Depression SIADH, syndrome of inappropriate antidiuretic hormone The presentation and management of increased ICP is not unique in pediatric cancer patients (see Chapter 97 Neurologic Emergencies ) The differential diagnosis includes tumor (see the “Tumors of the CNS” section) or shunt malfunction more often than treatment effect Tretinoin (all transretinoic acid), an agent uniquely used in the treatment of APML causes increased ICP Children are particularly sensitive to this side effect For patients with severe symptoms attributable to tretinoin, a diagnostic and therapeutic lumbar puncture may be needed Opening pressure should be measured and cerebrospinal fluid should be withdrawn to reduce the pressure (see Chapter 97 Neurologic Emergencies ) Children with cancer are at increased risk of seizures from the causes summarized below and in Table 98.8 Severe metabolic disturbances can result from SIADH or from renal tubular wasting of electrolytes (see “Metabolic Complications of Cancer Treatment” section) Seizures can also be caused by primary brain tumors, particularly supratentorial, CNS metastasis of solid tumors, or carcinomatous meningitis Some chemotherapy agents can cause seizures New-onset seizures can be a sign of a bacterial abscess (more likely with Bacillus cereus bacteremia), fungal abscess, or viral encephalitis such as those caused by herpes simplex virus or CMV The approach to seizure management is not unique in patients with cancer and is addressed in Chapter 97 Neurologic Emergencies Specific consideration should be given to assess and correct metabolic and electrolyte abnormalities Children with cancer are at increased risk of CVAs Specific causes in children with cancer include sagittal sinus thrombosis and intracranial bleeding with contributing factors of hypertension, coagulopathy, thrombocytopenia, intracranial tumor, prior surgery, and radiation Spontaneous intracranial hemorrhage is extremely rare except when the platelet count is less than 5,000/μL (see “Hematologic Complications of Cancer Treatment” section) The approach to diagnosis and management is addressed in Chapter 93 Hematologic Emergencies Specific consideration should be given to assess and correct problems with coagulopathy and/or thrombocytopenia Side effects of some supportive-care medications can include extrapyramidal reactions Symptoms of such reactions can range from oculogyric crisis with mild repetitive eye deviation and/or neck motion to severe torticollis and eye deviations Reactions can also include tardive dyskinesia (“frozen”) and akathisia (restlessness/agitation) The key to diagnosis involves a thorough physical examination and a thorough medication history Dopamine-receptor antagonists used as antiemetics are the most common trigger in cancer patients Such drugs include high-dose metoclopramide; phenothiazines such as compazine, chlorpromazine