Tumor

General Information

1. True or False. The following tumor is considered to be a World Health Organization (WHO) grade IV:		G7 p.582:97mm
a. anaplastic astrocytoma	false (Anaplastic astrocytoma is a grade III.)	G7 p.582:117mm
b. gliosarcoma	true	G7 p.582:12mm
c. fibrillary astrocytoma	false (Fibrillary astrocytoma is a grade II.)
d. subependymal giant cell astrocytoma	false (Subependymal giant cell astrocytoma is a grade II.)	G7 p.582:148mm
2. True or False. Tumors of mixed neuronal-glial origin include the following:		G7 p.583:45mm
a. ganglioglioma	true
b. central neurocytoma	true
c. primitive neuroectodermal tumor (PNET)	false (Primitive neuroectodermal tumor [PNET] is listed under embryonal tumors. Old nomenclature is medulloblastoma—small round blue cell tumor.)
d. desmoplastic infantile ganglioglioma (DIG)	true
3. Complete the following about general tumor information:		G7 p.583:95mm
a. Medulloblastoma is considered to be what type of tumor?	embryonal
b. It is also known as_____.	PNET
4. What are the two types of craniopharyngioma?		G7 p.584:180mm
a. a_____	adamantinomatous (“Adam Antinomatous”)
b. p_____	papillary
5. List the four most common presentations of brain tumor and their frequency.		G7 p.585:160mm
a. p_____ n_____ d_____— _____%	progressive neurologic deficit—68%
b. h_____—_____%	headache—54%
c. m_____ w_____—_____%	motor weakness—45%
d. s_____—_____%	seizure—26%
6. When encountering a first-time seizure in a patient older than 20 years of age, think_____until proven otherwise.	tumor	G7 p.586:38mm

Infratentorial Tumors

7. What is the name of the so-called vomiting center?	area postrema	G7 p.586:145mm
8. What nerve has the longest intracranial course?	sixth nerve (abducens)	G7 p.586:160mm
9. Matching. Match the area of cerebellum with symptoms.		G7 p.586:165mm
Area of cerebellum:
hemisphere, vermis, brain stem Symptoms:
a. Ataxia of extremities
b. Broad-based gait
c. Truncal ataxia
d. Dysmetria
e. Intention tremor
f. Nystagmus
g. Cranial nerve dysfunction
10. Complete the following concerning a > 20-year-old patient presenting with a headache:		G7 p.587:120mm
a. The classical headache of brain tumor includes
i. a.m._____	worse
ii. strain cough_____	increases
iii. bending forward_____	increases
iv. associated with n_____ and/or v_____	nausea and/or vomiting
b. Is this constellation truly suggestive of brain tumor?	no
c. What percentage have these “classic” headaches?	8% (77% had headache similar to tension headache, 9% were similar to migraine, only 8% showed classic brain tumor headache; two thirds of these had high intracranial pressure [ICP])
11. Familial syndromes
a. are associated with_____ _____	CNS tumors	G7 p.588:40mm
b. which are (Hint: vntLT):
i. v_____ _____-_____	von Hippel-Lindau
ii. n_____	neurofibromatosis
iii. t_____ _____	tuberous sclerosis
iv. L_____-_____	Li-Fraumeni
v. T_____	Turcot
12. Matching. Match the familial syndromes with the associated CNS tumors.		G7 p.588:40mm
Syndromes:
von Hippel-Lindau, neurofibromatosis, tuberous sclerosis, Li-Fraumeni, Turcot
CNS tumors:
a. PNET
b. glioblastoma multiforme (gbm)
c. hemangioblastoma
d. subependymal grant cell astrocytoma
e. vestibular schwannoma
13. True or False. The following central nervous system (CNS) tumors occur in neurofibromatosis (NF):		G7 p.588:108mm
a. acoustic (vestibular schwannoma)	true (bilateral)
b. meningioma	true
c. ependymoma	true
d. astrocytoma	true (otherwise known as multiple inherited schwannomas, meningiomas, and ependymomas)
e. ganglioglioma	false
14. True or False. The beneficial effect of steroids is greater for		G7 p.588:115mm
a. metastatic tumor	true
b. primary tumor	false
15. What brain tumor has a generally favorable response to chemotherapy?	oligodendroglioma	G7 p.589:90 mm
16. What tactics can be used to circumvent the blood-brain barrier (BBB)?
Hint: lhdb
a. l_____	lipophilic agent nitrosoureas
b. h_____	higher doses of medications
c. d_____	disrupt BBB with mannitol
d. b_____	bypass BBB with intrathecal methotrexate for primary lymphoma
17. What common medication can be used to disrupt the BBB for chemotherapy delivery?	mannitol	G7 p.589:135mm
18. Complete the following about general tumors:		G7 p.589:160mm
a. What is the proper time to obtain postop computed tomographic (CT) scan after brain tumor surgery?
i. to check for bleeding use contrast immediately. True or false?	false
ii. to check for residual tumor use contrast_____?	in the first 2 days postop
b. What period of time would be inappropriate to obtain a postop head CT scan with contrast to assess for residual tumor?	during the period 2 days to 8 weeks after surgery is not a reliable testing time for CT or MRI
c. Any exception to this timing rule of thumb?	yes
i. In what case?	pituitary tumors
ii. How long to wait?	4 months’ delay is recommended
19. Complete the following about general tumors:		G7 p.590:45mm
a. In a pediatric patient with a posterior fossa tumor, what additional test should be done preoperatively?	MRI of lumbosacral spine with contrast
b. Why?	to rule out drop metastases
c. Why not do it postoperatively when you are sure the test is needed?	because postoperative blood may cause an artifact
d. Artifact will last for_____.	3 weeks
20. Should we place a shunt or external ventricular drain (EVD) into a pediatric patient with a posterior fossa tumor and hydrocephalus?		G7 p.590:60mm
a. pros
i. possible lower o_____ m_____	operative mortality
b. cons
i. l_____ shunt	lifelong
ii. s_____ of peritoneum	seeding
iii. u_____ _____ herniation	upward transtentorial
iv. i_____ in shunt	infection
v. d_____ in definitive treatment	delay

