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INTRA-CRANIAL SPACE OCCUPYING LESIONS

A MORPHOLOGICAL ANALYSIS
M. EJAZ BUTT, SAEED A. KHAN, NASEER A. CHAUDRHY AND G. R. QURESHI
Department of Pathology, Postgraduate Medical Institute, Lahore - Pakistan

The purpose of this study was to provide preliminary data on morphological patterns of intracranial space occupying lesions (ICSOL) in central Punjab province. This is a cross-sectional
prospective study on 100 consecutive cases of intra-cranial space occupying lesions admitted to
both the neurosurgery units of Lahore General Hospital, Lahore, Pakistan. The biopsy materials
were examined histologically using paraffin sections. Eighty nine (89) patients had neoplasms,
while eleven (11) had non-neoplastic lesions. Neuroepithelial tumours comprised 41% of all the
neoplasms, followed by meningiomas being 23%, schwannomas 11% and metastatic tumours
6%. Males were affected slightly more than females (1.17:1). Tuberculomas constituted 3% of the
lesions. It was concluded that age and sex distribution were generally comparable to the other
published literature. Similarly neuroepithehal tumours formed majority of the lesions. However
meningiomas had a higher frequency as compared to the western literature; moreover
tuberculomas should also be considered in the differential diagnosis of such lesions in this part
of the world.

INTRODUCTION
The term Intra-cranial space occupying lesion is
defined as any neoplasm, benign or malignant, primary or secondary, as well as any inflammatory or
parasitic mass lying within the cranial cavity1. The
list also includes haematomas,2 different types of
cysts,3,4 and vascular malformations5,1,6. Space
occupying primary tumours of the central nervous
system and its coverings account for about 9% of
all the primary neoplasms of the human body.
Among the intracranial space occupying tumours,
those of central neurogenic origin claim priority in
number and complexity. These are the tumours
derived from parenchymatous neuroepithelial elements of central nervous system excluding the
microglia; and they are widely credited to account
for 40-50% of all the intra-cranial space occupying
tumours7,8. Systemic study of tumours of the central nervous system began when Baily and Cushing started their studies in the early 1920s. Over
the past three decades, many reports suggested
that both incidence and pattern of intracranial
neoplasia are subject to considerable geographic
and racial variations. Knowledge of the regional
peculiarities of these lesions, may, therefore, help
in identifications of possible risk factors and also
in establishing measures for an improved
diagnosis, treatment and outcome. No accurate

statistics reporting the morphological pattern of

intracranial space occupying lesions were available
in the province of Punjab. Therefore, it was
decided to study the morphological pattern of
intracranial space occupying lesions in this part of
the world.

MATERIALS AND METHODS

A total of 100 cases of intracranial space occupying
lesions (ICSOLS) were collected from both the
neurosurgery wards of the Lahore General
Hospital Lahore, between the period from
September 1999 to April 2000. As these are the
oldest, the biggest and very busy neurosurgical
units of the province, hence the patient population
was fairly equally representative of the province of
Punjab. The patients were of all age groups and
belonged to both sexes. All cerebral neoplasms in
this study were grouped according to the
classification of the World Health Organization9.
Each patient had at least one cranial tomographic
scan (CT) and was found having a space occupying
lesion in the cranium. The gross examination of
the biopsy specimens was performed. They were
collected in, 10% buffered formalin as fixative.10,11.
All the specimens were dehydrated, cleared,
impregnated and embedded in suitable medium to
facilitate their cutting. The tissue sections were
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M. EJAZ BUTT, SAEED A. KHAN, NASEER A. CHAUDRHY et al

stained with haematoxylin and eosin following the

method of Harris haemotoxylin12,13.

number and percentage of different histological

types of this group are shown in Table 4.

RESULTS

Table 3: Distribution of 89 cases of neoplastic

Intra-cranial space occupying lesions.

