What is the management of space-occupying lesions?

Management of Space-Occupying Lesions

Decompressive craniectomy is the definitive treatment for space-occupying lesions causing significant mass effect, with early intervention showing a significant reduction in mortality (NNT of 2) without increasing the number of severely disabled survivors. 1, 2

Initial Assessment and Diagnosis

• Imaging:

  • MRI with contrast is the preferred initial imaging modality for suspected space-occupying lesions 3
  • CT scan may be used in emergency situations, when MRI is contraindicated, or to evaluate for acute hemorrhage 3
  • MR Venography should be performed if venous sinus thrombosis is suspected 3

• Risk Assessment:

  • All patients with risk factors for developing space-occupying brain edema should be evaluated immediately in a stroke unit by both a neurologist and neurosurgeon 1
  • Lumbar puncture should NOT be performed if a space-occupying lesion is suspected before neuroimaging 3

Immediate Management for Increased Intracranial Pressure

• Elevate head of bed to 30 degrees 3
• Administer mannitol or hypertonic saline 3
• Consider dexamethasone for significant edema 3
• Maintain cerebral perfusion pressure (CPP) >60 mmHg using volume replacement and/or catecholamines if necessary 1
• Close neurological and cardiovascular monitoring in an intensive care unit 1

General Management Measures

• Ensure sufficient cerebral oxygenation 1
• Treat hyperthermia 1
• Correct hypovolemia with isotonic fluids 1
• Avoid oral intake of food and fluids 1
• Treat hyperglycemia 1
• Withhold antiplatelet agents if surgical intervention is likely 1
• Provide thromboembolic prophylaxis with subcutaneous low-dose heparin, LMWH, or heparinoids 1

Specific Management Based on Lesion Type

Space-Occupying MCA Infarction

• Surgical Approach: Fronto-parieto-temporo-occipital craniectomy up to the midline with a diameter of at least 12 cm, with durotomy and duroplasty 1
• Timing: Early intervention (within 24 hours of symptom onset) is crucial as delayed intervention may cause additional irreversible brain damage 1, 2
• Monitoring: Intracranial pressure monitoring is recommended post-surgery 1

Space-Occupying Cerebellar Infarction

• Surgical Approach: Craniectomy up to the transverse sinus and opening of the foramen magnum, with durotomy, duroplasty, and removal of ischemic cerebellar tissue 1
• Additional Measures: For concomitant hydrocephalus, consider external ventricular drainage with ICP monitor placement 1, 4
• Warning: Shunt placement without craniectomy is not recommended 1

Other Space-Occupying Lesions

• Brain Tumors: Surgical resection when feasible, with adjuvant radiation therapy and/or chemotherapy based on histology 3
• Metastatic Lesions: Surgical resection for solitary, accessible lesions; stereotactic radiosurgery for multiple or deep lesions 3
• Brain Abscess: Empiric broad-spectrum antibiotics, surgical drainage for lesions >2.5 cm 3
• Post-operative Cystic Lesions: Various treatment options including percutaneous drainage, cyst fenestration, or shunt placement 5

Postoperative Management

• Apply general intensive care concepts (lung-protective ventilation, blood sugar control, treatment of hyperthermia, early enteral nutrition) 1
• Continue ICP and CPP monitoring 1
• Perform control CT after 24 hours or earlier if signs of intracranial hypertension are present 1
• Attempt waking the patient from sedation as soon as there are no more signs of significant intracranial hypertension 1
• Resume thromboembolic prophylaxis from the second postoperative day after consulting with neurosurgeon 1
• Begin early mobilization and rehabilitation after successful extubation and absence of intracranial hypertension 1

Important Considerations and Pitfalls

• Age Factor: While younger patients show better outcomes with decompressive surgery, advanced age alone should not be a contraindication 2, 4
• Dominant Hemisphere: The possibility of persistent speech disorders in infarctions of the dominant hemisphere should be discussed preoperatively 1
• Timing is Critical: Delayed intervention beyond 24 hours after symptom onset may lead to poorer outcomes 1, 2
• Patient Consent: The patient's will should be documented and taken into account whenever possible, as significant long-term disability may persist despite intervention 1
• Outcome Expectations: Contrary to general belief, long-term outcomes after space-occupying cerebellar stroke may not always be good, particularly in elderly patients and those with additional brainstem infarction 4