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Mass in brain

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Good Morning Dr.Sudhir Kumar,

Please find below the details of MRI
Left cerebellar hemisphere shows heterogeneous mass lesion with surrounding hyperintensity in T2/Flair sequence. The lesion measuring 43x23x19 mm (RLXAPXCC) The lesion shows heterogeneous enhancement with irregular prominent enhancement of the margins. The adjacent left sigmoid and tranverse sinuses show increased singal intensity.
The fourth ventricle is compressed and deviated towards right side
Subtle tonsilar herniation seen in the left side
Hetrogeneously irregular marginal enhancing mass lesion in left cerebellum with mass effect on the fourth ventricle, perilesional edema and minimal tonsilar herniation. No flow seen in the left sigmoid and transverse sinuses - suggestive of thrombosis, bilateral mastoiditis.

Patient had a heavy vomitting and vertigo. Doctor opted for surgery for benefit of doubt and result is CVT infarction after surgery. Is surgery is required. Please clarify. Most Urgent. Thanks, Jayakumar India - 09840009756 - mail:bejayin@yahoo.com

Category: Neurologist, Medical

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Category: Pediatric Neurologist
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Expert:  Dr. Sudhir Kumar replied 4 Days.


Thank you for posting your query at DoctorSpring.com.

I have gone through the MRI brain report. As per that, there is a mass lesion in the back of brain, causing swelling and compression of normal brain structures. This needs to be operated to save the patient's life.

The mass lesion would be sent for biopsy to confirm the diagnosis. Further treatment would depend on the biopsy report.

In the meanwhile, medications such as heparin may be required for treating CVT.

I hope it helps. Please get back if you have any more queries.

Best wishes,

Dr. Sudhir Kumar MD (Medicine), DM (Neurology)
Senior Consultant Neurologist,
Institute of Neurosciences,
Apollo Hospitals, Jubilee Hills,
Hyderabad- 500 033, India

Patient replied :

Good Morning Doctor,
Thank you very much for your valuable advice and guidance. I am confused due to MRI suggestive of thrombosis and mass lesion due to thrombosis. At this juncture, is biopsy and surgery required for infarction. Surgeon is of the opinion that mass lesion may be a tumour and he is opted surgery. One of the other surgeon opined that thrombosis proves that it is a infarction and infarction can be treated medically. Hence, there is no need for biopsy and surgery for infarction. I am totally depressed due to this comment. Now, I am very clear with your advice and trust that the surgeon doubt is benefit for the patient only. Please brief. Sorry to trouble you again. Thanking you, Jayakumar - bejayin@yahoo.com

Expert:  Dr. Sudhir Kumar replied 3 Days.

Thank you for getting back.

I can understand your confusion.

However, in the area where the mass lesion is located, both infarction and tumor may require surgery. This is because both these conditions can cause severe compression of the normal brain structures, endangering the patient's life.

If you can upload the MRI pictures, we could give you a more precise answer, whether surgery is mandatory now or we can wait with medical treatment (heparin).

Best wishes

Patient replied :

Final doubt whether wr surgeon will think of tumour or thrombosis based on abv report.Thank you very dr. Now I am very clear that infarction need surgery due to compression and mild tonsilar herniation Also Doctor will view on larger picture ie mass mass lesion may be a tumour inlieu of looking smaller picture of suggestive of thrombosis. Thank you very much for your help and and advice. Thanks Jayakumar

Expert:  Dr. Sudhir Kumar replied 2 Days.

Thank you for getting back.

The surgeon looks at the MRI report and correlates with the clinical ridings of the patient. So, MRI report of the radiologist helps, but the final diagnosis is made by the surgeon after reviewing the patient's symptoms. The need for surgery also depends on patient's clinical condition, in addition to MRI report.

Best wishes

Patient replied :

Good Evening Doctor,

I have tried my level best to upload MRI pictures from CD and unable to upload due to numerous files.

I am depressed due to the following:

My Neuro Surgeon suspected tumour or TB or abscess based on MRI report for benefit of doubt to the patient and opted Retromastoid craniectomy inspite of thrombosis.

However, other neurologist and surgeons advised that MRI states thrombosis. Hence, it is implied that it is an infarction and this would have been treated medically or drained out the mass through aspiration instead of craniectomy. Hence, benefit of doubt to the patient does not arise in this case. In addition to that one surgeon told that mass infarction will subside on its own and surgery is not required.

Being a layman, please clarify whether Retromastoid craniectomy is the right solution as per my neuro surgeon or by oversight he has ignored that thrombosis may caused infarction.

Also, biopsy and surgery is required even to know the infarction or the above MRI indicates infarction.

Please help me to come out of this issue and to move forward in my life.

Again, I deeply regret the inconvenience caused to you in this regard. Please help.

Trust that you will appreciate my anxiety and situation. Thank you very much for your patience and advice.


Expert:  Dr. Sudhir Kumar replied 1 Day.


Thank you for getting back.

The surgery is required in the following situations:

1. If there is pressure on the normal brain tissue due to the lesion (to save the normal brain tissue from damage, retromastoid craniotomy may be done),

2. If there is a doubt in the diagnosis (biopsy can be done).

If there is infarction with thrombosis (confirmed), then, there is no need of surgery. Now I hope you would understand that since I do not have acess to the files, MRI or medical report I can only give generic information. In general I would say trust your team of Doctors who are treating you. A more aggressive approach (like Surgery ) need to be considered only if there is immediate threat to life. Otherwise the decision can be reviewed after a repeat MRI and seeing the treatment response.

I hope it helps.

Best wishes,
Thank you

Dr. Sudhir Kumar
Category: Pediatric Neurologist
Senior Residency, Fellowship: DM, Neurology, CMC, Vellore, 2001
Junior Residency: MD, Internal Medicine, CMC, Vellore, 1998
Medical School: MBBS, Christian Medical College, Vellore, 1995
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