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Hello, everyone. It's great to have you join us today today. We've got Doctor Neil Boru, we consultant neurosurgeon based at South Mead Hospital in Bristol UK. And he's running a teaching session for us on brains. So he'll give his talk for around 45 minutes and then we'll have some time for questions at the end. But as we go along, also feel free to add your questions and he'll answer them as they come up as put your questions in the chat and then we'll try and answer as many of them as possible. As always, the feedback form will be sent out via email after the event. And then once you've completed the, the feedback form, the certificate will be added to your mental account, please let us know also in the feedback form, what other topics you want to learn about and then we can try and arrange teaching sessions on those topics as well. Er, so now I'm going to hand over to doctor Ru. Thanks very much Gemma. Er, and thanks everyone for joining talk um for about 40 minutes or so about brain tumors in adults. And um we've got a few learning objectives. So hopefully I'm going to take you through clinical assessment. Um what sort of signs and symptoms might point you to the possible diagnosis of a brain tumor, how to confirm that diagnosis? And then what initial treatments you might want to consider instituting? One really key area when managing patients with brain tumors is of course communication with patients and families and I'll talk a little bit about that and some of the things we do here in Bristol and then finish off by talking about the multidisciplinary nature of managing brain tumors effectively. So, um please feel free to ask any questions as we go along. I'll, I'll try and keep an eye on the chat as we go. So just by way of background, I'll start by telling you a little bit about the different types of brain tumor that we commonly see. And by far the most common type of brain tumor we deal with are metastases or secondaries in adults anyway. And up to about 30% of patients with cancers suffer with brain metastases. And up to about 10% of patients with cancer develop disseminated leptomeningeal disease. So there is a big burden of disease. The most common primary sites of cancer that spread to the brain are breast cancer, lung melanoma, and renal cancers. Certainly in the UK. Now this may change a little bit around the world. Um But nonetheless, these are the most common that are likely to be seen less common. But one I deal with most as a neurosurgeon are primary brain tumors. And the most common type of primary brain tumor is the glioma. And the term glioma relates to a number of different types of tumor. All arising predominantly from the glial cells or astrocytes of the brain. It's very rare that tumors actually arise from the neuronal subset of cells. All of the tumors that I'm gonna really focus on arise from the glial or astrocyte populations. Glo can be slow growing or low grade or fast growing and high grade. And the most common high grade or malignant type of glioma is the glioblastoma or GBM for short. And that really forms quite a substantial part of my workload as a brain tumor surgeon. And the incidence around the world varies from about 3 to 6 per 100,000 per year, which means in the UK, we see about 4000 to 5000 new cases per year. So certainly glioblastomas are rare compared to other types of tumor or cancer. But one of the most common that I deal with as a brain tumor surgeon. The other way people often classify brain tumors is either as intrinsic or extrinsic with the glioma arising within the brain substance itself being an example of an intrinsic tumor. Whereas tumors which arise from out with the brain itself ie from the nerves or from the dural layers such as meningioma or pituitary tumors are extrinsic tumors. So what I've got here is a few examples of those different types of tumor in the top left, we've got a Coronal MRI image and the type of image is called a flare image. And what this does is shows up t uh tumor related fluid as white. So on the left hand side in the left temporal lobe and insular, we've got that white area and this is quite a common appearance of a primary or intrinsic low grade or slow growing type of glioma. Next from the left, we've got an axial postcontrast T one MRI scan. And what you can see there is the very typical appearance of a glioblastoma, a malignant type of tumor in these types of tumors, we very often see enhancement around the outside which is the white areas and black internally, which is necrosis and necrosis is a very common indicator of a malignant or fast growing sort of tumor. The next one across the third from the left, what we can see is multiple tumors, we can see on that one slice, at least four different spherical areas of tumor. And when we see multiple tumors like this, almost always, it means we're dealing with a metastatic process tumor that has spread from elsewhere in the body. Finally, on the right hand side, we've got a sagittal MRI image. And what we can see here is an extrinsic tumor arising from the dura, the linings around the brain and pushing the brain away. And this is a very classical appearance for a meningioma, a tumor which has arisen from the meninges the layers outside the brain in terms of clinical assessment. Unfortunately, the age of the patient will not give you much clue that you may be dealing with a brain tumor. If you're seeing a patient in your family practice clinic or in general practice or even in the emergency department, because brain tumors are rare, but they can occur in any age group in adults. They are more common as we get older. So