Supratentorial Mass Lesions Research Articles

The value of motor evoked potentials in detecting mechanical versus vascular injury during resection of supratentorial mass lesions

The value of motor evoked potentials in detecting mechanical versus vascular injury during resection of supratentorial mass lesions

Large intracranial supratentorial tuberculoma imitating as a malignant lesion: a case report

BackgroundCNS TB roughly correlates to 1–10% of all intracranial tumors. The spectrum of CNS-TB is wide and can present as tuberculous meningitis, tubercular abscess, tuberculoma, or hypertrophic pachymeningitis. Tuberculomas are usually located at the corticomedullary junction and periventricular region, as expected for hematogenous dissemination. They are mostly infratentorial in children and supratentorial in adults. They may present months to years after infection.ObservationsHere we have a 55-year-old female who presented with a history of headaches, sudden loss of consciousness, and seizures. Initial imaging showed a right parietal mass lesion appearing to be malignant on initial imaging which had a significant mass effect and midline shift. The patient was operated on for the same and histopathology showed chronic granulomatous lesion and tissue staining s/o tuberculosis.LessonsSo a diagnostic option for infective etiology should be kept even for an intracranial supratentorial mass lesion.

The Kinetics of Transtentorial Brain Herniation: Kernohan-Woltman Notch Phenomenon Revisited.

To critically review recent literature in understanding the pathological consequences of transtentorial brain herniation resulting from unilateral expanding supratentorial mass lesions. Modern neuroimaging assists in understanding the consequences of transtentorial brain herniation with the development of the Kernohan-Woltman notch phenomenon. MRI studies in post-operative patients undergoing craniotomy and removal of expanding unilateral hemispheric mass lesions (usually an extradural or subdural hematoma) have shown striking findings in the contralateral crus cerebri suggestive of damage as a result of impact against the free margin of the opposite tentorium as suggested by Kernohan and Woltman nearly a century back in autopsy studies. MR changes include T1 hypointensity, T2 and fluid-attenuated inversion recovery (FLAIR) hyperintensity, DW1 hyperintensity with restriction of diffusion, presence of hypointensity in GRE sequences and evidence of axonal damage in the corticospinal tracts in the cerebral peduncle in diffusion tensor imaging and MR tractography. The pathological basis of such changes may be variable or a combination of several pathological processes, which may all be related to the impact/compression of the contralateral crus with the tentorial margin. These include contusion, compression, demyelination, and perhaps most importantly microvascular damage including microbleeds. The role of uncal herniation is debatable. It appears that as a result of massive lateral shift in the supratentorial compartment, there is a transient forceful impact of the opposite cerebral peduncle against the rigid tentorial border to induce one or more of the abovementioned phenomena to explain the imaging findings. The limitation of these studies is that most of them have been done in the post-operative periods and surgical manipulations can surely alter anatomical relationships between intracranial structures. The exact sequence of events happening intracranially in the face of rapidly expanding supratentorial mass lesions is largely unknown. Even with rapid progress in neuroimaging, documentation of such changes during life are difficult, principally for logistic reasons. Consequently, the very truth of the much taught about phenomenon of uncal herniation and the resultant Kernohan-Woltman notch phenomenon and the false localizing sign of unilateral motor weakness and contralateral pupillary dilation have been questioned. Animal experimentation and autopsy studies have not contributed much in our understanding of the actual process happening intracranially in such an emergent situation. The midbrain undoubtedly is the key structure bearing the brunt of the effect of brain shift which is more lateral than downward in cases with unilateral expanding lesions. Structural changes in the cerebral peduncles have now been visualized with modern neuroimaging. These alterations may result from the interplay of one or more factors which include compression, contusion, demyelination, and perhaps most importantly microvascular ischemia and hemorrhage resulting from a forceful yet transient impact of the cerebral peduncle with the tough tentorial margin. The last mentioned hypothesis would be in conformity with Kernohan and Woltman's concept of elastic deformation of the midbrain. In the present article an attempt is made to provide a historical account of the changing concepts in relation to brain herniation as systematically and chronologically as possible, and then, critically review recent neuroimaging observations with a view to hypothesize on the sequence of events during transtentorial brain herniation.

