Raised Intracranial Pressure in Children and Young People with Malignancy - Management of

Publication: 16/09/2014  --
Last review: 14/04/2020  
Next review: 03/04/2023  
Clinical Guideline
CURRENT 
ID: 3949 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Management of Raised Intracranial Pressure in Children and Young People with Malignancy

Background

Raised intracranial pressure (ICP) may develop insidiously or present acutely as a result of a wide range of pathologies. In some children it will be a presenting feature of their malignancy whereas in others it may result from disease progression or treatment complications.

The problem may arise because of obstruction to the flow of cerebrospinal fluid (CSF) in hydrocephalus or mass effect from the tumour/bleed/infective pathology.

Potential causes of raised ICP include

  • Brain tumour (primary or metastases)
  • Leukaemia
  • Intracranial haemorrhage
  • Hydrocephalus (obstructive or communicating)
  • Cerebral oedema e.g. post op or following radiotherapy or rapid biochemical changes with associated fluid shifts
  • Venous sinus thrombosis
  • Shunt blockage
  • Intracranial infection including fungal
  • Hypertension
  • Prolonged seizure

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Diagnosis

The signs and symptoms of raised ICP vary with age. Classical symptoms include

  • Headache      Classically morning headache present on waking
    Headache that wakes patient from sleep is also very suspicious
  • Vomiting
  • Visual disturbance
  • Change in behaviour or mood
  • Fluctuating level of consciousness
  • Ataxia or other motor disturbance
  • Abnormal pupils (may be noted by relatives)
  • Seizures

However as mild or chronically raised ICP may produce subtle signs it is important to have a high index of suspicion and take a thorough history in children at risk.
 
Severely raised ICP is indicated by the following signs and symptoms

  • Cushing’s response (bradycardia and hypertension)
    • This is a pre-terminal sign due to impending herniation of the brainstem requiring immediate action (neurosurgical review and likely scan).
  • Papilloedema (late sign) in the presence of any decrease in conscious level
    • This constitutes an oncological emergency and immediate help should be sought with managing the patient.
  • Sunsetting – eyes deviated medially and inferiorly
    • Signifies critically raised intracranial pressure. Requires immediate action (scan and neurosurgical review).

If any of the following are present, investigation and management (in conjunction with paediatric intensivists and neurosurgeons) as to the cause of the problem should be urgently undertaken:

  • Conscious level reduced to GCS ≤8 (or responding to Pain or less on the AVPU scale)
  • Abnormal respiratory pattern (hyperventilation, irregular resps or apnoeas).
  • Abnormal pupils (unilaterally or bilaterally dilated or unresponsive pupils).
  • Abnormal posture (decorticate, decerebrate or complete flaccidity)
  • Abnormal doll's eyes (oculocephalic) response

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Investigation

DO NOT PERFORM LP UNLESS A SCAN HAS EXCLUDED A BRAIN LESION
(e.g. TUMOUR or BLOOD CLOT) AS THE CAUSE
Check with neurosurgery and radiology first if any doubt
The immediate management of raised ICP is aimed at preventing further brain injury whilst the underlying cause is identified and definitive management instituted. Always discuss patient with Haematology/Oncology Consultant and Neurosurgeons.
Investigation is necessary during and after resuscitation: please institute management before proceeding to scan.

Urgent CT scanning is needed once patient has been resuscitated and is stable. CT scanning cannot diagnose raised intracranial pressure, but may indicate the cause of the clinically defined problem. Discussion should be undertaken with the Radiologist regarding the potential benefit of contrast.

MRI may subsequently be required to define further the nature of any problem that has been identified. An out-of-hours MRI is occasionally necessary, and should be undertaken after discussion.

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Treatment / Management

DO NOT PERFORM LP UNLESS A SCAN HAS EXCLUDED A BRAIN LESION
(e.g. TUMOUR or BLOOD CLOT) AS THE CAUSE
Check with neurosurgery and radiology first if any doubt

The immediate management of raised ICP is aimed at preventing further brain injury whilst the underlying cause is identified and definitive management instituted. Always discuss patient with Haematology/Oncology Consultant and Neurosurgeons.

