Brain Tumors in Children
Introduction
Last year, 60 children were newly diagnosed and treated for
brain tumors at Cincinnati Children’s. Growth in the Greater
Cincinnati population and changes in referral patterns may
account for this increased number.
While brain tumors in children are quite rare, a primary care
provider still may have a child present with symptoms of a
brain tumor. The signs and symptoms can be highly variable
according to age and location. This publication will attempt
to review the common presentations for children with brain
tumors and recommendations for care.
accelerated head growth, a bulging anterior fontanelle,
splayed cranial sutures, developmental delay, loss of
developmental milestones, lethargy and vomiting, and
failure to thrive may prompt imaging studies to exclude
intracranial pathology.
Common signs and symptoms in children with brain tumors, by age:
Statistics
In children less than 15 years of age, brain tumors constitute
the most common solid tumor in children. Brain tumors also
comprise 20 percent of all childhood cancers. In the United
States, approximately 1,700 new cases are diagnosed each
year, or about 25-30 new brain tumors per million child
population. Each year approximately 60 children diagnosed
with new brain tumors are evaluated and treated at
Cincinnati Children’s Hospital Medical Center.
Children, now with fused but still growing skulls, typically
are verbal and more communicative than infants. They
are more likely to complain of headache, blurred vision,
nausea and vomiting, or difficulties in the routine use of
their arms or legs, including poor balance or coordination.
Having started school, they may exhibit declining school
performance as well.
Presentation by Age
Infants, school-aged children and adolescents may present
with differing signs and symptoms due to both the types
of tumors seen in these different age groups and to the
accommodating skull size of the infant.
In infants and toddlers who have an open anterior
fontanelles and unfused sutures, symptoms may be
more generalized and less focal than in the older child.
As with the child in whom hydrocephalus is a concern,
The adolescent child, nearing adulthood, can articulate
subtle symptoms caused by a brain tumor, such as sensory
changes, diplopia or progressive headache. Generally
speaking, isolated or chronic headaches typically do not
indicate the presence of a space-occupying lesion. A new
onset seizure in an older adolescent would be less common
than those commonly seen in younger children, and as in
adults, may be the presenting symptom of a brain tumor.
A New Outpatient Location in West Chester!
We recently opened a pediatric neurosurgery clinic at the
new Cincinnati Children’s Outpatient West Chester, located
off I-75 in the University Pointe medical facility.
For more information, call the Department of Pediatric
Neurosurgery at 513-636-4726 or 1-800-344-2462, ext. 4726.
Outpatient West Chester
Our staff holds weekly outpatient clinics at this location.
The office is very convenient, just minutes from the
I-75/Tylersville Road interchange, and is centrally located
between Dayton and Cincinnati.
7700 University Court, West Chester, OH 45069
For more information about Pediatric Neurosurgery visit www.cincinnatichildrens.org/neurosurgery.
Radiology
Imaging should be considered when there is new or
progressive neurologic deficit or worsening headache. This
would include the very suspicious morning headache that
may or may not be accompanied by vomiting.
CT and MR are the most frequent studies by which brain
tumors are imaged. CT demonstrates bony anatomy and
calcified lesions most adequately, while MR is superior for
soft tissues.
A CT of the brain generally is adequate as a screening tool in
a child with no specific findings and a low index of suspicion
of harboring a tumor. With the quality of CT scanning, the
majority of tumors of the brain are revealed.
age tend to be very aggressive and malignant. Conversely, the
older the child, the more likely the diagnosis will favor a less
malignant tumor.
Supratentorial tumors include various grades of gliomas,
such as gangliogliomas and oligodendrogliomas, as well as
intraventricular tumors, such as choroid plexus papillomas.
Suprasellar tumors are largely craniopharyngiomas or optic
pathway gliomas, and the pineal region tends to harbor
germinomas and non-germinomatous germ cell tumors.
Typical tumors in the posterior fossa include the more
benign juvenile pilocytic astrocytomas, the more malignant
medulloblastoma and ependymomas, and the devastating
diffuse pontine glioma.
Treatment
Figure 1: MR of the brain with
contrast enhancement revealing
a large left temporal lobe
oligodendroglioma in a 3-year-old
child presenting with a bulge over
the left ear.
MR imaging is much more
sensitive and specific for
defining tumors of the brain.
MR should be reserved for
children with suspicious CT
scans, or children with very
focal signs and symptoms indicating a high probability of
intracranial pathology.
Both CT and MR angiography can be used to evaluate
the involvement of major arteries and dural venous
sinuses. Formal angiography is not commonly utilized in
the treatment of brain tumors except in the preoperative
evaluation and possible endovascular occlusion of significant
feeding vessels that would decrease the risk and enhance
the result of surgery.
