Intracranial Space Occupying Lesions


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Intracranial Space Occupying Lesions:

Intracranial Space Occupying Lesions Dr Rahul Chakor MD.,DM Dept of Neurology T. N. Medical. College B. Y. L. Nair Hospital Mumbai

Outline of Talk:

Outline of Talk General Comments List IC SOLs Neoplasms Symptoms and signs


IC SOLs Occupy physical space within the cranial cavity Results in symptoms and signs due to > Dysfunction of the nearby structures > Pressure symptoms - Rise in intracranial pressure > Electrical disturbance - Seizures


S/S are due to location of the SOL irrespective of etiology S/S often reflect the rapidity of growth ( expansile nature ) of the SOL * Slowly growing SOLs produce not many S/S * Rapidly growing SOLs produce many S/S Tendency to cause ↑ ICP IC SOLs


Pathology – Benign, malignant Extent of involvement of important structures – Early detection Tumors in silent areas may reach considerable size before becoming apparent IC SOLs


Neuroanatomy – Lobes, cortical, subcortical structures Blood supply Loss of Function due to various pathologic process IC SOLs

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Frontal lobe Cognition Executive Motor –Pr & Sec Motor speech Behavior Praxis Eye movements Dysexecutive Disinhibition Apathetic Temporal Lobe Memory Emotions Sexual Auditory Auditory Comprehension Kluver Bucy S Parietal Sensory Gerstmann’s S Construction Dressing Visuospatial Attention Occipital Vision Color Balint’s S Visual Agnosia


IC SOLs Brain parenchyma – astrocytoma, oligodendroglioma, Medulloblastoma (precursor cells), developmental (DNET) Meninges – meningioma Cranial nerves – acoustic neuromas, optic gliomas Skull - HFN Squamous cell Ca, osteosarcoma, chondrosarcoma,angiosarcoma


IC SOLs Infective SOLs Brain Abscess Subdural Abscess Epidural Abscess Hydatid Cyst Granulomas Neurocysticercosis Tuberculoma Hemorrhage Intracerebral Subdural Epidural Neoplasms Malignant * Primary * Metastasis Benign

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Intra axial Astrocytoma Oligodendrogliomas CNS Lymphoma Metastasis Extra axial Meningiomas Schwanomma Metastasis (Epidural) Skull

IC Tumors:

IC Tumors Overall Incidence of 25 per 100,000 per year Incidence of Malignant IC tumors 7 per 100,000 per year Incidence of non malignant tumors 7 per 100, 000 per year 40 to 50 % IC tumors are gliomas 15 to 20% IC tumors are meningiomas Metastases is 10 times common than Primary CNS tumors

Primary Brain Tumors:

Primary Brain Tumors Glial tumors (Glioma) - 50 to 60% Astrocytoma (Commonest), Glioblastoma, oligodendroglioma, ependymoma Meningioma - 25% Schwannoma - 10% Remaining - 10 to 15%


Astrocytomas Grade I Juvenile Pilocytic astrocytoma Subependymal giant cell astrocytoma Pleomorphic xanthoastrocytoma Grade II Fibrillary astrocytoma Grade III Anaplastic astrocytoma Grade IV Glioblastoma Multiform


Metastasis More prevalent than Primary CNS tumors 10:1 ratio Known cancer - Lung, Breast, Prostate, Melenoma,ovary Supratentorial, multiple, gray white junction, enhancement, edema CNS Metastases as initial manifestation in 10 to 30% cases (70% Lung cancer)

Clinical features:

Clinical features Headache - ↑ ICP, stretching or pressure of pain sensitive structures (dura, vessels, nerves, sinuses), referred pain Seizures - 4% of Epilepsy is due to IC SOLs , partial, secondarily generalized Cognitive dysfunction - Location, grade Nausea, vomiting - ↑ ICP, posterior fossa Visual symptoms - obscuration, papilloedema, bitemporal hemianopia, diplopia, hallucinations

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Neurological evaluation Localization Extent Papilloedema

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Pilocytic astrocytoma

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Pilocytic astrocytoma

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Primary CNS Lymphoma

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Meningioma ● Parasagittal ● Tentorial ● Convexity ● Subfrontal ● Cerebellopontine angle ● Sphenoid wing ● Foramen magnum ● Optic nerve Neuroimaging

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Acoustic Neuroma

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Gliobastoma Multiform

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Low grade Glioma

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Metastases - Lung


Management Immediate *Corticosteroids - 16mg then 12 to 24mg/day *Ventricular drainage or shunt for hydrocephalus *Ventilate and hyperventilation *Surgical decompression *Mannitol (sometimes) 1g/kg bolus then 200 to 700mg/kg every 4 to 6 hrly *Frusemide

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Antiepileptics *If seizures - Carbamazepine, Oxcarbazepine *If Status Epilepticus - Treat accordingly *No need of prophylactic AED therapy DVT prophylaxis *If high risk


Intermediate Management MRI (spectroscopy, diffusion images) CT of chest abdomen for ? Metastasis If Imaging diagnosis is uncertain Is it a primary or a secondary tumor

Good clinical practice:

Good clinical practice Multidisciplinary meeting to discuss management plan Timely, verbal, written communication between the doctor, patient and near ones. Between doctors involved in care. Histopathology is the key to appropriate treatment and accurate prognosis Not to discuss details of treatment before the diagnosis is certain

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Biopsy versus resection * Biopsy to confirm histological type and grade of tumor * Maximal resection for lobar tumors in <60 yr and good Karnofsky score * Deep hemispheric and diffuse cerebral tumors, elderly, poor performance score - safe resection not possible hence biopsy for confirming diagnosis

Low grade Glioma (Gr I or II):

Low grade Glioma (Gr I or II) Gr I - complete resection leads to cure. Radiation only if incomplete resection Gr I & II - Watchful waiting with interval scans at 3, 6 months Surgical treatment only if tumor progression Surgical biopsy at diagnosis to confirm grade

Low grade Glioma (Gr I or II):

Radiothearpy *Early - At histological diagnosis *Late - At radiological or surgical progression *45-50 Gy over 5 weeks in 25 fractions *Radiation induced leukoencephalopathy ? Chemotherapy Oligodendroglioma in children Low grade Glioma (Gr I or II)

High grade Glioma (Gr III or IV):

Prognosis better if *Age <40yr *Performance >70 *Gr III better tha IV *Tumor type (oligo better than astro) *? Extent of resection High grade Glioma (Gr III or IV)

High grade Glioma (Gr III or IV):

Surgery * No definite evidence that extent of resection improves survival * Morbidity related to location (eloquent versus non-eloquent) & extent of resection Radiotherapy * Standard postoperative external beam radiotherapy * 60 Gy in 30 fractions, 2 Gy over week days over 6 week period * Stereotactic radiotherapy, brachtherapy High grade Glioma (Gr III or IV)

High grade Glioma (Gr III or IV):

Chemotherapy Temozolomide -75mg/m2 per day for 7 days a week with radiotherapy for 6 weeks. Then 150-200mg/m2 on days 1 to 5 of each month for 6 cycles. Procarbazine with nitrosiureas and vincristine Multimodality approach High grade Glioma (Gr III or IV)

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