In a total of 100 cases of intracranial space

occupying lesions, 54 cases were males and 46
were females, having a male / female ratio of 1.17:1
as shown in Tables 1,2. Of all the 100 cases, 18
cases were found below the age of twenty, while
maximum number of cases (28) were found in the
third decade. Thirteen cases were seen in 3rd
decade, and 14 in 4th decade. A steep rise in the
number of cases in the sixth decade was noticed
i.e, 20 cases. These observations are depicted in
Table 2.
Table 1: Distribution of 100 cases of intracranial space occupying lesions.
Groups
Neoplastic Lesions
Non-neoplastic Lesions
Total

Sex

Total

Male

Female

48

41

89

11

54

46

100

Sex

Total

(%)

15

41

(41%)

16

23

(23%)

11

(11%)

(2%)

5. Vascular
Tumours

(1%)

6. Arterio-venous
malformation

(1%)

7. Extension from
regional Tumours

(2%)

8. Metastatic
Tumours

(6%)

9. Germ cell
Tumours

(1%)

Types of Tumor

Male

Female

26

2. Meningiomas
3. Nerve sheet
tumours (Schwannomas)
4. Primary
adenomas

1. Neuro-epithelial
Tumours

10. Lymphomas

Table 2: Age and Sex distribution of 100 cases of

intra-cranial space occupying lesions.
Age group (years)

Sex*

Total

Male

Female

1.

09

2.

10 19

13

3.

20 29

14

14

28

4.

30 39

13

5.

40 49

14

6.

50 59

13

20

7.

60 69

14

46

100

*No significant difference between males and females for all

age groups (P > 0.05).

Table 1 shows, that of all the 100 cases of

ICSOLs, 89 cases were intracranial neoplasms.
Among the 89 neoplasms, 48 were in males and 41
cases were in females. Male / Female ratio in case
these of neoplasms was counted as 1.17:1. Table-3
shows that neuroepithelial tumours ranked No. 1
with the highest number of cases. Meningiomas
were second in frequency schwannomas and
metastatic tumours ranked third and fourth
respectively in frequency. Neuroepithelial tumours
were the most common intracranial neoplasms
and comprised of 41% of the total (Figure 1). The
Biomedica Vol. 21 (Jan. Jun., 2005)

Total

(1%)

48

41

89

(89%)

Table 4: Relative frequency of the different types

of neuro-epithelial tumours.
Types of Tumor

Sex

Total

(%)

19

(46.3%)

(21.9%)

(14.6%)

Male

Female

1. Benign
Astrocytomas

15

2. Anaplastic
Astrocytomas
3. Glioblastomas
Multiforme
4. Ependymomas

(4.8%)

5. Oligodendrogliomas

(4.8%)

6. Medulloblastomas

(2.4%)

7. Choroid plexus
papilloma

(2.4%)

8. Mixed Tumour

(2.4%)

26

15

41

(100%)

Total

In a total 41 cases, 19 were benign astrocytomas and 15 cases were malignant astrocytomas.
These astrocytomas collectivity accounted for
82.8% of the total neuroepithelial tumours. M/F
ratio was 1.17:1. Meningiomas constituted 23% of

33

INTRA-CRANIAL SPACE OCCUPYING LESIONS

Oligodendroglioma
4.8%

Medulloblastoma
2.4%

Choroid plexus
papilloma 2.4%

Mixed tumors 2.4%

Ependymoma 4.8%
Glioblastoma
Multiforme 14.8%
Benign
Astrocytomas
46.3%

Anaplastic
Astrocytomas
21.9%

Table 5: Distribution of 11 cases of non-neoplastic Intra-cranial space occupying

lesions.
Sex

Types of Lesion

Total

(%)

(3%)

(2%)

(2%)

(2%)

5. Cholesteatoma

(1%)

6. Chronic infection

(1%)

11

(11%)

Male

Female

1. Tuberculoma

2. Fungal Infection

3. Cysts
4. Haemorrhages

Total

Chrohic
Chronic
infection
9%
Cholesteatoma 9%

Tuberculomas 27%

Haemorrhages 18%

Cysts 18%

Fungal
Infection
18%

Fig. 2: Distribution of 11 cases of non-neoplastic Intracranial space occupying lesions.

the total neoplasms and were the second most

common type. Females were affected almost twice
as often as males. As a result meningiomas were
the commonest intracranial neoplasms of the
females. These occurred exclusively in the middle
and higher age groups with maximum incidence
during fourth and fifth decades. Among the 11
cases of non-neoplastic intracranial masses, there

Fig. 1: Distribution of
41 cases of Neuroepithelial tumors

were 3 tuberculomas, two fungal granulomas, two

cysts, two haemorrhages and cholesteatoma and
chronic infection one each as shown in Table 5 and
Figure 2.