Primary Brain Tumors

21. Characterize low-grade gliomas.		G7 p.591:58mm
a. On T1-weighted image (T1WI), they are _____.	hypointense
b. On T2WI, they are_____.	hypointense
c. What percentage enhance?	30% only
d. A positron emission tomographic (PET) scan may demonstrate_____.	hypometabolism
e. Can they be diagnosed radiologically?	no (Biopsy is needed for definitive diagnosis.)
22. Under the WHO classification an astrocytoma with necrosis is called a_____.	GBM	G7 p.594:168 mm
23. Complete the following about astrocytoma:		G7 p.595:50mm
a. grade I
i. frequency_____%	0.7%
ii. frequency rule of thumb_____%	1%
iii. median survival_____years	10
iv. peak age incidence_____years	20
b. grade II
i. frequency_____%	16%
ii. frequency rule of thumb_____%	15%
iii. median survival_____years	4
iv. peak age incidence_____years	30
c. grade III
i. frequency_____%	17%
ii. frequency rule of thumb_____%	15%
iii. median survival_____years	1.6
iv. peak age incidence_____years	40
d. grade IV
i. frequency_____%	65%
ii. frequency rule of thumb_____%	65%
iii. median survival_____years	0.7 (8.5 months)
iv. peak age incidence_____years	50
24. Complete the following regarding astrocytoma:		G7 p.595:122mm
a. longevity with low-grade astrocytoma
i. aged 45 or younger_____	˜5 years
ii. aged 45 or older_____	˜1½ years
b. why?
i. Because low-grade astrocytomas undergo_____ _____	malignant transformation
ii. _____-fold more rapidly after	six
iii. age_____	45
25. List astrocytoma GBM microscopic characteristics.		G7 p.596:73mm
Hint: cgppmnn
a. c_____	cellular
b. g_____ a_____	gemistocytic astrocytes
c. p_____	pleomorphism
d. p_____	pseudopallisading
e. m_____	mitosis
f. n_____	necrosis
g. n_____	neovascularization
26. True or False. The following fluid clots:		G7 p.596:120mm
a. cerebrospinal fluid (CSF)	false
b. cyst fluid	true
c. subdural fluid	false
d. blood	true
27. Describe astrocytoma CT and MRI characteristics.		G7 p.596:165mm
a. grade I
i. CT	low
ii. MRI	abnormal
iii. mass?	no
iv. enhancement?	no
b. grade II
i. CT	low
ii. MRI	abnormal
iii. mass?	yes
iv. enhancement?	no
c. grade III
i. CT	low
ii. MRI	abnormal
iii. mass?	yes
iv. enhancement?	yes
d. grade IV
i. CT	low
ii. MRI	abnormal
iii. mass?	yes
iv. enhancement?	ring
e. In ring enhancement the center represents
i. n_____ and the rim is	necrosis	G7 p.597:88mm
ii. c_____ t_____.	cellular tumor
28. Meningeal gliomatosis occurs in_____% of high-grade gliomas at autopsy.	20%	G7 p.598:52mm
29. True or False. Treatments for low-grade gliomas should generally include		G7 p.598:145mm
a. biopsy or surgery for tissue diagnosis	true
b. excisional biopsy	false
c. radiation	false
d. chemotherapy	false
e. excision of pilocytic astrocytomas	true
f. removal because the more tumor removed improves longevity	false (not clearly proven)	G7:p.599:15mm
30. Complete the following regarding stereotactic biopsy:		G7 p.600:20mm
a. It underestimates the occurrence of GBM by_____%.	25%
b. Some CNS_____ mimic GBM radiographically.	lymphomas
c. Yield of biopsy is highest when
i. low density_____ and	center
ii. enhancing_____ are both sampled.	rim
d. If Karnosky rating is higher than_____	70
e. it portends a_____ prognosis.	better
31. Answer the following concerning malignant astrocytoma grade III or IV:		G7 p.600:120mm
a. True or False. Treatment is surgical excision when possible.	true
b. Prognosis from surgical excision and radiotherapy is_____ weeks in the elderly.	30
c. Prognosis from biopsy and radiotherapy is_____ weeks in the elderly.	17
d. Type of radiotherapy advised is_____.	focal
e. Amount is_____ Gy.	50 to 60
32. Characterize wounded glioma syndrome.		G7 p.600:175mm
a. Partial resection of a GBM carries significant risk of_____	hemorrhage
b. or_____	edema
c. with resultant_____.	herniation
d. The benefit of subtotal resection is_____.	dubious
e. Surgical excision should be considered if total removal is_____.	feasible
33. Characteristic radiation therapy for		G7 p.601:35mm
a. malignant gliomas is_____ Gy.	50 to 60
b. Is whole brain x-ray treatment (XRT) valuable?	no (It does not increase survival.)
34. Considering malignant gliomas, what is the only protocol fully validated by a phase 3 study for treatment of malignant glioma?		G7 p.601:125mm
a. s_____	surgery—maximal resection
b. r_____, _____ Gy	radiation, 60 Gy
c. c_____ (B_____)	chemotherapy (BCNU at 6-week intervals)
35. Matching. Match level of risk with patient characteristics.		G7 p.603:45mm
Risk:
low risk, low moderate risk, moderate high risk, high risk
Patient characteristics:
a. Age under 40
b. Age between 40 and 65
c. Frontal tumor
d. Tumor outside frontal lobe
e. Karnofsky scale < 80
f. Age above 65
g. Subtotal resection (STR)
h. Gross total resection (GTR)
36. What are the common locations of pilocytic astrocytoma?		G7 p.603:118mm
Hint: hoc
a. h_____	hypothalamus
b. o_____ _____	optic chiasm
c. c_____	cerebellum
37. Characterize pilocytic astrocytoma.		G7 p.604:110mm
a. Appearance on CT and MRI
i. True or False. It enhances.	true (enhancing lesion)
ii. True or False. It is solid.	false (often cystic)
iii. It may have a_____ nodule.	Mural
iv. True or False. It is diffuse.	false (well circumscribed)
b. You should resect the wall of the cyst if the wall_____.	enhances
38. Characterize the radiologic appearance of pilocytic astrocytoma.		G7 p.604:110mm
a. What is their shape?	well circumscribed
b. Do they enhance?	yes—on MRI and CT
c. Are they cystic?	yes
d. Is there anything in the cyst?	mural nodule
e. Are they surrounded by edema?	no
f. Where are they located?	periventricular	G7 p.604:135mm
39. Complete the following about primary brain tumor:		G7 p.605:15mm
a. cystic cerebellar astrocytoma
i. incidence in adults_____%	10% of CNS tumors
ii. percentage of childhood tumors_____%	27 to 40% of posterior fossa
b. optic glioma		G7 p.606:15mm
i. incidence in adults_____%	2% of gliomas
ii. percentage of childhood tumors_____%	7% of gliomas
c. brain stem gliomas		G7 p.607:45mm
i. incidence in adults_____%	1% of CNS tumors
ii. percentage of childhood tumors_____%	10 to 20% of CNS tumors
d. oligodendroglioma		G7 p.609:155mm
i. incidence in adults_____%	2 to 4% of CNS tumors and 35% of all gliomas
ii. percentage of childhood tumors_____%	small%
e. meningioma		G7 p.613:125mm
i. incidence in adults_____%	15 to 20%
ii. percentage of childhood tumors_____%	1.5% of CNS tumors
f. vestibular schwannoma		G7 p.620:160mm
i. incidence in adults_____%	8 to 10%
ii. percentage of childhood tumors_____%	0%
40. According to Collins’ law, a patient’s tumor is considered cured if		G7 p.605:160mm
a. it does_____ recur	not
b. after a postop period equal to the patient’s_____	age
c. plus_____.	9 months
41. Consider treatments for optic glioma.		G7 p.606:85mm
a. One optic nerve involved sparing chiasm, painless proptosis, gliosis of optic nerve head on funduscopy perform_____ and_____ _____.	craniotomy and orbital exploration
i. Treatment should be to e_____ o_____ n_____	excise optic nerve
ii. from g_____ b_____	globe back
iii. to c_____.	Chiasm
b. More posterior lesions with nonspecific visual defects, no proptosis, hypothalamic dysfunction, pituitary dysfunction, hydrocephalus, it is likely a _____ _____.	chiasmal lesion
i. Treatment should be b_____ and	biopsy
ii. X_____.	XRT
42. Diencephalic syndrome consists of		G7 p.606:135mm
Hint: diencephalic
i. d_____ s_____	diencephalic syndrome
ii. i_____ a_____ r_____	intraventricular appearance radiographically
iii. e_____ e_____	excessively energetic
iv. n_____	macrocephaly
v. c_____	cachexia
vi. e_____	euphoria
vii. p_____	failure to thrive
viii. h_____	hypoglycemia
ix. a_____ h_____	anterior hypothalamus
x. l_____ of s_____ f_____	loss of subcutaneous fat
xi. i_____	infiltrating
xii. c_____ u_____	children usually
43. Characterize brain stem glioma.		G7 p.607:28mm
a. Lower-grade tumors tend to occur in the_____ brain stem.	higher
b. Higher-grade tumors tend to occur in the_____ brain stem.	lower
c. They present with_____ _____ _____ _____.	multiple cranial nerve palsies
d. True or False. Most are surgical candidates.	false
44. How do upper brain stem gliomas present?		G7 p.607:65mm
a. c_____ f_____	cerebellar findings
b. h_____	hydrocephalus
45. How do lower brain stem gliomas present?		G7 p.607:65mm
a. l_____ c_____ n_____	lower cranial nerves
b. l_____ t_____ f_____	long tract findings
46. Characterize four categories of brain stem gliomas.		G7 p.607:120mm
a. diffuse
i. location _____, _____, _____	pons, medulla, cord
ii. glioma grade_____	malignant
iii. percent_____%	100%
iv. treatment_____ _____	no surgery
b. cervicomedullary
i. location_____	cervicomedullary
ii. glioma grade_____	low
iii. percent_____%	72%
iv. treatment_____ _____ _____	surgery if exophitic
c. focal
i. location_____	medulla
ii. glioma grade_____	low
iii. percent_____%	66%
iv. treatment_____ _____ _____	surgery if exophitic
d. exophytic
i. location _____, _____ _____	medulla, spinal cord
ii. glioma grade_____	low
iii. percent_____%	60%
iv. treatment_____ _____ _____	surgery is okay
47. How do brain stem gliomas appear on MRI?		G7 p.607:175mm
a. T1_____	hypointense
b. T2_____	increased signal
c. gad_____	gadolinium highly variable
48. Complete the following about brain stem gliomas:		G7 p.608:140mm
a. Prognosis of most patients is_____ months.	6 to 12
b. Subgroup of dorsally exophytic pilocytic astrocytomas have a longer survival of up to_____ years.	5	G7 p.608:150mm
49. Characterize tectal gliomas.		G7 p.608:165mm
a. Pathology is usually_____-_____ _____ that	low-grade astrocytoma
b. presents with_____.	hydrocephalus
c. Diagnostic study of choice is_____.	MRI
d. Symptoms resolve with treatment of the _____.	hydrocephalus
e. MRI appearance
i. mass arising from the q_____ p_____	quadrigeminal plate
ii. on T1_____	isointense
iii. on T2_____	iso- or hyperintense
iv. gadolinium_____%_____	18% enhance
f. Treatment
i. s_____ or	shunt
ii. t_____ v_____	third ventriculostomy
50. Characterize oligodendroglioma.		G7 p.609:120mm
a. Presenting symptom is_____ in_____%.	seizure in 50 to 80%
b. Calcified on
i. _____% of skull x-rays	30 to 60%
ii. _____% of CT scan	90%
c. Oligodendroglioma cells in a tumor suggests what for the patient?	a better prognosis
51. Characterize oligodendrogliomas.		G7 p.609:155mm
a. They have a predilection for the f_____ l_____.	frontal lobes
b. A classic description of cytoplasm is f_____ e_____.	fried egg
c. The role of chemotherapy is the p_____ t_____	primary treatment
d. after s_____ r_____.	surgical resection
52. What are the chemotherapy agents used for oligodendrogliomas?		G7 p.611:30mm
Hint: Cvpt
a. C_____	CCNU
b. v_____	vincristine
c. p_____	procarbazine
d. t_____	temozolomide
53. Prognosis: best, middle, worst. Relate.		G7 p.611:130mm
a. Pure oligodendroglioma	best
b. Mixed oligodendroglioma	middle
c. Pure astrocytoma	worst
54. Complete the following regarding prognosis:		G7 p.611:130mm
a. An oligodendroglial component conveys a_____ prognosis.	better
b. Pure oligo 10-year survival is_____%.	10 to 30%
c. Postop survival is_____ to_____ months.	35 to 52
d. Calcification in an oligodendrogliioma (ODG) conveys a_____ prognosis.	better
e. Loss of chromosome 1p conveys a_____ prognosis.	better
f. Loss of chromosome 1p and 19q conveys a_____ prognosis.	better
55. Describe central neurocytoma.		G7 p.612:105mm
a. It is located in the l_____ v_____	lateral ventricles
b. or in the s_____ p_____.	septum pellucidum
c. It tends to affect y_____ a_____	young adults
d. and is curable by t_____ r_____.	total resection
56. Characterize meningiomas.
a. They arise from what cell of origin?	arachnoid cap cell	G7 p.613:90mm
b. What percentage of meningiomas occur at the falx? (includes parasagittal)	60 to 70%	G7 p.613:155mm
c. With foot drop plus hypereflexia, think_____ _____.	parasagittal meningioma	G7 p.614:50mm
d. Olfactory groove meningiomas		G7 p.614:68mm
i. can produce what syndrome?	Foster Kennedy
ii. consisting of a_____, i_____ o_____ a_____, and c_____ p_____	anosmia, ipsilateral optic atrophy, and contralateral papilledema
iii. What other syndrome?	frontal lobe
iv. consisting of a_____, i_____	apathy, incontinence
57. Abulia is		G7 p.614:85mm
a. l_____ o_____ w_____.	lack of willpower
b. characteristic of damage to f_____ l_____.	frontal lobes
c. can occur with a meningioma of the o_____ g_____.	olfactory groove
58. Give a description of asymptomatic meningiomas.		G7 p.615:30mm
a. The most common primary intracranial tumor is_____.	meningioma
b. Percent of primary brain tumors that are meningiomas_____%	32%
c. Percent that are stable in size over 2½ years_____%	66%
d. Percent that increase in size when observed for 2½ years_____%	33%
e. What does calcification tell us about rate of growth?	slower
f. Operative morbidity in patients under 70_____%	3.5%
g. Above 70_____%	23%
h. Classic histological finding is the p_____ b_____.	psammoma body
59. Complete the following about MRI and meningioma:		G7 p.616:175mm
a. Meningioma on T1W1 and T2W1 may be _____.	isodense
b. With contrast most will_____.	enhance
c. Accurately predicts sinus involvement in _____%.	90%
d. A common finding is a d_____ t_____.	dural tail

60. What metastatic cancer can mimic meningioma in the bone on MRI?	prostate	G7 p.617:40 mm
61. Olfactory groove meningiomas tend to be fed by the		G7 p.617:52mm
a. _____arteries	ethmoidal
b. which are branches of the_____ artery.	ophthalmic
62. The artery of B_____and C_____is enlarged in lesions involving the tentorium (i.e., tentorial meningiomas).	Bernasconi and Cassinari (a branch of the meningohypophyseal trunk)	G7 p.617:65mm
63. True or False. The artery most likely to be enlarged on an angiogram depicting a tentorial meningioma is the		G7 p.617:65mm
a. superficial temporal artery	false
b. artery of Bernasconi and Cassinari	true
c. occipital artery	false
d. posterior inferior cerebellar artery	false
e. anterior choroidal artery	false
64. Regarding meningiomas and plain x-rays, the plain x-rays may show		G7 p.617:110mm
a. b_____ _____ _____	blistering of bone
b. c_____ _____ _____	calcification in tumor 10%
c. d_____ _____—_____	density changes—hyperostosis
d. e_____ _____ _____	enlarged vascular grooves
e. f_____ _____ _____	frontal fossa hyperostosis
65. Complete the following regarding sinus involvement:		G7 p.618:20mm
a. Occlusion of middle third of the SSS is _____.	treacherous
b. Morbidity/mortality is_____/_____%,	8/3%
c. due to v_____ i_____.	venous infarction
66. Complete the following regarding sinus involvement:		G7 p.618:60mm
a. The sinus may be divided safely anterior to the_____ _____.	coronal suture
b. Posterior to this site the sinus_____ _____ be divided.	must not
c. If tumor is attached, it is best to leave_____ _____.	residual tumor	G7 p.618:82mm
d. True or False. It is safe to occlude the dominant transverse sinus.	false	G7 p.618:92mm

