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Space-occupying lesions (SOLs) (Clinical presentation (High ICP…
Space-occupying
lesions (SOLs)
Definition
Pathology within the brain
causing mass effect and
compression of the brain
Aetiology
Neoplastic
CNS tumour (astrocytoma, GBM)
Metastasis (lung, breast, melanoma)
Lymphoma
Meningioma
Infection
Abscess
Granuloma e.g. TB
Cyst
Vascular
Aneurysm
Haemorrhage (e.g. SDH)
Pathophysiology
Compression of the ventricles causing
raised ICP and papilloedema
Compression of brain parenchyma, causing
e.g. seizures, focal deficits, personality change
Localising features
Frontal
Personality change
Hemiparesis
Release phemomena
Broca's aphasia
Unilateral anosmia
Reduced executive function
Temporal
Dysphasia
Homonymous hemianopia/quadrantinopia
Amnesia
Parietal
Dysphasia
Hemisensory loss
Sensory innattention
Occipital
Visual field defects
Polyopia (multiple images)
Cerebellum
Dysdiadochokinesis
Dysmetria (past pointing)
Ataxia
Dysarthria
Intention tremor
Hypotonia
Nystagmus
Gait abnormality
Midbrain
Failed up/down gaze
Light/near dissoc pupil responses
Nystagmus
Cerebellopontine angle
Ipsilateral deafness
Nystagmus
Reduced corneal reflex
Facial weakness
Cerebellar signs
Papilloedema
CN VI palsy
Corpus collosum
Lost connection between two sides
Cognitive decline
Focal signs
Clinical
presentation
Focal signs
(Can be false localising with
high ICP e.g. CN VI lesion)
Seizures
High ICP
Vomitting
Confusion/coma
Headache
Character
Radiation
Onset
Gradual
Associated symptoms
Vomiting, reduced GCS, vision defect
Site
Head!
Timing
Continous
Exacerbating/relieving factors
Exacerbating: waking, lying down, bending, coughing
Relieving - sitting/standing up
Personality change
Often subtle
Irritable, poor conc,
socially inappropriate
Diagnosis
Examination
Neuro - focal signs, seizures, low GCS
Fundo - papilloedema
Investigations
Bedside
Obs - pyrexia if infection
Bloods
FBC, U+E, LFTs
Blood cultures
Imaging
CT head - SOL, high ICP (large ventricles)
MRI - posterior fossa
Lumbar puncture
After CT if no ventricle enlargement (risk coning)
Cytology, WCC, glucose, lactate, protein
History
PC - headache, confusion, N+V,
focal signs, personality change, red flags
HPC - previous cancers, infection, HTN
DH - anticoagulation, allergies
FH - cancers
SH - travel, smoking, alcohol
Management
Conservative
Establish cause
Surgery
VP shunt
Indication: hydrocephalus
Tumour resection
Indication: primary tumour, accessible
Medical
Steroids
Indication: cerebral oedema e.g. tumour
E.g. dexamethasone
Mannitol
Indication: acute raised ICP
Chemotherapy
Indication: advanced tumours, adjuvant
E.g. crmustine, telozolamide
Radiotherapy
Indication: advanced tumours, adjuvant, mets