in our forties, fifties and sixties onwards, they become increasingly common, but they do occur in young adults as well. If we think about the kinds of signs and symptoms you might see in a patient presenting with a brain tumor for the first time, the problem is a lot of the presenting symptoms are very nonspecific and really you have to have a high degree of vigilance. You have to be almost looking for the possibility of a brain tumor to spot it. And there's been quite a few studies done to try and identify what signs and symptoms might alert you to a brain tumor. But unfortunately, these are very nonspecific symptoms. About a third of patients present with a focal neurological deficit. And of course, that's going to be a red flag and require further investigation. But of course, some of these signs and symptoms are very subtle and that is because for slow growing tumors, in particular, the brain can accommodate for a slowly enlarging mass for a very long time. Headache is actually only seen in a minority of patients. And I'll talk a bit more about the features of headache to look out for about 10% of patients present with cognitive or behavioral problems such as confusion and memory disturbance. But of course, memory disturbance and confusion they can occur in the older population anyway, for a very wide range of reasons. Something that I think is really important to consider is the first onset of a seizure in an adult. And for me, this is an absolutely key presenting feature which needs further investigation. And studies have shown that of all of these things that I've talked about so far, a first seizure in an adult has a higher positive predictive value in identifying a tumor than almost any other symptom. I think that's really important to remember because once in a while I see a adult who's had a seizure for the first time and it's not investigated for months and months and it turns out that that patient has a brain tumor. And of course, we've missed an opportunity to intervene at an earlier stage. So I've got a question here. Um I wanted to ask you if you have ever experienced a big change in personality or behavior post-surgery compared with presurgery. Um after possible tumor removal or trauma in areas of the limbic system or prefrontal cortex. Um, it's a good question. Yeah, absolutely. Um, of course, we don't fully understand the neuro anatomical substrates of personality per se. Um, but we know that frontal lobe surgery carries a, a risk of changes in behavior and personality, er, as does the limbic system, but also memory and the higher cognitive functions can be affected as well. All of which, of course, con contribute to uh how we come across as individuals and our personality. And of course, I've put there at the bottom of that list of common presenting symptoms, nonspecific and that it is as unhelpful as it sounds. Sometimes patients present with very unusual symptoms. So often people think that if you have a brain tumor, patients are likely to present with headaches, of course, that does occur. And as you just saw, it's a presenting complaint in about 20% of patients with brain tumors. But of course, those of you who are in general practice or family practice will know that headache is such a common symptom and it's very, very difficult to differentiate a serious cause of headache from a less serious one rather than classical high pressure symptoms. A lot of patients present with tension or or migrainous type headaches. So for example, the patient who has a long standing sufferer of migraines, who comes with a change in their frequency or the type of headache they're talking about may consider you may want to consider further investigation. When a headache is becoming increasingly frequent or severe, that's another sign. And there are of course, high pressure features, bending, coughing, straining can alert you to the possibility of raised intracranial pressure, particularly when headaches occur at night or wake patients up and when headaches are present on waking. These are the classical features of raised intracranial pressure. Any of these types of headache in combination with a neurological sign or symptom should of course alert you to the pro possibility of a space occupying lesion in the brain and should lead you to consider further investigation in terms of signs. Of course, depending on where the tumor is. Patients may present with motor and sensory deficits. And it's quite common for patients to be sent into the hospital um when they're thought to have suffered a stroke. And we find that they've got a actually um a space occupying lesion. If you are at all suspicious of raise intracranial pressure fundoscopy to look for pap edema is a really helpful thing to do. And this takes a bit of practice. It takes a bit of getting used to. But the thing about pap edema is that it is not an acute phenomenon, it probably takes days if not longer, even in the presence of very elevated intracranial pressure for pap edema to develop. So if you see pupil edema, then this should alert you to the possibility of chronically raised intracranial pressure on a similar note branch hus can present with abnormal visual fields because of raise intracranial pressure. But also classically tumors like pituitary lesions, of course compress the optic chiasm and lead to a bitemporal hemianopia. Finally, at the most extreme end of things, patients can present with altered consciousness. And studies have shown that patients who present with drowsiness, confusion are associated with having a worse prognosis probably because this happens late on in the pathogenesis of the tumor. So by the time patients present