Not only has imaging aided in early detection, but also
in tumor staging. If an MR has been ordered, and there is
concern about the malignant behavior of a brain tumor,
concomitant spine imaging may prove helpful in ruling out
metastases. In the case of both benign and malignant tumors,
pre and postoperative imaging aids in monitoring the results
of surgery, as well as the therapeutic results of adjuvant
therapies. In addition, postoperative complications, which
may not be clinically evident, may be detected and addressed
prior to the development of subsequent problems.
Histopathology
Many different types of brain tumors may occur in children.
Although younger children are more likely to harbor
posterior fossa tumors located in the cerebellum or
brainstem, half of all childhood tumors are in the posterior
fossa and half are supratentorial affecting the cerebrum.
In general, tumors found in children less than 2 years of
Current Concepts in Pediatric Neurosurgery
The hydrocephalus associated with brain tumors typically
is obstructive in nature. Successful reduction or removal
of the tumor oftentimes allows for the establishment of
normal CSF flow dynamics and subsequent resolution of the
hydrocephalus. If hydrocephalus persists, despite definitive
tumor surgery, a CSF diversionary shunt may be placed,
or an endoscopic third ventriculostomy (ETV) may be
performed. For suspected obstructive hydrocephalus, and in
the absence of previous radiation therapy, an ETV may allow
for restoration of CSF flow without the need for a shunt.
Brain tumors that are small, are located in eloquent cortex
or deep structures, are felt to be slow growing, and have
no mass effect may be followed conservatively, with
periodic sequential radiographic imaging without surgical
intervention. Many of these lesions are found incidentally,
such as when imaging for mild head injury. Small benign
lesions may be identified following new onset seizures.
Treatment with medical management of the seizures and
serial imaging to follow the tumor would be advised.
Subsequently, intractable epilepsy, tumor progression or
parental/surgeon consensus may lead to surgery.
Figure 2: Sagittal MR of the
brain revealing a large cystic
posterior fossa tumor with an
acquired Chiari malformation,
severe brainstem compression,
syringomyelia and hydrocephalus
in a 5-year-old child presenting
with ataxia and hand tremor.
Because benign tumors
have been known to change
histologic characteristics and
undergo malignant transformation into more aggressive
tumors, they may become more invasive and more difficult
to treat. Therefore children with surgically accessible tumors
in non-eloquent areas of the brain should strongly be
considered as surgical candidates.
Surgery
The goals of surgical intervention for children with brain
tumors are establishing a tissue diagnosis; relieving
increased intracranial pressure; and depending on the
histology, behavior, location and size of the lesion, achieving
complete resection. Surgical success also is based on the
functional and neurologic outcome of the child. As such,
every attempt is made to avoid neurologic injury.
Surgical skill, experience and judgment all contribute to a
desired outcome. Intra-operative decisions based on surgical
findings, as well as preliminary histologic diagnosis, are
paramount in achieving the best functional and surgical
results.
Benign tumors such as low grade gliomas often are treated
by surgery alone. Optic tract gliomas and brain stem gliomas
may be treated without surgery due to a low probability of
cure and a high risk of severe permanent neurologic deficits.
However, in many instances surgery may be followed by
chemotherapy and/or radiation therapy as focused adjuvant
therapy.
marrow, may bring hope to children with malignant
tumors that are resistant to conventional treatment or
suffer tumor recurrence. Risks of chemotherapy involve the
sequelae of bone marrow suppression and a compromised
immune system.
The side effects and potential complications from brain
tumor treatments are as varied as the functions the brain
controls. Therefore the treatment of children with brain
tumors becomes a multidisciplinary effort. Frequently
children have visual disturbances for which ophthalmology
is consulted, growth alteration for which endocrinology is
involved, fine and gross motor impairment, or cognitive
impairment, which affects learning and behavior.
Cincinnati Children’s has the appropriate resources, which
are monitored through the oncology department, to meet
these needs. The primary care provider, however, still is the
pivotal patient advocate to ensure these children receive all
the services that they need.
The Division of Pediatric Neurosurgery
Radiation Therapy
The advent of radiation therapy has enhanced the treatment
of both malignant and benign brain tumors. Administered
in various dosing schemes, including focused stereotactic
radiosurgery, radiation therapy now can be targeted to small
lesions in sensitive or inoperable areas of the brain, such as
the optic apparatus or the brainstem, with little damage to
surrounding normal structures.
Figure 3: CT scan of the
head revealing a calcified
craniopharyngioma and
hydrocephalus in a 6-year-old
child with short stature, visual
field deficit and esotropia.
In general, whole brain
radiation is reserved for
children older than 3 years of
age because of the significant
functional deficits that may
result. These include
perceptual-motor incoordination, maladaptive behavior and
diminished intellectual capacity. Localized radiation at ages
7 and above, however, is associated with few late effects.
