WIDI - P17) New-onset seizures, headache, and vomiting

P17) New-onset seizures, headache, and vomiting

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a pediatric patient with headache and vomiting.
Review the DDx considerations in a pediatric patient with headache and vomiting.
Identify the spectrum of imaging findings in appropriate modalities for evaluating a pediatric patient with headache and vomiting.

History

A 15-year-old boy to the pediatric emergency department following a new-onset seizure that resolved on its own. The patient also reports five weeks of worsening headaches and episodes of nausea and vomiting occurring in the morning.

Physical Exam

BP: 110/85, HR 60, RR 12, Temp 99.1F, O2 saturation 98%. Neuro: ataxic gait. Difficulty performing finger to nose testing. Dysdiadochokinesia. Disconjugate gaze with lateral eye movements. Diplopia on lateral gaze bilaterally. Bilateral papilledema on optic nerve examination.

Labs

CBC and CMP results within normal limits.

Provisional Diagnosis

Select the Dx you believe is most appropriate

Supratentorial mass lesion with hydrocephalus

Infratentorial mass lesion with hydrocephalus

Supratentorial mass lesion without hydrocephalus

Infratentorial mass lesion without hydrocephalus

This patient with new-onset progressive headache, vomiting, and acute cerebellar ataxia (ataxic gait, dysdiadochokinesia, and difficulty with finger-to-nose testing) most likely has a brain tumor in the posterior fossa. This mass lesion likely results in hydrocephalus considering the papilledema and CNVI palsy.

Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Well done. You were correct

The patient requires urgent workup and management.

First Imaging Study

What is the first imaging study you will order?

Brain CT without IV Contrast

Brain CT with and without IV Contrast

Brain MRI without IV Contrast

Brain MRI with and without IV contrast

A brain MRI with and without contrast can help identify and characterize a brain mass lesion. In this pediatric patient who is not undergoing emergent imaging and is without contraindication to MRI, CT should be avoided to minimize radiation.

View ACR Appropriateness Criteria

Well done. You were correct

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

MRI with and without contrast

What ventricle is the mass located in?

Lateral Ventricles

Third Ventricle

Cerebral Aqueduct

Fourth Ventricle

There is a fourth ventricular mass.

The lesion homogeneously enhances with IV contrast.

Yes

The solid component of the lesion demonstrates heterogeneous enhancement.

The ventricles are normal.

Yes

The images show that the third and fourth ventricles are abnormally dilated. Therefore, the lesion results in obstructive hydrocephalus.

View Report

Watch our video

View the full study if you'd like to take a look yourself.

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Second Imaging Study

What is the next imaging study you will order?

Brain CT

None

No further imaging is needed.

Well done. You were correct

What is your Diagnosis now that you have seen the imaging results?

Medulloblastoma

Ependymoma

The patient likely has an ependymoma. A medulloblastoma also shares similar features (patient demographic, location in 4th ventricle) but is more likely to be homogeneous.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

The patient will require urgent workup and management.

Assessment and Plan

Please provide your assessment and plan for this patient

This patient is a 15-year-old boy presenting with a posterior fossa mass lesion with resultant hydrocephalus. Pediatric neurosurgery should be urgently consulted. In the interim, the patient should be made NPO and placed on IV fluids in preparation for surgical intervention. The patient should undergo serial neurological exams. Steroids (like dexamethasone) should be started to decrease inflammation from the tumor and alleviate symptoms from the increased ICP.

Lessons Learned:
- Most pediatric brain tumors are infratentorial. The most common infratentorial brain tumor is a medulloblastoma. However, ependymomas, pilocytic astrocytomas, medulloblastomas, pinealomas, and craniopharyngiomas can also occur.
- When the diagnosis is suspected in a pediatric patient, an MRI with and without contrast should be performed to avoid radiation dosage.
- Compared to medulloblastomas, ependymomas are more likely to be heterogeneous and with coarse calcifications.

Socioeconomic Factors:
- There is a positive correlation between parental educational and income level with a risk of pediatric ependymomas.
- Increased age is associated with improved survival in children with ependymomas.
- African Americans with ependymomas have a higher risk of mortality when compared to others.

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