Early liaison with PICU is needed if GCS <13 or if there is progressive deterioration. The patient may require sedation and ventilation to control PaCO2 and protect their airway as well as consideration for invasive blood pressure and ICP monitoring.  If the patient will require transfer to another hospital then there needs to be early discussion with the Embrace transport team.

If patients’ observations are being recorded on Paediatric Advanced Warning Score (PAWS) charts then the appropriate version which includes neuro-observations must be used.

  • Assess and manage A,B,C. Provide high flow oxygen
  • Document GCS initially and frequently reassess (Appendix 1)
  • Take blood for full blood count, clotting and electrolytes
  • Check blood sugar and capillary blood gas. Manage glucose abnormalities.
  • Take paired urine/blood sample for urgent assessment of osmolality. (This may help differentiate cause of the raised ICP. Will need telephone contact with biochemist on call.)
  • Tilt patient 30° head up. Alert PICU to the presence of the patient.
  • Consider stopping hyperhydration and change fluids to normal saline.
  • Consider Mannitol if cause is likely to be related to head injury, intra-cranial bleed or fungal infection.
    • 0.25 g/kg IV over 30 minutes (via 5 micron filter) = 1.25 ml/kg of 20% solution.
    • May need to be repeated when transferred to PICU
    • May be contraindicated in some patients – discuss before use
  • Consider IV Dexamethasone if cause is likely to be related to a space-occupying lesion. Contraindicated in fungal infection
    • 0.25-0.5/kg daily, given oral or IV (maximum 16mg/day)
      • normal dose 0.25mg/kg;
      • 0.5mg/kg reserved for critically raised ICP
        Taper after 3 days or as soon as clinically indicated (See BNFc)
  • Prescribe antibiotics +/- antivirals +/- antifungals if any suspicion of infection
  • Prescribe antipyretics if febrile
  • Request platelets for transfusion if any possibility of thrombocytopenia
  • Use 0.9% saline maintenance fluids
  • Request appropriate imaging investigations

DO NOT PERFORM LP UNLESS A SCAN HAS EXCLUDED A BRAIN LESION
(e.g. TUMOUR or BLOOD CLOT) AS THE CAUSE
Check with neurosurgery and radiology first if any doubt

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APPENDIX I 

GLASGOW COMA SCALE

Best Motor response

(May be unilateral)

6 = Responds to commands
5 = Localises pain
4 = Withdraws from pain
3 = Abnormal flexion to pain (Decorticate)
2 = Abnormal extension to pain (Decerebrate)
1 = None

   

Eye opening

4 = Spontaneous
3 = To speech
2 = To pain
1 = None

   

Best verbal response

5 = Fully orientated
4 = Appropriate words but confused
3 = Inappropriate words
2 = Incomprehensible sounds
1 = None

Score = Best motor response + eye opening + best verbal response
Maximum score = 15             Minimum = 3

MODIFIED GLASGOW COMA SCALE FOR CHILDREN (Use aged <5 years)

Best Motor response

(May be unilateral)

6 = Responds to commands/Normal spontaneous movement
5 = Localises pain
4 = Withdraws from pain
3 = Abnormal flexion to pain (Decorticate)
2 = Abnormal extension to pain (Decerebrate)
1 = None

   

Eye opening

4 = Spontaneous
3 = To speech
2 = To pain
1 = None

   

Best verbal response

5 = Alert, babbles, coos, words or sentences to usual ability
4 = Less than usual ability/spontaneous irritable cry
3 = Cries inappropriately
2 = Occasionally whimpers/moans
1 = None

Provenance

Record: 3949
Objective:

Aims

To improve the diagnosis and management of raised intracranial pressure in children and young people with malignant disease.

Objectives

To provide recommendations for appropriate diagnosis, investigation and management of raised intracranial pressure in children and young people with malignant disease.

Clinical condition:

Raise intracranial pressure

Target patient group: Children and Teenagers under management of paediatric/TYA oncology service with suspected raised intracranial pressure Target professional group (clinical competence): All clinical staff working with these patients (nursing, paediatrics, oncology, neurosurgery, neuroradiology)
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

2017 review: Wording changes for clarity. Reviewed by LCH Paediatric Oncology Guidelines Group

Evidence Base:   

References  and Evidence levels:
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

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