Intracerebral Space Occupying Lesions

Causes
1. 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
1. Stroke, head injury, vasculitis eg SLE, syphilis, PAN, giant cell arteritis, MS, encephalitis, post-ictal, metabolic, 3rd ventricle colloid cysts, benign intracranial hypertension
Investigations
1. CT,MRI. Consider biopsy. Avoid LP (risk of coning)
Treatment
1. Benign mass: removal if possible, but may be inaccessible
2. 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.
Prognosis
1. Poor but improving for gliomas and benign masses
Examples
1. 3rd ventricle colloid cysts
  1. 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
2. Benign intracranial hypertension (pseudotumour cerebri)
  1. 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%
Localising signs
1. 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.
2. 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)
3. Parietal lobe: hemisensory loss ie reduced 2 point discrimination
4. Occipital lobe: contralateral visual field defects, hallucinations
5. 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
6. Cerebellopontine angle: (ie acoustic neuroma) ipsilateral deafness, nystagmus, reduced corneal reflex, facial weakness (rare), ipsilateral cerebellar signs, papilloedema, VI nerve palsy
7. Corpus callosum: (rare site for lesions) intellectual deterioration, loss of communication between lobes (eg left hand unable to carry out verbal commands)
8. Midbrain: (ie pineal tumours/midbrain infarction) failure of up/down gaze, light/near dissociated pupil responses, nystagmus

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Intracerebral Space Occupying Lesions

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	Criado por emailk8 quase 11 anos atrás