Abstract
This chapter, provides an overview of the basics of pediatric neurological tumors. The author identifies the common tumor pathologies and presenting symptoms in children by anatomic region. The key anesthetic concerns present for posterior fossa tumor resection are presented. The chapter reviews the differentiation and treatment of Syndrome of Inappropriate Antidiuretic Hormone, diabetes insipidus and Cerebral Salt Wasting Syndrome.
A seven-year-old girl presents to the emergency department with recent onset of severe headaches, nausea and vomiting. Her vital signs include: BP 98/68, HR 122, RR 26/minute. An urgent CT scan demonstrates a large infra-tentorial mass. An MRI of the head with and without contrast is booked.
What Are the Different Types of Pediatric Intracranial Tumors? What Are Their Presenting Symptoms?
There are numerous types of intracranial tumors, but they can be divided into basic regions of supra-tentorial, infra-tentorial, posterior fossa tumors, and brain stem tumors. Subdivisions and common presenting symptoms are noted in the graphic, often with overlap. The most common pathologies based on intracranial location are noted in Figure 36.1 and Table 36.1.
Figure 36.1 Sagittal and coronal CT images demonstrating the most common pediatric brain tumor pathologies by anatomic region (see Table 36.1 for region-specific descriptions)
Table 36.1 Common neurological tumor pathologies and presenting symptoms in children by anatomic region (numbers correlate with Figure 36.1)
| Anatomic region | Common tumor subtypes | Common symptoms | |
|---|---|---|---|
| 1 | Suprasellar/chiasmatic | Optic glioma, cranopharyngioma, germinoma, prolactinoma, pituitary adenoma, pliomyxoid astrocytoma | Headache, nausea, vomiting, visual field deficits, precocious or delayed puberty, anorexia, diabetes insipidus |
| 2 | Pons | Pontine glioma | Diplopia, cranial nerve palsy, incoordination, headache |
| 3 | Pineal/midbrain | Glioma, pineoblastoma, pineocytoma, germinoma, primitive neuroectodermal tumor (pNET) | Upwards gaze paralysis, vomiting, nystagmus, diplopia, tremors |
| 4 | Cerebellum | Medulloblastoma, ependymoma, pilocytic astrocytoma, atypical teratoid rhabdoid tumor (ATRT), glioma | Headache, vomiting, ataxia, tremors, nystagmus |
| 5 | Basal ganglia/thalamus | Gliomas, germinoma, oligodendroglioma | Movement disorder, weakness, hemisensory deficit, visual field deficit |
| 6 | Cerebral cortex | Gliomas, dysembroplastic neuroectodermal tumor (dNET), pNET, ependymoma, oligodendroglioma, ganglioglioma | Elevation of intracranial pressure (ICP), seizures, weakness, language disorder, encephalopathy, visual field deficit, headache |
| 7 | Ventricular system | Choroid plexus papilloma/carcinoma, ependymoma, ATRT, astrocytoma, desmoplastic infantile ganglioglioma | Nausea, vomiting, elevated ICP |
| 8 | Meninges | Meningioma | Seizures, headache |
What Are the Signs of Increased Intracranial Pressure in Children?
Increased intracranial pressure is often insidious and the signs are often subtle. These include irritability, crying, headaches, diplopia, nausea, stiff neck, vomiting, and motor weakness. The classic Cushing’s triad is a more advanced stage of untreated increased ICP consisting of hypertension, bradycardia, and irregular breathing/bradypnea. Cushing’s triad is potentially deleterious and requires immediate assessment and decompression to prevent morbidity/mortality.
What Is the Monro–Kellie Hypothesis?
This hypothesis states that the cranium has a fixed volume of brain tissue, blood, and CSF. Therefore, any increase in one compartment, such as tumor, is offset by decreases in one or more of the other compartments. Any increase in intracranial pressure due to tumor for example, has to be offset by either decreasing cerebral blood volume or CSF.
Since dural punctures can lead to herniation in this scenario, manipulation of the blood flow compartment through PaCO2 management has been a mainstay of anesthetic management. The conundrum in these cases is that reducing the coronary blood flow (CBF) also reduces cerebral perfusion pressure (CPP). This is explained in the following equation:
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