Welcome to the EANS Case of the Month for August! Good luck!

Management of a vascular incisural tumour
J Tailor, P D’Urso, D Walsh
King’s College Hospital, London

Vascular tumours of the brain are challenging to treat surgically due to the risks of intraoperative haemorrhage. These risks are minimized through careful surgical planning, characterization of the arterial anatomy through cerebral angiography, and sometimes by adjunctive pre-surgical embolization [1, 2]. This case study illustrates the management of a hypervascular tumour within the tentorial incisura.

Case history:
This 48-year old lady with a 2-month history of intermittent headaches presented to the Emergency Department with a 1-day history of worsening frontal headache and vomiting. She had no photophobia or neck stiffness, no fevers, no weight loss, no speech or visual disturbance, no balance problems or limb weakness. She was otherwise fit and well with no significant past medical history or smoking history. On examination, she was drowsy, disorientated, eye opening to speech, and obeying commands. Her pupils were equal and reactive to light and she had no focal neurological deficit. A plain CT scan showed a posterior fossa lesion extending into the tentorial incisura with associated ventriculomegaly due to compression of the cerebral aqueduct and 4th ventricle (Figure 1). The lesion enhanced avidly after contrast administration, and CT angiography suggested it to be highly vascular (Figure 2). There was evidence of pial congestion indicative of severe intracranial hypertension.

Figure 1. Plain axial CT scan

Figure 2. CT angiography. Axial (A), Coronal (B) and Sagittal (C) views are shown.

* 1. What is the differential diagnosis of this lesion? (Tick one or more answer that applies)

* 2. How will you initially manage this patient? (Tick one or more answer that applies)
Will you: