John A. Grant, MD, FACS, BCh, MB, neurosurgeon and Director of Pediatric Brain Tumors with the Long Island Brain Tumor Center at Neurological Surgery, P.C., offers reassurance for families with children who have brain tumors or malformations.
Having a child undergo brain surgery is a daunting experience for families. Brain tumors account for 1 in 4 childhood cancers, with about 4,000 children and adolescents diagnosed each year. After leukemia, brain and spinal cord tumors are the second most common cancers among children. According to the American Cancer Society, 3 out of 4 children with all types of brain tumors survive at least five years after being diagnosed.
“Many people have the belief that if you need neurosurgery you may not survive. That’s not the case anymore,” Dr. Grant says. “The brain is very complicated, but that’s not a reason not to operate, particularly for children.”
Since the primary indicator of a brain tumor or malformation is head circumference, John A. Grant, MD, FACS, BCh, MB, neurosurgeon and Director of Pediatric Brain Tumors with the Long Island Brain Tumor Center at Neurological Surgery, P.C., points out that measuring a young patient’s head is most important.
Dr. Grant points to plasticity — the innate ability of children’s brains to recover function after operations for tumors or vascular malformations. His confidence lies in his experience and expertise. Dr. Grant’s main emphasis, therefore, is on educating families, pediatricians and primary care physicians about the symptoms that should trigger a CT scan.
“What we’re trying to affect is the speed of a patient getting from the waiting room in the pediatrician’s office into the emergency room as quickly as possible,” Dr. Grant says. “It’s not a question of ‘let’s watch it for a while and see what happens.’ There are very few pediatric brain tumors you don’t want to remove.”
When to Get a CT Scan
“Headache plus” — a headache plus vomiting, especially projectile vomiting, or recurring headaches that intensify over time — is the classic indicator for having a CT scan. Other indicators include neck pain, backsliding from developmental milestones, sudden impaired vision, facial drooping, arm or leg weakness, and even, potentially, sudden weight loss. Among infants, hydrocephalus, measured by an enlarged head circumference, is the key indicator.
These symptoms vary to a degree among different age groups, especially between infants, preschoolers and teenagers. To illustrate different presentations, Dr. Grant refers to several cases from his six years at NSPC. These examples also demonstrate how brain tumors or malformations are detected and treated.
Some neurological problems are found even before a baby is born, underscoring the importance of prenatal ultrasounds. Dr. Grant diagnosed one infant with massive hydrocephalus in utero, which was later found to be caused by a serious congenital brain malformation. He successfully operated on the infant after she was born.
The majority of women have ultrasounds, most frequently occurring at 20 weeks into a pregnancy. When ultrasounds uncover a serious neurological problem — whether a malformation, a tumor or issue, such as spina bifida or hydrocephalus — Dr. Grant urges parents to see a neurosurgeon who can provide reliable information about treatments and/or interventions.
Dr. Grant joins a young patient and her family six months after treatment for a post fossa abscess.
Presentation in Infants
For babies ages 0 to 2, the primary indicator of a brain tumor or malformation is head circumference. Irritability can also be a factor, particularly if it gets worse, and babies will sometimes pull at their ears because of it. Projectile vomiting, especially in the morning,as well as falling short of milestones is an additional warning sign.
Dr. Grant recalls another infant patient, who was born prematurely and spent time in the NICU. After she went home, her pediatrician noticed that her head circumference was getting larger, but didn’t see any other concerning health issues.
“If a physician hasn’t measured the head circumference of a baby, then he or she hasn’t fully examined the child,” Dr. Grant says. “It’s important to plot the head circumference out on a graph and see how the child ranks according to other children of the same age.”
Due to the pediatrician’s measurements of the infant’s head circumference, Dr. Grant was able to remove a huge posterior fossa cyst from the baby’s brain, which was caused by an infection.
Presentation in Young Children
Children ages 2 to 6, are somewhat better able to articulate when something is wrong. The general rule is still “headaches plus,” but one indicator that can sometimes be missed is vision impairment. These children may just stand too close to the TV because of impaired vision.
“Parents have to work out what a child’s problem is by observing him or her,” Dr. Grant says. “Watching younger children play and how they use their hands is slightly more challenging than talking with older children about symptoms.”
One 5-year-old boy presented with what might be considered classic symptoms. He had headaches for six weeks, started throwing up and then finally refused to eat. After a CT scan, he was diagnosed with an ependymoma, a brain tumor, which Dr. Grant removed and later treated with radiation. Since then, the child has completely recovered.