67. Complete the following about the removal of meningiomas:		G7 p.619:140mm
a. The Simpson grading system grades the degree of removal of _____.	meningiomas
b. It is important because it correlates with_____ _____.	recurrence rate
c. Components of the system are	In order of complexity, from minimal surgery to complete removal:
i. s_____ r_____,b_____	small removal, biopsy
ii. p_____ r_____	partial removal
iii. c_____ r_____	complete removal
iv. c_____ d_____	coagulate dura
v. r_____ d_____ and b_____ ands_____	remove dura and bone and sinus
d. Correlates with grade
i. _____	V
ii. _____	IV
iii. _____	III
iv. _____	II
v. _____	I
e. What is the most important factor regarding recurrence?	extent of tumor removal
68. Five year survival for patients with menigioma is _____%.	91.3%	G7 p.619:150mm

Vestibular Schwannoma

69. True or False. Vestibular schwannomas (VS) usually arise from which nerve?		G7 p.620:145mm
a. facial nerve	false
b. cochlear nerve	false
c. nervus intermedius	false
d. vestibular nerve, inferior division	false
e. vestibular nerve, superior division	true
70. Vestibular schwannomas arise from the junction of the _____and_____ myelin called the_____-_____zone.	central and peripheral; Obersteiner-Redlich	G6p.429:170mm
71. Complete the following about primary brain tumors:		G6p.429:175mm
a. What is the Obersteiner-Redlich zone?	site of junction of central and peripheral myelin
b. Where is it located?	8 to 12 mm from brain stem
c. From what cells do acoustic tumors arise?	from the neurilemmal sheath
d. On what structure do they arise?	the superior division of the vestibular nerve
e. Therefore, are they schwannomas or neuromas?	schwannomas

f. They are the result of a chromosomal defect that leads to
i. loss of a t_____ s_____gene on the	tumor suppressor on the	G7 p.620:148mm
ii. l_____ arm of c_____ #_____.	long arm of chromosome 22
72. True or False. What is the most common chromosomal defect in vestibular schwannomas?		G7 p.620:150mm
a. P53 mutation	false
b. gain of function mutation on Ch 3	false
c. loss of tumor suppressor gene on Ch 22	true
d. loss of tumor suppressor gene on Ch 17	false
e. loss of heterozygosity on Ch 10	false
73. List the common triad of symptoms seen with vestibular schwannomas.		G7 p.621:40 mm
a. h_____ -_____ %	hearing loss—98%
b. t_____ -_____ %	tinnitus-70%
c. d_____ -_____ %	dysequilibrium-67% (insidious, progressive, 70% have high-frequency loss, word discrimination difficulties)
74. A patient with good hearing has an MRI study that shows a cerebellopontine angle mass.		G7 p.621:65mm
a. Is this compatible with a vestibular schwannoma?	no (At the time of diagnosis virtually all VS have otologic symptoms.)
b. When hearing is involved in VS, what is lost?
i. low frequencies?	no
ii. high frequencies?	yes (70% have a high-frequency loss pattern.)
iii. word discrimination?	yes (Most have impaired word discrimination, e.g., telephone conversation.)
75. What cranial nerve deficits, other than CN VIII, occur with vestibular schwannomas?		G7 p.621:125mm
a. CN_____;o_____,f_____ n_____,and t_____ c_____	CN V; otalgia, facial numbness, and taste changes
b. CN_____;f_____ w_____	CN VII; facial weakness
c. CN_____;h_____ and d_____	CN IX, X, XII; hoarseness and dysphagia

76. Answer the following about vestibular schwannoma:		G7 p.621:135mm
a. As tumor increases in size the following occur in what sequence?	C, B, A (Facial numbness occurs earlier than facial
A. facial weakness	weakness even though CN V
B. facial numbness	is only slightly compressed,
C. impaired hearing	whereas CN VII is severely distorted early—a paradox. Why? Differential resilience of motor nerves relative to sensory nerves.)
b. What size tumor causes fifth and seventh nerve compression?	larger than 2 cm
77. Complete the following about vestibular schwannomas:		G7 p.621:170mm
a. What percentage of patients have no abnormal physical findings except for hearing loss?	66%
b. The Weber test lateralizes to the_____ side.	uninvolved (Hearing loss is sensorineural.)
c. Is the Rinne test positive or negative if hearing is preserved?	positive
d. What is normal for the Rinne test?	air conduction > bone conduction = positive means normal. (Note: An A is better than a B.)
78. Complete the following about primary brain tumors:		G7 p.622:75mm
a. In VS what causes nystagmus?	vestibular involvement
b. What fibers constitute VS?
i. A_____ _____ n_____ e_____ b_____ f_____	Antoni A narrow elongated bipolar fibers
ii. A_____ l_____r_____f_____	Antoni B loose reticulated fibers
c. What is the growth rate for VS?	1 to 10 mm/year
d. What is the proper follow-up protocol, if no surgery is done?	repeat scan at 6-month intervals for 2 years then once each year
e. Recommend surgery if what occurs?
i. size changes by_____	> 2 mm/year
ii. or symptoms_____	progress

79. Answer the following about the House and Brackmann scale:		G7 p.622:15mm
a. What does the House-Brackmann scale measure?	clinical measurement of facial nerve function
b. What are the categories?	normal mild moderate moderate-severe severe no movement
c. Synkinesis is defined as i_____m_____ accompanying a v_____m_____.	involuntary movement accompanying a voluntary movement
80. Answer the following about vestibular schwannomas:		G7 p.625:30mm and G6p.431:110mm
a. What is the growth rate of vestibular schwannomas?	slow (1 to 10 mm/year)
b. Do some shrink?	yes (6%)
c. Can they remain stable?	yes
d. Can they grow faster?	yes (2 to 3 cm/year)
e. If followed most will show_____ in 3 years.	enlargement
81. Describe the audiometric findings for “useful” hearing in vestibular schwannomas.	50/50 rule	G7 p.623:90mm
a. pure-tone audiogram threshold of_____	≤50%
b. speech discrimination of_____	≥50%
82. Complete the following regarding the Gardener-Robertson system:		G7 p.623:108mm
a. The Gardener-Robertson system is used to grade h_____ p_____.	hearing preservation
b. It consists of
i. testing patient with_____ _____ of increasing loudness.	pure tones (decibels [db]) (If patient hears dB 0 to 30—excellent hearing; 30 to 50 dB—serviceable; 50 to 90 dB—nonserviceable; 90 dB max—poor; not testable—none)
ii. Evaluating patient ability to understand spoken words is called_____ _____.	speech discrimination (understands words spoken to him or her correct 100 to 70%-excellent; 70 to 50%—serviceable; 50 to 5%— nonserviceable)
c. Useful hearing is judged to be present up to a cutoff point of_____.	50/50 patient can hear at 50 dB or less and understands at least 50% of words spoken to him or her

83. Name the findings for the following tests in vestibular schwannomas:		G7 p.622:175mm
a. pure-tone audiogram	hearing difference between eachear>10to15dB
b. speech discrimination	4 to 8% score (normal is 92 to100%)	G7 p.623:45mm
c. brain stem auditory evoked response (BSAER)	prolonged I-III and I-V interpeak latencies	G7 p.624:45mm
d. electronystagmography (ENG)	abnormal if one ear has ≤35% of total (Normally, 50% of response is from each ear.)	G7 p.624:20mm
84. Complete the following concerning vestibular schwannoma:		G7 p.623:20mm
a. It causes what kind of hearing loss?	sensorineural loss of high tones
b. This is the same as the loss from
i. _____	old age
ii. _____	loud noise exposure
c. Think tumor if the difference between the ears on audiogram is more than_____ dB.	10to15
85. True or False. A 55-year-old male is referred for evaluation of a 4.0 cm right cerebellopontine angle (CPA) mass. You conclude it is a vestibular schwannoma. The following is least likely to be a factor in your treatment. Give rationale for each.		G7 p.624:65mm
a. pure-tone audiogram score of 95 dB	false (Audiogram with hearing threshold <50 dB may allow consideration of hearing—sparing procedure, but with a score of 95 dB hearing—saving procedure is not an option.)	G7 p.622:175mm
b. effacement of the fourth ventricle with modest ventriculomegaly	false (Evidence of hydrocephalus warrants CSF diversion—needs a shunt.)	G7 p.621:170mm
c. stereotactic surgery 2 years previously	true (Stereotactic radiosurgery 2 years previously is long enough for SRS effect to be over. Surgery should be avoided during the interval 6 to 18 months after SRS because this is the time of maximum damage from the radiation.)

d. contralateral (left) vestibular schwannoma, 1.0 cm in diameter	false (Bilateral VS unable to preserve right hearing [95 dB], will need to plan for second procedure to address the left-sided lesion. Chance of preserving left hearing— 35 to 71% for a 1 cm tumor.)
e. angiogram showing absence of right transverse sinus	false (Atretic/obstructed right transverse sinus allows consideration of translabyrinthine and suboccipital approach as a combined procedure.)
86. True or False. Possible treatments for vestibular schwannomas include		G7 p.624:120mm
a. expectant observation, following symptons, hearing testing, serial, CT, or MRI	true
b. radiation therapy, external beam radiation therapy (EBRT)	true
c. radiation therapy, stereotactic radiosurgery (SRS)	true
d. retrosigmoid (suboccipital) resection	true
e. translabyrinthine resection	true
f. extradural subtemporal (middle fossa approach) resection	true
87. Complete the following about vestibular schwannoma treatment:		G7 p.625:115mm
a. Under 20 mm can be_____,	observed
b. Protocol is to retest at 6,12,18, 24,36, 48,60, 84,108,and 168_____	months
c. Growth of more than_____ mm between studies deserves treatment.	2
d. Tumors larger than 15 to 20 mm should be_____.	treated
e. Tumors with cysts can_____ _____.	grow dramatically	G7 p.625:103mm
88. Matching. Match outcome with technique with microsurgery and SRS.		G7 p.625:170mm
Outcome: hearing, facial nerve function, trigeminal neuropathy, tumor control Technique:
a. microsurgery	,
b. stereotactic radiosurgery
c. equal
89. Classically, vestibular schwannomas push the facial nerve in which direction? Pushed_____ and_____ in_____% of cases.	forward and superiorly in 75%	G7 p.627:92mm

90. Complete the following about vestibular schwannomas:		G7 p.627:145mm
a. Small, laterally located intracanalicular vestibular schwannomas can be removed by what surgical approach?	subtemporal extradural (also known as middle fossa approach)
b. A disadvantage is that the seventh nerve may be_____ at the_____ ganglion.	injured at the geniculate
c. An advantage is that hearing function may be_____.	preserved
91. What is the size vestibular schwannomas should be considered for hearing and CN VII preservation procedures?	< 2 to 2.5 cm	G7 p.627:80mm
92. What are the advantages of translabyrinthine approach for resecting vestibular schwannomas?		G7 p.628:65mm
a. early identification of the_____	facial nerve
b. less risk to_____ and_____ _____ _____	cerebellum and lower cranial nerves
c. best for VS that are located_____	intracanalicular
93. What are the disadvantages of a translabyrinthine approach for resecting vestibular schwannomas?		G7 p.628:65mm
a. Hearing is_____.	sacrificed
b. Exposure is_____.	limited
c. CSFleakis_____.	more common
94. Complete the following about vestibular schwannomas:		G7 p.628:135mm and also G6p.434:122mm
a. What are the disadvantages of suboccipital approach (also known as retrosigmoid) for vestibular schwannomas?
i. higher_____ when compared with the translabyrinthine approach	morbidity
ii. small tumors_____	difficult to remove in lateral recess of internal auditory canal (IAC)
iii. facial nerve is located_____	on blind side deep to the tumor
b. The advantage is the possibility of h_____ p_____.	hearing preservation

95. Complete the following about localizing the VII nerve origin:		G7 p.629:145mm
a. The seventh nerve originates in the_____ sulcus,	pontomedullary
b. anterior to the eighth nerve by_____ mm.	2
c. It lies just anterior to the foramen of_____	Lushka
d. and anterior to a tuft of_____.	choroid
e. It originates _____ mm cephalad to the ninth nerve.	4
96. How do you treat postoperative facial nerve weakness after vestibular schwannoma resection?		G7 p.630:130mm
a. N_____T_____	Natural Tears (2 drops to eye every 2 hours as needed)
b. L_____	Lacrilube (to eye and tape eye at bedtime)
c. t_____	tarsorrhaphy within a few days if there is a complete CN VII palsy
d. Anastomose by attaching a portion of the_____ nerve to the_____ nerve	hypoglossal facial
e. When there is no CN VII function and
i. nerve is known to be divided you may anastomose in_____	2 months
ii. nerve is known to be intact you may anastomose in_____	1 year
97. True or False. The following symptoms of brain stem compression from a vestibular schwannoma if present postop is not likely to improve:		G7 p.630:155mm
a. nausea	false (Nausea resolves with time.)
b. vomiting	false (Vomiting resolves with time.)
c. balance difficulties	false (Balance difficulties clear rapidly.)
d. ataxia	true (Ataxia from brain stem dysfunction may be permanent.)

