Normal Lab Values

Nervous System Pathology Part 2

Readings from Robbins Basic Pathol, 11th ed.  
PAGES TOPICS  
637 - 641 Pituitary adenoma  
727 – 729 Edema, herniation, hydrocephalus  
731 - 737 Cerebrovascular diseases  
729 – 730 Congenital malformations  
757 - 763 CNS tumors  

Website Cases:

Additional case (NOT assigned):

 

 

CASE NUMBER 427
[DigitalScope]

Clinical History: A 78-year-old man presented to his primary care physician with a two-year history of headache that had worsened recently. In addition, he said that he had difficulty seeing. Visual field examination revealed bitemporal hemianopsia. No endocrine abnormalities were identified. He was admitted to the hospital for evaluation where MRI showed a 1.5 cm suprasellar mass. Screening CT showed no other abnormalities.  While in the hospital, the patient contracted pneumonia and died. No other CNS pathology was noted at autopsy.  

 

427-1. What is the differential diagnosis?

 

Image Gallery:

The pituitary gland, weighing 3 gms and measuring 2 cms in greatest diameter, contained a large pink-gray soft tumor mass in the anterior lobe. The optic chiasm was slightly atrophic due to the compression of the tumor.
The tumor occupies nearly the entire anterior lobe, so that only a thin rim of normal hypophyseal tissue is present in the subcapsular area. The tumor is composed of uniform cells arranged in a trabecular or sinusoidal pattern. The stroma is highly vascular. Some of the tumor cells contain fine eosinophilic granules, but most of them are chromophobes with special stains.
Review Pituitary Histology

Norm No. 14 Pituitary gland
[DigitalScope]

The pituitary is an endocrine gland with neurohypophysis and adenohypophysis. The neurohypophysis (right side of the section) is composed of spindle cells that are derived from neural crest. These are neurosecretory cells. The adenohypophysis (left side of the section) is an endocrine gland which is composed of three histological cell types, acidophils, basophils and chromophobes. The staining properties vary with the hormonal product. For example, growth hormone secreting cells are acidophils. In between the anterior and posterior pituitary is the pars intermedia, which frequently contains colloid-filled Rathke's cysts, which are remnants of Rathke's pouch formed from the roof of the mouth during development.

This section of brain is stained with hematoxylin and eosin. The tumor of the left side of the brain was due to the proliferation and infiltration of moderately pleomorphic fibrillary astrocytic cells. There is focal necrosis. Necrosis is the hallmark of glioblastoma. Better differentiated slower growing astrocytomas do not exhibit necrosis.

 

Gross image questions:

On the gross image, identify the following:

  • the mass
  • cerebellar vermis
  • parahippocampal gyrus
  • superior frontal cortex
  • medulla oblongata
  • lateral wall of lateral ventricle
  • body of the fornix
  • body of the corpus callosum
  • anterior commissure
  • pons
  • fourth ventricle
  • pineal body
  • genu of the corpus callosum
  • head of the caudate nucleus
  • mesencephalon (midbrain)

 

427-2. Which of the following is most accurate about this diagnosis?

  1. Classification is based on size and location
  2. It can be distinguished from hyperplasia by its pleomorphism and well-formed reticulin network
  3. G-protein mutations are commonly seen in somatotroph cell adenomas
  4. Gonadotroph adenomas cause Cushing syndrome
  5. Malignant transformation occurs in 25% of cases

 

 

CASE NUMBER 540 - slide courtesy of UMich
[DigitalScope]

Clinical History: A 51-year-old woman presented to her GP with a 6-week history of increasingly severe headaches. A neurological exam was unremarkable. An MRI was performed and based on the presumptive diagnosis, an attempt at embolization of the mass was made.  While she was in recovery, she experienced a massive myocardial infarction and died. An autopsy was performed.

 

540-1. What is the differential diagnosis?