DISCUSSION
Despite some limiting factors in this study, the
analysis shows that these 100 cases of ICSOLs
share several features common with other
published series. Both age and sex distribution lie
within the estimated ranges in the other reports.
In this study, brain tumours occurred mostly
during the third and sixth decades of life. In comparison to that most series reported from Asian
countries,14,3,15,5,1,16,17 brain tumours occurred mostly during fourth decade of life, in Western countries during the fifth and sixth decades of life18,19,20.
This could be due to the differrrent age characteristics of the populations as well as different case
ascertainment in the two country groups, with a
higher rate of autopsies in the latter.
The percentage of pediatric brain tumours, occurring below the age of twenty years, in the present series was18% as compared with13% in Saudi
Arabia1, 10.0% in United States,21 16.8% in India22,
18.6% in China,5 28.4% in Thailand23. This figure
seems to be related to the size of the pediatric
population in each country. The most common
tumours in pediatric group were astrocy-tomas,
followed by medulloblastomas, in line with other
published reports24,25. The male to female ratio of
1.17:1 in the present 100 cases corresponds to an
overall male / female ratio ranging from 1:1 to
1:626,27,28,29,30,31,32. i. e. more males that females
develop brain tumours.
As in all other series tumours of the neuroepithelial origin were also in the present study, the
most frequent type of intracranial neoplasms
except in a study reported from Nigeria,33 where
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M. EJAZ BUTT, SAEED A. KHAN, NASEER A. CHAUDRHY et al

metastatic tumours ranked first followed by glial

tumours in frequency. As regards age distribution
of tumours, neuroepithelial tumours occurred at a
significantly younger age (P<0.01) in this study
(Table 6).

preponderance of females over males in our study,

which is in agreement with majority of the other
studies.

Table 6: Range and mean age in neuroepithelial

tumors & non-neuroepithelial tumors.
Age (Years)

Number
of cases

Range

Mean SD

Neuroepithelial Tumours

41 (41%)

9-60

29.34
14.10

Non-Neuroepithelial tumours

48 (48%)

1-65

*38.26
15.89

Lesion

*p < 0.01 as compared to neuroepithelial tumors

These finding are comparable to that of

Jamjoom1, who also reported that majority of the
neuroepthelial tumours were found in a younger
age. Two cases of pleomorphic xanthoastrocytomas were also in line with reported six cases
from India34 .

Photo 2: Photomicrograph of a Meningioma showing

Psammoma Bodies (H & E x 100).

The relative incidence of malformative tumours in this series was markedly below the rates reported from Japan, Thailand and China but within
the comparable ranges given by most Western
series.
The ratio of secondary brain tumours in the
present series is near the limits estimated in the
other series. Unexpectedly, the incidence of cerebral tuberculomas in the present series is less than
the rates reported from India and Saudi
Arabia14,15,1 and more than the other series from
Kuwait, Germany and France38,39,40. Thus in
conclusion, this study has highlighted the relative
frequency of different intracranial space occupying
lesions in the central Punjab Province.
REFERENCES

Photo 1: Photomicrograph of a Pleomorphic Xanthoastrocytoma (H & E x 100).

1.

The relative frequency of meningiomas in this

series of 100 intra-cranial space occupying neoplasms was 23% which is higher than the rates
reported from Western and Asian countries.
Jamjoom1 from Saudi Arabia showed 28%
meningiomas in the Saudi population. This view is
supported by the findings of Chowdhry35 who reported a ratio of 26% for the meningiomas in a
small series of 54 intracranial tumours from the
Eastern province of Saudi Arabia. Also statistics
about meningiomas from KFSH36 showed a high
proportion of meningiomas in Saudi Arabia as
compared to our study in the central Punjab. A
report from JPMC Karachi37 analyzed 13.7% meningiomas, which is a fairly low incidence as compared to our study. The meningiomas have a clear

2.