Chemotherapy
As with radiation therapy, chemotherapy may be used as
primary therapy after biopsy, or as adjuvant therapy after
partial or complete resection, depending on tumor
pathology. These agents are aimed at killing cells that are
dividing. They may be administered intravenously, as well
as intrathecally, into the CSF pathways. Autologous stem
cell rescue, aimed at introducing a new, tumor free bone
About Our Staff, Services and Programs
Cincinnati Children’s Hospital Medical Center has
the largest and most comprehensive pediatric
neurosurgical program in the region. Thorough
evaluation and surgical care are available for all
phases of neurological disease.
Our entire team has a commitment to providing
family-centered and prompt care to all our patients
and their families. We work with our referring
physicians – our partners in coordinated care – by
providing state-of-the-art technological care, fullservice capabilities and specialized programs.
Specialties include functional neurosurgery, cranial
malformation and neuro-oncology. And all of our
surgeons have received pediatric neurosurgery
training in approved fellowship programs.
Referrals, Appointments and Locations
Surgical intervention and inpatient and outpatient
neurosurgical consultations are available on a
24-hour basis. Appointments are available at our
main campus near the University of Cincinnati and
at Outpatient West Chester.
For a referral or an appointment,
call 513-636-4726
or 1-800-344-2462, ext. 4726.
Meet Our Surgeons
Kerry R. Crone, MD
Stuart S. Kaplan, MD
John S. Myseros, MD
Division Director Kerry Crone, MD, has
an international reputation as a leader
in the field. He is one of the few
neurosurgeons in the world considered
an expert in endoscopic neurosurgery and
is recognized as an "Outstanding Physician
in America." Other special interests include
skull base surgery, craniosynostosis,
hydrocephalus and brain tumors.
Dr. Kaplan’s specialties include
general and functional neurosurgery,
with subspecialization in medically
refractory epilepsy, spasticity and brachial
plexus surgery. Dr. Kaplan has experience
and interest in neuroscience research
and will assist in developing pediatric
neurosurgery’s participation in the
medical center’s mission to create and
use knowledge to improve the lives of
children.
Dr. Myseros’ specialties include the
treatment of brain tumors, neuro-oncology,
radiosurgery, craniosynostosis, vascular
malformation, hydrocephalus, spina bifida
and neuro-trauma
Dr. Crone has been at Cincinnati
Children’s for more than 15 years. During
that time he has performed more than
4,000 neurosurgical procedures on
children and has built a reputation as
a leader in pediatric neurosurgery.
A graduate of the University of Cincinnati
College of Medicine, Dr. Crone completed
his internship in general surgery and his
residency in neurosurgery at the North
Carolina Baptist Hospital, Bowman-Gray
School of Medicine in Winton-Salem.
Dr. Crone also was a clinical fellow in
pediatric neurosurgery at The Hospital
for Sick Children in Toronto, and a clinical
scholar in neurosurgery at Cincinnati
Children’s. He is certified by the American
Board of Neurological Surgery and the
American Board of Pediatric Neurological
Surgery.
Current Concepts in Pediatric
Neurosurgery offers medical
education and the latest advances
in pediatric neurosurgery. It is
written and published by the
staff of the Division of Pediatric
Neurosurgery at Cincinnati
Children’s.
If you have comments or
questions, please contact us at
513-636-4726 or 1-800-344-2462,
ext. 4726 or send an email to
[email protected].
Dr. Kaplan completed his neurosurgery
residency and pediatric neurosurgery
fellowship at Washington University
Medical Center in St. Louis. He was
awarded his undergraduate degree with
honors from Dartmouth College and his
medical degree from Harvard Medical
School. Dr. Kaplan has achieved several
honors through his research, including
the National Institutes of Health National
Research Service Award and The Southern
Neurosurgical Society Basic Science
Resident Award.
Cincinnati Children’s Hospital Medical Center
MLC 2016
3333 Burnet Avenue
Cincinnati, OH 45229-3039
www.cincinnatichildrens.org
Prior to coming to Cincinnati Children’s,
Dr. Myseros was in private practice at
the Inova Fairfax Hospital for Children.
He also worked as a staff pediatric
neurosurgeon and assistant professor of
neurosurgery at the Allegheny University
Hospital in Pittsburgh.
Dr. Myseros received his doctor of
medicine degree from Johns Hopkins
University and completed his neurosurgery
residency at the Medical College of Virginia
in Richmond. He completed his pediatric
neurosurgical fellowship at The Hospital
for Sick Children in Toronto and is
certified by the American Board of
Neurological Surgery and the American
Board of Pediatric Neurological Surgery.