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