referral from primary care imaging

Headaches• Considerabraintumourinanychildwithanew,persistent*headache

• Headacheinisolation,unlikelytobeabraintumour

• Braintumourheadachesoccuratanytimeofday

• Childrenagedyoungerthan4yearsmaynotbeabletodescribeaheadache–observebehaviour

CNS imaging required with

• Persistentheadachethatwakesachildfromsleep

• Persistentheadachethatoccursonwaking

• Persistentheadacheinachildunder4

• Confusionordisorientationwithaheadache

• Persistentheadachewith1ormoreothersymptoms

Common pitfalls

• Failuretoreassessachildwithamigraineortensionheadachewhentheheadachecharacterchanges

*Persistent = continuous or recurrent headache present for more than 4 weeks

Nausea and vomiting• Considerabraintumourinanychildwithpersistent*nauseaand/orvomiting

• Headcircumferenceshouldbemeasuredandplottedinchildrenunder2withpersistentvomiting

CNS imaging required with

• Persistentvomitingonwaking(NB:excludepregnancywhereappropriate)

• Persistentnausea/vomitingwith1ormoreothersymptom

Common pitfalls

• FailingtoconsideraCNScauseforpersistentnauseaandvomiting

*Persistent = nausea and/or vomiting present for more than 2 weeks

Visual signs and symptoms• Considerabraintumourinanychildwithpersistent*visualabnormality

• Visualassessmentrequiresassessmentof:

visualacuity

eyemovements

pupilresponses

opticdiscappearance

visualfields(>/=5yrs)

• Pre-schoolandunco-operativechildrenshouldbeassessedbyhospitaleyeservicewithin2weeksofreferral

• Parentconcernalonewarrantsreferralforvisualassessment

CNS imaging required with

• Papilloedema

• Opticatrophy

• Newonsetnystagmus

• Reductioninvisualacuitynotduetorefractiveerror

• Visualfieldreduction

• Proptosis

• Newonsetparalyticsquint

• Visualsymptomwith1ormoreothersymptom

Common pitfalls

• Failuretofullyassessvision–REFERIFNECESSARY

• Failureofcommunicationbetweencommunityoptometryandprimaryandsecondarycare

*Persistent = visual abnormality present for more than 2 weeks

Head circumference• Considerabraintumourinanychildundertwoyearswithanincreasinghead

circumferenceoutsidethenormalrangeincomparisontotheirheightandweight

• Carefulassessmentofothersignsandsymptomsofabraintumourshouldbeundertakeninthesebabies

CNS imaging required with

• Rapidrateofheadcircumferencegrowthcrossingcentiles

• Increasingheadcircumferencewithanyotherassociatedsymptoms

Common pitfalls

• Failingtomeasureandmonitorheadcircumferenceinababyoryoungchildwithpersistentvomiting

Motor symptoms and signs• Considerabraintumourinanychildwithpersisting*motorabnormality

• Motorassessmentrequireshistoryorobservationof:

sittingandcrawlingininfants

walkingandrunning

handlingofsmallobjects

handwritinginschoolagechildren

• Braintumourscancausealossorchangeinmotorskillsandthiscanbesubtlee.g.abilitytoplaycomputergames

CNS imaging required with

• Regressioninmotorskills

• Focalmotorweakness

• Abnormalgait/co-ordination(unlesslocalcause)

• BellspalsywithNOimprovementwithin4weeks

• Swallowingdifficulties(unlesslocalcause)

• Headtilt/torticollis(unlesslocalcause)

• Motorsymptomwith1ormoreothersymptom

Common pitfalls

• Attributingabnormalgait/balancetomiddleeardiseasewithnocorroboratingfindings

• Failuretoidentifyswallowingdifficultiesandaspirationasacauseofrecurrentchestinfections

*Persistent = motor abnormality present for more than 2 weeks

Growth and endocrine• Considerabraintumourinanychildwithanycombinationofgrowthfailure,

delayed/arrestedpubertyandpolyuria/polydipsia

• Earlyspecialistassessmentifrequiredfor:

precociouspuberty/delayedorarrestedpuberty

growthfailure

galactorrhoea

primaryorsecondaryamenorrhoea

CNS imaging required with

• Growthorendocrinesymptomwith1ormoreothersymptoms

Common pitfalls

• FailingtoconsideraCNScauseinchildrenwithweightlossandvomiting

• Failuretoconsiderdiabetesinsipidusinchildrenwithpolyuriaandpolydipsia

Behaviour• Considerabraintumourinanychildwithnewonsetlethargy,

mooddisturbance,withdrawalordisinhibition

Common pitfalls

• Failingtoconsideraphysicalcauseforbehaviouralsymptoms

Referral from primary care• Highriskoftumour–SAMEDAYreferraltosecondarycare

• Lowerrisk*–specialistassessmentwithin2weeks

Imaging• Highriskoftumour–URGENTCNSimaging

• Lowerrisk*–CNSimagingwithin4weeks

*Lower risk = CNS tumour in differential diagnosis, low index of suspicion

Consider a brain tumour in any child presenting with• Headache

• Nauseaand/orvomiting

• Visualsymptomsandsigns:

reducedvisualacuityand/orfields

abnormaleyemovements

abnormalfundoscopy

• Motorsymptomsandsigns:

abnormalgait

abnormalco-ordination

focalmotorweakness

• Growthandendocrinesymptoms:

growthfailure(weight/height)

delayed,arrestedorprecociouspuberty

galactorrhoea

primary/secondaryamenorrhea

• Increasingheadcircumference

• Behaviouralchange

• Diabetesinsipidus

• Seizures(seewww.nice.org.uk/guidance/qs27)

• Alteredconsciousness(seewww.nottingham.ac.uk/paediatric-guideline/Guidelinealgorithm.pdf)

Assess these children with

• History:associatedsymptoms,anypredisposingfactors

• Examinationof:

visualsystem

motorsystem

heightandweight

headcircumference(<2yrs)

pubertalstatus

IF TWO OR MORE SYMPTOMS – SCAN

Assessment pitfalls

• Initialsymptomsofbraintumourcanmimicothercommonillnesses

• Symptomsfrequentlyfluctuate–resolutionthenrecurrencedoesnotexcludeabraintumour

• Anormalneurologicalexaminationdoesnotexcludeabraintumour

• Languagedifficulties–useinterpreter

the diagnosis of brain tumours in children: a guideline for healthcare professionals

ThisguidelinehasthesupportoftheRCPCHfollowingarigorousassessmentoftheguidelinedevelopmentmethodologyandafullendorsementisexpecteduponcompletionofafullstakeholderconsultation.

Ask about common predisposing factors

• PersonalorFHofbraintumour,sarcoma,leukaemiaorearlyonsetbreastcancer

• Neurofibromatosis

• Tuberoussclerosis

• Otherfamilialgeneticsyndromes

HeadSmart is funded and promoted by The Brain Tumour Charity and run in partnership with the Children’s Brain Tumour Research Centre (CBTRC) and the Royal College of Paediatrics and Child Health (RCPCH). The Brain Tumour Charity Registered Charity No. 1150054 (England and Wales) SC045081 (Scotland), CBTRC Charitable Status Inland Revenue No. X15294, RCPCH Registered Charity No. 1057744 (England and Wales) SC038299 (Scotland) © 2016 The Brain Tumour Charity, CBTRC and RCPCH.headsmart.org.uk