WE-221. The value of motor evoked potentials in detecting mechanical versus vascular injury during resection of supratentorial mass lesions

WE-221. The value of motor evoked potentials in detecting mechanical versus vascular injury during resection of supratentorial mass lesions

What is the Role of Hyperosmolar Therapy in Hemispheric Stroke Patients?

The role of hyperosmolar therapy (HT) in large hemispheric ischemic or hemorrhagic strokes remains a controversial issue. Past and current stroke guidelines state that it represents a reasonable therapeutic measure for patients with either neurological deterioration or intracranial pressure (ICP) elevations documented by ICP monitoring. However, the lack of evidence for a clear effect of this therapy on radiological tissue shifts and clinical outcomes produces uncertainty with respect to the appropriateness of its implementation and duration in the context of radiological mass effect without clinical correlates of neurological decline or documented elevated ICP. In addition, limited data suggest a theoretical potential for harm from the prophylactic and protracted use of HT in the setting of large hemispheric lesions. HT exerts effects on parenchymal volume, cerebral blood volume and cerebral perfusion pressure which may ameliorate global ICP elevation and cerebral blood flow; nevertheless, it also holds theoretical potential for aggravating tissue shifts promoted by significant interhemispheric ICP gradients that may arise in the setting of a large unilateral supratentorial mass lesion. The purpose of this article is to review the literature in order to shed light on the effects of HT on brain tissue shifts and clinical outcome in the context of large hemispheric strokes, as well as elucidate when HT should be initiated and when it should be avoided.

Automated Pupillometry and Detection of Clinical Transtentorial Brain Herniation: A Case Series.

Transtentorial herniation (TTH) is a life-threatening neurologic condition that typically results from expansion of supratentorial mass lesions. A change in bedside pupillary examination is central to the clinical diagnosis of TTH. Materials and. To quantify the changes in the pupillary examination that precede and accompany TTH and its treatment, we evaluated 12 episodes of herniation in three patients with supratentorial mass lesions using automated pupillometry (NeurOptics, Inc., Irvine, CA). Herniation was defined clinically by the onset of fixed and dilated pupils in association with decreased levels of consciousness. Automated pupillometry was measured simultaneously with the bedside clinical examination, but the clinical team was blinded to these results and could not act on the data. Data from the pupillometer were downloaded 1-2 times per week onto a secured laptop, and data processing was facilitated by the use of Mathematica 8.0. Neurologic Pupil Index measurements, values generated by the pupillometer based on an algorithm that incorporates pupillary size and reactivity in a normal population, were found to be abnormal before 73% of TTHs. This abnormality occurred at a median of 7.4 h before TTH. All episodes of TTH were reversed after clinical intervention at a median of 43 min after the event. The value did not fall to 0 in 42% of clinical herniations, but it did decrease to very abnormal values of 0.5-0.8. The potential of automated pupillometry to guide the management of severely injured neurologic patients is intriguing and warrants further study in the critical care unit and beyond. The utility of a portable device in the combat setting may allow for triage of patients with severe neurologic injury.

Reversible parkinsonism secondary to chronic subdural hematoma

Secondary parkinsonism is attributable to a wide variety of causes including supratentorial mass lesions. While tumors are known to present with parkinsonism, chronic subdural hematoma is rarely seen presenting as rapidly deteriorating parkinsonian features with complete disappearance following evacuation of hematoma. The authors present two such patients—70- and 78-year-old males who presented with sudden onset of parkinsonism features. Both failed to recollect any significant head injury. Imaging diagnosed the presence of chronic subdural hematomas, being unilateral in one and bilateral in other. Surgical evacuation resulted in complete resolution of parkinsonian symptoms. These cases reinforce earlier studies for chronic subdural hematoma to be one of the causes of reversible parkinsonism apparently from distortion of basal ganglia mechanically and bringing changes in dopaminergic function, harming the susceptible aging brain.

Role of computed tomography scan in supratentorial mass lesions

Role of computed tomography scan in supratentorial mass lesions

Outcome of surgery for operable supratentorial mass lesions in patients presenting with decerebration following severe head injury: A retrospective analysis of factors affecting outcome.

