In this podcast, I link to and excerpt from the PedsCases‘ podcast and transcript from Approach to Brain Tumors in Children by Chelsea.Howie May 30, 2020.
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Here are excerpts from the transcript:
Clinical Case
Let’s start with a clinical case. You are a clinical clerk doing your emergency medicine rotation at the local children’s hospital. Charlie is an 8-year-old boy who has been complaining of intermittent headache for 2-3 months. They have seen a doctor in a walk-in clinic twice in the last few months, who reassured the family that everything was fine. When you ask about other symptoms, you discover that for the past week, he has vomited, usually in the morning, and his parents have noticed him having troubles with balance – bumping into walls and furniture which is uncharacteristic of him. He’s also
had difficulty going up and down stairs, needing to hold the handrail.You perform a neurological examination. Charlie has some unsteadiness walking heel-to-toe and loses his balance when trying to stand on his left leg alone. The cranial nerve exam reveals horizontal diplopia and what you believe to be an abducens (or a 6th) nerve palsy, as he has a right esotropia. The rest of the examination is unremarkable. What are your thoughts about Charlie’s problems?
Introduction
Central nervous system, or CNS tumours represent 19% of cancers in children aged 0-14 (1). These are the most common solid tumors of childhood and are the most common cause of deaths from childhood cancer in the developed world.
Clinical Presentations
Children with CNS tumours often present due to the physical effects of a tumour mass on the structures of the brain itself. Symptoms are usually new neurological signs or may be due to hydrocephalus. As such these symptoms can be very diverse. Headache is the most common symptom. This finding is often a part of a slowly developing triad of headache, nausea & vomiting, and ataxia, or unsteadiness, which is usually due to
hydrocephalus.In infants and younger children (under 4), who are not yet
walking or are unable to verbalize, common signs include macrocephaly, vomiting, irritability, and lethargy.Other signs and symptoms of a new brain tumor, depending on
anatomic location, could include visual complaints, onset of weakness, regression of developmental milestones, and failure to thrive. Understandably, these signs and symptoms in isolation may not immediately raise alarm for presence of a brain tumor, and, need to be evaluated alongside other features on careful physical examination, and neuroimaging (6,7).The differential diagnoses for a brain tumor in a child often
include common conditions such as tension or migraine headaches or non-specific infections.Less common conditions may include a brain abscess, non-malignant hydrocephalus, intracranial hemorrhage and arteriovenous malformations.
In terms of general historical findings, the history could include a progressive decline in school performance, change in mood, or personality in older children, or regression of developmental milestones in younger children
[A Careful Neurological Examination]
A careful neurological examination is of utmost importance in evaluating a new brain tumor. Let’s go through possible exam
findings, step by step.A more rapid presentation could be an acute decrease in level of
consciousness.Cranial nerve examination may reveal various visual field deficits,double vision, papilledema, nystagmus, gaze paralysis, facial weakness, hearing deficits, and drooling or difficulty swallowing.
Examination of peripheral motor function could show unilateral or bilateral weakness, with or without muscle wasting, pronator
drift, changes in tone due to atrophy, and early handedness.Examination of peripheral motor function could show unilateral or bilateral weakness, with or without muscle wasting, pronator
drift, changes in tone due to atrophy, and early handedness.Sensory examination can show deficits in a focal distribution.
Evaluation of cerebellar function and coordination can reveal abnormality or asymmetry of finger or toe tapping, or rapid repetitive movements. There may be over or undershooting of finger-to-nose testing, otherwise known as dysmetria. There may be a broad-based, unsteady, or ataxic gait, difficulty performing tandem gait, and balance abnormalities, which may be unilateral or bilateral.
Reflex testing is important, and may reveal hyper, or hypo-reflexia. Clinicians should also look for clonus and abnormal plantar reflexes.
Neuroimaging is a crucial part of solidifying the diagnosis. In the emergency setting, a CT is often used as a first-line scan, as it is more widely available, is fast, and may not require sedation. MRI with contrast enhancement, however, is the standard of care for children with a suspected CNS tumor.
Clinical Case – Continued
Let’s go back to our case and review Charlie’s presentation. He presented with a longstanding history of intermittent headaches, and more recently developed episodes of vomiting and trouble with coordination and balance. He has a handful of concerning signs on exam, including a cranial nerve deficit. You also note that he does not have any neurocutaneous findings suggestive of neurofibromatosis or tuberous sclerosis.
You request a head CT, which reveals a mass in the posterior fossa. What are your next steps?
Management & Treatment
It is important to note that a definitive diagnosis cannot be
given to the patient and family until the tumor tissue is examined by pathology, following either surgical resection, or biopsy.Generally, a consultation to neurosurgery is the initial
step in managing and treating newly diagnosed brain tumors. A detailed assessment including appropriate MRI imaging is essential.Neurosurgical intervention can be for diagnostic and/or therapeutic purposes. Depending on the size and location of the tumor, a biopsy may be taken, or a partial or complete resection may occur.
Looking back at the case, an urgent referral to neurosurgery is essential. The degree to which the tumor can be resected, and the definitive treatment plan would be determined by the multidisciplinary brain tumour team. . .
Conclusion
• A common triad of signs and symptoms for a brain tumor include headache, nausea and/or vomiting, and gait imbalance. All signs and symptoms need to be
considered within the context of the clinical presentation, including a thorough history, detailed physical exam, and neuro-imaging.
• Although variable, surgery, chemotherapy and radiation are mainstays of treatment for brain tumors in children. In some cases, surgery may be curative alone, whereas others require combination therapies.
• All involved health professionals should be aware and screening for the short and long-term effects post-treatment.