Biomedica Vol. 21 (Jan. Jun., 2005)

3.
4.

5.
6.

Jamjoom ZAB. Pattern of intra-cranial space occupying lesions: experience at King Khalid University
Hospital. Ann Saudi Med, 1989;9:3-10.
Duncan G, Caird F. Review of 18 years experience of
a diagnostic geriatricneurology referral service.
Scot-Med-J 1991; 36: 139-42.
Darrel F, Weinman. Incidence and Behaviour Pattern of intra-cranial Tumours in Ceylon. International Sur-gery 1973; 58: 548-54.
Conley FK. Epidermiod and dermiod tumours:
Clinical features and surgical management. In
Wilkins R.H. and Rengachary S.S. (eds), Neurosurgery Vol. No. 1. 2nd Ed. New York: McGraw-Hill
1996; 971-6.
Wen-Qing QQ, Shi-Jow, Qing-sheng T, et al. Statistical analysis of central nervous system tumours in
China. J. Neurosurg 1982; 56 (4): 555-64.
Lombardi D, Scheithauer B.W., Piepgras D, Meyer
FB., and Forbes G.S. Angioglioma and the arteriovenous malformation-glioma association. Journal
of Neurosurgery 1991; 75: 589-96.

INTRA-CRANIAL SPACE OCCUPYING LESIONS

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.
19.

20.
21.
22.

23.
24.

Burger PC, Scheithauer BW. Tumours of Central

Nervous System. Atlas of tumour Pathology, Third
series, Fasc 10, Washington DC AFIP 1994.
Mwangombe NJ, Ombachi RB. Brain tumours at
Kenyatta National Hospital, Nairobi, East Afr Med
J. 2000 Aug; 77 (8): 444-7.
Kleihues P, Burger PC, Scheithauer BW. The new
WHO classification of brain tumours. Brain Pathol
1993; 3: 255-268.
Brown GG (ed). An Introduction to Histotechnology. A manual for the student, Practicing Technologist and Resident-in-Pathology. New York: Appleton-Century-Crofts, 1978: 211-13.
Prophet EB, Mills B, Arrington JB, Sobin LH. Laboratory methods in Histotechnology Washington DC
AFIP, 1992: 53-58.
Stevens A. The haematoxylin. In: Bancroft JD, Stevens A (eds). Theory and Practice of Histological
Techniques. 3rd Ed. Edinburgh: Churchill Livingstone 1990: 107-17.
Bancroft JD, Gamble M. Theory and Practice of
Histological techniques. 5th Ed. Churchill Livingstone 2002: 127-28.
Dastur DK, Lalitha VS, Prabhakar V. Pathological
analysis of intra-cranial space-occupying lesions in
1000 cases including children: 1. Age, sex and pattern; and tuberculomas; J Neurol Sci 1968; 6: 57592.
Ramamurthi B. Intra-cranial tumours in India:
incidence and variations. International Surgery
1973; 58 (8): 542-47.
Ranganayakulu Y, Khurana P, Binitie OP, Rohatgi
SM, Venkataramana B, Facharzt M.Y.H. Pattern of
intracranial neoplasms in Asir Area; Experience in
Asir central Hospital. Annals of Saudi Med 1994;
14: 166.
Ahmed Z, Muzaffar S, Kayani, N, Pervez S, Husainy
AS, Hasan SH. Histological Pattern of central nervous system neoplasms. J Pak Med Assoc. 2001
April; 51 (4): 154-7.
Zuelch KH. Brain tumours. Their biology and their
pathology 2nd ed. New York Springer 1965:62-88.
Zimmerman HM. Brain tumours; Their incidence
and classification in man and their experimental
produc-tion. Ann N.Y. Academy of sciences 1969;
159: 337-59.
Walker AE, Robins M, Weinfeld ED. Epidemiology
of brain tumours: the national survey of intracranial neoplasms. Neurology 1985;35(2):219-26.
CBTRUS. 1996 Annual report. Central Brain
tumour Registry of the United States (1997).
Dastur DK, Lalitha VS. Pathological analysis of
intracranial space occupying lesions in 1000 cases
including children:11. Incidence, types and unusual
cases of glioma. J Neurol Sci 1969; 8: 143-70.
Shuangshoti S, Panyathanya R. Neural Neoplasms
in Thailand; a study of 2897 cases. Neurology 1974;
24 (12): 1127-34.
Shah SH, Soomro IN, Hussainy AS, Hassan SH. Clinicomorphological Pattern of intra-cranial tumours in children. J Pak Med Assoc. 1999 Mar; 49 (3):
63-5.

