Glioblastoma: WHO Grade IV; large heterogenous masses with edema; heterogenous contrast enhancement; can cross the corpus callosum (butterfly pattern)
Lower grade gliomas include oligodendrogliomas and astrocytomas
Meningioma: usually low grade
Can be left alone and monitored with yearly MRI
If symptomatic, may need resection/radiation
Ependymoma: uncommon. Can cause CSF outflow obstruction
CNS lymphoma: diffuse white matter involvement with mass effect, diffusion restriction on MRI with prominent contrast enhancement; can cross the corpus callosum
Usually B-cell, initially responds significantly to steroids
Presentation
A significant number of brain lesions are detected incidentally
If a pt has a first-time seizure, brain mass needs to be ruled out with head imaging
Symptoms: headache (usually constant, severe), seizure, and focal neurologic deficits
Evaluation and Management
Imaging: MRI w/wo contrast provides the most information
Findings suggesting malignant lesions: Marked edema, multifocal lesions, or presence at gray-white junctions
LP may be indicated if herniation risk is low, particularly if concerned for infection
Biopsy (with assistance from Neurosurgery) will ultimately be needed in many cases
Management
Work up for primary malignancy, including CT C/A/P and PET
Steroids are generally indicated for treatment of edema
Decadron 10 mg IV to start; then transition to 4mg IV Q6H with SSI and PPI
If pt is clinically stable and there is a concern for CNS lymphoma, consider delaying steroids to increase yield of cytology and biopsy, unless edema/mass effect warrants emergent treatment
Symptomatic tumors need evaluation by Neurosurgery for resection consideration and Radiation Oncology
