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Brain Masses


  • Neoplasm is the biggest concern

    • 90% of malignant brain masses are metastatic

      • Most commonly: lung, RCC, breast, melanoma

      • Highest bleeding risk: melanoma, thyroid, choriocarcinoma, RCC

    • Primary brain tumors

      • Gliomas: WHO Grade I-IV

        • Glioblastoma multiforme (GBM) – WHO Grade IV; large heterogenous masses with edema; heterogenous contrast enhancement; can cross the corpus callosum

        • Lower grade gliomas – include oligodendrogliomas and astrocytomas

      • Meningioma: usually low grade

        • Can be left alone and monitored with yearly MRI

        • If symptomatic, may need resection/radiation

      • Ependymoma: uncommon. Can cause CSF outflow obstruction

      • CNS lymphoma – diffuse WM involvement, with mass effect, restricts diffusion on MRI with prominent contrast enhancement. Can also cross the corpus callosum

        • Usually B-cell, initially responds significantly to steroids


  • A significant number of brain lesions are detected incidentally

  • If a patient has a first-time seizure, brain mass needs to be ruled out

  • HA (usually constant, severe), seizure, and focal neurologic deficits


  • Imaging: MRI w/ and w/o contrast provides the most information

    • Findings suggesting malignant lesions: marked edema, multifocal lesions, or presence at gray-white junctions
  • LP may be indicated if herniation risk is low, particularly if concerned for infection

  • Biopsy will ultimately be needed in most cases, which is done by NSGY


  • Work up for primary malignancy, CT C/A/P + PET

  • Steroids are generally indicated for treatment of edema

    • Decadron 10 mg IV to start; then transition to 4mg IV q6h with SSI

    • If pt is clinically stable and there is a concern for CNS lymphoma, consider delaying steroids to increase yield of cytology and biopsy, unless edema/mass effect warrants emergent treatment

    • Symptomatic tumors need eval by NSGY for resection consideration and radiation oncology