Therapeutic Options

Therapeutic considerations for patients with intracranial lipomas must be made within a risk-benefit analysis. Although there are limited data on the treatment of intracranial lipomas, surgical resection versus observation alone has been the standard of care. There are no reports of attempts to treat intra-cranial lipomas with radiation or chemotherapy. Because intracranial lipomas are benign entities whose contribution to the patient's underlying symptomatology is often unclear, the indications for surgical removal must be strong. Although there are case reports of intracranial lipomas increasing in size and causing symptom progression,19,23 this appears to be the exception rather than the rule.

Intracranial lipomas are congenital lesions and hence the associated malformations, often the source of the actual symptoms, occur early in development and are not amenable to treatment. In general, surgical resection of intracranial lipomas should be the last resort. Hydrocephalus, if present, should be treated appropriately by shunting. Attempts to manage seizure disorders with medications should be made, because there is no strong evidence that surgical resection of pericallosal or sylvian fissure lipomas leads to seizure reduction. Lipomas of the CPA or IAC, likewise, should not be operated on except in cases of medical treatment failure or rehabilitation failure. A review by Tankere et al19 highlights the danger of surgical resection of these lesions.

Tankere et al studied 54 patients with CPA or IAC lipomas who underwent surgical resection. Approximately 50% had improvement of their initial complaint; however, more than half those patients complained of multiple new deficits after surgery, and 65% suffered postoperative hearing loss.19 With regard to surgical technique, the translabyrinthine approach appears to provide the best chance for total resection, but hearing loss is virtually assured. Use of the middle and posterior fossa approaches provides more hearing preservation (26%) but less chance for total resection.19 As stated previously, Tankere et al concluded that surgical resection of CPA or IAC lipomas should be restricted to patients who have failed all medical and rehabilitative options or those with severe trigeminal neuralgia or hemifacial spasm.19

Little recurrence or outcome data exist regarding intracranial lipomas. The available reports suggest that these lesions remain stable over time and do not recur following surgical resection. Standard vestibular rehabilitation may be useful for some patients, and many authors recommend periodic surveillance of these lesions with MRI or magnetic resonance angiography.

In summary, intracranial lipomas range from relatively common "incidentalomas" on neuroimaging studies, to rare isolated lesions unassociated with other brain abnormalities, to even rarer lesions associated with congenital anomalies. Regardless of the co-associated conditions, most are found in the midline. They may be diagnosed with MRI because of their characteristic hyperintense signal on T1-weighted images and null signal with fat-suppression techniques. Management strategies for these lesions should be conservative, including medical therapy for seizure and cochleovestibular symptom control; vestibular rehabilitation; ventricular shunting for hydrocephalus; and cosmetic surgery for associated frontal bone anomalies. Surgical resection of intracranial lipomas or cranial nerve decompression or vestibular nerve transection should be done only in selected cases where other management strategies have failed.

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