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
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
Neurological signs (ataxia, focal deficits, papilledema)
Occurring in high risk groups (sickle cell disease, VP shunts, malignancy)
Postural (worse leaning forward/bending)
Younger age (2-3 years old)
Squint (new onset)
Waking from sleep
Early morning vomiting
Pertinent findings suggestive of a tumor
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
Early handedness, delayed motor milestones, pronator drift, focal changes in tone with associated atrophy
Hyperreflexia, babinski sign, hofmann's sign
Dysmetria, overshooting/missing on finger-to-nose and/or heel-to-shin test, asymmetry of finger and/or toe tapping
Wide based unsteady gait, inability to perform straight-line test, circumduction of gait
sensory deficits in focal anatomic distribution
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
Derived from ependymal cells within the CNS
Most commonly in posterior fossa
Can also occur in supratentorial region and spinal cord
Juvenile pilocytic astrocytoma most common
Associated with Neurofibromatosis Type 1
Usually arise in cerebellum, near the brain stem, in hypothalamic region or optic chiasm
Can present with bitemporal hemianopsia and pituitary insufficiency
Signs and Symptoms
Early morning vomiting, recurrent vomiting, enlarged head
Posterior fossa, ventricular system
Failure to thrive, Anorexia
Visual compaints, abnormal extraocular movements
Optic Pathway, suprasellar, brain stem, posterior fossa
Tics, tremors, movement disorders
basal ganglia, thalamus, midbrain
Cortex, subcortical, brain stem, spinal cord
Facial nerve palsy
Brain stem, cerebellar pontine angle
cerebellar pontine angle
Precocious puberty, nocturnal enuresis
head tilt, torticollis
Cerebellar pontine angle, cervicomedullary junction
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