Presentation in Teenagers
Brain tumors and vascular malformations can be difficult to diagnose at any age. In general, school-age children may complain of nonspecific symptoms, such as headaches or stomach problems, but the complaints are usually far less frequent than with adults. Children rarely complain of neck or back pain — so when they do, adults should pay attention.
“A child complaining of neck pain is a serious issue,” Dr. Grant says. “There might be some non-neurosurgical issue, but we have to diagnose what that is. The same applies for back pain.”
Dr. Grant interviews a patient four years after surgery for the removal of an ependymoma, a rare primary brain tumor.
One teenage boy’s brain malformation had a fairly typical presentation. After falling and hitting his head while playing soccer, the boy developed a headache that was accompanied by vomiting. The anti-nausea drug Zofran failed to help. His mother noticed that his face drooped on one side, a symptom caused by an internal brain hemorrhage. Treatment for the head injury led to a diagnosis of cavernous malformation in his brainstem. After the majority of the bleed was removed, the child improved significantly.
In another case, a teenage girl presented with an inability to swallow for several months and as a result lost a significant amount of weight. The gastroenterologist who initially examined her thought, not unreasonably, that there might be a psychological issue. He sent her home. A month later, she still couldn’t eat, and a CT scan of her neck showed a large tumor in her lower brainstem. Dr. Grant removed the hemangioblastoma. Dr. Grant reports that his patient can now swallow normally and is recovering.
Another somewhat unusual presentation was a teenage boy who was thought to have suffered from severe neck pain as a result of twice-a-day summer football practice. Toward the end of summer, he also began suffering from headaches. After diagnosing the child with a pineal region tumor, Dr. Grant removed the tumor before the child underwent chemotherapy and radiation.
Genetics of Tumors
Often, patients with brain abnormalities or benign tumors, need no further treatment once Dr. Grant has performed the procedure to correct the problem. Some patients, however, will need continuing oncological treatment, and there is good reason for optimism about positive outcomes for these children.
One of Dr. Grant’s patients three days after treatment for a brain stem cavernous malformation.
Recent advances in the genetics underpinnings of various tumors have allowed doctors to better tailor radiation and chemotherapy treatments, both the medications used and the duration, ultimately improving the survival odds for patients.
“We used to infer the biology from the shape — how tumors looked under a microscope — whereas now we can infer more about the tumor from the genetics,” Dr. Grant says. “A medulloblastoma, for example, might behave benignly or malignantly depending on its genetic makeup.”
The plasticity of children’s brains is another factor that Dr. Grant wants to emphasize. For example, it’s possible for a baby to have a major stroke in the left middle cerebral artery and parents may not even notice signs that the stroke took place. The result might be a couple of episodes of apnea or other mild effects, or maybe a little delay in milestones, but the child often is asymptomatic in 10 years’ time. The same stroke would leave an adult with a hemiplegia and increase his or her risk of death because of swelling.
“Even with something as major as a hemispherectomy in, say, a 5-year-old suffering from seizures, the remaining half of the brain will take over and rewire itself,” he says. “If a child survives, he or she is going to get better. The question is how long it will take and how much better will the child get.”
NSPC’s service area is all of Long Island, which includes about 5 million people. Dr. Grant would like to reach more patients in Brooklyn and Queens because it would be easier for them to visit NYU Winthrop in Mineola, where he has privileges, than to go into Manhattan.
“If your child is throwing up, you want the closest ER. You want to be told ‘we’ve got this, your child is safe, you’re not going to get anything better somewhere else,’” he says of the world-class care available at NSPC. “I’m comfortable saying that.”
Five years after Dr. Grant successfully removed a pineal tumor from a patient’s brain, he is enrolled in nursing school.
For the vast majority of Dr. Grant’s patients, any follow-up usually involves other care providers. If his young patients do need further surgery as they get older, he continues to offer them treatments and consultations they might not have access to at a purely children’s hospital.
“You don’t outgrow my care at 18 years old,” he says. “Very few places can take care of both children and adults, and NSPC is one of them.”
There’s a particular trust that is built when patients put their lives in the hands of a neurosurgeon, and Dr. Grant has occasionally ended up performing procedures on siblings or extended family members.
Dr. Grant confers with his secretary, Erika Tenaglia, about his next patient.
Above all, Dr. Grant wants to prevent families from avoiding consultations with him because of fears about what they might learn. He sees patients with abnormal CT scans, of course, but he also welcomes those who have concerns but haven’t yet had a scan performed.
“If a patient comes to see me and I say ‘this is no big deal and you don’t need an operation,’ that’s probably the most useful thing I do from a public health point of view,” he says. “If you bring your child to see me and he or she does have an issue, the outcome is by no means hopeless.”
For more information, visit nspc.com.