoustic Neuroma 7

Medulloblastoma and Pinealomas 5

Anaplastic Astrocytoma and lymphomas 4

Oligodrogliomas 3

All others 12

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Most Common Brain Tumor by Age Group

Age Range (yr ) Tumor Types

0-9 Primitive Neuroectodermal tumors medulloblastomas

10-19 Astrocytomas

20-34 Pituitary tumors

35-44 Menigiomas

45-75 Glioblastomas

76 and older Meningiomas

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Anatomic location of Brain Tumors and Frequency of Neuropsychiatric symptoms

Anatomic location % of all Brain tumors % with Psychiatric & Behavioral Symptoms

Frontal lobes 22 As much as 90

Temporal lobes 22 50-55

Parietal lobes 12 As much as 16

Pituitary 10 As much as 60

Occipital 4 As much as 25

Diencephalic Region 2 50 or more

Posterior fossa, Cerebellum and Brainstem

28 Uncertain,Numerous neuropsychiatric symptoms reported

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General characteristics in Brain Tumors

• Only 18 % of Brain tumor psychiatric 1st manifest with behavioral/ Neuropsychiatric symptoms.

• When mental disturbance most common pt may first come to psychiatrist

• Many patient with cerebral symptoms have some psych symptom during illness

• Mental symptoms little guide to location of tumor Vs Neurological signs.

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General characteristics in Brain Tumors• Tumor material proved to be

disappointing for study of cerebral basis of mental symptoms

• Depressive symptoms- single most important predictor of quality of life.

• Slow growing tumor tumor cause changes of personality , allow premorbid tendencies to manifest themselves

• Rapid growing tumors-impairment of consciousness

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Neuropsychiatric & Behavior associated Symptoms in Parietal lobe tumors

• Primarily affective symptoms, depressive > hypomania or mania

• Psychotic manifestation Paranoid delusions & Cotard’s syndrome (delusion that they are dead/do not exist/putrefying/lost blood/internal organs,rarely delusion of immortality)

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Neuropsychiatric & Behavior associated Symptoms (Contd)

• Many have imp lateralizing characteristics• Results in Contralateral disturbance in - Two point discrimination - Joint position sense - Stereognosis - Graphesthesia

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Neuropsychiatric & Behavior associated Symptoms (Contd)

• Tumors in Dominant Parietal lobe - difficulties with reading & spelling - receptive aphasias - Gerstmann’s syndrome• Tumors in Non dominant lobe - visuospatial discrimination - anosognosia (lack of awareness, denial or complete neglect

of obvious contralateral neurological deficits )• Various Apraxias

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Psychiatric & Behavioral Complications of Medical & Surgical Treatment

• Therapeutic interventions causing abnormalities• Intraoperative injury to normal brain tissue in

resection/debulking. e.g. Nonverbal learning disabilities & psychotic

symptoms in children, in frontal lobe –executive dysfunction.• Radiation induced damage – transient & reversible vs

Permanent• Chemotherapy causing Delirium• Treatment of ↑ ICT /Cerebral oedema , Corticosteroid result

in Psychotic and affective symptoms

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Contributing factors in development of Neuropsychiatric manifestations

• General Considerations - Prevalence more in Psychiatric population - Not commonly the earliest manifestation

• Anatomical localization - not sole criteria - lateralization & features not consistent - symptom far away from location of tumor due to diaschisis and

connection syndrome esp corpus callosum. - only two mental syndrome consistent – in acute stage clouding of

consciousness & chronic amnesic syndrome in chronic stage

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Contributing factors in development of Neuropsychiatric manifestations (contd)

• Tumor growth - Rapidity/extent of spread-type/acuity & severity of symptoms - Rapid growing– acute, significant neurocognitive impairment - Slow growing – more vague & subtle behavioral change - Metastatic lesion & multiple locations

• Tumor type - more aggressive tumor (high grade gliomas) - Menigiomas – slow growing & disproportionately in frontal

region cause silent growth & vague/subtle change.

