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Intracranial Space Occupying Lesions
Prof. Salman Sharif, FRCSChief of Neurosurgery
Liaquat National Hospital and Medical College
Objectives
• Definition• Types• Clinical Presentations• Diagnosis• Treatment
Definition
These are lesions which expand in volume to displace normal neural structures & may lead to increase in intra – cranial pressure.
Intracranial Mass Lesions – Differential Considerations
1. Primary Brain Tumor/Lesion (non-neoplastic cysts, congenital, etc.)
2. Metastatic Lesion3. Trauma (subdural, extra-dural haematomas)• )
Primary Brain Tumor
Metastatic Lesions
Intracranial Bleed
4. Parasitic (Cysticercosis, Hydratid cyst, Amebic abscess)
5. Vascular (aneurysms, AVMs, stroke, etc.)
6. Inflammatory (Abscess, Tuberculoma, Syphilitic gumma, fungal Granulomas)
Angiogram: AVM Tuberculoma
Tumors
• Gliomas• Meningiomas• Schwannoma• PNET• Pituitary• Pineal
Primary
• Metastatic• Lung• Kidney• Breast
Secondary
Clinical PresentationsHeadache
Seizures
Personality Changes
Focal Deficits
Papilledema
Increased ICP
GLIOMAS
• Site• Seizures• Language
Difficulty• Headache• Behavioral
Changes• Hemiparesis
Meningiomas
• Middle age• Slow growing• Headache• Seizures
Schwannomas
• Hearing Problems
• Vertigo• Headache• Facial
weakness/numb
Pituitary Adenoma
• Headache• Visual Effects• Endocrine
Penial Region
• Headache• Hydrochephalus• Perinaud’s
Syndrome
DIAGNOSIS
DIAGNOSIS
• Physical Examination Findings• CT Scan Brain• MRI Brain• MR Angiography• Laboratory Studies ( CBC, ESR, LFTS, Tumor
Makers, etc)• Biopsy
Gliomas
• Most common Primary Brain Tumors
Grade III Astrocytoma
Meningioma
Acoustic Schwannoma
Pineal Gland Tumor
Pituitary Adenomas
Treatment
Treatment
Varies on histology of various tumors
Craniotomy+ Biopsy
Craniotomy + Excision
Radiotherapy Chemotherapy
Palliative
•Benign: Surgical Excision•Malignant: Surgical Excision + Radiotherapy
Gliomas•Surgical Resection +/- RadiotherapyMeningiomas
•Surgical resection >3cmSchwannoma
•Surgical: (Trans-shenoidal Transcranial)•Pharmacological Rx (Dopamine agonist Somatostatin
analogs)•Radiotherapy
Pituitary•Depends on histology•Resection and RadiotherapyPineal
•For solitary lesion or less than 4 lesions all < 3 cm. – biopsy if undiagnosed, plus Gamma Knife
•For > 3 cm. tumor, surgery followed by WBRT•For > 4 lesions, biopsy for diagnosis, plus whole brain
radiation therapy
Mets
TRAUMA
• Intracranial haematomasI. Extra dural haematomas :- – between the dura & the skull –middle meningeal artery– Common site is temporal fossa.
TRAUMA
•Progressive deterioration of level of consciousness
•Lucid Interval•Pupillary changes :- called
Hutchinson’s pupillary reaction.
Clinical Features
EDH
INVESTIGATIONS:CT (Biconvex hyperdense lesion)MRICEREBRAL ANGIOGRAPHY
Treatment:Surgical evacuation followed by Craniotomy
• II. Subdural haematomas :-–between the dura and the arachnoid. –Common causes are bleeding from
superficial veins or venous sinuses. –Anticoagulant treatment predispose to
intracranial bleeding and subdural haematoma.
• Clinical features:– Acute : Clinical features are similar to extra dural
hematoma.– Chronic : Dementia, altered behaviour, psychiatric
manifestations or focal neurological deficits may develop.
– In middle aged headache, contralateral hemiplegia, papilledema
– children: vomiting, restlessness. Irritability, refusal to feed, anaemia, seizures and failure to thrive.
Treatment:•Craniotomy for Acute Subdural Hematoma•Surgical evacuation by Burr hole for chronic subdural hematoma.
DIAGNOSIS:•Acute-concave hyperdense lesion on CT
•Chronic- 0-10days(hyperdense)10days-2wks(isodense)>2wks(hypodense) lesions on CT.
BRAIN ABSCESS
• Mostly single may be multiple• Majority Supratentorial, 10% infratentorial• Metastatic:– hematogenesis,direct spread from adjacent
structures or penetrating brain injury.
Clinical presentation
• Neurologic:– Raised ICP(nausea,vomiting)– Focal neurologic deficits(hemi-pariasis)– Epileptic seizures
• Systemic toxicity(Fever,malaise)• Symptoms of primary focus
infection(Otitis,sinusitis etc)
DIAGNOSIS
• Method of Choice- CT scan of Brain– Ring enhancing Lesion
• Peripheral Blood smear– Leukocytosis– Raised ESR
TREATMENT
• SPECIFIC TREATMENT– Anti-microbial therapy
• MEASURES TO REDUCE ICP– Drainage of abscess– Mannitol– corticosteroids
• ANTI-EPILEPTIC TREATMENT– Phenytoin– Carbamazapine
SURGICAL TREATMENT
• GOALS:– Obtain pus for culture & sensitivity– Decrease ICP
• TECHNIQUES:– Burr hole & aspiration– Excision & craniotomy for recurrent, thickwalled
brain abscess.
INTRACRANIAL TUBERCULOMA
• Mostly in developing countries caused by Micro-bacterium tuberculus.
• Nodular or irregular avascular masses of variable sizes surrounded by edema.
• Frequently multiple• Common location: sub-cortical in cerebral
hemisphere.
Clinical presentation
Symptoms & signs of progressive intracranial SOL:– Raised ICP– Focal neurologic deficits – Seizures etc– General malaise,fever in 50% patients.
INVESTIGATIONS
• Lab work-up– Leukocytosis– ESR- raised or normal– Mantox test- often+ve
• Chest X-ray• Plain skull X-ray• CT & MRI- Investigation of choiceHyper-dense masses with ring and surroundind
edema, often”Target sign”
TREATMENT
• Anti-tubercular therapy• Measures to reduce ICP• Control seizure
INDICATIONS:Intracranial lesions could not be specifiedProgressive neurological detoriation
ALTERNATIVES:Excision: CSF-shunting: mandatory in complicating obstructive hydrocephalus
SURGICAL TREATMENT
THANK YOU