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Brain tumors can cause increased ICP by blocking CSF drainage The symptoms of increased ICP vary based on patient age Infants with an open fontanelle can sometimes present with bulging of the fontanelle as well as seizure, vomiting, irritability, or loss of acquired skills Older children often have headache and early morning vomiting Sixth nerve palsies are common Sometimes increased ICP is detected only on imaging of the brain that reveals enlargement of the ventricles or effacement of the gyri Seizures developing in the setting of a child with cancer, whether due to a CNS tumor or another malignancy, should be managed as described in Chapter 72 Seizures Brain tumors should be considered in the differential diagnosis of newonset seizures Patients with brain tumors are at risk for several metabolic complications The presence of an intracranial tumor may cause for cerebral salt wasting or SIADH DI can result from tumor involvement of the pituitary gland Patients should be screened for these abnormalities with serum chemistries However, these complications are not managed uniquely because of the brain tumors Chapter 89 Endocrine Emergencies provides guidelines on evaluation and management Clinical Assessment After ensuring that the airway, breathing, and circulation are stable, the evaluation in the ED should focus on a thorough history and physical examination, assessing for any neurologic symptoms and screening for complications described above A complete physical examination should include a thorough ophthalmologic and neurologic assessment and an evaluation of the patient’s external genitalia for precocious puberty or virilization, since some pediatric brain tumors may be hormone secreting A rectal examination to evaluate the anal “wink” is also useful as a screen for spinal cord compression If the history or physical examination raises concern for increased ICP or spinal cord compression, therapy should be initiated as described below A CT scan is useful to rule out hemorrhage and assess for increased ICP, and can sometimes visualize a brain tumor However, a CT scan may miss infratentorial masses so in most cases, magnetic resonance imaging (MRI) with gadolinium will ultimately be needed Laboratory evaluation should include serum electrolytes to evaluate for SIADH, salt wasting, or DI A CBC is also useful to ensure the patient’s hematocrit and platelet count are adequate for any upcoming procedures Management The emergency management of increased ICP is critical as patients often present with signs and symptoms of this condition at the time of diagnosis If increased ICP is known or suspected, a lumbar puncture should be avoided, as this theoretically
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