Online module:Online module:Intracranial Mass Intracranial Mass

LesionsLesions

Couple of quick thingsCouple of quick things

As you can imagine, this is a HUGE As you can imagine, this is a HUGE topic that encompasses parts of topic that encompasses parts of Neurosurgery that some individual Neurosurgery that some individual develop subspecialties within!develop subspecialties within!

Don’t fret. The point here is to develop Don’t fret. The point here is to develop a general understanding of a general understanding of presentation, what clues the presentation, what clues the presentation(s) can provide as to the presentation(s) can provide as to the diagnosis, what you should or should diagnosis, what you should or should NOT do, etc.NOT do, etc.

Intracranial Mass Lesions – Intracranial Mass Lesions – Differential ConsiderationsDifferential Considerations

Primary Brain Tumor/LesionPrimary Brain Tumor/Lesion Including non-neoplastic cysts, congenital, Including non-neoplastic cysts, congenital,

etc.etc. Metastatic LesionMetastatic Lesion Trauma (see module on Neurotrauma)Trauma (see module on Neurotrauma) InfectionInfection Vascular (see module on Neurotrauma)Vascular (see module on Neurotrauma)

Including aneurysms, AVMs, stroke, etc.Including aneurysms, AVMs, stroke, etc. InflammatoryInflammatory

Clues to diagnosis…Clues to diagnosis…

Have an idea of those differential Have an idea of those differential considerations in your mind, to considerations in your mind, to “choose from” when a patient “choose from” when a patient presents.presents.

Mass lesions can present any of a Mass lesions can present any of a number of different ways, but clues number of different ways, but clues to the diagnosis is often times to the diagnosis is often times hidden within the manner in which hidden within the manner in which they present.they present.

TumorsTumors

Mass effect from tumor itselfMass effect from tumor itself Presentation is function of brain compressionPresentation is function of brain compression

A large frontal convexity meningioma may cause A large frontal convexity meningioma may cause arm weakness, slurred speech, gradual confusion, arm weakness, slurred speech, gradual confusion, etc.etc.

Mass effect from irritation of brainMass effect from irritation of brain Presentation is function of edema/swelling Presentation is function of edema/swelling

around tumoraround tumor A small focus of lung cancer, for example, can A small focus of lung cancer, for example, can

incite a large surrounding area of edema/irritation.incite a large surrounding area of edema/irritation.

TumorsTumors

Tumors usually present insidiously.Tumors usually present insidiously. Most common presentation of brain Most common presentation of brain

tumor is progressive neurologic deficit, tumor is progressive neurologic deficit, particularly motor weakness.particularly motor weakness.

Seizures in 26% (especially Seizures in 26% (especially supratentorial) - any first time seizure supratentorial) - any first time seizure in an adult needs thorough w/u to rule in an adult needs thorough w/u to rule out brain lesion.out brain lesion.

Posterior fossa tumors commonly Posterior fossa tumors commonly present with increased ICP and other present with increased ICP and other symptoms secondary to hydrocephalus.symptoms secondary to hydrocephalus.

Metastatic Brain LesionMetastatic Brain Lesion

Cerebral metastasis is initial Cerebral metastasis is initial presentation in 15% of patients with presentation in 15% of patients with previously-unknown cancer.previously-unknown cancer.

Lung cancer by far most common, Lung cancer by far most common, followed by breast, kidney, and GI.followed by breast, kidney, and GI.

Metastatic Brain LesionMetastatic Brain Lesion

Question – surgery or not?Question – surgery or not? Very important to consider patient’s Very important to consider patient’s

functoinal status at time of functoinal status at time of presentation. Poor functional status presentation. Poor functional status generally = poor surgical candidate.generally = poor surgical candidate.

Surgery for metastatic Surgery for metastatic diseasedisease

Solitary lesionSolitary lesion Obtain tissue for diagnosis (primary unknown)Obtain tissue for diagnosis (primary unknown) Symptomatic and/or life-threatening lesionSymptomatic and/or life-threatening lesion Lesion is accessible to surgical removal (i.e. Lesion is accessible to surgical removal (i.e.

not buried beneath the motor strip)not buried beneath the motor strip) Good functional status, good relative Good functional status, good relative

prognosisprognosis Multiple lesionsMultiple lesions

Palliative (a lesion is symptomatic/life-Palliative (a lesion is symptomatic/life-threatening)threatening)

Obtain tissue for diagnosisObtain tissue for diagnosis

Intracerebral Intracerebral Infection/AbscessInfection/Abscess

Risk factors: Dental abscess, pulmonary Risk factors: Dental abscess, pulmonary abscess, immunocompromised state, IV abscess, immunocompromised state, IV drug use, pulmonary A/V fistulas, drug use, pulmonary A/V fistulas, penetrating head trauma, etc.penetrating head trauma, etc.

Presentation is usually secondary to Presentation is usually secondary to symptoms of increased ICP, and more symptoms of increased ICP, and more acute than tumors but not “sudden.” acute than tumors but not “sudden.” Seizures are common, as are focal Seizures are common, as are focal neurological deficits.neurological deficits.

Fever, abnormal labs (ESR, CRP) are Fever, abnormal labs (ESR, CRP) are clues.clues.

Inflammatory lesionsInflammatory lesions

Classic presentation would be Classic presentation would be middle-aged female with hx of MS middle-aged female with hx of MS who presents with 4 to 5 days of new who presents with 4 to 5 days of new progressive neurologic deficit.progressive neurologic deficit. No fevers, etc.No fevers, etc. Brain imaging shows one or multiple Brain imaging shows one or multiple

lesions.lesions. Tumefactive MS can be very difficult to Tumefactive MS can be very difficult to

distinguish from tumor, especially glioma.distinguish from tumor, especially glioma.

Intracranial Mass Intracranial Mass LesionsLesions

Trauma patients would present with Trauma patients would present with appropriate history, or physical exam appropriate history, or physical exam findings c/w that.findings c/w that.

Vascular patients present with SUDDEN Vascular patients present with SUDDEN changes in mentation or neurological changes in mentation or neurological status, either from stroke, hemorrhage, etc.status, either from stroke, hemorrhage, etc.

Important thing to always keep in mind in Important thing to always keep in mind in cases of space-occupying lesions in the cases of space-occupying lesions in the brain: Do not rush to LP!!! You can cause brain: Do not rush to LP!!! You can cause tonsillar herniation!tonsillar herniation!

SummarySummary

Keep in mind these six “possibilities” Keep in mind these six “possibilities” for patients presenting with head for patients presenting with head lesions (Primary brain tumor, lesions (Primary brain tumor, metastatic disease, trauma, metastatic disease, trauma, infection, vascular, inflammatory), infection, vascular, inflammatory), and compare the “logical” and compare the “logical” presentation for each with your presentation for each with your patient’s presentation to help patient’s presentation to help narrow down your differential.narrow down your differential.