What is the management for an intracranial (within the skull) mass?

Management of Intracranial Mass

All patients with suspected intracranial mass should be immediately transferred to a specialized neurosurgical center for multidisciplinary evaluation and treatment planning. 1

Immediate Assessment and Stabilization

Critical Clinical Evaluation

• Document Glasgow Coma Scale score immediately to establish baseline neurological status and monitor for deterioration 2
• Assess for focal neurological deficits including weakness, sensory changes, cranial nerve palsies, or visual field defects based on mass location 2
• Evaluate for signs of increased intracranial pressure: headache, vomiting, papilledema, altered consciousness 2
• In posterior fossa lesions, specifically assess for brainstem compression symptoms (cranial nerve dysfunction, ataxia, respiratory changes) 2

Emergency Medical Management

• Initiate dexamethasone immediately to reduce peritumoral edema in patients with significant mass effect or neurological symptoms 2
• Administer appropriate antiepileptic medication for any seizure activity 2
• Maintain head elevation and close neurological monitoring for patients with signs of increased intracranial pressure 2

Diagnostic Imaging Protocol

First-Line Imaging

• MRI with contrast is the gold standard for characterizing intracranial masses and should be obtained urgently 2, 3
• Look for: enhancement pattern, dural-based features, peritumoral edema, mass effect, hemorrhage, and calcifications 2, 3
• CT scan should be used if MRI is contraindicated or unavailable, particularly useful for detecting acute hemorrhage and calcifications 2, 3

Advanced Imaging Considerations

• Somatostatin receptor (SSTR) PET imaging should be considered when diagnosis is uncertain or to differentiate tumor progression from treatment-related changes 2, 3
• MR perfusion may be useful for tumor grading, as many intracranial masses are highly vascular 3
• Functional MRI (fMRI) may be beneficial when the mass is near eloquent brain areas to help preserve neurological function 3

Surgical Decision Algorithm

Immediate Neurosurgical Consultation Required

• Progressive neurological deterioration despite medical management 2
• Rapid decline in Glasgow Coma Scale score 2
• Signs of herniation or severe mass effect 2
• Brainstem compression in posterior fossa lesions 2

Optimal Surgical Candidates

All patients should be offered optimal surgical resection when technically feasible, EXCEPT those with: 1

• High physiological age with significant co-morbidities
• Poor performance status (low Karnofsky score)
• Lesions in functional, multifocal, or centrally localized zones where resection carries high risk of permanent postoperative functional deterioration

Surgical Approach

• Tumor resection should be optimal with margins as wide as possible, avoiding major functional risks 1
• Surgical excision is the best means to obtain representative tissue samples and reduce mass effect 1
• Technical aids (preoperative functional MR, ultrasound aspiration, surgical microscope, neuro-navigation, intraoperative brain mapping) can optimize surgical resection 1
• If optimal resection is not possible, histological evidence should be obtained by biopsy (stereotactic or open skull) 1

Special Surgical Considerations

• Skull base masses require specialized neurosurgical expertise and multidisciplinary approach 2
• Intraventricular masses need careful surgical planning with higher risk of significant blood loss 2, 3
• Pediatric cases should involve specialized pediatric neurosurgical expertise 2, 3

Post-Operative Management

Timing of Additional Treatment

• All histology and imaging findings should be reviewed before initiating additional anticancer treatment to verify coherence of the clinical picture 1
• Additional treatment should be started within one month of surgery 1
• The modalities of radiotherapy and chemotherapy should be adapted to the patient's status 1

High-Grade Glioma (Grade 3-4) Post-Operative Treatment

• First-line external-beam radiotherapy should be offered since it has been shown to improve survival 1
• A total dose of 60 Gy should be delivered, with fractionation from 1.8 to 2 Gy per fraction per day 1
• For glioblastoma: mono-drug chemotherapy with a nitrosourea (BCNU) should be offered 1
• For anaplastic astrocytoma: either mono-drug chemotherapy with nitrosourea (BCNU) or multidrug chemotherapy with procarbazine, lomustine, and vincristine (PCV) 1

Low-Grade Glioma (Grade 2) Post-Operative Treatment

• The therapeutic decision must weigh symptom relief and delaying anaplastic transformation against iatrogenic treatment risks 1
• When radiotherapy is proposed, the dose should be between 45 and 54 Gy (recommended 50-54 Gy) 1
• Chemotherapy can be proposed in symptomatic oligodendroglial tumors, preferentially in clinical trials 1

Meningioma Post-Operative Treatment

• External beam radiation therapy (EBRT) is indicated for WHO grade 3 (malignant) meningiomas after surgery 3
• EBRT is also indicated for subtotally resected WHO grade 2 (atypical) meningiomas 3
• Peptide receptor radionuclide therapy (PRRT) shows promising results for treatment-refractory meningiomas 3

Supportive Care Management

Thromboembolism Prevention

• Surveillance, prevention and treatment for thromboembolism should be performed, as this occurs frequently in patients with intracranial masses 1
• Prophylactic use of low-molecular weight heparin and compression stockings is recommended for preventing perioperative thromboembolic complications 1
• After 4-5 days of surgery, anticoagulant treatment at therapeutic dose can be prescribed for thromboembolic complications without undue hemorrhagic risk 1

Seizure Management

• Perioperative anticonvulsant treatment should be prescribed routinely for patients who have had seizures 1
• In patients without previous seizures, perioperative anticonvulsant treatment is optional 1
• Postoperatively, patients with previous seizures should continue anticonvulsant treatment 1
• First-line treatment should be single-drug therapy 1
• Consider drug interactions with chemotherapy when selecting anticonvulsants 1

Corticosteroid Management

• Prophylactic corticosteroid treatment should not be prescribed routinely for radiotherapy 1
• Corticosteroids can be used to reduce risk of acute or early-delayed encephalopathy (radiation-induced edema) 1
• Gastroprotection should be prescribed for patients receiving high doses of corticosteroids and/or those with risk factors for ulcers 1

Pain Management

• Appropriate analgesic treatment should be prescribed for intracranial hypertension, neoplastic meningitis, or pain associated with permanent deficit 1

Surveillance and Follow-Up

Imaging Schedule

• MRI with contrast should be performed within 2 weeks prior to any intervention as baseline for disease monitoring 3
• For WHO grade 1 tumors: MRI without and with contrast every 6-12 months 3
• Post-radiotherapy MRI should be considered the "new baseline" rather than post-surgical MRI 3

Interpretation of Post-Treatment Changes

• Clinical and/or radiological deterioration in the 2 months after radiotherapy should be interpreted with caution and not automatically considered treatment failure 1
• SSTR PET may be useful in distinguishing tumor recurrence from post-treatment changes 3
• Tc-99m MIBI brain scintigraphy can help differentiate between recurrence and radionecrosis 1

Critical Pitfalls to Avoid

• Do not delay transfer to specialized neurosurgical center - all patients should be routinely transferred for biopsy or surgery 1
• Do not assume all enhancing masses are the same - metastases, gliomas, and primary CNS lymphoma can mimic meningiomas 2
• Do not underestimate potential for significant blood loss, particularly with large hemispheric or intraventricular tumors 2, 3
• Do not overlook the need for specialized surgical expertise for complex locations such as skull base, cavernous sinus, or intraventricular locations 2, 3
• Do not abruptly discontinue corticosteroids as this can worsen cerebral edema 4
• In rare cases where optimal cancer treatment is not feasible (high physiological age, multiple pathologies, poor functional status, centrally localized lesion), biopsy is not mandatory and palliative treatment can be offered 1