Space occupying lesion

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2]

Overview

Intracranial space occupying lesions are tumors or abscesses present within the cranium or skull. These lesions put pressure on the adjacent brain tissue causing its damage.

Pathophysiology

  • Tumors of brain may develop focally or can be of metastatic origin. They grow in size causing focal tissue damage by pressure and infiltration.
  • Bleeding into the brain tissue causes formation of hematoma. If these hematoma's get infected they may turn into abscess.
  • With increasing volume in the brain pressure increases too leading to signs of increased intra cranial pressure.

Causes

  • Primary brain tumors
  • Metastatic lesion
  • Hematoma
  • Cerebral abscess
  • Lymphomas
  • Granuloma
  • Tuberculoma
  • Cysticercosis

Differentiating Space occupying lesions from other diseases

Pituitary apoplexy should be differentiated from other diseases causing severe headache for example: [1][2][3][4][5][6][7][8][9][10]

Disease Symptoms Diagnosis
CT/MRI Other Investigation Findings
Subarachnoid hemorrhage
Meningitis
  • CT scan of the head may be performed before LP to determine the risk of herniation.
  • Diagnosis is based on clinical presentation in combination with CSF analysis.
  • CSF analysis is the investigation of choice.
  • For more information on CSF analysis in meningitis please click here.
Intracranial mass
  • CT or MRI is the initial test to detect intracranial lesions.
  • These imaging tests determine the location of intracranial mass lesion(s) and help in guiding therapy.
  • Biopsy of the lesion is needed to identify the nature of the lesion such as:
  • X- ray of the skull is a non specific test, but useful if any of the lesions are calcified.
Cerebral hemorrhage
  • Progression of focal neurological deficits over periods of hours
  • CT scan without contrast is the initial test performed to diagnose ischemic stroke and rule out hemorrhagic stroke.
  • CT is very sensitive for identifying acute hemorrhage which appears as hyperattenuating clot.
  • Gradient echo and T2 susceptibility-weighted MRI are as sensitive as CT for detection of acute hemorrhage and are more sensitive for identification of prior hemorrhage.
Cerebral Infarction The symptoms of an ischemic stroke vary widely depending on the site and blood supply of the area involved. For more information on symptoms of ischemic stroke based on area involved please click here.
Intracranial venous thrombosis
  • The classic finding of sinus thrombosis on unenhanced CT images is a hyperattenuating thrombus in the occluded sinus.
  • Cerebral angiography may demonstrate smaller clots, and obstructed veins may give the "corkscrew appearance".
Migraine
  • CT and MRI may be needed to rule out other suspected possible causes of headache.
Migraine is a clinical diagnosis that does not require any laboratory tests. Laboratory tests can be ordered to rule out any suspected coexistent metabolic problems or to determine the baseline status of the patient before initiation of migraine therapy.
Head injury
  • CT scan is the first test performed and identifies cerebral hemorrhage (appears as hyperattenuating clot) following head injury. CT scan is also less time consuming.
  • MRI is more sensitive, takes more time and is done in patients with symptoms unexplained by CT scan.
Lymphocytic hypophysitis Lymphocytic hypophysitis is most often seen in late pregnancy or the postpartum period with the following symptoms:
  • CT & MRI typically reveal features of a pituitary mass.
Radiation injury

CT & MRI will show:

PET scan

Risk factors

  • Trauma
  • HIV infection
  • Diabetes
  • Malignancy
  • COPD (Chronic obstructive pulmonary disease)
  • Tuberculosis

History and symptoms

  • Headache
  • Nausea
  • Vomiting
  • Change in mental status
  • Seizures
  • Focal symptoms of brain damage
  • Associated co-morbid conditions like tuberculosis, etc

Diagnosis

Blood tests

  • Total blood count, hemoglobin levels for general condition of the person.
  • Electrolyte levels
  • Serum BNP(Brain natriuretic peptide)

Biopsy

  • Biopsy of the lesion is needed to know the nature of the lesion.

