Neuro-oncology — MCQs
Signs of increased intracranial tension are all except:
Which mutation is characteristic of oligodendroglioma?
What is the most common cerebellar tumor in children?
Which of the following is the most common tumor of the brain?
Which of the following statements about meningiomas is true?
Which of the following statements about astrocytoma is false?
Pseudotumor cerebri is most commonly seen in:
Which of the following CNS tumor shows increased growth during pregnancy?
In acoustic neuroma, which cranial nerve is involved earliest?
Spontaneous CSF leak occurs in all except:
Neuro-oncology Indian Medical PG Practice Questions and MCQs
Question 1: Signs of increased intracranial tension are all except:
- A. Headache
- B. Seizures
- C. Papilledema
- D. Tachycardia (Correct Answer)
Explanation: ***Tachycardia*** - **Tachycardia** is generally *not* a sign of increased intracranial pressure (ICP); rather, **bradycardia** (Cushing's reflex) is a classic finding. - While other systemic responses may occur, a direct, consistent increase in heart rate due to elevated ICP is uncommon. *Papilledema* - **Papilledema** is a swelling of the **optic disc** due to increased ICP, a critical diagnostic sign [1]. - The increased pressure impedes venous return from the retina, causing the optic nerve head to bulge. *Headache* - **Headache** is a common and often early symptom of increased ICP due to the stretching of pain-sensitive meningeal and vascular structures [1]. - It is typically described as a dull, throbbing pain, often worse in the morning or with straining. *Seizures* - **Seizures** can result from increased ICP as the pressure on brain tissue can lead to electrical instability and abnormal neuronal discharge [2]. - This symptom indicates significant cortical irritation or dysfunction caused by the elevated pressure.
Question 2: Which mutation is characteristic of oligodendroglioma?
- A. BRAF V600E
- B. IDH1 mutation alone
- C. EGFR amplification
- D. 1p19q codeletion (Correct Answer)
Explanation: ***1p19q codeletion*** - The **codeletion of chromosomal arms 1p and 19q** is a molecular hallmark of oligodendroglioma and is crucial for diagnosis according to WHO classification [1]. - This specific genetic alteration is associated with **better prognosis** and increased responsiveness to chemotherapy and radiation in patients with oligodendroglioma. *BRAF V600E* - The **BRAF V600E mutation** is commonly found in **pleomorphic xanthoastrocytoma (PXA)** and **ganglioglioma**, but not typically in oligodendroglioma. - It is also characteristic of other cancers like **melanoma** and some **thyroid cancers**. *IDH1 mutation alone* - While an **IDH1 mutation** is present in most oligodendrogliomas, it is usually accompanied by the **1p19q codeletion** [1]. Isolated IDH1 mutation without 1p19q codeletion suggests other diffuse gliomas, such as astrocytoma. - An isolated IDH1 mutation is more characteristic of **IDH-mutant astrocytoma**, especially when 1p19q is intact. *EGFR amplification* - **EGFR amplification** is a classic genetic alteration found in **glioblastoma (GBM)**, a highly aggressive primary brain tumor [2]. - It is rarely seen in oligodendrogliomas and is associated with a **worse prognosis** in GBM. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1311-1312. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1308-1310.
Question 3: What is the most common cerebellar tumor in children?
- A. Ependymoma
- B. Medulloblastoma (Correct Answer)
- C. PNET
- D. Astrocytoma
Explanation: ***Medulloblastoma*** - **Medulloblastoma** is the most common **malignant** cerebellar tumor in children, accounting for about 20% of all childhood brain tumors [2]. - In the context of this question, medulloblastoma is considered the "most common cerebellar tumor" as it is the most frequently encountered **malignant** tumor requiring aggressive treatment. - These tumors arise from neuroectodermal cells in the cerebellum and are typically **highly aggressive**, often spreading through the cerebrospinal fluid (CSF) pathways [1], [2]. - Peak incidence is between 5-9 years of age, with a male predominance [1]. *Astrocytoma* - **Cerebellar pilocytic astrocytomas** are actually the most common **benign** cerebellar tumor in children and represent a significant portion of all cerebellar tumors [1]. - However, in competitive exam contexts, when asking about "most common cerebellar tumor," the question typically refers to **malignant tumors**, where medulloblastoma takes precedence. - **Pilocytic astrocytomas** are usually low-grade (WHO Grade I) and have an excellent prognosis, often presenting as cystic lesions with a mural nodule. *Ependymoma* - **Ependymomas** are the third most common posterior fossa tumor in children (after medulloblastoma and pilocytic astrocytoma). - They typically arise from the ependymal lining of the **fourth ventricle**, making them cerebellar-adjacent rather than primarily cerebellar tumors [3], [4]. - They account for about 10% of pediatric brain tumors and have an intermediate prognosis. *PNET* - **PNET (Primitive Neuroectodermal Tumor)** is a historical term that has largely been replaced by more specific classifications in the current WHO CNS tumor classification. - Medulloblastoma was previously classified as a type of PNET, but is now recognized as a distinct entity. - The term PNET is now rarely used in modern neuropathology practice, having been superseded by molecular and genetic classification systems. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Manifestations Of Central And Peripheral Nervous System Disease, pp. 725-726. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1314-1315. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Manifestations Of Central And Peripheral Nervous System Disease, pp. 726-727. [4] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1312-1313.
