476719
Intracerebral Space Occupying Lesions
- Causes
- Tumour (primary (astrocytoma, glioblastoma multiforme,
oligodendroglioma, ependymoma, primary CNS lymphoma, cerebellar
haemangioblastoma, meningioma) or secondary (30% - ie breast, lung,
melanoma), aneurysm, abscess (25% multiple), chronic subdural
haematoma, granuloma, cyst
- Tumour (primary (astrocytoma, glioblastoma multiforme,
oligodendroglioma, ependymoma, primary CNS lymphoma, cerebellar
haemangioblastoma, meningioma) or secondary (30% - ie breast, lung,
melanoma), aneurysm, abscess (25% multiple), chronic subdural
haematoma, granuloma, cyst
- Differential diagnoses
- Stroke, head injury, vasculitis eg SLE, syphilis, PAN,
giant cell arteritis, MS, encephalitis, post-ictal,
metabolic, 3rd ventricle colloid cysts, benign
intracranial hypertension
- Stroke, head injury, vasculitis eg SLE, syphilis, PAN,
giant cell arteritis, MS, encephalitis, post-ictal,
metabolic, 3rd ventricle colloid cysts, benign
intracranial hypertension
- Investigations
- CT,MRI. Consider biopsy.
Avoid LP (risk of coning)
- CT,MRI. Consider biopsy.
Avoid LP (risk of coning)
- Treatment
- Benign mass: removal if possible,
but may be inaccessible
- Malignant mass: Excision if possible then
consider chemo-radiotherapy. If inaccessible just
chemo-radiotherapy. If inaccessible but causing
hydrocephalus try ventriculo-peritneal shunt. Give
prophylaxis for epilepsy, analgesia ie codeine for
headache and give dexamethasone for cerebral
oedema and mannitol if acutely raised ICP. Plan
palliative treatment.
- Benign mass: removal if possible,
but may be inaccessible
- Prognosis
- Poor but improving for
gliomas and benign masses
- Poor but improving for
gliomas and benign masses
- Examples
- 3rd ventricle colloid cysts
- Congenital cysts. Present
in adulthood with amnesia,
headache, obtundation
(blunted consciousness),
incontinence, dim vision,
bilat paraesthesiae, weak
legs, drop attacks.
Investigations: CT
scan/MRI. Treatment:
excision or VP shunt
- Congenital cysts. Present
in adulthood with amnesia,
headache, obtundation
(blunted consciousness),
incontinence, dim vision,
bilat paraesthesiae, weak
legs, drop attacks.
Investigations: CT
scan/MRI. Treatment:
excision or VP shunt
- Benign intracranial
hypertension (pseudotumour
cerebri)
- Present with symptoms of mass
(headache, raised ICP,
papilloedema) but none found.
Typically obese women with blurred
vision +/- diplopia, VIth nerve palsy,
enlarged blind spot if papilloedema
present. Consciousness and
cognition are preserved. Cause:
Often unknown or secondary to
venous sinus thrombosis or drugs ie
tetracycline, nitrofurantoin,
isoretinoin. Treatment: weight loss,
acetazolamide, loop diuretics,
prednisalone (may reverse
papilloedema). Consider optic nerve
sheath fenestration or
lumbar-peritoneal shunt if drugs fail
and visual loss worsens. Prognosis:
often self-limiting, permanent visual
loss in 10%
- Present with symptoms of mass
(headache, raised ICP,
papilloedema) but none found.
Typically obese women with blurred
vision +/- diplopia, VIth nerve palsy,
enlarged blind spot if papilloedema
present. Consciousness and
cognition are preserved. Cause:
Often unknown or secondary to
venous sinus thrombosis or drugs ie
tetracycline, nitrofurantoin,
isoretinoin. Treatment: weight loss,
acetazolamide, loop diuretics,
prednisalone (may reverse
papilloedema). Consider optic nerve
sheath fenestration or
lumbar-peritoneal shunt if drugs fail
and visual loss worsens. Prognosis:
often self-limiting, permanent visual
loss in 10%
- 3rd ventricle colloid cysts
- Localising signs
- Temporal lobe: HAPPY-CLAPPY DJ. Hemianopia,
Automatisms, Psychosis, Precognition, Yells and falls
to floor (type of seizure), (or) Complex-partial
seizures, Language disorders, Amnesia, Panic or
rage, Pains ie abdo, You do not believe pts bizarre
story, Déjà vu, Jamais vu.
- Frontal lobe: Hemiparesis, motor seizures,
personality change, grasp reflex, Broca’s dysphasia,
concrete thinking, orbitofrontal syndrome (reduced
empathy, inhibition, social skills), utilization
behaviour (whatever is provided is used)
- Parietal lobe:
hemisensory loss ie
reduced 2 point
discrimination
- Occipital lobe:
contralateral visual
field defects,
hallucinations
- Cerebellum: DASHING: Dysdiadochokinesis,
Ataxia (if trunchal ataxia worse on eye closure then
more likely dorsal column pathology), Slurred
speech, Hypotonia, Intention tremor, Nystagmus,
Gait abnormality
- Cerebellopontine angle: (ie acoustic neuroma)
ipsilateral deafness, nystagmus, reduced corneal
reflex, facial weakness (rare), ipsilateral
cerebellar signs, papilloedema, VI nerve palsy
- Corpus callosum: (rare site for
lesions) intellectual deterioration,
loss of communication between
lobes (eg left hand unable to carry
out verbal commands)
- Midbrain: (ie pineal
tumours/midbrain infarction) failure
of up/down gaze, light/near
dissociated pupil responses,
nystagmus
- Temporal lobe: HAPPY-CLAPPY DJ. Hemianopia,
Automatisms, Psychosis, Precognition, Yells and falls
to floor (type of seizure), (or) Complex-partial
seizures, Language disorders, Amnesia, Panic or
rage, Pains ie abdo, You do not believe pts bizarre
story, Déjà vu, Jamais vu.
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