Central nervous system tumor (peds)

This page is for pediatric patients. For adult patients, see: Central nervous system 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

Giant parietal lobe infantile gliosarcoma in a 5-year-old child.

Pediatric choroid plexus carcinoma.

• 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)

See Also

• Herniation Syndromes
• Elevated ICP
• Cerebral edema in brain cancer