with altered consciousness or confusion, the tumor is already quite large and advanced. So just to summarize the key points in the history and examination, to consider headaches with the feature of raised intracranial pressure that is waking up the patient at night, occurring early in the morning. If they're increasing in frequency and severity or different to a longstanding preexisting headache, maybe consider further investigation. Of course, patients won't come to you and tell you my personality or behavior has changed. So it's really important that you think about getting a cholesterol history from family when you ask them if you look back over the last three or six months, has your loved one changed in any way? Sometimes it becomes more obvious, especially things like subtle memory problems, seizures, as I say, are really one of the signs that need further investigation. A first onset seizure for me is a real alarm bell. And again, patients won't necessarily come to you and say that they've suffered seizures. They may tell you something like I found myself on the floor when I woke up or I bit my tongue and I can't remember how incontinence, another sign of seizures. Potentially, I had one patient who only noticed that they had blood on their pillow in the morning after biting their lip or tongue during a seizure. A full neurological examination is always going to be beneficial, both cranial and peripheral nerve, a very simple confrontation, visual field test may point you to a brain tumor as well. And as I've said, fundoscopy is really helpful and you can see some images on the right hand side there showing a blurred disc margin compared to the the sharp disc margins of a normal optic disc. In terms of medical history, it is always really helpful to find out if a patient has a known history of cancer. So a known history of cancer with progressive headaches or a new neuro neurological symptom must always alert you to the possibility of an intracranial tumor. There are of course important different differential diagnoses for brain tumors with depending on where you are in the world. TB and other infections being important to consider as is immunosuppression. And we do see a uh a relatively small number of patients who are immunosuppressed for whatever reason who first presents with intracranial lymphoma as a sign of that immunosuppression. So once you suspect the possibility of a brain tumor, the next step is of course to, to confirm or refute that diagnosis. And in most centers probably around the world. CT scanning is going to be the first point of call. And it's important that both both pre and post contrast scans are taken the definitive test really though is the MRI scan with and without contrast and something to request or ask for if you can is diffusion weighted imaging or DW I, which can help you to exclude an abscess from a brain tumor. But certainly, MRI is the most sensitive modality for diagnosing a brain tumor. Almost always. When you find a space occupying lesion in the brain, it is important to get a CT scan of the chest abdomen and pelvis. Even if the patient is already known to have a primary malignancy, this can help you to stage the disease to understand how disseminated the disease is or to identify a new diagnosis of disseminating malignancy, which has first presented with brain disease. And we do see that relatively commonly. The other reason a CT body scan is important is of course, we do have to think about these patients holistically. Unfortunately, for the majority of brain tumors, the prognosis remains relatively poor, which means that putting a patient forward for brain tumor surgery when they have uncontrolled body disease and a primary malignancy is unlikely to be the right thing for the patient. So these three steps ct brain confirmation of the brain tumor with an MRI scan and then a body scan to determine if there is any other disseminated disease or source of the primary tumor is really important. So I've got a question here for from someone who's asked, when do we use pet scans? So pet scans are in terms of body, pet scans can be helpful when a ct scan of the chest abdomen and pelvis has not revealed a definite malignancy, but you are very suspicious that you are missing a tumor. A primary tumor. A pet scan may show a hot spot of tumor not seen on a CT body scan. Pet scans are also used uh relatively routinely for some cancers for staging tumors. Um Pet scans, we don't use very often in the brain. Actually. Um pet scans can be used for certain types of metabolic imaging in the brain. Uh but not that often for brain tumor diagnosis. Another question, one is the role of each of the MRI types T one T two flare DW I. So all of those um modalities, T one T two flare DW I would say are important for the first diagnostic scan that you do to identify or confirm the diagnosis of a brain tumor. T one and T two sorry T one, pre and post contrast imaging will tell you whether or not there is bleeding or enhancement. And historically, we used to think of enhancement being more likely to mean that you're dealing with a malignant tumor T two and flare are particularly helpful for the low grade or slower growing gliomas. And sometimes you see very extensive T two and flare signal change beyond enhancement or beyond T one signal change. DW I is the key test to exclude an abscess. And actually, I've got a, a slide on that as well. So this is an example of DWY imaging. So in the top row, you've got uh on the left hand side, A T two image and you can see the circular lesion but around it is the edema represented in white on T two. So T two is also very important for identifying edema. The