 

Image Gallery:

Imaging shows a dural based mass which is isointense to grey matter on both T1 and T2 weighted imaging, and demonstrate vivid contrast enhancement on both MRI and CT.
There is a well circumscribed tumor attached to the dura. The tumor has compressed but has not invaded the brain.
A dural based mass composed of bland cells with indistinct cell borders arranged in whorls. Rare psammoma bodies are present. Embolization material is seen in blood vessels.
Review CNS Histology
Cerebrum
Slide 76
(cerebrum, luxol blue/cresyl violet) [DigitalScope]
Slide 76b (toluidine blue & eosin) [DigitalScope]
  
The cerebral cortex is loosely stratified into layers containing scattered nuclei of both neurons and glial cells.  Examine the layered organization of the cerebral cortex using slide 76 stained with luxol blue/cresyl violet [ORIENTATION] (which stains white matter tracts and cell bodies) or toluidine blue and eosin [ORIENTATION] (TB&E, toluidine blue stains the nuclei and RER of cells whereas eosin stains membranes and axon tracts).  Typically one or more sulci (infoldings) will extend inward from one edge of the section.  Examine the gray matter on each side of the sulcus using first low and then high power.  Neurons of the cerebral cortex are of varying shapes and sizes, but the most obvious are pyramidal cells.  As the name implies, the cell body is shaped somewhat like a pyramid, with a large, branching dendrite extending from the apex of the pyramid toward the cortical surface, and with an axon extending downward from the base of the pyramid.  In addition to pyramidal cells, other nuclei seen in these sections may belong to other neurons or to glial cells also present in the cortex.  You may be able to see subtle differences in the distribution of cell types in rather loosely demarcated layers. There are 6 classically recognized layers of the cortex:

  1. Outer plexiform (molecular) layer: sparse neurons and glia
  2. Outer granular layer: small pyramidal and stellate neurons
  3. Outer pyramidal layer: moderate sized pyramidal neurons (should be able to see these in either luxol blueor TB&E-stained sections)
  4. Inner granular layer: densely packed stellate neurons (usually the numerous processes aren’t visible, but there are lots of nuclei reflecting the cell density)
  5. Ganglionic or inner pyramidal layer: large pyramidal neurons (should be able to see these in either luxol blue or TB&E-stained sections)
  6. Multiform cell layer: mixture of small pyramidal and stellate neurons

Pyramidal cells in layers III and V tend to be larger because their axons contribute to efferent projections that extend to other regions of the CNS –pyramidal neurons in layer V of motor cortices send projections all the way down to motor neurons in the spinal cord!

Deep to the gray matter of the cerebral cortex is the white matter that conveys myelinated fibers between different parts of the cortex and other regions of the CNS. Be sure you identify the white matter in both luxol blue and TB&E-stained sections, as it will appear differently in these two stains. Review the organization of gray and white matter in cerebral cortex vs. spinal cord.

Review Neuroradiology

Radiology image questions:

  • On an annotated screenshot, identify the lesion on the MRI.
  • Is it circumscribed or infiltrative?

Gross image questions:

  • On an annotated screenshot, identify and describe the lesion.
  • From which structure is the lesion arising?
  • Do you think it is growing quickly or slowly?

VM image questions:

  • On an annotated screenshot, identify a psammoma body.
  • Describe the lesion.
  • What do you think is seen in the blood vessels?

 

540-2. Which of the following is the MOST COMMONLY mutated gene in patients with this tumor?

  1. IDHI
  2. MYC
  3. NF2
  4. TSC2
  5. VHL

 

540-3. Which of the following is a histologic feature frequently seen in this type of tumor?

  1. Brisk mitotic activity
  2. Cytoplasmic halo
  3. Homer Wright rosettes
  4. Necrosis
  5. Psammoma bodies

 

CASE NUMBER 541 - slide courtesy of UMich
[DigitalScope]

Clinical History: A 34-year-old woman with no prior history of disease presents to the emergency department after her husband noticed her having a seizure. An MRI revealed a 3 x 4 x 4.2 cm mass in the right temporal lobe. A biopsy was performed.

 

541-1. What is the differential diagnosis?

 

Image Gallery:


The image on the left is a T2-weighted image and the one on the right is a T1-weighted image enhanced with gadolinium, a contrast agent that highlights brain tumors due to the breakdown of the blood-brain barrier. The image on the left shows peritumoral edema. In the image on the right, the central, dim area corresponds to areas of necrosis whereas the thickened ring shows pooling of gadolinium.
Sections show areas of necrosis, hemorrhage and vascular proliferation. The tissue is hypercellular and displays atypical cells.
Review CNS Histology
Cerebrum
Slide 76
(cerebrum, luxol blue/cresyl violet) [DigitalScope]
Slide 76b (toluidine blue & eosin) [DigitalScope]
  
