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Focal Mass Lesions


Introduction

Focal brain masses are a common reason for neurologic consultation, particularly in the inpatient setting. The main etiologic considerations include malignancy, infection, and, less commonly, inflammatory disease. The management of the brain mass varies widely depending on the etiology. This chapter will focus on the initial diagnostic evaluation and initial management of focal brain lesions.

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Questions

  • 1.

    Is the patient fully awake and alert?

    A stuporous patient is at risk for airway compromise.

  • 2.

    What are the vital signs?

    Hypertension with or without bradycardia (Cushing syndrome) is a sign of increased intracranial pressure.

  • 3.

    Does the patient have any preexisting medical conditions?

    In particular, a prior history of cancer or immunocompromised state can help narrow the differential diagnosis.

  • 4.

    Has the patient traveled recently?

    This raises concern for fungal/parasitic infections (see the following).

  • 5.

    Does the patient have any neurologic symptoms (e.g., headache, weakness, visual complaints, speech difficulty)?

    If so, approximately how long have these symptoms existed? Symptoms occurring over the course of days would raise concern for infection, whereas symptoms occurring over weeks to month would be more consistent with a cancer.

Orders

  • 1.

    If there is clinical concern for increased intracranial pressure, the following measures should be implemented: (a) elevate the head of the bed to 30 degrees and (b) administer osmotherapy with either 20% mannitol 1g/kg intravenously (IV) or 30 mL of 23.4% hypertonic saline (this requires dental venous access).

  • 2.

    If there is concern that the patient cannot protect his or her airway, the patient should be intubated and hyperventilated to a Pa co 2 of 30mm Hg.

  • 3.

    Rapid HIV test.

  • 4.

    Complete blood count (CBC) with differential, basic metabolic panel (BMP), coagulation tests.

  • 5.

    Chest X-ray (CXR).

Elevator thoughts

What is the differential diagnosis for focal mass lesions? The main two considerations are malignancy (metastatic or primary) or infection (abscesses or cerebritis). Other etiologies include autoimmune/inflammatory and vascular.

Before seeing the patient, the neurologist should visually review the imaging of concern. Usually, the imaging of concern is a computed tomography (CT) scan. Most brain masses are hypodense on CT scan. A divergence from this can be helpful in narrowing the differential diagnosis:

  • 1.

    Hyperdense signal mixed into the hypodense mass:

    • Tumor with hemorrhage (e.g., glioblastoma), tumor with calcification (e.g. oligodendroglioma) or abscess

  • 2.

    Homogenous hyperdense signal:

    • Melanoma, medulloblastoma, or meningioma.

  • 3.

    Punctate calcification:

    • Ependymomas > meningiomas > medulloblastomas. Tuberculomas have a pathognomonic “target sign” resulting from central calcification surrounded by a hypodense area with peripheral ring enhancement with IV contrast.

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