next slide along the next image along is the T one with contrast. And you can see you've got a thin peripheral rim of contrast with central black that could be necrosis or it could be abscess. Finally, on the right hand side, we've got DW I images. So DW I is diffusion weighted imaging. And the way to understand this is to think that within free fluid there is free diffusion of molecules. So if there's free diffusion, the signal on DW I will be the same as it is for CS F which is like water. Here. On the top row, the DW I signal is white. So it is the opposite signal to CS F which is black. That means there is restricted diffusion, which means that this is most likely to be an abscess, which contains pus rather than a necrotic tumor. Then on the bottom row, you've got the opposite. The diffusion weighted image on the right is black centrally, which means that there is free diffusion as in water, which is more likely to be a tumor with a necrotic center. There are some important caveats with that TB and fungal brain abscesses might not show restriction. And also CNS lymphoma can show restriction on DW I. So I'll just go to a couple of questions here. Is there any specific way to diagnose whether a tumor is primary or secondary? So there is no definitive way on MRI alone. More commonly with metastases or secondaries, we see multiple lesions and classically metastases occur at the interface of the gray white matter. Now, that is not always true and sometimes it can be very difficult to differentiate a primary for from a secondary brain tumor on MRI imaging. Of course, if the patient has a body scan showing a primary lung cancer or primary disease elsewhere, then metastases becomes more likely. But it it is not uncommon that we have to do surgery or a biopsy to confirm which of these, which of those types of tumors. It is. So biopsy sometimes is the only way to differentiate a primary from a secondary tumor. Some brain secondaries have certain classical features. For example, Melanoma metastases are sometimes or most often hemorrhagic on MRI. How does it change treatment? While the treatment for a primary glioma and a metastasis is very different. So, in both cases, if there is mass effect or diagnostic doubt, we may do surgery to remove the tumor. But with metastases for small tumors, less than three centimeters, if we are certain that we're dealing with a metastasis, we may simply treat with radiosurgery, which is a focused form of radiotherapy and that can avoid surgery. The other way that the treatment changes is that for a secondary, you must also treat the source of the disease ie the primary tumor. So there may be different chemotherapy, immunotherapy or radiotherapy for the primary tumor for a primary brain tumor. The treatment modalities are surgery, radiotherapy and sometimes chemotherapy. But chemotherapeutic options are very limited for primary brain tumors. So it makes a very big difference. Um And we must know whether we're dealing with a primary or secondary brain tumor. Um Someone has asked, can I explain DW I again? So DW I is diffusion weighted imaging. So if you look back at the slide that I've got up at the moment on the right hand side, we can see the DWY images at the top, the abscess at the bottom, the lung metastasis or brain tumor. So sometimes we see lesions in the brain which enhance peripherally. So they're white outside, which you can see in the middle two images and black in the middle. When you see that type of image, there are two possibilities. Either it is black in the middle because it's an abscess and you've got pus in the middle or it's black because it's a necrotic malignant tumor diffusion weighted imaging measures the free diffusion of molecules within the brain. So if you've got an abscess which is full of pus, then molecules cannot freely diffuse. And we call that restricted diffusion and that causes an MRI signal which is opposite to free diffusion such as what you see from CS F which is basically water. So in the top right image, the diffusion weighted image is white in the tumor or in the lesion, that means it's the opposite of CS F. And that means we're dealing with an abscess whereas below is black, which means there's free diffusion and we're dealing with a tumor with a necrotic center. So the bottom line is if you want to differentiate or at least try to differentiate a tumor from an abscess DW I or diffusion weighted imaging is the best modality to do so. OK. So let's imagine you've identified a brain tumor in a patient, they have significant mass effect from the tumor or from edema. Then the first line of treatment really is dexamethasone. And I would go as far as to say that dexamethasone is the treatment which has made the most difference to patient benefit. In the last 100 years of brain tumor management. I've seen patients who are almost comatose and more abundant. Given dexamethasone who improve rapidly within hours or 24 hours. And we've known about dexamethasone in the treatment of brain tumors for 60 or 70 years. Now. And what dexamethasone does is treat the vasogenic edema related to a tumor. Of course, it doesn't treat the tumor itself, but that can improve intracranial pressure and neurological symptoms very, very quickly. And this can be a life saving intervention. So if you have a patient who is very unwell for a mass effect from a tumor, then the starting dose is often something like 16 mg per day. And dexamethasone can be given given orally or through a nasal gastric tube or intravenously and it can be given four times a day. So four mg, four times a day or split into two doses, eight mg twice per day. And because of the pharmacokinetics