Pediatric emergency medicine trisk 1150 1150
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TABLE 59.6
FREQUENCY OF PRESENTING SIGNS AND SYMPTOMS IN
CHILDREN UNDER 4 YEARS OF AGE WITH BRAIN TUMORS
Macrocephaly (41%)
Nausea and vomiting (30%)
Irritability (24%)
Lethargy (21%)
Abnormal gait and coordination (19%)
Weight loss (14%)
Bulging fontanelle (13%)
Seizures (10%)
Reprinted from Wilne S, Collier J, Kennedy C, et al. Presentation of childhood CNS tumours: a systematic
review and meta-analysis. Lancet Oncol 2007;8:685–695. Copyright © 2007 Elsevier. With permission.
Laboratory and Radiographic Testing
Most children presenting in an acute-care setting with headache as the chief
complaint will not require any laboratory tests. The child with a possible serious
infectious process causing headaches can require a variety of tests, including a
complete blood cell count, lactic acid, blood cultures, and a lumbar puncture. Yet
these patients are more likely to have other symptoms such as high fever and
lethargy, rather than headache, as the primary complaint. When a lumbar puncture
is necessary, it is important to remember that a head CT scan should be obtained
first if the patient is suspected of having a lesion that could lead to subsequent
cerebral herniation (e.g., a large intracranial mass or obstructive hydrocephalus).
Signs suggestive of such a condition include focal neurologic deficits, focal
seizures, papilledema, and mental status depression with unilateral pupillary
dilation. This is generally considered a prudent practice despite the fact that
considerable controversy exists about whether herniation is ever actually caused
by a lumbar puncture, even if temporally related. For suspected idiopathic
intracranial hypertension (i.e., a patient with papilledema who has a negative head
CT), an opening pressure measurement should be obtained when the lumbar
puncture is performed. Serum electrolytes, blood urea nitrogen, creatinine, and a
urinalysis should be obtained for any child with headaches who is found to have
an elevated blood pressure. The patient with a ventricular shunt who has fever
and headaches will likely require a shunt tap by a neurosurgical consultant.
Finally, a child with a suspected subarachnoid hemorrhage should undergo a
lumbar puncture if the head CT scan is negative. This is necessary because a