The cerebral cortex is loosely stratified into layers containing scattered nuclei of both neurons and glial cells.  Examine the layered organization of the cerebral cortex using slide 76 stained with luxol blue/cresyl violet [ORIENTATION] (which stains white matter tracts and cell bodies) or toluidine blue and eosin [ORIENTATION] (TB&E, toluidine blue stains the nuclei and RER of cells whereas eosin stains membranes and axon tracts).  Typically one or more sulci (infoldings) will extend inward from one edge of the section.  Examine the gray matter on each side of the sulcus using first low and then high power.  Neurons of the cerebral cortex are of varying shapes and sizes, but the most obvious are pyramidal cells.  As the name implies, the cell body is shaped somewhat like a pyramid, with a large, branching dendrite extending from the apex of the pyramid toward the cortical surface, and with an axon extending downward from the base of the pyramid.  In addition to pyramidal cells, other nuclei seen in these sections may belong to other neurons or to glial cells also present in the cortex.  You may be able to see subtle differences in the distribution of cell types in rather loosely demarcated layers. There are 6 classically recognized layers of the cortex:

  1. Outer plexiform (molecular) layer: sparse neurons and glia
  2. Outer granular layer: small pyramidal and stellate neurons
  3. Outer pyramidal layer: moderate sized pyramidal neurons (should be able to see these in either luxol blueor TB&E-stained sections)
  4. Inner granular layer: densely packed stellate neurons (usually the numerous processes aren’t visible, but there are lots of nuclei reflecting the cell density)
  5. Ganglionic or inner pyramidal layer: large pyramidal neurons (should be able to see these in either luxol blue or TB&E-stained sections)
  6. Multiform cell layer: mixture of small pyramidal and stellate neurons

Pyramidal cells in layers III and V tend to be larger because their axons contribute to efferent projections that extend to other regions of the CNS –pyramidal neurons in layer V of motor cortices send projections all the way down to motor neurons in the spinal cord!

Deep to the gray matter of the cerebral cortex is the white matter that conveys myelinated fibers between different parts of the cortex and other regions of the CNS. Be sure you identify the white matter in both luxol blue and TB&E-stained sections, as it will appear differently in these two stains. Review the organization of gray and white matter in cerebral cortex vs. spinal cord.

Review Neuroradiology

Radiology image questions:

  • On an annotated screenshot, identify the lesion.
  • Does it appear circumscribed or infiltrative? How would you describe it?
  • What does the pattern of gadolinium in the right-sided image reveal about the lesion?

VM image questions:

  • On an annotated screenshot, identify:
    • an area of necrosis,
    • an area of vascular proliferation, and
    • some pleomorphic cells.

 

541-2. Which of the following genes is commonly mutated in this tumor?

  1. IDH2
  2. MYC
  3. TP53
  4. TSC
  5. VHL

 

541-3. Which of the following is most accurate regarding this disease?

  1. In situ stages are detectable up to 5 years before diagnosis
  2. Median survival is less than two years
  3. Metastases to lung and liver are common
  4. Posterior fossa is the most common site of origin
  5. Psammoma bodies are commonly found histologically.

 

 

CASE NUMBER 542 - slide courtesy of UMich
[DigitalScope]

Clinical History: A 3-year-old boy was brought to the ED after an episode of projectile vomiting. According to his parents, 2 days earlier, he had begun vomiting after meals. Physical exam was notable for a temperature of 37.7C. His pupils were equal in size, but eye movements could not be fully evaluated due to his lack of cooperation. The ED physician believed he saw a down-beating nystagmus when the child opened his eyes. MRI shows the findings below and the patient was scheduled for surgery

 

542-1. What is the differential diagnosis?

 

Image Gallery:


The first, T1-weighted, image shows a large, low signal mass along the midline of the posterior fossa with patchy contrast enhancement. The T2-weighted image shows a signal that is hyperintense compared to the gray matter; there is a focus of bright signal that may represent cyst formation. In both images, the tumor appears heterogeneous. The third image shows hydrocephalus which is due to obstruction.
The lesion is composed of monomorphic small, round blue cells. They are primitive in appearance with fine chromatin and minute nucleoli. Necrosis is not present.
Review CNS Histology
Cerebrum
Slide 76
(cerebrum, luxol blue/cresyl violet) [DigitalScope]
Slide 76b (toluidine blue & eosin) [DigitalScope]
  