of dexamethasone, it is effective either way if a patient has a relatively small tumor, minimal edema and is relatively well, it's perfectly reasonable to start at a lower dose. And as a general rule with any steroid treatment, you should try to use as low a dose as possible. And even if you start a high dose, just maintain that for 48 to 72 hours, then start to reduce it to the lowest possible maintenance dose. And the reason for that of course is that whilst dexamethasone can be life saving, there are very important side effects that can occur with both short and long term use with long term use, it can cause muscle weakness, poor glucose control, cushingoid features, even with short term use, it can cause psychosis. And I've seen patients get very, very bad mental health problems from steroids which resolve when steroids are stopped. And of course, there is a risk of gastric ulceration. And my practice is also to give a proton pump inhibitor PPI to try to protect the stomach whenever I administer steroids. The other thing to remember of course is that these patients have to be monitored long term if they are kept on steroids for a prolonged period of time and the steroids are suddenly stopped, that can of course precipitate an adrenal crisis. So, steroids, they're very, very important, very, very useful in this circumstance. But don't forget the side effects and, and the risks which can be very significant as well. People always uh often ask me about antiepileptic treatment as well, anti seizure medications. And very often patients come to me, they've had a diagnosis of a brain tumor presenting without a seizure and they are put on prophylactic anti seizure medications. To be honest, I wouldn't criticize that it's not unreasonable, but generally speaking, prophylaxis is not advised if a patient hasn't suffered from a seizure. There is of course a very wide practice, particularly when patient patients go for surgery. And um sometimes I will choose to give perioperative anti seizure medications for a week or so to try to minimize the risk of a seizure in patients with brain tumors who have one seizure. Then my recommendation is that you must treat with anti seizure medications. And don't forget that in this situation, seizures can be fatal in Europe, levetiracetam or Keppra is the most commonly used drug. It can be loaded rapidly. It's relatively well tolerated and it gets to a therapeutic dose very quickly. Other options are valproate, lamoTRIgine and coside which are newer anti seizure medications. But it's not that long ago that I would use phenytoin as well. And phenytoin is well understood and the loading dose is well known. And so it's also a reasonable choice but don't underestimate how important seizure management really is because seizures are implicated in the death of patients with gliomas. In, in quite a number of cases. I've got a question here is the use of Mannitol recommended to reduce ICP. So for me, the use of Mannitol is really a temporizing measure in a life threatening condition. So if you had a patient who had very severe brain swelling, a mass effect from a tumor, the Mannitol. Yes, absolutely. Um And the recommended dose is is 200 mils or 20% Mannitol. But it's very rare in my experience for patients to present in extremist with brain tumors more common that they have slow rumbling signs and symptoms and ultimately are found to have a brain tumor and even those patients, they compensate very well. So I would really reserve Mannitol for those re re real life and death situations because it only has a temporary effect. Mannitol must then be followed up with a definitive intervention. So let's move on to some things to think about when you're communicating to patients and families regarding a new diagnosis of a brain tumor. And for those of you who are in family practice, general practice, the truth is these patients are gonna be very rare and it is not uncommon for general practitioners to go their whole career without ever seeing a patient with a new diagnosis of a brain tumor. But if this does happen to you and you want some idea of how to approach the situation, um I'll, I'll try and give you a couple of things that I I say to patients um when I meet them to explain this diagnosis and of course, you can imagine that these are highly emotional patients and families er that may be already suspect that they have a brain tumor and they're very scared. So I think it is important to acknowledge to patients that this is a life changing diagnosis. Things will not be the same again. And certainly when I'm talking about glioma diagnoses, we have to be honest and say that gliomas are not curable. We do not have a cure for gliomas, even with secondary brain tumors which are completely removed or treated with radiotherapy. There is a very high recurrence rate with up to 50% of patients suffering recurrence within one year. So I think it is important that patients of families understand that this is a life changing diagnosis, which ultimately is likely to be the cause of their death. And because of that, my aim as a brain tumor surgeon is to help the patient make a decision to give them the best quality of life for as long as possible. Patients sometimes ask me whether a glioma is a type of cancer. And again, there is variation in practice here. Ultimately, I would say that biologically, gliomas are all cancers because even low grade, slow growing gliomas can become faster growing aggressive gliomas having said that some gliomas can remain dormant or static for many years. And with certain types of glioma patients can live a very long time. But I think the key message that I want to get across