Central nervous system tumor

Background

• Metastatic tumors more common than primary CNS in adults
• CNS tumors are second most common pediatric cancer, leading cause of cancer-related death in children
• Most primary tumors in children are infratentorial, whereas most infratentorial masses in adults are metastases

Clinical Features

• Depend on location and size of tumor
• Focal neuro deficits
  • Cranial nerve palsies
  • Behavioral changes, psychosis
  • Focal weakness
  • Focal sensory deficits
  • Abnormal reflexes
  • Endocrinopathies (craniopharyngiomas and other suprasellar tumors)
  • Bowel/bladder dysfunction
• 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 fontenelle in infants
• Seizure
• Altered mental status, irritability, coma

Evaluation

• CT head
• MRI required for small tumors or areas not well visualized on CT (e.g. posterior fossa)
• Evaluate for other causes of symptoms (i.e. stroke, metabolic derangement, ICH)

Management

• See elevated ICP
  • Corticosteroids (reduce tumor capillary permeability, inflammatory cytotoxicity)
    • Dexamethasone 10-20mg IV, followed by 4mg IV q6h
  • 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)
• Treat seizure with benzodiazepines +/- AEDs, prophylactic AEDs are not recommended
• Consult neurosurgery

See Also

• Cerebral edema in brain cancer
• Elevated ICP
• Brain herniation syndromes
• Oncologic emergencies
• Seizure, Seizure (peds)
• Headache, Headache (peds)
• CNS tumors (peds)