The cerebral cortex is loosely stratified into layers containing scattered nuclei of both neurons and glial cells.  Examine the layered organization of the cerebral cortex using slide 76 stained with luxol blue/cresyl violet [ORIENTATION] (which stains white matter tracts and cell bodies) or toluidine blue and eosin [ORIENTATION] (TB&E, toluidine blue stains the nuclei and RER of cells whereas eosin stains membranes and axon tracts).  Typically one or more sulci (infoldings) will extend inward from one edge of the section.  Examine the gray matter on each side of the sulcus using first low and then high power.  Neurons of the cerebral cortex are of varying shapes and sizes, but the most obvious are pyramidal cells.  As the name implies, the cell body is shaped somewhat like a pyramid, with a large, branching dendrite extending from the apex of the pyramid toward the cortical surface, and with an axon extending downward from the base of the pyramid.  In addition to pyramidal cells, other nuclei seen in these sections may belong to other neurons or to glial cells also present in the cortex.  You may be able to see subtle differences in the distribution of cell types in rather loosely demarcated layers. There are 6 classically recognized layers of the cortex:

  1. Outer plexiform (molecular) layer: sparse neurons and glia
  2. Outer granular layer: small pyramidal and stellate neurons
  3. Outer pyramidal layer: moderate sized pyramidal neurons (should be able to see these in either luxol blueor TB&E-stained sections)
  4. Inner granular layer: densely packed stellate neurons (usually the numerous processes aren’t visible, but there are lots of nuclei reflecting the cell density)
  5. Ganglionic or inner pyramidal layer: large pyramidal neurons (should be able to see these in either luxol blue or TB&E-stained sections)
  6. Multiform cell layer: mixture of small pyramidal and stellate neurons

Pyramidal cells in layers III and V tend to be larger because their axons contribute to efferent projections that extend to other regions of the CNS –pyramidal neurons in layer V of motor cortices send projections all the way down to motor neurons in the spinal cord!

Deep to the gray matter of the cerebral cortex is the white matter that conveys myelinated fibers between different parts of the cortex and other regions of the CNS. Be sure you identify the white matter in both luxol blue and TB&E-stained sections, as it will appear differently in these two stains. Review the organization of gray and white matter in cerebral cortex vs. spinal cord.

Review Neuroradiology  

Radiology image questions:

  • On an annotated screenshot, identify the lesion on the MRI.
  • What does the third image suggest about the cause of this patient’s projectile vomiting?

VM    image questions:

  • On an annotated screenshot, describe the biopsy findings.
  • Are the cells monomorphic or pleomorphic?
  • Is there necrosis?

 

542-2. Which of the following is associated with the worst prognosis in patients with this disease?

  1. 1p/19 q deletions
  2. Epstein-Barr virus infection
  3. PTCH1 LOF mutation
  4. TP53 mutations
  5. Wnt pathway activation

 

542-3. Which of the following is most accurate regarding this tumor?

  1. Approximately 25% of tumors arise in the cerebellum
  2. Median survival following treatment is 6 months
  3. Metastasis to soft tissue is common
  4. Radiation therapy is a useful adjunct
  5. This tumor accounts for approximately 80% of pediatric brain tumors

 

 

 

CASE NUMBER 380
[DigitalScope]

Clinical History: An 82-year-old man in a nursing home with a history of dementia developed left-sided upper and lower extremity weakness with hemiparesis of the left side of his face.  He had been confined to his bed for the previous week due to a bad cold.  Upon review of his records, a patent foramen ovale was detected by transesophageal echocardiography as part of a work-up for a suspected transient ischemic attack a year ago. A non-contrast CT showed no intraparenchymal hemorrhage but before tPA could be started, he became increasingly obtunded and was transferred to the ICU.  He died the following afternoon.  An autopsy was performed. 

 

380-1. What is the differential diagnosis?

 

Image Gallery:


At autopsy, a patent foramen ovale was noted. The right hemisphere of the brain was edematous. The cut sections showed moderate ventricular dilation. Blurring and discoloration of the gray-white junction was noted in the right frontoparietal regions along with parenchymal softening. A thrombus was found in the right MCA, occluding approximately 80% of the lumen.
The sections demonstrate numerous red neurons with cytoplasmic eosinophilia, pyknotic nuclei, and perineuronal edema. Foci of parenchymal and perivascular hemorrhage are noted. In some areas a focal macrophage infiltrate is noted.