to patients is there is no cure, whether or not it's cancer is not really the most important thing. More important is whether we think the tumors are likely to grow quickly or slowly. So let's look at the average life expectancy for patients with gliomas, primary intrinsic brain tumors. And sadly, these numbers have really not changed for many years. So the way we think of gliomas is on a grading scale of 1 to 4, one being slowest growing, four being fastest growing grade one tumors we most commonly see in Children. An example is a pilocytic astrocytoma. And that is a very different group of patients. And actually pilocytic astrocytoma in a child which is completely removed is pretty much curable, but it's not that common that we see that in adults really, we're dealing with the grade 2 to 4 tumors in adults. So average survival with a grade two astrocytoma with full treatment that is surgery to remove the tumor, radiotherapy and chemotherapy. Average survival in the region of 6 to 8 years. Grade three and grade four tumors are considered high grade and with a grade three tumor prognosis comes down to three years. And with grade four glioblastoma, the most aggressive type of tumor we see with surgery, radiotherapy and chemotherapy. Average survival is only in the region of 12 to 18 months. And remember that not all patients are well enough to have the full treatment. Some patients only have a biopsy and radiotherapy. And then in that patient group, average survival is less than 12 months, probably in the region of 6 to 9 months. The exception to this is something called an oligodendroglioma, which is a specific type of primary brain tumor, which is very sensitive to radiotherapy and chemotherapy. An average survival for that patient group is much longer. And at the moment, the studies have not been going long enough to tell us the definite median survival, but it is probably more than 15 years. So, out of all of the primary brain tumors, the oligodendroglioma even grade three oligodendroglioma have better prognosis, as I was saying, because we can't cure brain tumors or primary brain tumors. In particular, what I really try to focus on when I talk to patients is prioritize quality of life. And this is of course, a very individual thing. It differs from one person to another. And that's why we really wanna try to put the patient centrally in the decision making process and you know, the days have long gone when we can tell patients what we think is the right thing to do. The phrase we see more and more certainly in, in UK practice is shared decision making where our role as doctors is to give patients the information they need to try, try and decide on what the right course of action is for them as an individual because all surgeries or treatments have pros and cons risks and benefits. And it's really important that patients understand the implications. And you can imagine that some patients will want all the treatment possible, irrespective of the risks. Whereas whereas others may say, well without treatment, average survival may only be a few months, but I can be at home with my family and friends. I could have surgery, radiotherapy and chemotherapy and I may live a bit longer, but it could. But of course, all of those things have risks and they can make patient's quality of life worse. So it is not a straightforward decision equally important as supporting the patient is supporting family and carers. And we're very lucky here where I work in Bristol and the UK, we work very closely with brain tumors. Support a charity which supports everyone and their families with brain tumors. And we have a role in the UK called a clinical nurse specialist. Now, these nurses are absolutely vital in managing and looking after our patients. Well, they provide a very holistic approach and what you will find, dealing with very difficult conditions like this is that sometimes patients will rather tell the nurse specialist how they're feeling what they're worried about much more easily than they will tell a doctor. And so the clinical nurse specialists are really a vital gateway to the patients, real feelings and thoughts and um sometimes patients feel less able to share with doctors. I think that's understandable and the clinical news specialists do a great job of getting around that problem. So someone asked, is there a specific cause of glioblastoma? No, we don't know why glioblastomas occur. Uh It's not smoking, drinking anything like that. Um We just don't know. So what I've got here is er an example of uh what's called a shared decision making matrix. Um This was published by a group in Southampton in the UK recently and we use something similar in the UK, er in Bristol. So what this tries to do is really give information in a way that's easily understandable to patients and relatives of, of course, it can't be specific to a particular patient's individual situation, but it can give some helpful information. So if we imagine a situation where a patient were telling them for the first time that they're likely to have a glioblastoma, essentially, there are three options available, best medical care, which basically means steroid treatment. Uh, symptom control, anti sickness, painkillers. This might be the right choice for a patient who is older less well, has a number of comorbidities and doesn't feel that they want to put themselves through surgery, radiotherapy and chemotherapy. And if patients accept that this is likely to result in a shorter prognosis. But without the downsides of treatment, it might be the right thing to do. Next, we've got biopsy followed by radiotherapy and chemotherapy. So, a biopsy is just