Aim:Abnormal motor response in the form of decerebration signifies either injury or compression of brain stem. The presence of decerebrate rigidity following head injury is a grave prognostic sign. Mortality may increase up to 70% in patients showing signs of decerebration. Although many studies have identified the prognostic factors in severe head injuries, few studies have focused on the operated patients with decerebration in predicting the long-term outcome. This study was planned to determine the outcome in this group of patients for prognostication and to help plan further line of management.Materials and Methods:All the patients admitted with severe head injury with decerebration (M2 motor response) admitted in neurosurgery department from September 2009 to January 2011 were included in the study. All the patients had operable supratentorial mass lesions with no direct evidence of brain stem damage. Patients with penetrating injury and diffuse injury with no operative mass lesions were excluded from the study. Clinical and computerized tomography (CT) data were correlated with outcome retrospectively. Glasgow outcome scale (GOS) was used as a measure of functional outcome.Results:The patients admitted with decerebration (M2 motor response) comprised 8% of the total head injury related operative procedures performed at our institute during the period. Of the 72 patients, 14 (19%) patients were more than 60 years old and 21% (15) were females. The surgical mass lesions comprised extradural hematoma in 27 (38%), cerebral contusions in 19 (26%), acute Subdural Hematoma alone in 7 (10%), and acute Subdural Hematoma (SDH) with cerebral contusion in 19 (26%) of the patients. Of the 72 patients, 36(50%) were operated within 24 hours of injury Follow-up of all, but 2 (3%) was obtained. Favorable outcome (GOS 4 and 5) was obtained in 14% (n = 10) of the patients with 83% (n = 60) mortality rate. The favorable outcome rate among the patients operated for Extradural Hematoma was 26% and for cerebral contusions was 11%. Only 5% of the patients operated for acute SDH survived.Conclusion:Radiological diagnosis (type of lesion), followed by duration of decerebration and age of the patient are the most important prognostic factors determining the outcome of surgery in decerebrating patients. Our results confirm that despite the poor prognosis in decerebrate patients, a significant number of patients may still survive and have a good outcome.

Descending transtentorial herniation, a rare complication of the treatment of trapped fourth ventricle: case report.

Descending transtentorial herniation (DTH) is a complication of raised pressure in the supratentorial compartment, usually resulting from mass lesion of several etiologies. The authors report an exceptional case of DTH complicating the implant of a CSF shunting device in the trapped fourth ventricle of a 17-year-old boy in whom a second CSF shunting device had been implanted for neonatal posthemorrhagic and postinfectious hydrocephalus. The insidious clinical and radiological presentation of DTH, mimicking a malfunction of the supratentorial shunt, is documented. Ultimately, the treatment consisted of removal of the infratentorial shunt and endoscopic acqueductoplasty with stenting. The absence of supratentorial mass lesion and other described etiologies of DTH prompted the authors to speculate on the hydrodynamic pathogenesis of DTH in the present case.

Uncorrected traumatic coagulopathy is associated with severe brain swelling during decompressive surgery to evacuate a supratentorial intradural mass lesion in patients with traumatic brain injury

Objective: This study investigated the relationship between traumatic coagulopathy and severe brain swelling (SBS) during decompressive surgery to evacuate a supratentorial intradural mass lesion in patients with traumatic brain injury (TBI).Methods: A retrospective study was conducted in 96 patients who consecutively suffered from isolated TBI and underwent decompressive surgery to evacuate a supratentorial traumatic mass lesion by unilateral craniotomy. Their medical history, radiographic information, and surgical notes were reviewed. The relationship between traumatic coagulopathy and intraoperative SBS was evaluated.Results: Fifty-six patients presented with traumatic coagulopathy according to their preoperative coagulation panels. Thirty of them had the disorder corrected before surgery while the remaining patients did not. Twenty-four patients developed intraoperative SBS, and 22 (91·7%) of them were related to new or progressive formation of distal intracranial lesions during the surgery. Patients with uncorrected coagulopathy demonstrated a significantly higher risk of intraoperative SBS than those with corrected and no coagulopathy (61·5% vs 11·4%, P < 0·001). There was no significant difference in the incidence of intraoperative SBS between patients with corrected and no coagulopathy (13·3% versus 10·0%, P > 0·05). Multivariate logistic regression analysis showed that uncorrected coagulopathy was an independent risk factor and related to an 11·5-fold increased risk of intraoperative SBS.Conclusions: Intraoperative SBS is not a rare event during decompressive surgery to evacuate a supratentorial intradural mass lesion in patients with TBI. Such surgery should be cautiously considered and performed given the existence of uncorrected traumatic coagulopathy, which is associated with an increased risk of intraoperative SBS.