General Microscopic Features Observed with Injury to the CNS are as follows:
  • 12 – 24 hours: acute neuronal injury manifests as “red neurons”
  • 24 hours to 2 weeks: subacute changes – tissue necrosis, macrophage influx, reactive gliosis (nonspecific reactive change with increased astrocytes, microglia and oligodendrocytes)
  • Repair – after 2 weeks – remove of necrotic tissue, gliosis
  • -->
    Review CNS Histology
    Cerebrum
    Slide 76
    (cerebrum, luxol blue/cresyl violet) [DigitalScope]
    Slide 76b (toluidine blue & eosin) [DigitalScope]
      
    The cerebral cortex is loosely stratified into layers containing scattered nuclei of both neurons and glial cells.  Examine the layered organization of the cerebral cortex using slide 76 stained with luxol blue/cresyl violet [ORIENTATION] (which stains white matter tracts and cell bodies) or toluidine blue and eosin [ORIENTATION] (TB&E, toluidine blue stains the nuclei and RER of cells whereas eosin stains membranes and axon tracts).  Typically one or more sulci (infoldings) will extend inward from one edge of the section.  Examine the gray matter on each side of the sulcus using first low and then high power.  Neurons of the cerebral cortex are of varying shapes and sizes, but the most obvious are pyramidal cells.  As the name implies, the cell body is shaped somewhat like a pyramid, with a large, branching dendrite extending from the apex of the pyramid toward the cortical surface, and with an axon extending downward from the base of the pyramid.  In addition to pyramidal cells, other nuclei seen in these sections may belong to other neurons or to glial cells also present in the cortex.  You may be able to see subtle differences in the distribution of cell types in rather loosely demarcated layers. There are 6 classically recognized layers of the cortex:

    1. Outer plexiform (molecular) layer: sparse neurons and glia
    2. Outer granular layer: small pyramidal and stellate neurons
    3. Outer pyramidal layer: moderate sized pyramidal neurons (should be able to see these in either luxol blueor TB&E-stained sections)
    4. Inner granular layer: densely packed stellate neurons (usually the numerous processes aren’t visible, but there are lots of nuclei reflecting the cell density)
    5. Ganglionic or inner pyramidal layer: large pyramidal neurons (should be able to see these in either luxol blue or TB&E-stained sections)
    6. Multiform cell layer: mixture of small pyramidal and stellate neurons

    Pyramidal cells in layers III and V tend to be larger because their axons contribute to efferent projections that extend to other regions of the CNS –pyramidal neurons in layer V of motor cortices send projections all the way down to motor neurons in the spinal cord!

    Deep to the gray matter of the cerebral cortex is the white matter that conveys myelinated fibers between different parts of the cortex and other regions of the CNS. Be sure you identify the white matter in both luxol blue and TB&E-stained sections, as it will appear differently in these two stains. Review the organization of gray and white matter in cerebral cortex vs. spinal cord.

    Gross image questions

    • Take a screen shot of the gross image and annotate an area of normal brain and the area of injury.
    • Describe the injured area.
    • How does it differ from normal brain?

    VM image questions:

    • Take a screen shot of the VM and identify a macrophage, perivascular and parenchymal hemorrhage and an area of edema.

     

    380-2. List 5 risk factors for this disease process:

     

    380-3. Which of the following arteries is most commonly occluded in this sort of patient?

    1. Anterior cerebral artery
    2. Anterior communicating artery
    3. Middle cerebral artery
    4. Ophthalmic artery
    5. Posterior cerebral artery

     

    380-4. Which of the following is the proposed mechanism for hemorrhagic infarction?

    1. Acute vascular occlusion without resolution
    2. Direct trauma to brain parenchyma
    3. Global hypoxia due to hypotension
    4. Reperfusion of ischemic tissue
    5. Rupture of an aneurysm

     

    380-5. What is the significance of the patent foramen ovale?