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Contributing factors in development of Neuropsychiatric manifestations (contd)

- local effects may be seen e.g. focal cognitive deficits with parietal lobe tumor & focal amnesic syndrome with diencephalic tumors

- Hallucination – derive from focal lesions of brain

• Intra cranial pressure - focal & nonfocal neurological symptoms/signs ( - diffuse cognitive impairment, - changes in attention & concentration - alteration of level of consciousness - anxiety,agitation,irritability,depression/apathy )

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Premorbid Patient characteristics & Psychosocial factors

• Depression or preexisting psychiatric illness• Cognitive capacity,coping skills,

adaptive/maladaptive behavioral style• Psychosocial support• Challenges by tumor and treatment

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Diagnostic considerations

• Symptoms and signs• High index of suspicion & low threshold for diagnosis in new onset psychiatric symptoms, esp - if negative past/personal history - unexplained personality change - New neurological/neurocognitive dysfn • Family History

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Symptoms suggestive of Brain tumor in Psychiatric patients

• New onset seizure (focal/partial/generalised) in adult • Headache - ↑frequency/severity, persistent & nonmigrainous ,

nocturnal, present on awakening, worsened by position/Valsalva maneuver• Nausea/Vomiting - esp if nonmigrainous headache• ↓ Visual acuity, field cuts and double vision• Unlilateral High Frequency hearing loss,intermittent tinnitus, vertigo• Focal weakness• Focal sensory loss, paresthesias, and dysyesthesias• Gait disturbances, incoordination, ataxia, and dysarthria

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Diagnostic studies

• Plain Skull X-ray : pituitary adenomas, craniopharyngiomas, intracranial calcification, bony metastasis

involving skull ( Bone Scan Preferred )

1. Calcification - oligodendroglioma - meningioma - craniopharyngioma

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Diagnostic studies

• Signs Of Raised Intracranial Pressure: -suture separation(diastasis) - “beaten brass” appreance

• Osteolytic lesion : primary/secondary bone tumour. - dermiod/epidermoid - chordoma - nasopharyngeal carcinoma - myeloma

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Diagnostic studies (contd)CAT SCAN : • Calcification• erosion of bony intracranial structures• shift in midline cerebral structures• Abnormalties involving venetricular system : Hydorcephalus

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Diagnostic studies

• High definition scan: indication - pituitary - orbital - posterior fossa tumour - tumour of skull baseCoronal and sagital reconstruction - diagnosing vertical extent - relationship with other structure

• IV Contrast : enhance visibility

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Diagnostic studies (Contd)• MRI Indication - tumours around the skull base/close to bone - brainstemAdvantage of MRI - Multiplanar - exact anatomy - paramagnetic enhancement - ↑ sensitivity & clarifies the site of origin. - delineate border b/w tumour & surrounding edema - more sensitive in identifying - small tumours ( < 0.5 cms diameter) solid or cystic - multiple lesions- metastasis

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Diagnostic studies

• Angiography/ MRA: reveal - tumour ‘blush’ - vessel displacement - preoperative information - for identifying feeding to

vascular tumours - tumour involvement and

constriction of major vessels.

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Diagnostic studies (Contd)

• CT & MRI Cistenography - evaluation of circulation of CSF - morphology of ventricular system - tumor associated hydeocephalus - CSF leaks - Intraventricular tumors • MRI cisternography is better

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Diagnostic studies (Contd)

• Electroencephalography - Non specific information, no precise location - 10-25 % of undiagnosed tumor has no finding/non diagnostic

non specific - useful for tumor causing seizure - Findings more in rapidly growing/aggressive

• Lumbar Puncture - may be useful in leukemias,lymphomas & meningeal

carcinomatosis ( may be missed othervise )

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Diagnostic studies (Contd)

• Other diagnostic procedures - Chest x-ray, urinalysis & stool exam ( rule out origination of metastatic tumors) - PET & SPECT - tumor recurrence from radiation necrosis - CNS lymphoma from opportunistic infn - Magnetoencephalography (MEG) -may help in phenomenon of disachiasis &

disconnection syndromes

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Diagnostic studies (Contd)

- Visual field assesment By Goldman Kinetic perimetry, Humphries static perimetry

- Endocrinological evaluation – hypothalamic-pituitary axis (for regional involvement & pt treated with radiotherapy.

- Evoked potentials – role in diagnosis & monitoring of Neurological function during surgical resection.

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Management of Brain tumors• Medical Management (Pharmacological) -Acute treatment/Psychiatric sequelae• Non pharmacological management• Management of tumor - Chemotherapy/Surgery/Radiotherapy• New Therapeutic Modalities

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Acute Medical Management– Stablise patient with peritumoral oedema/↑

ICT/seizure/Delirium.– Cognitive impairment (slowing of mental

performance ,sedation & fatigue )may result from antiepileptics drugs.