98. True or False. The routes of CSF leakage after vestibular schwannoma resection can be via the		G7 p.631:20mm
a. apical cells	true (to tympanic cavities or eustachian tube—most common)
b. vestibule	true (Posterior SCC is usually entered by drilling—via the oral window.)
c. perilabyrinthine cells	true (and tracks to mastoid antrum)
d. mastoid air cells	true (at craniotomy site)
*99. True or False. The following is the most likely* source of a postoperative CSF fistula after resection of a vestibular schwannoma:**		G7 p.631:20mm
a. mastoid air cells via craniotomy site	false
b. through the vestibule of the bony labyrinth via the oval window	false
c. perilabyrinthine cells to the mastoid antrum	false
d. apical cells to the tympanic cavity or eustachian tube	true (All are potential routes but this is the most frequent.)
100. With vestibular schwannoma, postoperative routes for rhinorrhea are		G7 p.631:20mm
Hint: avam
a. a_____	apical cells to tympanic cavity and down the eustachian tube
b. v_____	vestibule after drilling the ICA into the semicircular canal via oval window
c. a_____	to antrum of mastoid via the perilabyrinthine cells
d. m_____	mastoid air cells at site of craniotomy
101. What are treatment strategies for CSF leakage after vestibular schwannoma resection?		G7 p.631:92mm
a. What percent stop spontaneously?	25 to 35%
b. Do what with the head of the bed?	elevate
c. Place a drain where?	lumbar
d. If hydrocephalus is present place a_____.	CSF shunt
e. If leak persists_____.	reexplore surgical site to pack with tissue or apply bone wax