a small, relatively low risk operation where we just take a sample of the tumor to confirm the diagnosis and then plan uh chemotherapy and radiotherapy accordingly. The advantages of this is that the risks are low, very low. The downside is that we know patients do better in the longer term ie survival is better response to chemo radiotherapy is better when we remove as much tumor as safely possible. And that's the third option. But of course, the downside is that, that carries bigger risks. And of course, we have to individualize those risks to where the patient's tumor is um to the patient's comorbidities, anesthetic risk. But something like this can really just give patients something to, to read through and think about when trying to think what is right for me as an individual. So this leads on to uh quite nicely to a question that's just come up. Is there any part of the brain that is absolutely not accessible surgically? If so, what is the plan in such cases? So uh I'll give you a real life example, I would say for a biopsy, you can access almost anywhere in the brain. But of course, some areas of the brain are much higher risk than others. So the thalamus, the brainstem, the pineal region in particular are three high risk places. So um I recently had a patient with a possible brainstem tumor. Uh We discuss the role of biopsy. I would never remove a tumor from the brainstem because the risks are very, very high. Uh Looking at the literature, the risk of a neurological deficit with a brain stem biopsy is about 5 to 10%. Uh This patient chose not to take that risk in that circumstance. The patient proceeded directly to radiotherapy without a biopsy. So that might seem sensible and it's very reasonable. But of course, there is a small risk that we could be treating something that isn't a brain tumor because there are other conditions which mimic brain tumors like neuro inflammatory diseases, rare infections. And although that risk is low radiotherapy also carries some risks as well, so I would say that you can biopsy almost anywhere in the brain provi providing the patient accepts the risks. And there are areas of the brain that are much higher risk to operate in. If a patient does not want to accept those risks, we may treat without surgery. But there are important risks to consider with that as well. But one thing that is really important to understand, certainly in in UK practice is that we have to be very clear to the patient about the risks of surgery. Because if a patient develops a permanent neurological deficit from surgery, not only will that worsen their quality of life, but that will reduce their life expectancy. And also the patient may not be well enough to have radiotherapy and chemotherapy. So here in the UK, only patients who have a good performance status ie they're relatively independent, they are able to look after themselves reasonably well. Only those patients will have radiotherapy and chemotherapy. Now that is different in different countries in some areas of the world, patients will be treated irrespective of their performance status. So it's important to understand and individualize accordingly. Finally, um It's really important that these patients are managed by a multidisciplinary team. And uh this is very hard for me to say as a a neurosurgeon, but we are not the most important people in this team actually. Um I know I hate to say it but there are some people who are more important than neurosurgeons. So, the oncologists who give the radiotherapy and chemotherapy are absolutely vital because only they can really counsel the patient or understand if the patient is gonna be well enough to have chemotherapy and radiotherapy. Of course, we as neurosurgeons have an important role to play in advising on the pros and cons of surgery, whether that's biopsy or what we call a craniotomy, that's a bigger operation to remove a tumor. The radiologists are vital as well because as I've just said, there are other conditions which can mimic brain tumors. Neuropathologist are increasingly important. And nowadays, the way we diagnose tumors is very, very sophisticated, it's no longer a case of looking at a slide under a microscope for primary intrinsic brain tumors, ie gliomas. Nowadays, um diagnosis is based on molecular and genetic testing of a tumor. I've already talked about the importance of our clinical nurse specialists in helping to represent the patient's interests. Other members of the team, which we're lucky to have are neuropsychologists and for cognitive testing for understanding the psychological implications of the brain tumor, you know, they are vital and then the therapist, the physiotherapist, occupational therapist, speech and language therapists all have really important roles to, to play. And of course, at some point for almost all of our patients, palliative care and end of life care is gonna be important and it's really important that patients are counseled and their families are prepared um for the likely uh terminal nature of these diagnoses. And of course, it's important that they all understand that there's never a need for patients to suffer. And our palliative care team are very good at managing symptoms appropriately. So, uh that's my last slide. I just uh oh, sorry, just in summary, thinking about history and examination. Unfortunately, no single sign or symptom can really help you. The one that I, I think you must consider is a new onset seizure in an adult that must prompt further investigation, headaches. They're so common in family practice in general practice. But there's certain features you can look at, look at is the headache getting progressively