OHCM - Space-Occupying Lesions Flashcards Preview

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Flashcards in OHCM - Space-Occupying Lesions Deck (40):

SOLs - Seizures:

Seen in


SOLs - Evolving focal neurology:

Incr. ICP causes false localizing signs: VI nerve palsy is commonest due to its long intracranial course.


SOLs - Subtle personality change:

1. Irritability.
2. Lack of application to tasks.
3. Lack of initiative.
4. Socially inappropriate behavior.


SOLs - Causes:

1. Tumor (primary or metastatic).
2. Aneurysm.
3. Abscess (25% multiple).
4. Chronic subdural hematoma.
5. Granuloma (tuberculoma).
6. Cyst (cysticercosis).


SOLs - Tumors:

1. 30% are metastatic (breast, lung, melanoma).
2. Primaries: Astrocytome, GBM, oligodendroglioma, ependymoma.
3. Also meningioma (F:M=2:1).
4. Primary CNS lymphoma (as non infectious manifestation of HIV).
5. Cerebellar hemangioblastoma.


SOLs - DDx:

1. Stroke.
2. Head injuries.
3. Venous sinus thrombosis.
4. Vasculitis (SLE, syphilis, PAN, giant-cell arteritis).
5. MS.
6. Encephalitis.
7. Post-ictal (Todd's palsy).
8. Metabolic or U&E disturbance.
9. Colloid cyst of the 3rd ventricle.
10. Idiopathic intracranial HTN.


Tumor management - Benign:

Removal if possible but some may be inaccessible.


Management of tumors - Malignant:

Excision of gliomas is hard as resection margins are RARELY CLEAR, but surgery does give a tissue diagnosis + debulking + makes cavity for inserting CARMUSTINE WAFERS (may cause serious cerebral edema).


Oligodendroglioma with ... deletions are particularly sensitive to chemo-radiotherapy.

1p/19q deletions.


In GBM - Role of temozolomide:

New alkylating agent - Increases survival (benefit is mainly if tumors have methylated methylguanine methyltransferase gene promoters and are thus unable to repair chemotherapy-induced DNA damage).


Cerebral edema - Give:

Dexamethasone 4mg/8h PO - Mannitol if incr. ICP acutely.



Incr. ICP:
1. Headache worsens on waking, lying down, bending forward, or with coughing.
2. Vomiting.
3. Papilledema (only in 50% of tumors).
4. Decreasing GCS.


SOLs - Prognosis:

1. Poor but improving (


3rd ventricle colloid cysts:

Declare themselves in adult life with:
1. Amnesia.
2. Headache (often positional).
3. Obtundation (blunted consciousness).
4. Incontinence.
5. Dim vision.
6. Bilateral paresthesiae.
7. Weak legs.
8. Drop attacks.


3rd ventricle colloid cysts - Rx:

Excision or ventriculo-peritoneal shunting.


Idiopathic intracranial HTN (pseudotumor cerebri) - Think of this ...?

As if this in those presenting as if with a mass (headache, incr. ICP, papilledema) when NONE IS FOUND.


Idiopathic intracranial HTN - Typical patients are:

1. Obese women with narrowed visual fields.
2. Blurred vision +/- diplopia.
3. VI palsy.
4. An enlarged blind spot, if papilledema is present (it usually is).


Idiopathic intracranial HTN - Consciousness and cognition are ...?



Idiopathic intracranial HTN - Etiology:

1. Often unknown, or ...
2. Secondary to venous sinus thrombosis.
3. Drugs.


Idiopathic intracranial HTN - Drugs:

1. Tetracycline.
2. Minocycline.
3. Nitrofurantoin.
4. VitA.
5. Isotretinoin.
6. Danazol.
7. Somatotropin.


Idiopathic intracranial HTN - Rx:

1. Weight loss.
2. Acetazolamide.
3. Loop diuretics.
4. Prednisone (start at 40mg/24h PO, more SE than diuretics).
--> May REVERSE papilledema.


Idiopathic intracranial HTN - What to consider when drugs fail and visual loss worsens?