More evidence supporting a “brain code” protocol for reversal of transtentorial herniation

The syndrome of transtentorial herniation represents a usually fatal consequence of supratentorial mass lesions.1–3 Rapidly expanding supratentorial mass lesions cause displacement of the temporal lobe medially, leading to herniation of the uncus over the edge of the tentorium cerebri with subsequent compression of the posterior cerebral artery and third nerve.1 The earliest manifestation is a decrease in level of consciousness accompanied by unilateral pupillary dilation (because of third nerve dysfunction). The syndrome progresses to bilateral pupillary dilation, mechanical distortion, and secondary ischemia of the brainstem due to expansion of the primary lesion and impaction of the temporal lobe in the tentorial notch. Classically transtentorial herniation is considered to be a fatal consequence of a supratentorial mass lesion. Small experimental4 and clinical5,6 studies have demonstrated that transtentorial herniation can be reversed with aggressive medical and surgical management, but there is little information on eventual outcomes in such patients. In the current issue of Neurology ®, Koenig et al.7 report the results of using 23.4% sodium chloride in …

Serum GFAP is a diagnostic marker for glioblastoma multiforme

A serum marker for malignant cerebral astrocytomas could improve both differential diagnosis and clinical management of brain tumour patients. To evaluate whether the serum concentration of glial fibrillary acidic protein (GFAP) may indicate glioblastoma multiforme (GBM) in patients with single supratentorial space-occupying lesions, we prospectively examined 50 consecutive patients with histologically proven GBM, World Health Organization (WHO) grade IV, 14 patients with anaplastic astrocytoma (WHO grade III), 4 patients with anaplastic oligodendroglioma, 13 patients with diffuse astrocytoma (WHO grade II), 17 patients with a single cerebral metastasis and 50 healthy controls. Serum was taken from the patients before tumour resection or stereotactic biopsy. Serum GFAP levels were determined using a commercially available ELISA test and were detectable in 40 out of the 50 GBM patients (median: 0.18 microg/l; range: 0-5.6 microg/l). The levels were significantly elevated compared with those of the non-GBM tumour patients and healthy controls (median: 0 mug/l; range: 0-0.024 microg/l; P < 0.0001, respectively). Non-GBM tumour patients and all healthy subjects showed zero serum GFAP levels. There was a significant correlation between tumour volume (Spearman Rho, CC = 0.47; 95% confidence interval, 0.2-0.67; P < 0.001), tumour necrosis volume (CC = 0.49; 95% confidence interval, 0.2-0.72; P = 0.004), the amount of necrotic GFAP positive cells (CC = 0.61; 95% confidence interval, 0.29-0.81; P = 0.007) and serum GFAP level among the GBM patients. A serum GFAP level of >0.05 microg/l was 76% sensitive and 100% specific for the diagnosis of GBM in patients with a single supratentorial mass lesion in this series. Therefore, it can be concluded that serum GFAP constitutes a diagnostic biomarker for GBM. Future studies should investigate whether serum GFAP could also be used to monitor therapeutic effects and whether it may have a prognostic value.