102. What are common complications of vestibular schwannoma surgery?		G7 p.631:175mm
a. CSF leak in_____%	4 to 27%
b. infection in_____%	5.7% meningitis
c. stroke in_____%	0.7% cerebrovascular accident (CVA)
d. CN VII palsy in_____%	0 to 50%
e. hearing loss in_____%	34 to 43%
f. death in_____%	1%
103. Complete the following concerning hearing loss and CN VII weakness after suboccipital removal of VS:		G7 p.632:25mm
a. Tumor < 1 cm
i. CN VII preserved,_____%	95 to 100%
ii. CN VIII preserved,_____%	57%
b. Tumor 1 to 2 cm
i. CN VII preserved,_____%	80 to 92%
ii. CN VIII preserved,_____%	33%
c. Tumor > 2 cm
i. CN VII preserved,_____%	50 to 76%
ii. CN VIII preserved,_____%	6%
104. Complete the following concerning hearing loss after suboccipital removal of VS:		G7 p.632:25mm
a. Hearing preserved_____% with tumors < 1.5 cm	14 to 48%
b. After SRS hearing preserved_____% with tumors < 3 cm	26%
105. Concerning acoustic neuroma (i.e., vestibular schwannoma), recurrence following microsurgery is		G7 p.633:18mm
a. _____% after	10
b. _____ years follow-up.	15
106. Complete the following concerning SRS for vestibular schwannoma:		G7 p.633:47mm
a. Dose recommended is_____.	14 Gy
b. Local control achieved is_____%.	94%
107. For vestibular schwannoma, what are local control rates for?		G7 p.633:60mm
a. microsurgery	97%
b. SRS	94%
108. When is the time of maximal damage (possible tumor enlargement) from radiation to vestibular schwannomas?		G7 p.633:75mm
a. from_____ to_____ months	6 to 18
b. This is important to know because it can produce a false appearance of tumor_____.	enlargement (Surgery should be avoided during the interval of 6 to 18 months after SRS because of damage from radiation and the appearance of tumor enlargement.)
109. Most pituitary tumors are benign tumors that arise from the_____	adenohypophysis	G7 p.634:25mm
110. Answer the following about pituitary tumors:		G7 p.634:37mm
a. By definition what is the maximal size of a pituitary microadenoma?	1 cm
b. Larger tumors are called_____	macroadenomas
c. 50% of pituitary tumors are less than_____ mm.	5 mm
111. Complete the following about pituitary carcinoma:		G7 p.634:48mm
a. Occurence is_____.	rare
b. They are usually i_____	invasive
c. They are usually s_____	secretory
d. The most common hormones are
i. a_____	adrenocorticotropic hormone (ACTH)
ii. P_____	PRL
e. True or false. They can metastasize.	true
f. Prognosis of 1-year mortality is_____%.	66%
112. True or False. Regarding pituitary tumors:		G7 p.634:67mm
a. 10% of intracranial tumors	true
b. most common in third to fourth decades	true
c. affect females more often	false (Pituitary tumors affect both sexes equally.)
d. higher incidence in MEN or MEA syndrome	true
e. usually present due to endocrine disturbance or mass effect	true
113. Complete the following about pituitary tumors:		G7 p.634:70mm
a. MEN stands for_____ _____	multiple endocrine neoplasms
b. MEA stands for_____ _____	multiple endocrine adenomatosis
c. Incidence of pituitary tumors in MEN is_____.	increased
114. Complete the following about clinical presentation of pituitary tumors:		G7 p.634:125mm
a. Hormone hypersecretion
i. _____% of adenomas secrete active hormone	65%
ii. prolactin_____%	48%
iii. growth hormone_____%	10%
iv. ACTH_____%	6%
v. thyroid-stimulating hormone (TSH)_____%	1%
b. Growth hormone
i. If elevated it is due to a_____ _____	pituitary adenoma
ii. More than_____% of the time.	95%
c. Corticotropin
i. aka_____	ACTH
ii. Excess causes_____ _____	Cushing disease
iii. Nelson syndrome can develop only in patients who have had an _____	adrenalectomy
115. Complete the following about hormone hyposecretion:		G7 p.634:180mm
a. Due to_____ of the normal pituitary	compression
b. In order of sensitivity to compression
Hint: go look for the adenoma
i. G_____	GH
ii. L_____	LH
iii. F_____	FSH
iv. T_____	TSH
v. A_____	ACTH
c. Most common symptom		G7 p.635:52mm
i. o_____ h_____	orthostatic hypotension
ii. e_____ f_____	easy fatigability
d. selective loss of one hormone consider_____	hypophysitis
i. A_____	ACTH
ii. A_____	ADH
e. True or False. Diabetes insipidus is seen with preop pituitary tumors.	false
116. Complete the following about mass effect:		G7 p.635:95mm
a. The pituitary tumor that gains the greatest size is
i. non-secreting. (True or False)	true
ii. of the secreting type is the_____	prolactinoma
b. The tumor that is usually the smallest is the_____ tumor.	ACTH
117. Patient presents with sudden onset of headache, visual disturbance, ophthalmoplegia, and reduced mental status.		G7 p.635:155mm
a. Consider diagnosis of p_____ a_____.	pituitary apoplexy (due to expanding mass in sella turcica resulting from hemorrhage or necrosis)
b. This may occur in macroadenomas in as many as_____%.	3 to 17%	G7 p.636:110mm
118. Complete the following about primary brain tumors:		G7 p.636:150mm
a. What are the indications for rapid decompression after pituitary apoplexy?
i. s_____ c_____	sudden constriction of visual field (VF)
ii. s_____	severe deterioration of acuity
iii. mental status changes due to h_____	hydrocephalus (complete tumor removal usually not necessary)
b. What else needs to be done?	treat with corticosteroids
119. Complete the following about the anatomic classification of pituitary adenoma:		G7 p.637:15mm
a. Named the_____ system	Hardy
b. Suprasellar extension
i. O	none
ii. A expanding into the_____ cistern	suprasellar
iii. B anterior recesses of third ventricle_____	obliterated
iv. C_____ of third ventricle_____	floor; displaced
c. Floor of sella
i. Intact or_____ _____	focally expanded enlarged
ii. Sella_____	enlarged
d. Sphenoid extension
i. Localized_____ of sella floor	perforation
ii. Diffuse_____ of sella floor	destruction
120. Complete the following about functional pituitary tumors:		G7 p.637:135mm
a. What is the most common functional pituitary tumor?	prolactinoma
b. What are its most common symptoms?
i. In females,_____-_____	amenorrhea-galactorrhea
ii. called the syndrome of_____-_____	Forbes-Albright
iii. causes_____ in males	impotency
c. It arises from anterior pituitary l_____.	lactotrophs
d. The most common cause of amenorrhea is p_____.	pregnancy
121. Answer the following about Cushing syndrome:		G7 p.638:25mm
a. Which hormone?	ACTH
b. It is produced by a_____ tumor.	pituitary
c. It is called Cushing_____.	disease (if tumor is in the pituitary hypercorticalism, it is called Cushing disease)
122. Complete the following about pituitary adenoma:		G7 p.638:25mm
a. Adrenocorticotropic hormone (ACTH)— secreting pituitary adenoma is known as_____ _____.	Cushing disease
b. Other causes of hypercortisolism are known as_____ _____	Cushing syndrome
c. Nelson disease manifests by
i. hyper-_____ due to	hyperpigmentation	G7 p.639:30mm
ii. cross reactivity of m_____ s_____ h_____ with_____.-	melanocyte-stimulating hormone (MSH) with ACTH
123. Complete the following about Nelson syndrome:		G7 p.639:30mm
a. Follows bilateral_____	adrenalectomy
b. In only_____ to_____% of cases	10 to 30%
c. Classic triad of
i. h_____	hyperpigmentation
ii. ↑ in_____	ACTH
iii. Enlargement of the_____	pituitary tumor
iv. Usually occurs_____ to_____ years after adrenalectomy	1 to 40 years
d.		G7 p.639:90mm
i. The earliest sign is the_____ _____	linea negra
ii. Midline pigmentation from the pubis to_____	umbilicus
iii. And hyperpigmentation of_____ _____ and areolae	scars, gingivae
e. Have an ACTH level greater than_____ Ng/L	200	G7 p.639:130mm
f. The normal being less than_____ Ng/l	54
124. Complete the following about pituitary adenoma (Cushing syndrome):		G7 p.638:25mm
a. caused by_____	hypercortisolism—from any source
b. exogenous source_____	ingestion of steroids
c. endogenous sources
i. p_____ t_____, _____%	pituitary tumor, 60 to 80%
ii. a_____ t_____, _____%	adrenal tumor, 10 to 20%, 15 to 25%
iii. e_____ t_____, _____%	ectopic tumor, 1 to 10%, 5 to 10%
125. Characterize the typical Nelson syndrome scenario.		G7 p.639:53mm
a. patient who had_____ _____	Cushing syndrome
b. had a surgical procedure_____	adrenalectomy
c. develops_____	hyperpigmentation
d. occurs in_____% of such patients	10 to 30%
e. due to_____-_____of_____ and_____	cross-reactivity of ACTH and MSH
126. To remember Cushing syndrome versus disease:		G7 p.638:36mm
a. syndrome due to_____	steroids from any source Hint: syndrome = steroids
b. disease due to_____	pituitary only
127. List the findings in Cushing syndrome.		G7 p.638:115mm
Hint: steroids
a. s_____	striae
b. t_____	thin skin
c. e_____	ecchymosis
d. r_____	reduced libido
e. o_____	obesity
f. i_____	impotence, increased blood pressure
g. d_____	diabetes
h. s_____	skin hyperpigmentation
128. List the findings in Cushing syndrome.		G7 p.639:15mm
Hint: Ectopic sources of acth secretions
Hint: (a) c³ t² h
a. (a)
b. c_____	carcinoma small cell lung
c. c_____	carcinoid
d. c_____	(pheo) chromocytoma
e. t_____	thymoma
f. t_____	thyroid carcinoma
g. h_____	islet cell pancreas
129. Characterize pituitary adenoma in Cushing disease.		G7 p.638:36mm
a. secretion of_____	ACTH
b. most are small <_____ mm	5 mm
c. only_____% are large enough to produce mass effect	10%
d. cells produce_____	proopiomelanocortin (POMC)
e. which contains the precursors for:
i. A_____	ACTH
ii. a_____	alpha-MSH
iii. b_____	beta-lipotropin
iv. b_____	beta-endorphin
v. e_____	met-enkephalin
130. Criteria for biochemical cure is IGF-1 level less than_____ Ng/mL.	5	G7 p.639:180mm
131. Chart. List the effects of excess growth hormone alphabetically.		G7 p.640:50mm
	arthropathy
	acromegaly
	bone
	cartilage
	cardiomyopathy
	diabetes
	entrapment of nerve
	syndromes
	frontal bossing
	fatigue
	glucose intolerance
	gigantism
	hyperhydrosis
	hypertension
	headaches
	infection
	increased hand and foot size
	joint pain
	macroglossia
	malignancies
	neoplasia
	neuropathy
	oily skin
	polyps
	paresthesias
	prognathism
	palmar hyperhydrosis
	respiratory obstruction
	rings no longer fit
	shoe size enlarges
	sleep apnea
	skeletal changes
	soft tissue swelling
	thickened heel pad
	thyromegaly with normal
	thyroid studies
132. Describe the hypothalamic pituitary axis dysfunction in acromegaly.		G6 p.441:55mm
a. Hypothalamus produces_____.	GHRH
b. _____ causes the pituitary to make_____.	GHRH; GH
c. _____ affects the liver, which produces_____ also known as_____.	GH, somatomedin-C, IGF— 1 (hypothalamic GHRH stimulates pituitary GH secretion. Excess GH induces IGF-1 secretion from liver.)
d. What medication can suppress GH release?	somatostatin (Acromegaly findings are due to IGF-1, also known as somatomedin-C.)
133. Complete the following about acromegaly growth hormone releasing hormone (GHRH):		G6 p.441:56mm
a. produced in the_____	hypothalamus
b. causes
ii. sy_____	synthesis of growth hormone
ii. se_____	secretion
iii. re_____	release
c. somatomedin-C
i. produced in the_____	liver
ii. due to stimulus of_____	GH
iii. produces_____ _____	systemic effects
iv. also known as_____ _____ _____	insulin-like growth factor (IGF- 1, also known as somatomedin-C)
134. True or False. Regarding acromegaly, somatostatin suppresses growth hormone by interfering with		G6 p.441:60mm
a. synthesis	false
b. secretion	false
c. release of the hormone	true
135. Answer the following about acromegaly:		G7 p.640:18mm
a. Is there any possible ectopic source of growth hormone?	yes
b. If so, what?	carcinoid tumor
136. Answer the following about acromegaly:		G7 p.640:135mm
a. What effect on mortality does elevated GH levels have? Moratality rates are_____ to_____ times normal	2 to 3 times
b. due to
i. c_____	cancer
ii. c_____	cardiomyopathy
iii. d_____	diabetes
iv. h_____	hypertension
v. i_____	infection
vi. n_____ _____	neural entrapment
137. Concerning growth hormone, what effects does GH have on the following?		G7 p.640:136mm
a. mortality rates	↑
b. blood pressure	↑
c. diabetes	↑
d. infections	↑
e. cancer	↑
f. cardiomyopathy	↑
g. closure of epiphyseal plates in children	delays closure
138. Which pituitary tumor is		G7 p.638:90mm
a. least likely to cause mass effect?	ACTH-producing tumor
b. most likely to cause mass effect?	prolactin-producing tumor
139. Describe the mass effects of pituitary tumors.		G7 p.637:80 mm
a. What are the structures compressed?
Hint: cop
i. c_____ s_____	cavernous sinus
ii. o_____ c_____	optic chiasm
iii. p_____	pituitary
b. What are the mass effects usually seen in nonfunctioning pituitary tumors?
i. p_____, f_____ p_____, d_____	ptosis, facial pain, diplopia
ii. b_____ h_____	bitemporal hemianopsia
iii. h_____	hypopituitarism
140. Describe the Hardy system of pituitary adenoma classification.		G7 p.637:14mm
a. suprasellar extension of tumor
i. _____	no suprasellar extension
ii. _____	fills suprasellar cistern
iii. _____	anterior recess of III ventricle
iv. _____	displaces floor of III ventricle
v. _____	intracranial (intradural)
vi. _____	intracavernous sinus (extradural)
b. invasion
i. I s_____ n_____	sella normal
ii. II s_____ e_____	sella enlarged
iii. III l_____p_____ of s_____ f_____	localized perforation of sella floor
iv. IV d_____ d_____ of s_____ f_____	diffuse destruction of sella floor
v. V s_____via C_____	spread via CSF
141. What percentage of pituitary adenomas become locally invasive?	5%	G7 p.637:15mm
142. Cavernous sinus invasion		G7 p.637:60mm
a. can be suspected if medial wall of sinus is_____ _____.	pushed laterally
b. can be diagnosed if carotid artery is_____.	encased
143. What is the most definite sign of cavernous sinus invasion?	carotid artery encasement	G7 p.637:70mm
144. Matching. Match the light microscopic appearance of each of the following pituitary tumors with its most common secretory product.		G7 p.641:60mm
Secretory product:
growth hormone; ACTH; prolactin; TSH; nonsecretory
Appearance:
a. chromophobe
b. acidophil
c. basophil
145. What percentage of pituitary tumors are		G7 p.641:30mm
a. endocrine-secretorily active?	70%
b. endocrine-secretorily inactive?	30%
146. Complete the following about tumors of the neurohypophysis and infundibulum:		G7 p.641:105mm
a. Most common tumor in the posterior pituitary is_____.	metastasis
b. Most common primary tumor is the_____ _____ _____	granular cell tumor (GCT)
c. If this tumor is suspected, operative approach is_____.	transcranial
d. MRI appearance is identical to_____	adenoma
147. True or False. Baseline endocrinologic evaluation of patients presenting with pituitary tumors includes the following among others:		G7 p.642:80mm
a. 8 a.m. cortisol (24 hours is better)	true
b. serum prolactin level	true
c. somatomedin-C	true
d. serum thyroid-stimulating hormone (TSH)	true
e. serum T3	false
148. List the baseline pituitary function tests.		G7 p.642:81mm
Hint: pqrsTT
a. p_____	prolactin serum level
b. q_____	Q-cortisol 24 hour
c. r_____	rest FSH LH FBS (rest means the rest of the endocrine studies) (reproductive)
d. s_____	somatomedin C
e. T_____	TSH serum level
f. T_____	T4 serum level
149. What is the chiasm location in relationship to the sella and the resulting visual field defect?		G7 p.642:80mm
a. prefixed_____%	5%, homonymous hemianopsia
b. above_____%	80%, bitemporal hemianopsia
c. postfixed_____%	5%, ipsilateral loss of vision, junctional scotoma contralaterally, so-called “pie in the sky,” due to compression of the anterior knee of Willebrand
150. Visual fields is tested using a small red stimulus because desaturation of color is an early sign of _____ compression.	chiasmal	G7 p.642:170mm
151. Answer the following about pituitary adenoma:		G7 p.643:24mm
a. What is the classic finding when a tumor compresses the optic chiasm?	bitemporal hemianopsia
b. What occurs in patients with a postfixed chiasm?
i. s_____ o_____ q_____	superior outer (temporal) quadrantanopsia
ii. j_____ s_____	junctional scotoma
c. due to compression of the k_____ of v_____ W_____	knee of von Willebrand
d. What occurs in patients with a prefixed chiasm?	homonymous hemianopsia (complete or incomplete)
e. due to compression of _____ or _____ optic tracts	one or both
152. Characterize the pattern of progressive visual field defect caused by pituitary tumor.		G7 p.643:24mm

