How should I manage a 45-year-old woman with headaches and MRI showing a curvilinear intracranial lipoma surrounding the splenium of the corpus callosum and a small lipoma in the foramen of Monro without hydrocephalus?

Management of Intracranial Lipomas with Headache

Conservative management with symptomatic treatment is the standard approach for intracranial lipomas, as surgical intervention is not indicated in the absence of hydrocephalus or progressive neurological deficits. 1, 2, 3

Immediate Assessment Required

Rule Out Elevated Intracranial Pressure

• Perform fundoscopic examination immediately to assess for papilledema, as this would indicate elevated ICP requiring urgent intervention 4
• Assess for specific headache characteristics that suggest elevated ICP:
  • Headaches awakening from sleep 4
  • Worsening with Valsalva maneuver 4
  • Rapidly increasing frequency 5
• Verify absence of hydrocephalus on the MRI report, as this is already confirmed in your case 2, 3

Critical Clinical Examination

• Document any abnormal neurological findings, as these significantly increase likelihood of clinically significant pathology requiring intervention 5
• Assess for visual disturbances, particularly transient visual obscurations or diplopia 4
• Evaluate for pulsatile tinnitus, which suggests elevated ICP 4
• Check for seizure history, as sylvian fissure lipomas are associated with epilepsy 6

Management Algorithm

If Normal Neurological Exam and No Papilledema (Most Likely Scenario)

• Provide symptomatic treatment with analgesics and anti-inflammatory agents 1
• Counsel the patient that surgical removal is not indicated, as risks far outweigh potential benefits 1, 2
• Explain that intracranial lipomas are benign congenital malformations that are usually asymptomatic 2, 6
• The headaches may be unrelated to the lipomas or represent a rare secondary headache from the lipoma itself 1

If Papilledema or Signs of Elevated ICP Present

• Perform urgent lumbar puncture to measure opening pressure 4, 7
• Opening pressure >250 mm H₂O confirms elevated ICP and requires urgent intervention 4, 7
• Consider MR venography to evaluate for venous sinus stenosis, which occurs in approximately 52% of pseudotumor cerebri cases 7
• Note: The lipoma location at foramen of Monro could theoretically cause obstructive hydrocephalus, though your MRI shows no hydrocephalus 2, 8

If Hydrocephalus Develops (Not Present Currently)

• CSF shunt procedure is indicated rather than lipoma resection 2, 3
• Patients show remarkable clinical improvement following shunt procedures when hydrocephalus is present 2

Long-Term Follow-Up Strategy

• Establish long-term follow-up with serial clinical assessments 1
• Monitor for development of new focal neurological deficits, which would necessitate repeat imaging 1
• Repeat MRI only if new symptoms develop, not routinely 1
• If seizures develop, initiate anticonvulsant therapy, which usually results in remission 3

Common Pitfalls to Avoid

• Do not pursue surgical resection - intracranial lipomas are intimately associated with surrounding neurovascular structures, making surgery high-risk with minimal benefit 1, 2
• Do not assume the headaches are definitely caused by the lipomas - most intracranial lipomas are asymptomatic incidental findings 2, 6
• Do not overlook associated malformations - midline anomalies and other brain malformations frequently coexist with intracranial lipomas 6
• Do not miss hydrocephalus on imaging - lipomas near CSF spaces can be overlooked on T2-weighted images; T1 sequences are critical 8

Specific Considerations for This Case

• The curvilinear pericallosal location is the most common site for intracranial lipomas 6
• The foramen of Monro lipoma warrants attention for potential future obstruction, though currently no hydrocephalus is present 2, 8
• If headaches persist despite symptomatic treatment, consider that this may represent an atypical secondary headache from the lipoma, which is rare but documented 1
• Screen for hypothyroidism and other systemic conditions that may contribute to headaches, as coexisting conditions often explain symptoms attributed to lipomas 2