Question 4: Which of the following is the most common tumor of the brain?
- A. Cerebral metastasis (Correct Answer)
- B. Meningioma
- C. Glioma
- D. Pituitary adenoma
Explanation: ***Cerebral metastasis*** - **Cerebral metastases** are the most common type of brain tumor overall, significantly outnumbering all primary brain tumors combined [1]. - They originate from cancers elsewhere in the body (most commonly **lung, breast, melanoma, renal, and colorectal carcinomas**) and spread to the brain via the bloodstream [1]. - Metastases typically occur at the **gray-white matter junction** and are often **multiple**. *Meningioma* - **Meningiomas** are the most common *primary* **benign** brain tumors, originating from arachnoid cap cells of the meninges [2]. - They account for ~30% of primary intracranial tumors but are still less frequent than metastatic brain tumors overall. - More common in **middle-aged females** and typically slow-growing [2]. *Glioma* - **Gliomas** are common *primary* **malignant** brain tumors, arising from glial cells (astrocytes, oligodendrocytes, or ependymal cells) [3]. - **Glioblastoma** is the most common primary malignant brain tumor in adults, but all gliomas combined are still less common than metastatic brain lesions overall. *Pituitary adenoma* - **Pituitary adenomas** are common benign tumors of the sellar region, accounting for ~10-15% of intracranial tumors. - While frequent among primary tumors, they are less common than metastatic brain lesions overall. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1317-1318. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1316-1317. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Manifestations Of Central And Peripheral Nervous System Disease, pp. 725-726.
Question 5: Which of the following statements about meningiomas is true?
- A. Approximately 5% of meningiomas are malignant.
- B. Arise from the dural layer
- C. Meningiomas are more common in women due to hormonal influences.
- D. 95% cure rate following total surgical resection of benign meningiomas (Correct Answer)
Explanation: ***95% cure rate following treatment*** - Meningiomas generally have a **high cure rate of approximately 95%** following surgical resection, especially when they are completely excised [1]. - They are typically **benign tumors**, resulting in favorable outcomes with appropriate management [1]. *Arise from arachnoid layer* - Meningiomas actually arise from **meningothelial cells** of the **arachnoid layer**, but this statement does not fully explain their pathogenesis. - This mischaracterization does not provide an accurate understanding of the tumor's origin and biology. *50% are malignant* - Most meningiomas are benign; only a small percentage, about **1-5%**, are classified as malignant. - Thus, stating that **50% are malignant** significantly overestimates the incidence of aggressive forms. *More common in men* - Meningiomas are more prevalent in **women**, especially those aged between 30-70 years, with a female-to-male ratio of approximately **3:1**. - This option is incorrect as it misrepresents the demographic distribution of the disease. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1316-1317.
Question 6: Which of the following statements about astrocytoma is false?
- A. Low grade tumors are more common in children
- B. These are mostly infratentorial in children
- C. Pilocytic astrocytoma is most common childhood brain tumor
- D. They are more common in males than females (Correct Answer)
Explanation: ***They are more common in males than females*** - This statement is **false** because, while specific types of astrocytomas might show slight sex predominance, astrocytomas as a whole do not consistently show a significantly higher incidence in males compared to females. [1] - The incidence of astrocytomas is generally considered to be **roughly equal** between sexes or with only minor, inconsistent differences depending on the specific subtype and age group. *Low grade tumors are more common in children* - This statement is **true** because pediatric gliomas, including astrocytomas, are predominantly **low-grade (WHO grade I or II)**, accounting for about half of all central nervous system tumors in children. [2] - **Pilocytic astrocytoma (WHO grade I)** is a common example, known for its slow growth and often favorable prognosis. [2] *These are mostly infratentorial in children* - This statement is **true** as astrocytomas in children frequently occur in the **infratentorial region**, particularly the cerebellum, brainstem, and optic pathways. [1], [2] - This contrasts with adults, where supratentorial locations are more common; **cerebellar astrocytoma** is a classic example in children. [1] *Pilocytic astrocytoma is most common childhood brain tumor* - This statement is **true** as **pilocytic astrocytoma (WHO grade I)** is indeed the most common type of pediatric primary brain tumor, accounting for a significant proportion of all childhood CNS neoplasms. [2] - It often presents as a **cystic lesion with a mural nodule** and has a relatively good prognosis compared to higher-grade astrocytomas. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Manifestations Of Central And Peripheral Nervous System Disease, pp. 725-726. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1319-1320.