35
25. Cho KT, Wang KC, Kim SK, Shin SH, Chi JG, Cho
BK. Pediatric brain tumours; statistics of SNUH
Korea (1959-2000). Childs Nerve Syst. 2002 Feb;
18 (1-2): 30-7. Epub 2002 Jan 25.
26. Cohen, A. and Modan, B. Some epidemiological aspects of neoplastic diseases in Israeli immigrant
population III. Brain tumours. Cancer 1968; 22:
1323-8.
27. Kurland, L.T., Schoenberg, B.S., Annegers, J.F.,
Okazaki, H. and Molgaad, C.A. The incidence of primary intracranial neoplasms in Rochester, Minnesota 1935-1977. Annals of New York Academy of
Sciences 1982; 381: 6-16.
28. Sant, M., Crosignani, P., Bordo, B.M., Nicola, G.N.,
Bianchi, M. and Berrino, F. Incidence and survival
of brain tumours; a population based study.
Tumori 1988; 74: 243-52.
29. Preston-Martin S., Thomas, D.C., Wright, W.E and
Henderson, B.E. Noise trauma in the etiology of
acoustic neuromas in men in Los Angeles county,
1978-1985. British Journal of Cancer 1989; 69: 7836.
30. Kallio, M. The incidence, survival, and prognostic
fac-tors of patients with intra-cranial glioma and
meningioma in Finland from 1953-1987. Academy
of Dissertation, University of Helskinki, Finland
1993.
31. Preston-Martin S., Staples, M., Farrugia, H. and
Giles, G. Primary tumours of the brain, cranial
nerves and cranial meninges in Victoria, Australia,
1982-1990: pattern of incidence and survival. Neuroepidemiology 1993; 12:270-9.
32. Olasode BJ, Shokunbi MT, Aghadiuno PU, Intracranial Neoplasms in Ibadan, Nigeria, East Afr Med J.
2000 Jan; 77 (1): 4-8.
33. Olasode BJ. A pathological review of intra-cranial
tumours seen at the University College Hospital,
Ibadan between 1980 and 1990. Nigeria Post grad
Med J. 2002 Mar; 9 (1): 23-8.
34. Sundaram C, Naidu MR, Reddy JJ. Pleomorphic
xanthoastrocytoma - a clinicopathological study.
Indian J Pathol Microbiol. 2000 Jul; 43 (3): 357-61.
35. Chowdhary UM, Ibrahim AW, Sohaibani M, Boehme DH. Experience with brain tumours in Eastern
Province of Saudi Arabia (letter to the editor). Ann
Saudi Med 1987; 7 (2): 166.
36. Siqueira E. Neurosurgical diseases at King Faisal
specialist Hospital and Research centre, 1982 to
1986 (letter to the editor). Ann Saudi Med 1988; 8
(2): 152-3.
37. Irfan A, Qureshi A. Intra-cranial space occupying
lesions; review of 386 cases. JPMA 1995; 45 (12):
319-20.
38. Abdul-Ghaffar NU, El-Sonbaty MR, Rahman NA.
Intracranial tuberculoma in Kuwait. Int J tuberc
Lung Dis. 1998 May; 2 (5): 413-8.
39. Pagnou C, Genereau T, Lafitte F, Congy F, Chiras J,
Herson S. Brain Tuberculomas; Ann Med Interne
(Paris). 2000 Oct; 151 (6): 448-55.
40. Giese A, Kucinski T, Hagel C, Lohmann F. Intracranial tuberculomas mimicking a malignant disease in an immuncompetent patient. Acta Neurochir
(Wien). 2003 Jun; 145 (6): 513-7.
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