Fig. 21.1
a. first	superior temporal field
b. second	inferior temporal field
c. third	inferior nasal field
d. fourth	superior nasal field
e. clockwise in the ________ field	right
f. counterclockwise in the ________ field	left
153. Describe baseline pituitary evaluation before surgery. (^*Note: Results not listed here are also not listed in the Greenberg 6^th edition because results vary with age, gender, and menstrual cycle.)		G7 p643:70mm
a. Hint: P₈R³st²
i. p_____	prolactin
normal	< 30
measured in	ng/mL
maybe abnormal	25 to 150
abnormal value	> 150
ii. (sounds like q) c_____	cortisol 8 a.m.
normal	6 to 18
measured in	μg/100 mL
maybe abnormal	5 to 10
abnormal value	> 10
iii. ^*(r rest) f_____-s_____ _____	follicle-stimulating hormone (FSH)
normal
measured in
maybe abnormal
abnormal
iv. ^*(r rest) l_____	luteinizing hormone
normal
measured in
maybe abnormal
abnormal
v. (r rest) f_____ b_____s_____	fasting blood sugar
normal	65 to 99
measured in	mg/dL
maybe abnormal
abnormal
vi. ^*s_____	somatomedin-C
normal	0.31 to 1.4
measured in	U/mL
maybe abnormal
abnormal
vii. ^*T_____	TSH	G7 p.445:15mm
normal	0.4 to 5.5 mg
measured in	μg
maybe abnormal	peak 2× normal
abnormal	if TSH stimulation test causes peak 2× normal
viii. ^*T_____	TH thyroid hormone
normal	0.8 to 15
measured in	free T4 index
maybe abnormal
abnormal
b. Also include diagnostic studies of
i. f_____ v_____ f_____	formal visual fields
ii. M_____ w_____ and w_____ e_____	MRI with and without enhancement
iii. C_____-c_____ v_____	CT-coronal views (11 tests in all)
154. Thickening of the pituitary stalk and loss of a single pituitary hormone is strongly suggestive of l_____h_____.	lymphocytic hypophysitis	G7 p.643:83mm also see G7 p.1217:55mm
155. True or False. Regarding lymphocytic hypophysitis:		G7 p.643:83mm also see G7 p.1217:55mm
a. more common in men than women	false (more common in women; only 5 cases reported in men)
b. associated with postpartum state	true
c. affects multiple pituitary hormones	false (affects single hormone)
d. rarely causes diabetes insipidus	false (often causes diabetes insipidus)
156. Characterize screening for Cushing syndrome.		G7 p.643:92mm
a. 8 a.m. cortisol level: normal value is _____	6 to 18 μg/100 mL
b. 24-hour urine-free cortisol _____	more accurate—almost 100% sensitive and specific
157. True or False. Findings of primary hypothyroidism with secondary pituitary hyperplasia include the following:		G7 p.645:45mm
a. prolonged and elevated TSH response to TRH stimulation	true
b. low T4	true
c. hypoglycemia	false (Hypoglycemia is not part of the syndrome.)
d. elevated TSH	true
e. elevated prolactin	true (Enlarged pituitary causes stalk effect and prolactin increases.)
f. pituitary enlarges because of hypertrophy of the _____ producing cells	thyrotropin releasing hormone (TRH)
g. pituitary enlargement occurs because of the loss of _____ _____ from _____ _____	negative feedback from thyroid hormones
158. Considering pituitary tumors, prolactin is under:		G7 p.644:35mm
a. inhibitory control of the _____ and the infundibular stalk.	hypothalamus
b. Therefore, injury to the hypothalamus or injury to the pituitary stalk causes loss of the inhibitory chemical _____.	prolactin inhibitory factor (PRIF)
c. Does this lead to an increase or decrease in prolactin in the patient?	increase
159. After surgery for prolactin-secreting tumor, what should you think if prolactin is still elevated		G7 p.644:33mm
a. but less than 90 ng/mL _____?	injury to stalk and/or hypothalamus due to loss of prolactin inhibitory factor (PRIF), which is present in the intact stalk and hypothalamus
b. but more than 150 ng/mL _____?	persistent tumor
160. Answer the following about large adenomas with normal prolactin:		G7 p.644:160 mm
a. What should you instruct the laboratory to do?	perform several dilutions and rerun the PRL (This may be a false negative.)
b. This false negative is called the _____ effect.	hook
161. True or False. Extremely high prolactin levels may produce false negatives due to the tendency for large numbers of PRL molecules to prevent formation of PRL-antibody-signal complexes in assays.	true (hook effect)	G7 p.644:160mm
162. Complete the following about cortisol reserve insulin tolerance test:		G7 p.647:115mm
a. Insulin IV will promptly lower _____ _____.	blood sugar
b. Hypoglycemia is a _____.	stressor
c. In response the body produces _____.	cortisol
d.
i. An increment in baseline more than _____ mg/dL	6
ii. to a peak of _____ mg/dL is normal.	20
e.
i. An increment of less than _____ mg/dL	6
ii. to a peak less than _____ mg/dL	16
iii. indicates a need for g_____ r_____.	glucocorticoid replacement
163. The most useful test for acromegaly is an _____ level.	IGF-1	G7 p.647:170mm
164. Complete the following about acromegaly and somatomedin-C:		G7 p.647:170mm
a. also known as _____	IGF-1
b. normal fasting level _____	0.67 U/mL (range 0.31 to 1.4 U/mL)
c. in acromegalics level is _____	6.8 U/mL (range 2.6 to 21.7 U/mL)
165. Some growth hormone-secreting pituitary tumors also secrete _____	prolactin	G7 p.653:20mm also G6 p.447:115mm
166. Complete the following about growth hormone:		G7 p.648:15mm
a. Normal basal fasting level is _____.	less than 5 ng/mL
b. Acromegalic patients have levels _____ than _____.	greater than 10 ng/mL
c. Due to pulsatile secretion of GH sporadic peaks up to _____ can occur.	50 ng/mL
d. Is this a reliable test?	no
167. Complete the following about the size of the pituitary gland:		G7 p.648:115mm
a. Size of pituitary gland
i. in men up to _____ mm	10
ii. in women up to _____ mm child-bearing age up to_____ mm	9, 11
iii. in adolescent girls up to _____ mm	15
b. size of stalk is same size as b_____	basilar artery
c. differential diagnosis of large stalk
i. l _____	lymphoma
ii. l_____ h_____	lymphocytic hypophysitis
iii. g_____ d_____	granulomatous disease
iv. h_____ g_____	hypothalamic glioma
168. Findings compatible with pituitary microadenoma on MRI include the following:		G7 p.648:145mm
a. True or False. Lack of early (< 5 minute) gadolinium enhancement	true
b. True or False. Pituitary stalk deviation	true
c. True or False. Thickened pituitary stalk	false (A thickened pituitary stalk is not compatible with adenoma.)
d. True or False. Late (after 30 minute) gadolinium enhancement	true
e. True or False. Timing of scan after gadolinium infusion is important.	true (In early scanning, under 5 minutes, tumor will not enhance but gland will. In late scanning, after 30 minutes, tumor will enhance as well and may not be seen because the gland is also enhanced.)
f. The best time to scan for pituitary tumor is _____ minutes after infusion.	5
g. At that time what enhances?	normal pituitary tissue
h. Microadenoma is seen since it does _____ _____.	not enhance
169. Characterize the neurohypophysis.		G7 p.648:160 mm
a. normally on T1WI is _____ _____	high signal
b. possibly because it contains _____	phospholipids
c. absence of this sign suggests _____ _____	diabetes insipidus
170. For pituitary tumors, what is the benefit of coronal CT slices?		G7 p.649:42mm
a. sphenoid series _____	midline (can be identified by the anatomy of sphenoid sinus septa)
b. sella floor _____	erosion (of the sella floor to indicate presence of the tumor on one side)
171. What is the medical treatment for the following? a. growth hormone-secreting tumors _____	octreotide	G7 p.653:45mm
b. ACTH-secreting tumors _____	ketoconazole	G7 p.654:148mm
c. prolactin-secreting tumors _____	bromocriptine	G7 p.651:60mm
172. Complete the following about nonsecreting pituitary adenomas:		G7 p.649:100mm
a. Usual treatment is with _____ or _____	S× or XRT
b.
i. Medication (bromocriptine) may reduce tumor size by _____%	20%
ii. Due to the paucity of _____ receptors	dopaminergic
c. Octreotide reduces the tumor by _____%	10%
d. Follow-up by MRI at: _____, _____, _____, and _____ years	0.5, 1, 2, and 5
173. Surgical indications are v_____ f_____ d_____.	visual field defects	G7 p.649:165mm
174. Tumors secreting GH or ACTH		G7 p.650:70mm
a. warrant _____ treatment	surgical
b. because the secretion is _____	harmful
c. and there is no effective _____ _____.	medical treatment
175. Complete the following about hormone replacement therapy:		G7 p.650:125mm
a. corticosteroids
i. am replacement dose is _____ mg and	20
ii. pm replacement dose is _____ mg	10
b. thyroid hormone
i. Do not replace if patient has _____ _____	adrenal insufficiency
ii. Synthroid _____ μ g/d	125
176. Complete the following about primary brain tumors:		G7 p.651:24mm
a. Above what level of prolactin is surgery unlikely to normalize the prolactin?	above 500 ng/mL
b. In such a case what should your treatment be?	medication—dopamine agonists bromocriptine—not surgery
177. Complete the following about prolactinoma as treatment with bromocriptine:		G7 p.651:40mm
a. Response should be evident in _____ to _____ weeks.	4 to 6
b. _____% will not respond.	18%
c. _____% will continue to enlarge on bromocriptine.	1%
d. Upon discontinuation tumor may _____ _____.	rapidly enlarge
178. What does bromocriptine do?		G7 p.651:80 mm
a. binds to r_____	receptors
b. inhibits s_____ and s_____ of _____	synthesis and secretion of PRL
c. lowers prolactin to about _____% of its elevated amount	˜10%
d. reduces tumor size by _____% in _____	75% in 6 to 8 weeks
e. restores _____	fertility
f. harms patient by _____	producing fibrosis
g. This reduces good surgical results by _____%.	50%
h. Therefore, decide about surgery within _____ _____ of starting bromocriptine.	6 months
i. Prolactinomas may _____ _____ upon discontinuation of the drug.	enlarge rapidly
179. If response to dopamine agonists is satisfactory		G7 p.652:90mm
a. continue to treat for _____ to _____ years and	1 to 4
b. check prolactin every _____.	year
c. If tumor not visible on MRI may _____.	discontinue
d. Recurrence rate is highest in the _____ _____.	first year
180. True or False. Surgery is not indicated in elderly asymptomatic patients with GH-secreting pituitary tumors.	true	G7 p.652:125mm
181. Answer the following about pituitary tumors:		G7 p.652:130mm
a. best treatment for prolactinoma PRL < 500	transsphenoidal surgery
b. best treatment for prolactinoma PRL >	500 surgery not recommended if PRL > 500
c. best treatment if prolactin is < 500 try _____ first	medical treatment
d. meds will fail in _____%	18%
e. treat the failures with _____	transsphenoidal surgery
f. acromegaly best treatment is _____	transsphenoidal surgery (Surgery is not recommended for elderly; instead use bromocriptine and/or octreotide.)
g. cure for microadenoma _____%	85%
h. cure for macroadenoma _____%	30%
i. Cushing disease best treatment is _____.	transsphenoidal surgery
182. In acromegaly, IGF-1 stabilizes after surgery in _____.	months	G7 p.652:185mm
183. Complete the following about acromegaly and octreotide:		G7 p.652:98mm
a. suppresses _____ _____	growth hormone
b. reduces _____, _____% to _____% become _____	GH in 71%, 50 to 66% become normal
c. reduces _____ in _____%, _____% become _____	GF-1 in 93%, 66% become normal
d. requires injection _____	3 times per day
e. side effects can be _____	cholelithiasis (10 to 25% of patients)
f. may also be useful in _____	thyrotropic (TSH)-secreting tumors
184. True or False. Common side effects of octreotide include the following:		G7 p.653:120mm
a. decreased GI motility	true
b. sweating	false
c. diarrhea	true
d. steatorrhea	true
e. bradycardia	true
f. cholelithiasis	true
185. Complete the following about Cushing disease and ketoconazole:		G7 p.654:148mm
a. blocks _____ _____ synthesis	adrenal steroid
b. normalizes _____% of patients	75%
c. normalizes _____ _____ cortisol	urinary free
d. normalizes _____ steroids	hydroxycortico
e. may cause
i. adrenal _____	insufficiency
ii. hepato-_____	hepatotoxicity
186. True or False. Regarding bilateral total adrenalectomy:		G7 p.654:90mm
a. It is better tolerated than transsphenoidal pituitary surgery.	false
b. Lifelong glucocorticoid replacement is required.	true
c. Lifelong mineralocorticoid replacement is not required.	false	G7 p.654:94mm
d. Development of Nelson syndrome is rare.	false (Not rare; it occurs in 30%.)
187. Complete the following about thyrotropin-secreting adenomas:		G7 p.655:85mm
a. First-line treatment is _____ _____.	transsphenoidal surgery
b. The tumor may be difficult to remove and _____.	fibrous
c.
i. Medical treatment is with the same agent as for _____	acromegaly
ii. namely, _____.	octreotide
188. Complete the following about pituitary tumors and radiation therapy side effects on:		G7 p.655:147mm
a. cognition
i. m_____ d_____	memory disturbances
ii. l_____	lethargy
b. vision
i. o_____ n_____ and c_____ i_____	optic nerve and chiasm injury
ii. b_____	blindness
c. endocrine
i. h_____	hypocorticalism
ii. h_____	hypothyroidism
d. tumor
i. n_____	necrosis
ii. a_____	apoplexy
189. Radiation therapy should be routinely used:		G7 p.655:160mm
a. True or False. Following surgical removal of pituitary adenomas	false
b. True or False. If recurrence occurs	false (Repeat surgery is recommended.)
c. Radiation is appropriate in the following circumstances
i. if recurrence _____ _____ _____	can’t be removed
ii. if recurrence _____ _____ _____ _____	mass continues to grow
190. Answer the following about radiation for acromegaly:		G7 p.656:35mm
a. True or False. It is the preferred treatment.	false
b. 90% of patients reach normal growth hormone levels in _____ years.	20
c. During this time they are exposed to _____ levels of GH	unacceptable
d. and are also exposed to the risks of _____.	radiation