Consider optic nerve sheath fenestration or lumbar-peritoneal shunt.


Idiopathic intracranial HTN - Prognosis:

1. Often self-limiting.
2. Permanent significant visual loss in 10% (ie not so benign).
3. CSF shunting or optic nerve sheath fenestration can help vision.


SOLs - Localizing features, ask first WHERE the mass is, then WHAT IS IT?
Localizing features of SOLs can be thought of as dividing into ...?

1. Positive symptoms.
2. Negative symptoms.


Negative symptoms:

Deficits caused by DIRECT pressure or tumor invasion.


Positive symptoms:

Due to localized seizure activity caused by irritation of the brain parenchyma.


Negative and positive symptoms depend on the ...?

Function of the area of the brain affected.


SOLs in which locations present late?

1. Frontal lobe.
2. Midline.
3. Non-dominant temporal lobe.


SOLs - Temporal lobe - Features:

1. Dysphasia.
2. Contralateral homonymous hemianopia (or UPPER quadrantanopia if only Meyer's loop affected.
3. Amnesia.
4. Many odd or seemingly inexplicable phenomena.


SOLs - Frontal lobe - Features:

1. Hemiparesis.
2. Personality change (indecent, indolent, indiscreet, facetious, tendency to pun).
3. Release phenomena such as the grasp reflex (significant only if unilateral).
4. Broca dysphasia.
5. Unilateral anosmia (loss of smell).
6. General lack of drive or initiative.
7. Concrete thinking.
8. Perseveration (unable to switch from one line of thinking to another).
9. Executive dysfunction (unable to plan tasks).
10. Decr. verbal fluency, eg unable to list words beginning with the letter "A" or "F" (normal is about 15 words in 1 min).


Orbitofrontal syndrome:

1. Lack of empathy.
2. Over-eating.
3. Disinhibition.
4. Impulsive behavior.
5. Decr. social skills.
6. Over-familiar.
7. Unconscious imitation of postures (eg when you put your feet on the desk, or sit on the floor).
8. "Utilization behavior" (whatever is provided is used, eg hand the patient spectacles, and he puts them on, hand him another pair, and this goes on his nose too, ditto for a 3rd pain).


SOLs - Parietal lobe - Features:

1. Hemisensory loss.
2. Decr. 2-point discrimination.
3. Astereognosis (unable to recognize an object by touch alone).
4. Sensory inattention.
5. Dysphasia.
6. Gerstmann's syndrome.


SOLs - Occipital lobe - Features:

1. Contralateral visual field defects.
2. Palinopsia.
3. Polyopia (seeing multiple images).


SOLs - Cerebellum - Features:


Dysmetria (past-pointing)
Ataxia (limb/truncal).
Slurred speech (dysarthria).
Intention tremor.
Gait abnormality.


SOLs - Cerebellopontine angle - Features:

1. Ipsilateral deafness.
2. Nystagmus.
3. Diminished corneal reflex.
4. Facial weakness (rare).
5. Ipsilateral cerebellar signs.
6. Papilledema.
7. VI palsy.


SOLs - Corpus callosum - Features:

Rare site for lesions:
Severe rapid intellectual deterioration with focal signs of adjacent lobes and signs of loss of communication between lobes (eg left hand unable to carry out verbal commands).


SOLs - Midbrain - Features:

Eg pineal tumors or midbrain infarction.
1. Failure of up or down gaze.
2. Light/near dissociated responses with convergence globe-retracting nystagmus from co-contraction of opposing horizontal muscles, on attempted up-gaze.
3. Elicited by looking at a down-moving target.


The orbitofrontal cortex and right amygdala ...?

Appreciate beauty (and sexual allure). The poets were nearly right that "Beauty is in the eye of the beholder". It is about 1cm ABOVE the orbit.


Palinopsia is ...?

Persisting or recurring images, once the stimulus has left the field of view.


If truncal ataxia is worse on eye closure, blame the ...?

DORSAL COLUMNS - not the cerebellum.