     

     

    NERVOUS SYSTEM PATHOLOGY Review Items

    Key Vocabulary Terms (click here to search any additional terms on Stedman's Online Medical Dictionary)

    agyria gemistocytic neuronophagia
    AIDS dementia gliosis neuropathy
    Alzheimer type II cell glomeruloid body  Nissl substance
    amyloid angiopathy granulovacuolar degeneration open head injury
    anencephaly herniation ophthalmoplegia
    Antoni A pattern Hirano body pachygyria
    Antoni B pattern holoprosencephaly pachymeningitis
    arrhinencephaly hydranencephaly paresis
    aseptic meningitis hydrocephalus parkinsonism
    astrocytosis hydrocephalus ex vacuo peripheral nervous system (PNS)
    ataxia kernicterus phakomatosis
    Bergmann gliosis lacunar infarct  Pick body
    central nervous system (CNS) Lafora body polymicrogyria
    cerebral laminar cortical necrosis porencephaly
    cerebral palsy (CP) leptomeningitis presenilin
    cerebritis leukoencephalopathy prion
    cerebrospinal fluid (CSF) leukomalacia prion protein (PrP)
    cerebrovascular accident (CVA) Lewy body radiculitis
    choreiform lissencephaly Rosenthal fiber
    chromatolysis mad cow disease rosette/pseudorosette
    closed head injury megalocephaly satellitosis
    concussion meningitis schizencephaly
    contrecoup injury meningocele  spina bifida
    contusion meningoencephalitis spongiform
    corpora amylacea meningomyelocele storage disease
    coup injury meningovasculitis stroke
    cranial microcephaly syringomyelia
    dementia multiple sclerosis plaque tabes dorsalis
    demyelination myelitis transient ischemic attack (TIA)
    Duret hemorrhage myelocoele ulegyria
    encephalitis   Negri body von Recklinghausen disease
    encephalocele neuritic plaque Wallerian degeneration
    encephalomyelitis neuritis watershed (border) zone
    encephalopathy   neurofibrillary tangle  

    CNS-2: GOALS and LEARNING OBJECTIVES

    Goal: Vascular Pathology of the Brain
    Apply knowledge of the structure and function of the brain and general pathology concepts to discuss disorders resulting from altered blood supply and hypoxia to the brain.

    • Objective 1: Stroke
      Compare and contrast the two major mechanisms for stroke (ischemic vs hemorrhagic) and how treatment would differ for each.
    • Objective 2: Cranial Hemorrhage
      Compare and contrast the etiologies and clinical presentations of epidural, subdural, subarachnoid hemorrhages, basal ganglionic, and lobar hemorrhages.
    • Objective 3: Hypertensive Hemorrhage
      Describe the mechanism of hypertensive hemorrhage and name the common locations in which this occurs.
    • Objective 4: Embolic Infarction
      Describe how embolic infarcts differ from atherothrombotic infarcts in pathologic appearance and name three sources of emboli.
    • Objective 5: Acute vs Chronic Brain Infarction
      Compare and contrast the gross and histopathologic appearance of acute versus remote brain infarction.

    Goal: Congenital Malformations
    Apply knowledge of the clinical, anatomic and neuropathologic principles to describe the clinicopathologic features and consequences of congenital malformations.

    • Objective 1: Congenital Malformations
      Name the most common forms of congenital malformations of the CNS and outline their clinical presentation, natural history, and long- and short-term complications.

    Goal: Perinatal Brain Injury
    Apply knowledge of the clinical, anatomic and neuropathologic principles to describe the clinicopathologic features and consequences of perinatal brain injury.

    • Objective 1: Perinatal Brain Injury
      Describe the clinicopathologic features of perinatal brain injury and outline the clinical presentation, natural history, and long- and short-term complications

    Goal: CNS Neoplasia
    Apply knowledge of the pathological and molecular basis of common brain tumors to describe their clinical behavior, effects on the nervous system, and therapies.

    • Objective 1: Features of Brain Tumors
      Explain the pathophysiology underlying the signs and symptoms associated with brain tumors.
    • Objective 2: Classification of Brain Tumors
      List the common types of brain tumors that affect the cerebrum, the cerebellum, the meninges, and the cranial nerves in adults and children; and outline their molecular basis and clinicopathologic features.
    • Objective 3: Hereditary Tumor Syndromes
      Describe the major hereditary tumor syndromes of the nervous system, the genes responsible for each syndrome, and the spectrum of tumors associated with each syndrome.
    • Objective 4: Grading of Brain Tumors
      Explain the pathophysiologic basis for grading primary brain tumors and discuss how grading relates to prognosis and governs patient management.
    • Objective 5: Carcinomas Metastasizing to the CNS
      List carcinomas that commonly metastasize to the central nervous system and describe the locations in which metastases may be seen.

     

     

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