X ray

  • X- ray skull is quite a non specific test, but useful if any of the lesions are calcified.
  • X- ray chest may be warranted if any metastatic tumor is suspected.

CT and MRI

  • These tests are of higher value to detect intracranial lesions.
  • They have higher sensitivity and specificity compared to X-rays.

Treatment

Treatment depends on the type of the lesion and associated co morbid conditions.

Medical therapy

  • Pain killers to relieve the person from headache.
  • Steroids to reduce cerebral edema.
  • Mannitol to reduce intra cranial pressure.
  • Anticonvulsant medication to cover seizures.
  • Infections will need antibiotics which can cross blood brain barrier.
  • Tumors will treated with chemotherapy.

Surgery

  • Primary brain tumors can be surgical excised if they are amendable to surgery.
  • Brain radiation is useful in radio sensitive tumors.
  • Hematomas are surgically evacuated.

References

  1. Endrit Ziu & Fassil Mesfin (2017). "Subarachnoid Hemorrhage". PMID 28722987.
  2. Benedikt Schwermer, Daniel Eschle & Constantine Bloch-Infanger (2017). "[Fever and Headache after a Vacation in Thailand]". Deutsche medizinische Wochenschrift (1946). 142 (14): 1063–1066. doi:10.1055/s-0043-106282. PMID 28728201.
  3. Otto Rapalino & Mark E. Mullins (2017). "Intracranial Infectious and Inflammatory Diseases Presenting as Neurosurgical Pathologies". Neurosurgery. doi:10.1093/neuros/nyx201. PMID 28575459.
  4. I. B. Komarova, V. P. Zykov, L. V. Ushakova, E. K. Nazarova, E. B. Novikova, O. V. Shuleshko & M. G. Samigulina (2017). "[Clinical and neuroimaging signs of cardioembolic stroke laboratory in children]". Zhurnal nevrologii i psikhiatrii imeni S.S. Korsakova. 117 (3. Vyp. 2): 11–19. doi:10.17116/jnevro20171173211-19. PMID 28665364.
  5. Sanjay Konakondla, Clemens M. Schirmer, Fengwu Li, Xiaogun Geng & Yuchuan Ding (2017). "New Developments in the Pathophysiology, Workup, and Diagnosis of Dural Venous Sinus Thrombosis (DVST) and a Systematic Review of Endovascular Treatments". Aging and disease. 8 (2): 136–148. doi:10.14336/AD.2016.0915. PMID 28400981.
  6. Priyanka Yadav, Alec L. Bradley & Jonathan H. Smith (2017). "Recognition of Chronic Migraine by Medicine Trainees: A Cross-Sectional Survey". Headache. doi:10.1111/head.13133. PMID 28653369.
  7. S. Wulffeld, L. S. Rasmussen, B. Hojlund Bech & J. Steinmetz (2017). "The effect of CT scanners in the trauma room - an observational study". Acta anaesthesiologica Scandinavica. 61 (7): 832–840. doi:10.1111/aas.12927. PMID 28635146.
  8. Johnston PC, Chew LS, Hamrahian AH, Kennedy L (2015). "Lymphocytic infundibulo-neurohypophysitis: a clinical overview". Endocrine. 50 (3): 531–6. doi:10.1007/s12020-015-0707-6. PMID 26219407.
  9. Makale MT, McDonald CR, Hattangadi-Gluth JA, Kesari S (2017). "Mechanisms of radiotherapy-associated cognitive disability in patients with brain tumours". Nat Rev Neurol. 13 (1): 52–64. doi:10.1038/nrneurol.2016.185. PMID 27982041.
  10. Sato N, Sze G, Endo K (1998). "Hypophysitis: endocrinologic and dynamic MR findings". AJNR Am J Neuroradiol. 19 (3): 439–44. PMID 9541295.

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