191. True or False. Indications for pituitary surgery include		G7 p.649:164mm also G6 p.452:140mm
a. prolactinomas with levels greater than 500 ng/mL not controlled with surgery	true (Medical treatment will not suffice; both are needed in 18%.)
b. Cushing disease	true (Medical therapy is not adequate.)
c. acromegaly	true
d. macroadenoma	true (if not PRL secreting)
e. visual field defect	true
f. sudden visual loss	true
g. to obtain tissue for diagnosis	true
h. hypopituitarism	false
i. Nelson syndrome	true
192. What is the medical preparation for surgery?		G7 p656:90mm
a. Steroids _____ _____	stress doses
b. Hypothyroid patients ideally to be treated before surgery for _____ _____	4 weeks
193. Regarding pituitary tumors, what artery might you encounter laterally as you open the Hardy speculum and expose the keel of the sphenoid bone?	the sphenopalatine artery—a branch of the maxillary artery, which is the eighth branch of the external carotid artery	G7 p. 656:117mm
194. Concerning the sublabial approach for pituitary adenoma, what structures can be injured?		G7 p.656:118mm
a. artery g_____ p_____	greater palatine artery branches (AKA) descending palatal arteries (They enter the incisive foramina and incisive canals.)
b. nerve n_____	nasopalatine nerves (Branch of maxillary nerve [V2] serves roof of mouth, upper lip, and teeth.)
195. True or False. Regarding pituitary tumors:		G7 p.656:150mm
a. Minimal enlargement of the sella and a large suprasellar mass indicate a transcranial approach.	true
b. The subtemporal approach provides good visualization of the optic nerves, chiasm, and carotid arteries.	false (The subfrontal approach is better to see this anatomy.)
c. The subfrontal approach may be more difficult with prefixed chiasm.	true
d. The transsphenoidal approach is preferred for microadenomas.	true
196. Conditions indicating transsphenoidal approach that may not be appropriate for this pituitary tumor include:		G7 p.656:151mm
a. sella not_____	enlarged
b. large_____ mass	suprasellar
c. e_____ tumor	extrasellar
d. sphenoid_____	sinusitis
197. Complete the following about transspehenoidal surgery:		G7 p.657:185mm
a. Open the sella exactly in the_____.	midline
b. Use the_____ _____ as your landmark.	nasal septum
c. Is the sphenoid sinus septum also reliable?	no, it is unreliable
198. Complete the following about intraoperative disaster:		G7 p.659:100mm
a. Profuse arterial bleeding suggests_____ _____.	carotid injury
b. It can usually be controlled by_____.	packing
c.
i. The operation should_____ _____	be stopped
ii. and_____ be done.	angiography
d.
i. If_____ is found	pseudoaneurysm
ii. the patient is at risk for_____ _____.	lethal rupture
e.
i. It must be eliminated by_____ _____	endovascular techniques
ii. or surgical.	trapping
199. True or False. Common complications of transsphenoidal pituitary surgery include		G7 p.659:135mm
a. transient diabetes insipidus	true (common but lasts less than 3 months)
b. basilar artery injury	false (Basilar artery injury is rare.)
c. cerebrospinal fluid leakage	true (Cerebrospinal fluid leakage is common, 3.5%.)
d. carotid artery rupture	false (Carotid artery rupture is rare.)
200. True or False. Treatment for diabetes insipidus includes the following:		G7 p.661:125mm
a. desmopressin 2 to 4 mg daily (subcutaneous)	true
b. vasopressin 5 U (IV) every 6 hours	true
c. desmopressin 10 to 40 mg twice a day	true
d. clofibrate 500 mg four times a day by mouth	true
201. Complete the following regarding postoperative pituitary surgery:		G7 p.661:26mm
a. diabetes insipidus
i. can be diagnosed if urine output is more than_____ cc	250 cc
ii. for_____	1 to 2 hours
b. ACTH (corticotropin) reserve
i. take patient off steroids for_____ hours	24 hours
ii. check_____ a.m. cortisol level	6 a.m.
iii. normal cortisol level at 6 a.m. is_____	above 9 μg/dL
iv. suspect low cortisol is_____	3 to 9 μg/dL
v. definitely low cortisol is_____	below 3 μg/dL
c. To assess for residual tumor don’t do CT until_____ _____ postoperative.	4 months	G7 p.661:40mm
202. Characterize the good outcomes of transsphenoidal surgery.		G7 p.662:60mm
a. vision_____ _____	much improved
b. prolactin secreting tumors in_____%	25%
c. growth hormone secreting tumors in_____%	20%
d. Cushing disease—microadenomas in_____%	85%
e. acromegaly
i. microadenoma in _____%	85%
ii. macroadenoma in _____%	30%
iii. all acromegalics in _____%	50%
f. recurrence _____%	12%
203. Regarding acromegaly, cure requires:		G7 p.662:130mm
a. basal (morning) serum GH of less than_____	5 ng/mL
b. suppression after ingesting glucose less than_____	2 ng/mL
c. somatomedin-C (I-GF-1) of normal_____ acromegalics_____	normal range—0.31 to 1.4 ng/mL; acromegalics 2.6 to 21.7 ng/mL.
204. Characterize biochemical outcome acromegaly.		G7 p.662:120mm
a. Recommended is a_____ serum GH level.	morning
b. Cure is considered GH level of less than ng/ml.	5
c. In tumors less than 10 mm this is achieved in _____%.	85%
d. In all acrogmegalics cure is achieved in_____%.	50%
e. Macroadenomas cure is achieved in_____%.	30%
f. These patients should be seen for follow-up every_____ to_____ months.	6 to 12
205. Answer the following about craniopharyngiomas:		G7 p.663:130mm
a. Craniopharyngiomas are lined with what types of cells?	stratified squamous epithelium
b. They arise from_____ _____ _____ of the pituitary.	anterior superior margin
c. Show calcification
i. on histology in _____%	50%
ii. on plain x-ray in children in_____%	85%
iii. on plain x-ray in adults in _____%	40%
d. Do they contain cysts?	yes
e. Do they contain solid components also?	yes
f. Do they undergo malignant degeneration?	no
206. The pituitary stalk can be recognized by its pattern		G7 p.664:95mm
a. of l_____ s_____	longitudinal striations
b. which are the long_____ _____.	portal veins
207. Describe the Rathke cleft cyst (RCC).		G7 p.665:25mm
a. Where are they located?	intrasellar—pars intermedia
b. How common are they?	incidental finding in 20% of autopsies
c. Do you find RCC together with pituitary adenomas?	no
d. Why?	They arise from the same tissue, which goes one way or the other but not both.
e. appearance on CT
i. cystic?	yes
ii. density?	low density
iii. enhancement?	may have capsular enhancement
208. True or False. Rathke cleft cysts arise in/at the:		G7 p.665:35mm
a. anterior superior margin of pituitary	false
b. neurohypophysis	false
c. pars intermedia	true
d. none of the above	false
209. Answer the following about Rathke cleft cyst:		G7 p.665:35mm
a. Where is a Rathke cleft cyst located?	in the pars intermedia of pituitary
b. From what does Rathke cleft cyst originate?	remnant of Rathke pouch—stomodeum
210. True or False. A 14-year-old patient is found to have a 3 cm low-density lesion in the sella turcica. Surgical excision reveals a single-layer cuboidal epithelium. The most likely diagnosis is		G7 p.665:45mm
a. mucocele	false
b. epidermoid	false
c. craniopharyngioma	false
d. Rathke cleft cyst	true
211. With a colloid cyst, hydrocephalus involves only the_____ _____.	lateral ventricles	G7 p.665:90mm
212. Complete the following about primary brain tumors:		G7 p.665:120mm
a. True or False. A 40-year-old male complains of intermittent headaches and gait difficulty. CT scan of head shows a cystic mass in the third ventricle. The most likely diagnosis is
i. neurocystercercosis	false
ii. meningioma	false
iii. choroid plexus papilloma	false
iv. colloid cyst	true
b. the site of origin of this cystic mass is the
i. d_____ e_____ of the recess of the postvelar arch called	diencephalic ependyma
ii. the p_____	paraphysis (that is, an evagination of the roof of the third ventricle)
213. True or False. A 27-year-old male with a history of a colloid cyst who underwent a right frontal ventriculoperitoneal shunt 3 days ago returns to the emergency room (ER) with recurrence of severe headaches and gait difficulty. Treatment at this time could be		G7 p.110:110mm
a. removal of ventriculoperitoneal shunt	false
b. externalization of shunt	false
c. placement of left frontal ventricular drainage	true (Colloid cysts can obstruct both foramina of Monro; thus, bilateral ventricular drainage is needed.)
d. medical management and reassurance	false
e. fenestration of the septum pellucidum	true
f. removal of colloid cyst	true
214. Complete the following about colloid cyst:		G7 p.X:111mm
a. shunt
i. r_____ b_____ s_____	requires bilateral shunts
ii. or f_____ of s_____ p_____ plus o_____ s_____	fenestration of septum pellucidum plus one shunt
b. transcallosal approach complications
i. v_____ i_____	venous infarction
ii. f_____ i_____	fornix injury
c. transcortical approach complications
i. s_____ _____%	seizures 5%
d. stereotactic aspiration
i. f_____ —r_____	failure—recurrence
e. ventriculoscopy
i. f_____ —r_____	failure—recurrence
215. Answer the following about hemangioblastoma:		G7 p.667:80mm
a. What is the most common primary intraaxial tumor in the adult posterior fossa?	hemangioblastoma
b. It can occur sporadically or as part of v_____ _____ – _____ disease.	von Hippel-Lindau
c. What blood problem is associated?
i. P_____ also known as	polycythemia
ii. e_____ due to	erythropoietin
iii. e_____.	erythropoitin
d. Incidence of brain tumors _____%	1 to 2%
e. Characteristic appearance c_____ c_____ m_____ w_____ m_____ n_____	mural nodule
f. Should you remove the cyst wall?	no
216. True or False. A 42-year-old male presents with headache, nausea, vomiting, and right-sided dysmetria. Laboratory studies revealed a hemoglobin of 17. The likely diagnosis is		G7 p.667:80mm
a. metastatic lesion	false
b. renal cell carcinoma	false
c. hemangioblastoma	true (headache, nausea, vomiting-hydrocephalus-dysmetria-cerebellum high hemoglobin-polycythemia)
d. high-grade astrocytoma	false
217. Complete the following about the posterior fossa hemangioblastoma:		G7 p.667:80mm
a. May be associated with
i. p_____, e_____	polycythemia, erythrocytosis
ii. v_____ H_____ -L_____ d_____	von Hippel-Lindau disease
218. Complete the following about von Hippel-Lindau disease (VHL):		G7 p.667:130mm
Has hemangioblastomas tumors or cysts in the following sites:
a. c_____	cerebellum
b. r_____	retina
c. b_____	brain stem
d. s_____	spinal cord
e. p_____	pheochromocytomas
f. c_____	cysts in kidneys
219. Complete the following about von Hippel-Lindau disease (VHL):		G7 p.667:135mm
a. Most common in the_____	cerebellum
b. Second most common in the_____	retina
c. Always manifests before age_____	60
d. Incidence is 1 in every_____ persons	35,000
220. True or False. The mode of inheritance of von Hippel-Lindau disease is:		G7 p.667:175mm
a. autosomal recessive	false
b. autosomal dominant	true
c. sex linked	false
d. multifactorial	false
221. What is the diagnostic criteria for VHL?		G7 p.668:60mm
a.
i. One sign of VHL is needed if there is a_____ _____	family history
ii. It will be present in _____%	80%
b. Two signs of VHL if it is a_____ _____ mutation	de novo
222. Complete the following about tumors associated with VHL:		G7 p.668:105mm
a. Occur in younger persons if patient has_____	VHL
b. True or False. Cysts are associated with HGBs.	true
c. Cerebellar HGBs are located in the
i. s_____	superficial
ii. p_____	posterior
iii. s_____ half of the hemisphere	superior
d. _____% of cerebellar HGBs were found in the_____	7%, vermis
223. Complete the following about spinal cord hemangioblastoma:		G7 p.668:145mm
a. _____% are in the cervical and thoracic cord.	90%
b. _____% are located in the posterior cord.	96%
c. _____% of spinal HGBs are associated with VHL.	90%
d. _____% symptoms are associated with syringomyelia.	95%
224. The only disease with bilateral endolymphatic sac tumors is _____.	VHL	G7 p.668:180mm
225. Complete the following about VHL:		G7 p.: mm
a. Retinal hemangioblastomas occur in_____%	50%
b. Typically located in the_____	periphery
c. Frequently_____	multiple
d. Treat with laser_____	photocoagulation
226. Complete the following about renal cell carcinoma (RCC):		G7 p.669:130mm
a. Which is the most common malignant tumor in VHL?	RCC
b. Usually it is a_____ _____ _____.	clear cell carcinoma (CCC)
c. It is the cause of death in_____ to_____% of VHL patients.	15 to 50%
227. Complete the following about surgical treatment of HGB:		G7 p.: mm
a. Reserved until_____	symptomatic
b. Treatment of choice for_____ _____ HGBs	accessible cystic
c. True or False. The wall must be removed.	false
d. The_____ _____ must be removed.	mural nodule
228. Answer the following about hemangioblastoma (HGB):		G7 p.671:17mm
a. True or False. Starts at an earlier age in
i. von Hippel-Lindau disease	true
ii. sporadic cases	false
b. In sporadic cases
i. Most originate in the_____	cerebellum
ii. Next most common is the s_____ c_____	spinal cord
iii. _____% of patients with cerebellar HGB have VHL	30%
c. Erythropoitin liberated by the tumor may be responsible for the_____	erythrocytosis	G7 p.671:53mm
d. If one HGB is suspected we should do an		G7 p.671:140mm
i. MRI scan of the _____ _____.	entire neuraxis
ii. Vertebral angiography usually demonstrates _____ _____.	intense vascularity
iii. CBC reveals _____. polycythemia
229. Complete the following about surgery on a solitary HGB:		G7 p.672:22mm
a. It may be_____ in sporadic HGB	curative
b. but not in_____.	VHL
c. Preoperative _____may be helpful.	embolization
230. Complete the following about surgery on HGB:		G7 p.672:40mm
a. They should be removed using _____ technique.	AVM
b. Avoid_____ removal.	piecemeal
c. Work along the_____	margin
d. and_____ the blood supply.	devascularize