Supratentorial Low-Grade Glioma Resectability: Statistical Predictive Analysis Based on Anatomic MR Features and Tumor Characteristics

To retrospectively assess the main variables that affect the complete magnetic resonance (MR) imaging-guided resection of supratentorial low-grade gliomas. Institutional review board approval was obtained for this retrospective HIPAA-compliant study, with the requirement for informed consent waived. Data from 101 patients (61 men, 40 women; mean age, 39 years; age range, 18-72 years) who had nonenhancing supratentorial mass lesions that were histopathologically diagnosed as low-grade (World Health Organization grade II) gliomas and consecutively underwent surgery with intraoperative MR imaging guidance were analyzed. There were 21 low-grade astrocytomas, 64 oligodendrogliomas, and 16 mixed oligoastrocytomas. Initial and residual tumor volumes were measured on intraoperative T2-weighted MR images and three-dimensional spoiled gradient-echo MR images. The anatomic relationships between the tumor and eloquent cortical and/or subcortical regions and the influence of these relationships on the extent of resection were analyzed on the basis of preoperative MR imaging findings. Summary measures, univariate Fisher exact test and t test, and multivariate logistic regression analyses were performed. Tumor volume ranged from 2.7-231.0 mL. Univariate analyses revealed the following tumor characteristics to be significant predictive variables of incomplete tumor resection: diffuse tumor margin on T2-weighted MR images, oligodendroglioma or oligoastrocytoma histopathologic type, and large tumor volume (P < .05 for all). Tumor involvement of the following structures was associated with incomplete resection: corpus callosum, corticospinal tract, insular lobe, middle cerebral artery, motor cortex, optic radiation, visual cortex, and basal ganglia (P < .05 for all). Multivariate analyses revealed that incomplete tumor resection was due to tumor involvement of the corticospinal tract (P < .01), large tumor volume (P < .01), and oligodendroglioma histopathologic type (P = .02). The main variables associated with incomplete tumor resection in 101 patients were identified by using statistical predictive analyses.

A Comparison of Three Anesthetic Techniques in Patients Undergoing Craniotomy for Supratentorial Intracranial Surgery

Several anesthetic techniques have been used successfully to provide anesthesia for resection of intracranial supratentorial mass lesions. One technique used to enhance recovery involves changing anesthesia from vapor-based to propofol-based for cranial closure. However, there are no data to support a beneficial effect of this approach in the immediate postoperative period after craniotomy. We evaluated 3 anesthetic techniques in 60 patients undergoing elective surgery for supratentorial mass lesions. Patients were randomly assigned to three anesthesia study groups: propofol infusion, isoflurane inhalation, and these two techniques combined. In the combination group, once the dura was closed, isoflurane was discontinued and propofol infusion simultaneously started. We studied intra- and postoperative hemodynamics and several recovery variables for 2 h after the end of anesthesia. Baseline and average intraoperative blood pressure and heart rate values did not differ among the groups. Heart rate and blood pressure increased similarly in all groups in response to intubation and pin placement and postoperatively. None of the recovery event times (open eyes, extubation, follow commands, oriented, Aldrete score) or psychomotor test performance differed significantly. We conclude that the sequential administration of isoflurane and propofol did not provide earlier recovery and cognition than the intraoperative use of isoflurane alone.

Long-term outcome after medical reversal of transtentorial herniation in patients with supratentorial mass lesions.

To determine the short- and long-term outcomes after successful reversal of transtentorial herniation by medical treatment. Although it has been recognized that aggressive medical management can reverse transtentorial herniation, it is believed that overall outcome in such patients is poor. Prospective cohort study. Neurocritical care unit of a university hospital. A total of 28 consecutive patients who underwent an episode of transtentorial herniation (defined as decrease in level of consciousness accompanied by pupillary dilation) secondary to a supratentorial mass lesion followed by successful reversal. Herniation was reversed by using a combination of hyperventilation, mannitol and hypertonic saline. The following outcomes were analyzed: risk of second herniation, radiologic evidence of structural damage or vascular compromise related to herniation on post-herniation computed tomographic scan, in-hospital mortality, and long-term functional outcome using Rankin score and Barthel index. A total of 32 episodes of transtentorial herniations were reversed in 28 patients during a 14-month period. The most common precipitating cause were edema (n = 23) or new/expanding intracerebral hematoma (n = 5). After first reversal of transtentorial herniation in 28 patients, a second herniation episode was observed in 16 patients after a mean interval of 88.2 hrs (range, 23-432 hrs); four were successfully reversed. On follow-up computed tomographic scan, hypodense lesion in midbrain (n = 6), temporal lobe contusion (n = 2), posterior cerebral artery (n = 3), and middle cerebral artery (n = 1) infarction were visualized in a minority of patients. The in-hospital mortality was 60% (n = 15) with brain death being the cause of death in 13 patients; care was withdrawn in eight patients. Second episode of herniation (p = .002) and midbrain involvement during herniation (p = .02) were associated with in-hospital mortality. During a mean follow-up period of 11.4+/-4.2 months, two patients died of cerebral neoplasm and human immunodeficiency virus-related sepsis, respectively. Of the 11 survivors, 7 were functionally independent (Rankin score <3 and Barthel index >60). Although mortality after transtentorial herniation is high, we found a prominent potential for meaningful recovery with aggressive medical reversal of transtentorial herniation. Our study implies that timely medical intervention for reversing transtentorial herniation can result in preservation of neurologic function.