worse, progressively more frequent are high pressure associated symptoms. Is there a history of cancer, particularly a type of cancer which is known to go to the brain in terms of diagnosis? You may start with CT but MRI is the most sensitive. I remember the role of body scans, first line steroids and treating seizures. And when counseling patients for this sort of diagnosis, it's really important that um patients understand that for most of the conditions we deal with, we deal with, there isn't a cure and we've got to prioritize quality of life. Think about what is important to that and involved a multi disciplinary team. Um So is the take home message that the that brain tumors do not have a cure? I think really everything we do for brain tumors ultimately is palliative. But there is a lot we can do to keep patients well for as long as possible. Some brain tumors have much better prognoses like the oligodendroglioma and some of the benign tumors which I haven't really talked about today. Meningioma, Schwannoma, that sort of thing. Um But for the intrinsic glioma is the most common types of tumor that we see. Yes. Ultimately, the treatment we offer is palliative. But that treatment may involve surgery, radiotherapy and chemotherapy. What would be the prognosis of an ependymoma in the medulla? Uh So, ependymoma is another type of glioma. Ependymoma can commonly occur in the fourth ventricle. Uh if that's completely resected and it's not metastatic. The prognosis can be very good. Ependymoma can also occur within the brain stem and spinal cords. So they can be intramedullary surgery in those cases, is higher risk and prognosis is worse. But ependymoma is in general do have quite a good prognosis with surgery and radiotherapy and sometimes whole neuro axis radiotherapy is required. So that's radiotherapy to the brain and spine, particularly if there is a concern about um metastatic disease. Ok. So I'll put a s up that uh you may find helpful to look at particularly those of you in family medicine or primary care. Um Other questions popped up. What case had the least time survival and what was the diagnosis? Um So overall, uh I would say glioblastoma has the worst overall survival. Uh there are certain types of glioblastoma which we know are worse. For example, glioblastoma in the thalamus, uh which is highly unlikely to be resectable. But for some reason, um thalamic gliomas tend to behave more aggressively and also brainstem glioblastoma, uh more commonly seen in Children or brain brainstem glioma are are commonly seen in Children. But even in adults, there are certain subgroups which have a very poor prognosis. So I think that's almost our time up unless there's any more questions. Thank you so much, Neil. That was amazing. I really appreciate your time on that. Um We've got a couple of minutes if anyone wants to ask another question and we've got one more. Oh, some. Thank yous. There we go. Um Pop any other questions you've got in there just while we're waiting, you'll all be sent a feedback form later today. So please fill in the feedback form and then you'll get your stuff added to your middle account within the feedback form. As I said before, please tell us any topics that you want teaching on and we can try and get people to run teaching sessions on them. Um Oh, you've got a question there, Neil. What is the criteria to request CT or MRI in case of head? Um So do you mean what, what should lead you to if you're asking, what should uh lead you to request a CT or MRI scan of the brain? Uh So any, so features of uh headache associated with raised intracranial pressure, uh new neurological symptoms. Um anyone with a prior history of malignancy, primary malignancy with a neurological sign symptom or headache. Um So in the UK, we're very lucky we have something called a two week weight pathway where if a general practitioner or family doctor suspects a brain malignancy, they can get a CT scan or MRI scan done very quickly in hospital. Uh I think is there a specific age group at risk of brain tumors? So, unfortunately, brain tumors occur in all age groups, but they become increasingly increasingly more common as we get older. So, over the age of 40 with the peak occurring in the seventies and eighties age group, um but they can occur in any age group and actually the low grade slow growing tumors are more common in younger adults. Thanks Neil. So there's a couple of questions on there about the catch up. So we'll be adding the recording in the next couple of days and you'll all get an email saying when that's been added. So you can come back and have a look at this again or share it with anybody who's missed it. Um And we'll also have the slide so you can get these references. Um And then just taking my notes, we've got another event coming up. Oh, another question. Oh, no, just thank you. Um We've got another event coming up which I'll pop in the chat now and then please follow me or if you want to find out about more free events that we're running. Um, I think that's just about uh time. Let me just put this event in the chat and then we've got time for any more questions to Xanax event coming up and then give us a follow up medal if you want to find out about more events that are coming up there. Yeah, I think we're oh certificates. Yeah. So if you fill in the feedback form, you'll all get a feedback form via email later on today. And if you fill in the feedback form, then you'll automatically get a certificate added to your medical account. We'll also email that to you. Uh So that'll be coming to you later today. Do one more minute. Ok, great. Thank you very much. Thanks so much Neil. Really appreciate it.