CNS Lymphoma

231. Complete the following about CNS lymphoma:		G7 p.672:95mm
a. Associated with an eye condition called_____	uveitis
b. How frequently does it occur?	1 to 2% of all brain tumors
c. What relationship does CNS lymphoma have with the ventricles?	up close to ventricles
d. CT characteristics
i. plain CT tumor is_____	hyperdense to brain
ii. contrast CT tumor_____	enhances homogeneously
iii. reminiscent of_____ _____ _____	“fluffy cotton balls”
e. reaction to steroids_____	tumor may completely resolve
f. CSF is positive for lymphoma cells in_____%.	only 10%
g. What form of radiation therapy is given?	whole brain
232. True or False. A 70-year-old male with a homogeneously enhancing lesion in the central gray matter and corpus callosum is suspected of having CNS lymphoma. What would make this diagnosis more likely and how is it properly diagnosed?		G7 p.672:107mm
a. hydrocephalus	false
b. café au lait spots	false
c. uveitis	true (diagnosed with slit lamp)
d. proximal muscle weakness	false
233. A 73-year-old male with a history of recently diagnosed CNS lymphoma by biopsy presents to the ER with stupor and progressively deteriorating mental status. CT of the brain reveals the mass but no other abnormalities.		G7 p.675:55mm
a. True or False.
i. emergent surgical excision	false
ii. radiation therapy	true (CNS lymphomas are very sensitive to radiation.)
iii. chemotherapy	false
iv. steroids	false
b. followed by_____	chemotherapy

Chordoma

234. Complete the following about chordoma:		G7 p.675:165mm
a. It has a characteristic cell type called_____.	physaliphorous
b. It occurs in the clivus in _____%.	35%
c. It occurs in the sacrococcygeal area in_____%.	55%
d. The recurrence rate after surgery is_____%.	85%
e. X-rays show_____ lesions with_____.	lytic lesions with calcifications
f. Is there any gender predominance?	yes, male predominance for sacral chordomas
g. What are the risks to bladder and bowel control
i. from a sacrectomy between S1 and S2?	most will be impaired
ii. from a sacrectomy between S2 and S3?	50% will be impaired

Ganglioglioma

235. True or False. Physaliphorous cells are distinctive features of		G7 p.675:165mm
a. schwannomas	false
b. pinealoblastomas	false
c. gangliogliomas	false
d. chordomas	true
236. Answer the following about gangliogliomas:		G7 p.677:165mm
a. True or False. Peak age of occurrence for gangliogliomas is
i. children	true (Peak age is 11.)
ii. elderly	false
iii. no age predilection	false
iv. unknown	false
b. presenting symptom is_____	seizure

Paraganglioma

237. Complete the following about paraganglioma:		G7 p.678:175mm
a. used to be called_____	chemodectomas
b. now also called what if at
i. carotid bifurcation: c_____ b_____ t_____	carotid body tumor
ii. jugular foramens: g_____ j_____	glomusjugulare
iii. adrenal medulla: p_____	pheochromocytoma
c. may secrete
i. e_____	epinephrine
ii. n_____	norepinephrine
iii. c_____	catecholamines
d. Resection of carotid body tumor has a
i. morbidity of up to _____%	50%
ii. mortality of _____%	5 to 13%
238. Complete the following about pheochromocytoma:		G7 p.679:80mm
a. We used to study_____	catecholamines
b. Better test now is
i. f_____	fractioned
ii. p_____	plasma
iii. m_____	metanephrines
c. Imaging is_____ with_____	MRI; contrast
239. Carotid body tumor		G7 p.679:140mm
a. and_____are the most common paraganglioma.	pheochromocytoma
b. occur bilaterally in _____%.	5%
240. True or False. A 40-year-old female complains of a painless mass in her right upper neck and has deviation of the tongue to the right. The following is the most likely source of her mass:		G7 p.679:160mm
a. carotid bifurcation	true (Paragangliomas present with mass in neck and CN XI and CN XII nerve palsy.)
b. superior vagal ganglion	false
c. inferior vagal ganglion	false
d. hypoglossal nerve neuroma	false
e. auricular branch of vagus	false
241. Regarding carotid body tumors, treatment carries a_____ complication rate.	high	G7 p.680:25 mm
242. Complete the following about glomus jugulare tumors:		G7 p.680:50mm
a. They arise from_____ _____.	glomus bodies
b. Are they vascular or avascular?	vascular
c. Receives branches from the_____ _____ _____	external carotid artery
i. a_____ p_____	ascending pharyngeal
ii. p_____ a_____	posterior auricular
iii. o_____	occipital
iv. i_____ m_____	internal maxillary
d. _____ portion of the_____ _____ _____	petrous portion of the internal carotid artery
243. Characterize glomus jugulare tumors.		G7 p.680:88mm
a. female to male ratio	6:1
b. Does it occur bilaterally?	no
c. presenting symptoms
i. h_____ l_____	hearing loss
ii. p_____ t_____	pulsatile tinnitus
d. clinical exam abnormalities
i. h_____ l_____ and v_____	hearing loss and vertigo CN VIII
ii. t_____ p_____ t_____	loss of taste posterior third of tongue CN IX
iii. v_____ c_____ p_____	vocal cord paralysis CN X
iv. t_____ and SCM w_____	trapezius and sternocleidomastoid (SCM) CN XI weakness
v. t_____ a_____ and CN _____ i_____ to mass and s_____ of the hearing loss	tongue atrophy CN XII and ipsilateral to mass and side
244. During surgical excision of a paraganglioma the patient is noted to have abrupt onset of hypotension and respiratory distress. This is most likely related to		G7 p.680:170mm
a. intracranial pressure (ICP) changes	no
b. vasovagal response	no
c. inadvertent compression of airway	no
d. tumor manipulation	yes
e. due to r_____ of h_____ or b_____	release of histamine or bradykinin
245. Describe glomus jugulare differential diagnosis.		G7 p.681:15mm
a. Distinguish from_____ _____ in the CPA	vestibular schwannoma
b. True or False. By CT enhancement	false (Both enhance.)
c. True or False. By presence of cystic component	true (VS may have cystic component.)
d. True or False. By angiography	true (GJ [glomus jugulare] is very vascular.)
e. What else will be learned by angiography?	whether the transverse sinus is occluded
246. Complete the following about glomus jugulare:		G7 p.681:120mm
a. What chemical should be tested for?	vanillylmandelic acid (VMA)
b. If elevated, indicative of secretion of_____	catecholamines
c. similar to_____	pheochromocytoma
d. Treat medically_____ with and_____	alpha and β blockers
e. New clinical marker is_____ (NMN)	normetanephrine	G7 p.679:90mm

Ependymoma

247. Complete the following about ependymoma:		G7 p.682:165mm
a. Incidence among intracranial tumors in adults is _____%.	5 to 6%
b. Incidence among pediatric brain tumors is_____%.	9%
c. It occurs in children _____%.	70%
d. Incidence among spinal cord gliomas is_____%.	60%
e. Drop metastases occur in _____% of patients.	11%
f. What is the pathology of the distinctive type that occurs in the filum terminale?	myxopapillary	G7 p.683:190mm
248. Characterize intracranial ependymomas.		G7 p.683:160mm
a. usually occur in the_____ _____	fourth ventricle
b. dangerous to remove because they invade the_____	floor of the fourth ventricle
c. specifically they invade the_____	obex
d. current operative mortality _____%	5 to 8%
e. Is mortality higher in adults or in children?	children
249. Answer the following about postop ependymoma:		G7 p.684:123mm
a. What must we do?	LP
b. When?_____ weeks postop	2
c. What should be sent to lab?	10cc CSF
d. If positive follow with_____	radiation	G7 p.684:140mm
e. True or False. Ependymoma is sensitive to radiation.	true
f. Name the tumor that is more sensitive.	medulloblastoma
250. True or False. Regarding primary brain tumors:		G6 p.471:180mm
a. Calcifications, although uncommon in medulloblastomas, may be seen ^~20% of the time.	false (< 10%)
b. The “banana sign” in the fourth ventricle refers to the medulloblastoma rather than to ependymomas.	true
c. Ependymomas rank second only to medulloblastomas in radiosensitivity.	true
d. Medulloblastomas arise from the roof of the fourth ventricle, the fastigium.	true
e. Ependymomas arise from the floor of the fourth ventricle, the obex.	true
251. What is the most common glioma of the spinal cord below the midthoracic region?	ependymoma	G7 p.685:100mm