child with headaches must always be carefully assessed A diminished level of consciousness may be the result of encephalitis, a large intracranial hemorrhage, or significantly elevated ICP To the extent that the child can cooperate, cranial nerve function should also be evaluated Cranial nerve abnormalities may result from an elevated ICP or direct compression by a mass lesion Sensory and motor function should be examined, although here again the ability of a younger patient to cooperate may be limited A reasonable evaluation can be accomplished by observing the child’s gait while walking and/or running and by assessing the child’s dexterity in performing age-appropriate activities, such as transferring a toy from hand to hand and tying shoelaces Any evidence of abnormalities in gait or fine motor coordination warrants further investigation TABLE 59.5 FREQUENCY OF PRESENTING SIGNS AND SYMPTOMS IN CHILDREN WITH BRAIN TUMORS Headache (33%) Nausea and vomiting (32%) Abnormal gait or coordination (27%) Papilledema (13%) Seizures (13%) Squint (7%) Change in behavior or school performance (7%) Cranial nerve palsies (7%) 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