Central nervous system tumor (peds): Difference between revisions

Revision as of 18:42, 14 September 2019

For adult patients, see also brain tumor

Background

2nd most common pediatric cancer (20%)

Clinical Features

Depends on location
- Posterior Fossa
  - Headache
    - Early morning (sleep > hypoventilation > hypercarbia > increases CNS blood flow > increased ICP)
    - Red flags also include headaches that are worse with valsalva, wakes from sleep, occur daily
  - Effortless vomiting
  - Cranial nerve palsies (especially 6th nerve)
- Brainstem
  - Cranial nerve palsies (facial weakness, abducens palsy, dysphagia), ataxia
- Supratentorial
  - Headache, personality change, motor weakness, seizure
- Sellar
  - Visual changes, hypothalamic dysfunction (diabetes insipidus, stunted growth, hypothyroidism)
Increased ICP features
Features of elevated ICP (from cerebral edema, tumor bleed, or mass effect
- Headache (from increased pressure on heavily innervated meninges)
  - Red flags: worse in the morning, worse with valsalva, wakes from sleep, daily
- Nausea/vomiting
  - Also typically worse in the morning
- Papilledema, dilated optic nerve
- Cushing's triad: Bradycardia, hypertension, irregular respirations
- Bulging fontanelle in infants
Seizure
Altered mental status, irritability, coma

Differential Diagnosis

Pediatric Headache

Primary headache
- Migraine
- Tension
- Cluster
Secondary headache
- Viral illness and fever
- Post-traumatic
- VP shunt malfunction
- CO poisoning
- Epidural hematoma
- Subdural hematoma
- Brain abscess
- Pseudotumor cerebri
- Meningitis
- Space-occupying lesion
- AVM
- Sinusitis
- Dental abscess
- Otitis media
- CNS tumor

Evaluation

Head CT

Management

Increased ICP
- Benzodiazepines +/- AEDs if actively seizing
- Dexamethasone(reduce tumor capillary permeability, inflammatory cytotoxicity)- 1mg/yr of age (max 10mg)
  - Do NOT give if CNS lymphoma is in the differential
- Elevate head of bed to 30 degrees, provide adequate sedation in intubated patients
- Maintain cerebral perfusion (euvolemia, vasopressors if necessary)
- Consider osmotherapy (e.g. hypertonic saline, mannitol)

References

Authors:

@@ Line 8: / Line 8: @@
 **Posterior Fossa
 ***[[Headache]]
-****Early morning (sleep > hypoventilation > hypercarbia > incrreases CNS bloodflow > inreaced ICP)
+****Early morning (sleep > hypoventilation > hypercarbia > increases CNS blood flow > increased ICP)
+****Red flags also include headaches that are worse with valsalva, wakes from sleep, occur daily
 ***Effortless [[vomiting]]
 ***[[Cranial nerve palsies]] (especially 6th nerve)
@@ Line 17: / Line 18: @@
 **Sellar
 ***[[Visual disturbances|Visual changes]], hypothalamic dysfunction ([[diabetes insipidus]], stunted growth, [[hypothyroidism]])
+*[[Increased ICP]] features
+*Features of [[elevated ICP]] (from [[Cerebral edema in brain cancer|cerebral edema]], [[Intracranial hemorrhage|tumor bleed]], or mass effect
+**[[Headache]] (from increased pressure on heavily innervated meninges)
+***Red flags: worse in the morning, worse with valsalva, wakes from sleep, daily
+**[[Nausea/vomiting]]
+***Also typically worse in the morning
+**[[Papilledema]], dilated optic nerve
+**Cushing's triad: [[Bradycardia]], [[hypertension]], irregular respirations
+**[[Bulging fontanelle]] in infants
+*[[Seizure]]
+*[[Altered mental status]], irritability, coma
 ==Differential Diagnosis==
 {{Pediatric HA DDX}}
@@ Line 26: / Line 38: @@
 ==Management==
 *[[Increased ICP]]
-**[[Phenytoin]], [[benzodiazepines]] if actively seizing
+**[[Benzodiazepines]] +/- [[AEDs]] if actively seizing
-**[[Dexamethasone]] 1mg/yr of age (max 10mg)
+**[[Dexamethasone]](reduce tumor capillary permeability, inflammatory cytotoxicity)- 1mg/yr of age (max 10mg)
 ***Do NOT give if CNS lymphoma is in the differential
+**Elevate head of bed to 30 degrees, provide adequate sedation in intubated patients
+**Maintain cerebral perfusion (euvolemia, vasopressors if necessary)
+**Consider osmotherapy (e.g. [[hypertonic saline]], [[mannitol]])
 ==See Also==