CNS tumors (peds)

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)

See Also

References

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