Las características clínico­imaginológicas clásicas de los meningiomas son imitadas por otras lesiones expansivas

To analyze the surgical neurology cases in which both the clinical and neuroimaging features suggested supratentorial meningioma, and resulted in different entities from the neuropathological point of view. The clinical histories of patients harboring intracranial, supratentorial mass lesions diagnosed as meningioma operated in different hospitals of Maracaibo, Venezuela, during the period 1993-1997 were reviewed. Our analysis revealed 15 cases with different neuropathological diagnosis. They were distributed as follows: three cases of hemangiopericytoma, two cases each of anaplastic ependymoma, metastatic carcinoma, and solitary intracranial plasmacytoma, and one case each of plasma cell granuloma, pleomorphic xanthoastrocytoma, chondroma, actinomycetoma, meningeal fibroma and chronic inflammation not otherwise specified. A heterogeneous group of intracranial, supratentorial expansive mass lesions can masquerade as meningiomas both from the clinical and neuroimaging points of view.

601 Long-Term Outcome Following Medical Reversal of Transtentorial Herniation in Patients with Supratentorial Mass Lesions

601 Long-Term Outcome Following Medical Reversal of Transtentorial Herniation in Patients with Supratentorial Mass Lesions

Unco-parahippocampectomy for direct surgical treatment of downward transtentorial herniation.

Downward transtentorial herniation is a major cause of death and disability caused by acute supratentorial mass lesions. Thirteen patients, 7 men and 6 women aged from 23 to 75 years old, with progressive transtentorial herniation caused by cerebral contusion with acute subdural haematoma, acute brain swelling after aneurysmal subarachnoid haemorrhage, or massive cerebral infarction were treated by direct surgery using selective removal of the uncus and parahippocampal gyrus (unco-parahippocampectomy). All patients showed progressive deterioration of transtentorial herniation (late third nerve stage or midbrain stage) with unilateral pupillary dilation and absent light reflex. Preoperative Glasgow Coma Scale scores ranged from 4 to 8. Unco-parahippocampectomy was performed via the middle temporal gyrus under the operating microscope. The oculomotor nerve, posterior cerebral artery, and midbrain were directly decompressed. Incision of the arachnoid membrane in the tentorial incisura allowed free communication of the cerebrospinal fluid between the supra- and finfra-cranial fossae to reduce the pressure gradient. Two of the 13 patients died (15%). Two of the 11 survivors (18%) were functionally independent and 1 (9%) required minimal assistance but was independent at home. This series suggests the lifesaving nature of unco-parahippocampectomy in patients with deteriorating clinical condition because of transtentorial herniation.

Acute mental status changes.

Acute changes in mental status can occur in any hospital setting. Clinicians are often at a loss to define accurately the course of a change in mental status, because of poor differentiation in the terminology surrounding this difficult diagnosis. A clear understanding of the differences among several levels of altered mental status is needed to evaluate, accurately diagnose, and treat those patients with altered mental states. The differential diagnosis of altered mental status is diffuse and includes supratentorial mass lesions, infratentorial mass lesions, and metabolic disorders. Development of an individualized differential diagnosis and diagnostic approach for cases of altered mental status represents a challenge to all levels of clinicians.