Download NORMAL OPTIC DISC and congestion

LEC3
‫ علي الشالجي‬.‫د‬
INTRACRANIAL SPACE OCCUPYING LESIONS
( I.C.S.O.L )
CLASSIFICATION
 Haematoma :
1. EDH ( extradural haem. )
2. SDH ( subdural haem. )
3. ICH ( intracerebral haem. )
4. IVH ( intraventricular haem. )
● Infection :
1. Bact. : which could be Acute ( brain abscess ) or chronic ( Granuloma )
2. Parasitic : hydatid cyst
3. Fungal
● Tumour : Primary or Secondary .
General signs and symptoms of increased intracranial pressure
A- Headache
The most common complaint of ICSOL . It’s usually chronic, not very severe (mild), throbbing in
nature & it's an early morning headache awakening the patient from sleep. The localization of the
headache is not significant in the localization of the lesion, for example; having frontal headache does
not mean the lesion is in the frontal lobe.
The headache occurs at early morning due to :
i. Respiration during sleeping is usually slower than normal  increased C02  vasodilatation -  congestion  stretching of meninges ~> headache .
ii. CSF gets collected intracranially due to the supine sleeping position, and with the presence of
ICSOL; the gradual pooling of CSF intracranialiy increases the ICP which leads to headache.
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B- Vomiting
Usually projectile also occurs at early morning. It can give temporary relief of the headache and thus
can be self-induced (the patient himself induces vomiting so as to get relief).
** Vomiting is an important feature in Pediatrics  Brain tumour .
he’s having a bad day ..
C- Papilloedema
( swelling of the optic disc).
# The optic nerve is part of the brain with full meningeal coverings.
In early papilloedema ; there will be 1 absence of venous pulsation leading to
2 congestion of the disc, after that there will be 3 nipping of the blood vessels & later there will be
haziness of the temporal margin of the disc .
# At the very late stages there will be
5 complete
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absence of the disc with areas of haemorrhage.
# Vision will not be much affected by papilloedema even in late stages.
# There may be different types of scotomas.
# Prolonged papilloedema can lead to secondary optic atrophy (white or pale disc with small blood
vessels).In secondary optic atrophy the vision will be severely impaired.
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NORMAL OPTIC FUNDUS &
NORMAL OPTIC DISC
Papilloedema ( loss of venous pulsation
and congestion )
Papilloedema ( nipping of blood vessels ,
complete absence of the disc with area
of haemorrhage )
OPTIC NERVE ATROPHY
Notes:
•
Venous pulsation is absent in about 20% of normal people.
• Seeing the pulsation excludes the presence of papilloedema, but not seeing it means either there
is papiiloedema or the person examined is normal.
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•
We depend on temporal margins to detect haziness because nasal margins can be normally hazy.
• Nipping means a snake - like appearance of the blood vessels which happens because the
vessels don't enter the disc in a straight line due to its swelling .
• In optic disc atrophy there will be a white or pale area, detecting blood vessels would not be
possible then.
• There are two causes for late presentation: 1 headache being mild and
stages of papilloedema.
2 normal
vision until late
D. Others, such as epilepsy (in adults with negative family history) & 6th cranial nerve palsy.
* The 6tn cranial nerve has a long intracranial course and can be considered as an intracranial
structure & that's why its palsy is considered as a general sign ; it is also considered as a false
localization sign because it doesn't give an accurate idea about the lesion's site.
RIGHT 6TH NERVE PALSY
hold him tight people he’s having a seizure
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Focal signs :
Such as hermiplegia, hemianaesthesia , aphasia or focal epilepsy. They depend on the
site of the ICSOL.
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BRAIN ABSCESS
It's the collection of pus inside the brain's parenchyma surrounded by true capsule.
It’s usually secondary to a focus outside the cranial cavity which reaches the brain either directly or
indirectly (blood borne) .
1- Direct route :
a- Chronic otitis media, which reaches the brain by 2 mechanisms ;
i- Perforation of the tympanic membrane leading to temperal lobe abscess.
ii- Posterior perforation of the mastoid process leading to cerebellar abscess (less
common),
b- Paranasal sinuses (mainly ethmoidal or frontal sinus ).
c- Penetrating wounds especially with foreign bodies as missiles & bullets.
d- Infections around the face (the dangerous triangle).
e- Osteomyelitis of skull bones (uncommon as we here have a heavy blood supply).
2- Indirect (blood borne):
By emboli from lung abscesses, bronchiectasis, valvular heart disease (esp. cyanotic) or
osteomyelitis of peripheral bones. Congenital valvular heart diseases are the most important cause in
children.
Clinical features:
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1- Picture of the underlying cause, such as osteomyelitis, lung abscess or valvular heart disease.
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2- Signs & symptoms of ICSOL (general & focal).
3- Signs & symptoms of intracranial infection, including fever, lassitude and, if meningitis present ,
neck stiffness , kernig’s sign & brudzinski’s sign .
Diagnosis:
Is by C.T. scan with contrast which will show hypodense lesion surrounded by a ring of enhancement
(the capsule) & oedema, MRI is not used as it takes a long time to achieve good result, a time which
we don't usually have in patients with ICSOL as they are irritable and (unstable).
Mastoiditis
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Sinusitis
CT scan of a brain abscess
Treatment :
1. Drainage ; usually by bur hole drainage, sometimes there's recurrence & may need to do several
drainages, It's done by using a catheter but its downside is that the capsule will not be evacuated
which means high recurrence rates. Some surgeons prefer to do craniotomy & excision of the abscess
with the capsule, usually done in a single surgery but it carries high morbidity &mortality rates.
2. Heavy systemic antibiotics, usually combination. Steroids are given when there's focal oedema
only,
3. Proper treatment of the underlying cause.
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CRANIOTOMY
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HYDATID CYST
Primary or secondary (the latter can be multiple and if multiple priority is given to the brain EXCEPT
when the lung is involved).
Diagnosis;
C.T. scan: very well circumscribed orange-like hypodense area with ventricular shift.
* Do CXR to exclude lung involvement .
Treatment
Craniotomy & excision (always try to evacuate the cyst intact).
*If there was rupture then wash the brain with hypertonic saline then give albendazole for 3 months
* Some researches suggest that rupturing the cyst then a 3 month treatment with albendazole is
sufficient.
* In treatment we must begin with hydatid cyst in lung, brain and then to the other organs
Prognosis
If it's primary & removed intact the prognosis is excellent, otherwise it's bad.
INTRACRANIAL H.C. CT-SCAN
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CRANIOTOMY FOR AN IC H.C.
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