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, cognitive or behavioral changes, 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.
New CSF genomics assay through Belay Diagnostics can be considered for masses of unknown origin that are unamenable to biopsy.
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.
