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Intracranial space occupying lesions
- 1. Intracranial Space Occupying Lesions Prof. Salman Sharif, FRCS Chief of Neurosurgery Liaquat National Hospital and Medical College
- 2. Objectives • Definition • Types • Clinical Presentations • Diagnosis • Treatment
- 3. Definition These are lesions which expand in volume to displace normal neural structures & may lead to increase in intra – cranial pressure.
- 5. Intracranial Mass Lesions – Differential Considerations 1. Primary Brain Tumor/Lesion (non-neoplastic cysts, congenital, etc.) 2. Metastatic Lesion 3. Trauma (subdural, extra-dural haematomas) • ) Primary Brain Tumor Metastatic Lesions Intracranial Bleed
- 6. 4. Parasitic (Cysticercosis, Hydratid cyst, Amebic abscess) 5. Vascular (aneurysms, AVMs, stroke, etc.) 6. Inflammatory (Abscess, Tuberculoma, Syphilitic gumma, fungal Granulomas) Angiogram: AVM Tuberculoma
- 7. Tumors • Gliomas • Meningiomas • Schwannoma • PNET • Pituitary • Pineal Primary • Metastatic • Lung • Kidney • Breast Secondary
- 9. Clinical Presentations Headache Seizures Personality Changes Focal Deficits Papilledema Increased ICP
- 11. GLIOMAS • Site • Seizures • Language Difficulty • Headache • Behavioral Changes • Hemiparesis Meningiomas • Middle age • Slow growing • Headache • Seizures Schwannomas • Hearing Problems • Vertigo • Headache • Facial weakness/numb
- 13. DIAGNOSIS
- 14. DIAGNOSIS • Physical Examination Findings • CT Scan Brain • MRI Brain • MR Angiography • Laboratory Studies ( CBC, ESR, LFTS, Tumor Makers, etc) • Biopsy
- 15. Gliomas • Most common Primary Brain Tumors
- 18. Meningioma
- 22. Treatment
- 23. Treatment Varies on histology of various tumors Craniotomy+ Biopsy Craniotomy + Excision Radiotherapy Chemotherapy Palliative
- 24. • Benign: Surgical Excision • Malignant: Surgical Excision + RadiotherapyGliomas • Surgical Resection +/- Radiotherapy Meningiomas • Surgical resection >3cm Schwannoma
- 25. • 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
- 26. TRAUMA
- 27. • Intracranial haematomas I. 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
- 28. INVESTIGATIONS: CT (Biconvex hyperdense lesion) MRI CEREBRAL ANGIOGRAPHY Treatment: Surgical evacuation followed by Craniotomy
- 29. • 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.
- 30. • 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.
- 31. 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.
- 34. BRAIN ABSCESS • Mostly single may be multiple • Majority Supratentorial, 10% infratentorial • Metastatic: – hematogenesis,direct spread from adjacent structures or penetrating brain injury.
- 35. 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)
- 36. DIAGNOSIS • Method of Choice- CT scan of Brain – Ring enhancing Lesion • Peripheral Blood smear – Leukocytosis – Raised ESR
- 38. TREATMENT • SPECIFIC TREATMENT – Anti-microbial therapy • MEASURES TO REDUCE ICP – Drainage of abscess – Mannitol – corticosteroids • ANTI-EPILEPTIC TREATMENT – Phenytoin – Carbamazapine
- 39. SURGICAL TREATMENT • GOALS: – Obtain pus for culture & sensitivity – Decrease ICP • TECHNIQUES: – Burr hole & aspiration – Excision & craniotomy for recurrent, thickwalled brain abscess.
- 40. 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.
- 41. Clinical presentation Symptoms & signs of progressive intracranial SOL: – Raised ICP – Focal neurologic deficits – Seizures etc – General malaise,fever in 50% patients.
- 42. INVESTIGATIONS • Lab work-up – Leukocytosis – ESR- raised or normal – Mantox test- often+ve • Chest X-ray • Plain skull X-ray • CT & MRI- Investigation of choice Hyper-dense masses with ring and surroundind edema, often”Target sign”
- 44. TREATMENT • Anti-tubercular therapy • Measures to reduce ICP • Control seizure
- 45. INDICATIONS: Intracranial lesions could not be specified Progressive neurological detoriation ALTERNATIVES: Excision: CSF-shunting: mandatory in complicating obstructive hydrocephalus SURGICAL TREATMENT
- 46. THANK YOU