Intracranial space occupying lesions

Intracranial SOL

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.

4. 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

5. 4. Parasitic ( Cysticercosis , Hydratid cyst, Amebic abscess) 5. Vascular ( aneurysms , AVMs, stroke, etc .) 6. Inflammatory (Abscess, Tuberculoma , Syphilitic gumma , fungal Granulomas ) Angiogram: AVM Tuberculoma

6. Tumors

7. Clinical Presentations Headache Seizures Personality Changes Focal Deficits Papilledema Increased ICP

8. DIAGNOSIS

9. DIAGNOSIS Physical Examination Findings CT Scan Brain MRI Brain MR Angiography Laboratory Studies ( CBC, ESR, LFTS, Tumor Makers, etc) Biopsy

10. Gliomas Most common Primary Brain Tumors

11. Grade III Astrocytoma

12. Meningioma

13. Acoustic Schwannoma

14. Pineal Gland Tumor

15. Pituitary Adenomas

16. Treatment

17. Treatment Varies on histology of various tumors

18. TRAUMA

19. Intracranial haematomas I . Extra dural haematomas :- between the dura & the skull middle meningeal artery Common site is temporal fossa . TRAUMA

20. INVESTIGATIONS: CT ( Biconvex hyperdense lesion ) MRI CEREBRAL ANGIOGRAPHY Treatment: Surgical evacuation followed by Craniotomy

21. 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 .

22. 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.

23. 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 .

24. BRAIN ABSCESS Mostly single may be multiple Majority Supratentorial , 10% infratentorial Metastatic: hematogenesis,direct spread from adjacent structures or penetrating brain injury.

25. 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)

26. DIAGNOSIS Method of Choice- CT scan of Brain Ring enhancing Lesion Peripheral Blood smear Leukocytosis Raised ESR

27. TREATMENT SPECIFIC TREATMENT Anti-microbial therapy MEASURES TO REDUCE ICP Drainage of abscess Mannitol corticosteroids ANTI-EPILEPTIC TREATMENT Phenytoin Carbamazapine

28. SURGICAL TREATMENT GOALS: Obtain pus for culture & sensitivity Decrease ICP TECHNIQUES: Burr hole & aspiration Excision & craniotomy for recurrent, thickwalled brain abscess.

29. 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.

30. Clinical presentation Symptoms & signs of progressive intracranial SOL : Raised ICP Focal neurologic deficits Seizures etc General malaise,fever in 50% patients.

31. 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”

32. TREATMENT Anti-tubercular therapy Measures to reduce ICP Control seizure

33. INDICATIONS: Intracranial lesions could not be specified Progressive neurological detoriation ALTERNATIVES: Excision: CSF-shunting: mandatory in complicating obstructive hydrocephalus SURGICAL TREATMENT

34. THANK YOU