Stories of health professionals involved in diagnosing a childhood brain tumour

Satnam Punglia, Optician

Most people attend an optician’s because they feel they may need spectacles, or are having an eye problem. However, what most people don’t realise is that an eye examination checks visual functions, the need for spectacles and eye health. A common reason for visiting an optician is a persistent headache.

A normal eye examination (sight test) usually takes 20 minutes (excluding additional tests). In the case of headaches, the optician will investigate the possible causes.

Full details of a person’s symptoms, personal health and family medical background are taken, and then their eyes are checked for any dysfunction.

As part of this examination we check an area called the optic disc at the back of the eye, where all the nerves and blood vessels enter and leave the eye. Increased pressure within the cranium can cause the optic disc to be pushed forward into the eye, causing a blurred appearance of the optic disc and irregularities in the blood vessels.

As this increased pressure could be due to a brain tumour, the patient is usually sent straight to Accident and Emergency (A&E) for an immediate specialist (Ophthalmic or Neurological) opinion.

A young man who came in for an appointment a few years ago was experiencing continuous headaches, the cause of which had not been determined by previous visits to various medical persons. During a sight test I examined his optic disc and noticed that it was very blurred in appearance. Since this rare appearance indicated that there may be pressure within the young man’s skull, he was sent to the local hospital. After an urgent brain scan he was kept in overnight, and I was to find out later that he had been diagnosed with brain and spinal cord tumours.

I would advise a regular sight test which may help in the early detection of brain tumours.

Dr Richard Emms, GP

Dr Emms is a general practitioner who has been in practice for 20 years working with a practice population of 14,000 patients. Here, he tells us about his experience of acknowledging the possibility of a brain tumour in a seemingly 'well' child:

Around 4 years ago I became part of the process of an early referral for evaluation and eventual diagnosis of a malignant brain tumour. This was only the second brain tumour I had seen at the practice; the first having been just as I had started there 16 years previously.

My thoughts at the time of the original consultation were, "why has this intelligent, caring mother brought this 'well' 11-year-old child - who had vomited for no obvious cause three times in the previous three weeks - to see me?" She was worried and wanted reassurance. Alarm bells were ringing.

He had no specific neurological problems but the only abnormal finding was papilloedema (swollen optic disc).

I feel one should always bear in mind the possibility of something amiss if parents return with non specific symptoms - headaches, balance problems, vomiting - in a "well child". It is important to look at the eyeball fundi (eyeball depths), and the only way to feel more confident in this is to look in lots of normal eyes.

My feelings were that of professional pride for having recognised an abnormality of this boy's eyeball fundi but obviously distress for the implications for the future for him and his family.

The presence of a brain tumour is a rare event, and as such soft symptoms and signs may easily be missed. My message is to consider looking at the fundi of children if appropriate.

Dr Frances Morrison, Specialist registrar

Paediatric A&E St Mary's Hospital, Imperial College Healthcare NHS Trust, London

We have many children in the Paediatric A&E department coming in to see us because of a headache. People often think that children don’t suffer from headaches like adults do but they are actually very common. Fortunately most headaches are benign, although unpleasant, and are easily treated with rest and simple pain relief. However all health professionals who work with children learn to look out for certain warning signs or ‘red flags’ – these help us with the challenge of discovering which child has a pathological headache that requires urgent treatment.

Recently I saw a delightful 4 year old boy who had complained to his mother of a frontal headache every day for the past 2 months. Paracetamol was not relieving his pain and he was even waking at night because of the headaches. He had seen an optometrist and been given glasses for shortsightedness but those hadn’t helped either. His mother was understandably very anxious about him and wanted a diagnosis.

His neurological examination was normal (apart from reduced visual acuity) but his symptoms were enough for me to arrange an urgent MRI brain scan under general anaesthetic in our hospital. This revealed a type of tumour called a craniopharyngioma, which in his case was about the size of a tennis ball, in the centre of his brain. He was promptly transferred to a paediatric neurosurgical unit and has subsequently had successful surgery to remove the tumour.

I was very pleased to have quickly realised that his case was serious and to have contributed to his good clinical outcome.

I think the most important things to do when meeting a child with a headache are to pay attention to the red flags and to listen to the parents’ concerns. If you’re uncertain as to the diagnosis, be sure to see the child again or to ask for a second opinion.

Dr Laurence Abernethy, Consultant Paediatric Radiologist

Alder Hey Children’s Hospital, Liverpool

My department is where all sorts of x-rays and scans are done to help find out what is wrong with sick children. We would like to make sure that every child who has symptoms that might be due to a brain tumour (“red flag” symptoms) gets a brain scan as quickly as possible. The Royal College of Radiologists and the British Society of Paediatric Radiologists fully support the HeadSmart Campaign in its efforts to make sure that everyone is aware of the “red flag” symptoms. We are also committed to making sure that children throughout the UK have access to high quality diagnostic radiology services.

The clinical diagnosis of a brain tumour is often very difficult, even for experienced doctors, because the symptoms can be the same as those of other, more common conditions. This is why having a brain scan is so important. We have recently seen two children whose main symptoms were vomiting and loss of appetite. One was initially referred to a child psychiatrist with a diagnosis of anorexia nervosa, and the other was referred to a gastroenterologist. When their symptoms began to worsen, both had MRI brain scans, which showed large tumours. This was a terrible shock to the children and their families, but both children underwent neurosurgical operations at which the tumours were removed completely. We now have wonderful technology to help the neurosurgeons, including an MRI scanner that can be used to perform scans during the surgical operation, to help to achieve compete removal of a tumour. However, all of this modern technology and the skill of the specialist neurosurgeons and neuro-oncologists can only be useful once the initial diagnosis has been made. That is why the HeadSmart campaign is so important.