Brain Masses¶
Background¶
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Neoplasm is the biggest concern
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90% of malignant brain masses are metastatic
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Most commonly: lung, RCC, breast, melanoma
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Highest bleeding risk: melanoma, thyroid, choriocarcinoma, RCC
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Primary brain tumors
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Gliomas: WHO Grade I-IV
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Glioblastoma multiforme (GBM) – WHO Grade IV; large heterogenous masses with edema; heterogenous contrast enhancement; can cross the corpus callosum
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Lower grade gliomas – include oligodendrogliomas and astrocytomas
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Meningioma: usually low grade
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Can be left alone and monitored with yearly MRI
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If symptomatic, may need resection/radiation
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Ependymoma: uncommon. Can cause CSF outflow obstruction
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CNS lymphoma – diffuse WM involvement, with mass effect, restricts diffusion on MRI with prominent contrast enhancement. Can also cross the corpus callosum
- Usually B-cell, initially responds significantly to steroids
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Presentation¶
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A significant number of brain lesions are detected incidentally
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If a patient has a first-time seizure, brain mass needs to be ruled out
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HA (usually constant, severe), seizure, and focal neurologic deficits
Evaluation/Management¶
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Imaging: MRI w/ and w/o contrast provides the most information
- Findings suggesting malignant lesions: marked edema, multifocal lesions, or presence at gray-white junctions
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LP may be indicated if herniation risk is low, particularly if concerned for infection
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Biopsy will ultimately be needed in most cases, which is done by NSGY
Management¶
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Work up for primary malignancy, CT C/A/P + PET
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Steroids are generally indicated for treatment of edema
- Decadron 10 mg IV to start; then transition to 4mg IV q6h with SSI
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Symptomatic tumors need eval by NSGY for resection consideration and radiation oncology