II. Indication

  1. Approach to suspected Focal Brain Lesion in HIV patient

III. Step 1: Head CT

  1. Head CT Positive: Go to Step 2 below
  2. Head CT Negative
    1. Obtain more detailed imaging
      1. CT with double-dose contrast or
      2. MRI with gadolinium
    2. Interpretation of secondary imaging
      1. Positive: Go to Step 2 below
      2. Negative: Lumbar Puncture and treat per results

IV. Step 2 Focal Lesion: Check contrast enhancement

  1. Positive Contrast Enhancement: Go to Step 3 below
  2. Negative for contrast enhancement
    1. Perform MRI with Contrast
    2. Interpret for contrast enhancement
      1. Positive: Go to step 3 below
      2. Negative: Obtain PCR for JC Virus
        1. Pos: Progressive Multifocal Leukoencephalopathy
        2. Neg: Consider LP, other studies

V. Step 3 Contrast Enhancing: Check for Mass Effect

  1. Positive: Neurosurgical consult
    1. Treat intracranial Hypertension
    2. Open biopsy with decompression
  2. Negative: Check Toxoplasmosis serology
    1. Positive: Evaluate for effective therapy
    2. Negative: Obtain Epstein-Barr Virus Serology
      1. Positive: Evaluate with biopsy for Lymphoma
      2. Negative
        1. Single CNS Lesion: Biopsy
        2. Multiple CNS Lesions: Lumbar Puncture

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