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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. 1 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 4 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. 2 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. 3 • 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 4 Focal signs : Such as hermiplegia, hemianaesthesia , aphasia or focal epilepsy. They depend on the site of the ICSOL. 5 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: 9 1- Picture of the underlying cause, such as osteomyelitis, lung abscess or valvular heart disease. 6 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 7 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. 8 CRANIOTOMY 9 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 10 CRANIOTOMY FOR AN IC H.C. 11