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THE MORNING REPORT

The Best in FOAM Education

  • Masooma Kazmi, MD

Pediatric Brain Tumors (and other stuff)!

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

  1. Evacuate mass occupying lesions (e.g., hemorrhage, tumor, abscess, etc)

  2. Patient Positioning: Head up 30 degrees and midline, neck position neural. Enhances cerebral venous outflow and maximizes CPP.

  3. CSF drainage: Decreases volume, effective however associated with bleeding risk, infection

  4. Mannitol & Hypernatremia:

    1. Mannitol: 0.5 - 2 g/kg up to Osm of 320. Increases intravascular oncotic pressure.

    2. Hypertonic Saline (3%):

      1. 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. 2 to 5 mL/kg administered over 10 to 20 minutes (Lexicomp)

      3. Increases intravascular oncotic pressure, volume expander.

  5. Craniectomy: resection of large flap of skull, changes the “volume” part of the compliance equation.

  6. Sedation & Analgesia: Benzos, narcs, barbiturates, Lido pETT/IV; possibly premedicate before stimulation; cluster nursing activity; calm environment. Decrease CNS metabolic demand

  7. Seizure Control: Aggressively treat and consider prophylaxis, numerous choices of AED (phenobarb, dilantin).Decrease CNS metabolic demand

  8. Antipyresis:Tylenol, paralysis, cooling measures, caution with NSAIDS. Metabolic demands increase 5-10% per 1 degree C.

  9. Ventilation: Normoventilate if able, +/- Hyperventilation temporarily if necessary.

    1. Hypocapnia leads to cerebral vasoconstriction, decreased cerebral blood flow -> decreased volume -> decreased ICP.

  10. 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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