Question 7: Pseudotumor cerebri is most commonly seen in:
- A. Thin built males in the age group 50-60 years
- B. Obese females in the age group 20-45 years (Correct Answer)
- C. Obese males in the age group 20-45 years
- D. Thin built females in the age group 50-60 years
Explanation: ***Obese females in the age group 20-45 years*** - **Pseudotumor cerebri** (also known as **idiopathic intracranial hypertension**) is most commonly observed in **obese women** of childbearing age (typically 20-45 years) [1]. - This demographic has the highest incidence, often associated with a higher **body mass index (BMI)** [1]. *Thin built males in the age group 50-60 years* - This demographic is **not typically associated** with pseudotumor cerebri, which has a strong predilection for obese females [1]. - While pseudotumor cerebri can rarely occur in males, it is less common and usually not in this specific age and body habitus group. *Obese males in the age group 20-45 years* - While **obesity** is a risk factor, pseudotumor cerebri is far **less common in males** than in females, even with similar age and BMI [1]. - The prevalence in obese men is significantly lower compared to obese women. *Thin built females in the age group 50-60 years* - This demographic is generally at **low risk** for pseudotumor cerebri. - The condition is predominantly seen in younger, obese women, and older age and thin build are not characteristic risk factors [1].
Question 8: Which of the following CNS tumor shows increased growth during pregnancy?
- A. Oligodendroglioma
- B. Meningioma (Correct Answer)
- C. Craniopharyngioma
- D. Glioblastoma Multiforme
Explanation: ***Meningioma*** - **Meningiomas** often express receptors for **estrogen** and **progesterone**, leading to increased growth rates during the **estrogen-rich environment of pregnancy**. - This tumor's growth during pregnancy can exacerbate neurological symptoms or lead to the discovery of previously asymptomatic meningiomas. *Oligodendroglioma* - **Oligodendrogliomas** are a type of glioma that do not typically show an increased growth rate in response to hormonal changes during pregnancy. - Their growth is generally independent of **sex hormones**, and their progression is determined by other genetic and molecular factors. *Craniopharyngioma* - **Craniopharyngiomas** are benign epithelial tumors that arise from Rathke's pouch remnants and primarily affect children, though they can occur in adults. - Their growth is not significantly influenced by **hormonal changes** related to pregnancy. *Glioblastoma Multiforme* - **Glioblastoma multiforme (GBM)** is a highly aggressive and fast-growing primary brain tumor, but its growth is not directly stimulated by the hormonal changes of pregnancy. - While GBM can rapidly progress during pregnancy, this is due to its inherent aggressive nature rather than hormonal effects on tumor cells.
Question 9: In acoustic neuroma, which cranial nerve is involved earliest?
- A. CN V
- B. CN VII
- C. CN VIII (Correct Answer)
- D. CN X
Explanation: ***CN VIII*** - An **acoustic neuroma** (also known as a **vestibular schwannoma**) originates from the **Schwann cells** of the **vestibulocochlear nerve (CN VIII)**. - Due to its origin, symptoms related to **hearing loss**, **tinnitus**, and **balance issues** (all functions of CN VIII) are typically the earliest to manifest [1]. *CN V* - The **trigeminal nerve (CN V)** is responsible for **facial sensation** and **mastication**. - Compression of CN V usually occurs in later stages of acoustic neuroma growth, leading to **facial numbness** or **pain**. *CN VII* - The **facial nerve (CN VII)** controls **facial expressions** and taste sensation in the anterior two-thirds of the tongue. - **Facial weakness** or **paralysis** due to CN VII involvement typically occurs after significant tumor growth, as the nerve runs adjacent to the acoustic neuroma [1]. *CN X* - The **vagus nerve (CN X)** is involved in diverse functions including **swallowing**, **speech**, and **autonomic regulation** of organs like the heart and digestive tract. - **Vagal nerve** symptoms such as **dysphagia** or **hoarseness** are extremely rare in acoustic neuromas and would indicate a very extensive tumor likely compressing structures much more distant from the primary site.
Question 10: Spontaneous CSF leak occurs in all except:
- A. Pseudotumor cerebri
- B. Low risk encephalocele
- C. Increased intracranial tension (Correct Answer)
- D. Partial or complete empty sella syndrome
Explanation: Spontaneous CSF leak occurs in all except: ***Increased intracranial tension*** - Increased intracranial tension typically **prevents CSF leaks** or at least makes them less likely by maintaining a high pressure within the dural sac [1]. - Spontaneous CSF leaks are generally associated with conditions that lead to **low intracranial pressure** or structural defects. *Pseudotumor cerebri* - Also known as **idiopathic intracranial hypertension**, often leads to **elevated CSF pressure**, which can paradoxically strain weakened areas and predispose to spontaneous CSF leaks [2]. - The high pressure can cause bone erosion or thinning, creating pathways for CSF to leak, particularly at the **skull base**. *Low risk encephalocele* - An encephalocele is a **sac-like protrusion of the brain** and its surrounding membranes through an opening in the skull, inherently indicating a defect that can allow CSF leakage. - Even "low risk" encephaloceles represent a **structural weakness** in the skull base or cranium that can lead to spontaneous CSF fistulas. *Partial or complete empty sella syndrome* - **Empty sella syndrome** is often associated with signs of **intracranial hypotention**, which is a known risk factor for spontaneous CSF leaks. - The herniation of the arachnoid membrane and CSF into the sella turcica can contribute to or be a result of **decreased intracranial pressure**, favoring CSF leakage.
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