A tight squeeze with an intracranial brain tumour: LANCET ca
An 80-year-old man presented with a 4-day history of a throbbing pain in the front part of his head that was not relieved by analgesics. The pain had developed gradually and was not associated with any weakness in his arms or legs, numbness or visual symptoms. His medical history included a diagnosis of an intracranial epidermoid cyst, hypertension, and depression.

A full clinical neurological examination showed no abnormalities. A CT scan of his head (appendix) revealed no additional changes to those seen in a CT scan and an MRI done 4 months earlier; at the time when the epidermoid cyst was first found, it was a 9 cm × 7·5 cm mass in the left parietal region, thinning and scalloping of the skull vault, and a slight midline shift to the right.

No acute bleeds or infarcts were found. The patient was told his symptoms were due to the epidermoid cyst. At the time the cyst was first diagnosed, it was jointly decided by the patient and us to avoid any surgical interventions because epidermoid cysts are usually slow growing, benign, and asymptomatic.

Learning Points:-
• In such cases it is important to differentiate an epidermoid cyst from a dermoid cyst: the CT scans in this case revealed a lesion of low density, which might have been fat—typically associated with dermoid cysts.

• An MRI with the appropriate enhancement was needed to differentiate the two. T1-weighted MRI revealed strands of high signal in the lesion, which could also have represented fat. However, the diffusion-weighted MRI, which showed restricted diffusion, confirmed the diagnosis.

• Furthermore, these striking images—in a patient with no neurological signs—show how a large lesion can be accommodated by a relatively atrophic brain with increased cerebrospinal fluid (CSF) filled spaces and the clinical relevance of the Monro–Kellie doctrine.

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