– Dexamethasone (low mineralocorticoid activity & possibly lesser risk of infn & cognitive impairment(but can cause delirium/psychosis, sleep disturbance & osteopenia )

– Risk of Opportunistic infn– Risk of thromboemolism – Identify hypothalamic-pituitary abnormality

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Managing Psychiatric Sequalae• Treatment of Anxiety & Depression - SSRI drug of choice• Supportive psychotherapy & CBT recommended• Cognitive deterioration early marker of progression

(serial neuropsychiatric testing recommended)• Methylphenidate may improve cognition.• Palliative care – for disabling neurological symptoms ( e.g. dysphagia)

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Managing Tumor

• Chemotherapy : Medulloblastoma, lymphomas, oligodendriomas & germ cell tumor –Highly sensitive

• Neurotoxicity is troublesome s/e esp if intrathecal chemotherapy

• Intrathecal Methotrexate can cause necrotising encephalopathy.

• Cisplatin cause encephalopathy & peripheral neuropathy

• Risk of toxicity increases with associated radiotherapy

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Managing Tumor

• Radiotherapy - Cognitive deficits reported in children (RT to brain for acute

leukemia),adults in gliomas, brain metastasis, nasopharyngeal malignancies, small lung carcinoma.

- Vascular & endothelial damage main features of radiation damage.

- Demyelination may happen subsequently

- Acute radiation encephalopathy (within 2 weeks)

- About 1-6 months after RT may develop radiation encephalopathy

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Managing Tumor- Late-delayed encephalopathy is serious & irreversible

- Memory, attention & new learning are sensitive to RT.

- Common neurological sequelae include urinary incontinence, ataxia, pyramidal as well as extrapyramidal signs.

- Intensity modulated radiation therapy (IMRT) attack from various angles in 3 dimensional manner.

- Gamma knife uses emitted photons that are precisely directed

- Cyber knife has compact light weight linear accelerator on a robotic arm

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New Modalities

(a) Gene therapy – Viral genes to malignant cells

(b) Signal Transduction Inhibitors – aim to reverse the abnormal activation/suppression responsible for resistance to radiotherapy

(c) Immunotherapy – monoclonal antibody against antigens expressed by glioma cells

- Interferons also being used(d) Tamoxifen (modulated Protein Kinase C-involved in cellular signal

transduction) –may have a role. (e) Stem Cell Therapy- aim to deliver molecules capable of enhancing

antitumor immunity/altering their gene structure

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Main points• Disturbance of affect/personality is not specific

to specific portion of brain.• Fast growing tumors cause acute changes , slow

growing tumors results in changes in personality.• Neurological symptoms/signs has more

localising value.• Depressive symptoms- single most important

predictor of quality of life.• Premorbid cognitive capacity/coping skills

important in degree of dysfunction.

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Main points

• Treatment can also result in Neuropsychiatric abnormalities.

• Identify patient having suicidal tendencies• Avoid drugs at risk of inducing seizure in patient

with past h/o of seizure (Bupropion,Lithium carbonate)

• Adopt active “here & now” therapeutic psychoeducational approach along with pharmacotherapy

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• CANCERS SO LIMITED It can't cripple love

It can't shatter hopeIt can't corrode faithIt can't eat away peaceIt can't destroy confidenceIt can't kill friendshipIt can't shut out memoriesIt can't silence courageIt can't invade the soulIt can't reduce eternal lifeIt can't quench the SpiritsIt can't lessen the power of the resurrection.

CANCER IS SO LIMITED

It can't cripple love It can't shatter hopeIt can't corrode faithIt can't eat away peaceIt can't destroy confidenceIt can't kill friendshipIt can't shut out memoriesIt can't silence courageIt can't invade the soulIt can't reduce eternal lifeIt can't quench the SpiritsIt can't lessen the power of the resurrection.

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Thank You

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References

• (http://www.cbtrus.org/factsheet/factsheet.html

( Central Brain Tumor Registry of the United States )

• Comprehensive Textbook of Psychiatry (Kaplan & Sadock’s) – Ninth Edition

• Lishman’s Organic Psychiatry – Fourth Edition