Common presenting symptoms
Most common symptom reported by children with a newly diagnosed brain tumor is headache. Occurs in 1/3 of patients
Nausea and vomiting occur in 1/3 of children newly diagnosed
New onset seizure can be seen in up to 40% of children diagnosed with cortical based tumor
Young children can present with macrocephaly, vomiting, irritability and lethargy
Headache
Many benign causes of headache: tension headache, migraine headache, viral syndrome, etc
Not benign causes: Brain mass, ruptured SAH, meningitis, obstructive hydrocephalus (e.g. due to VP shunt malfunction)
How do you differentiate the benign vs not benign headaches?
Red flag headache findings:
SNOOPY IS WET
Systemic signs/symptoms
Neurological signs (ataxia, focal deficits, papilledema)
Occipital headache
Occurring in high risk groups (sickle cell disease, VP shunts, malignancy)
Postural (worse leaning forward/bending)
Younger age (2-3 years old)
Infectious signs
Squint (new onset)
Waking from sleep
Early morning vomiting
Thunderclap headache
Examination | Pertinent findings suggestive of a tumor |
Mental Status | Encephalopathy, progressive neurocognitive decline |
Cranial Nerve II | Visual field defects, papilledema |
Cranial Nerves III, IV, VI | Nystagmus (particularly upgaze), gaze paralysis, mid-position, poorly reactive pupils |
Cranial Nerve VII | Facial Weakness (upper vs. lower motor neuron distributions |
Cranial Nerve VIII | Decreased hearing, vertiginous symptoms |
Cranial Nerves IX, X, XII | Drooling, dysphaiga, uvula deviation, tongue protrusion deviation |
Motor exam | Early handedness, delayed motor milestones, pronator drift, focal changes in tone with associated atrophy |
Reflexes | Hyperreflexia, babinski sign, hofmann's sign |
Cerebellar function | Dysmetria, overshooting/missing on finger-to-nose and/or heel-to-shin test, asymmetry of finger and/or toe tapping |
Gait | Wide based unsteady gait, inability to perform straight-line test, circumduction of gait |
Sensory | sensory deficits in focal anatomic distribution |
Medulloblastoma
Most common malignant brain tumor of childhood
Derived from tumor stem cells of the external granular layer of the cerebellum
Generally presents as a posterior fossa mass, often associated with obstructive hydrocephalus
Ependymomas
Derived from ependymal cells within the CNS
Most commonly in posterior fossa
Can also occur in supratentorial region and spinal cord
Astrocytoma
Juvenile pilocytic astrocytoma most common
Associated with Neurofibromatosis Type 1
Usually arise in cerebellum, near the brain stem, in hypothalamic region or optic chiasm
Craniopharyngioma
Suprasellar mass
Can present with bitemporal hemianopsia and pituitary insufficiency

Signs and Symptoms | Tumor Location |
Early morning vomiting, recurrent vomiting, enlarged head | Posterior fossa, ventricular system |
Failure to thrive, Anorexia | Suprasellar, hypothalamic |
Visual compaints, abnormal extraocular movements | Optic Pathway, suprasellar, brain stem, posterior fossa |
Tics, tremors, movement disorders | basal ganglia, thalamus, midbrain |
Early handedness | Cortex, subcortical, brain stem, spinal cord |
Facial nerve palsy | Brain stem, cerebellar pontine angle |
Hearing loss | cerebellar pontine angle |
Precocious puberty, nocturnal enuresis | suprasellar |
head tilt, torticollis | Cerebellar pontine angle, cervicomedullary junction |
ICP Management
Evacuate mass occupying lesions (e.g., hemorrhage, tumor, abscess, etc)
Patient Positioning: Head up 30 degrees and midline, neck position neural. Enhances cerebral venous outflow and maximizes CPP.
CSF drainage: Decreases volume, effective however associated with bleeding risk, infection
Mannitol & Hypernatremia:
Mannitol: 0.5 - 2 g/kg up to Osm of 320. Increases intravascular oncotic pressure.
Hypertonic Saline (3%):
5-10 ml/kg 3% NaCl up to [Na] of 145-180 meq/L – may bolus 5-10 ml/kg and start a sliding scale gtt @ 0.5-2 ml/kg/hr. (Learn PICU)
2 to 5 mL/kg administered over 10 to 20 minutes (Lexicomp)
Increases intravascular oncotic pressure, volume expander.
Craniectomy: resection of large flap of skull, changes the “volume” part of the compliance equation.
Sedation & Analgesia: Benzos, narcs, barbiturates, Lido pETT/IV; possibly premedicate before stimulation; cluster nursing activity; calm environment. Decrease CNS metabolic demand
Seizure Control: Aggressively treat and consider prophylaxis, numerous choices of AED (phenobarb, dilantin).Decrease CNS metabolic demand
Antipyresis:Tylenol, paralysis, cooling measures, caution with NSAIDS. Metabolic demands increase 5-10% per 1 degree C.
Ventilation: Normoventilate if able, +/- Hyperventilation temporarily if necessary.
Hypocapnia leads to cerebral vasoconstriction, decreased cerebral blood flow -> decreased volume -> decreased ICP.
Glucose Control: Glucose control with prudent dextrose administration and insulin gtt if needed. Hypo-and hyperglycemia in the setting of cerebral ischemia leads to enhanced anaerobic metabolism.
Masooma Kazmi, MD
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