Brain tumours (intracerebral, meningioma, skull base, pituitary)

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  Emergency

  If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.

  Non-acute skull fracture/ non- acute traumatic brain injury

  • Acute trauma
  • Change in consciousness level or deteriorating neurological functions
  • Head trauma with seizures

  Brain tumours (intracerebral, meningioma, skull base, pituitary)

  • Symptoms of signs of raised intracranial pressure
  • Severe and increasing headache
  • Deteriorating neurological function
  • Seizures

  Neurovascular disorders (aneurysm, AVMs, other)

  • Symptoms of signs of raised intracranial pressure
  • Severe and increasing headache
  • Deteriorating neurological function
  • Seizures
  • Clinical suspicion or subarachnoid haemorrhage or intracerebral haemorrhage

  Hydrocephalus and VP shunt

  • Symptoms of signs of raised intracranial pressure
  • Increasing severity of headache
  • Deteriorating neurological function
  • Seizures
  • Swelling pain or redness along shunt tract
  • Abdominal pain or swelling
  • Clinical suspicion of shunt infection

  Trigeminal neuralgia and other cranial nerve abnormalities

  • Severe intractable pain preventing adequate fluid intake

  Spine

  • Actual or threatened cauda equina syndrome
    • Unilateral or bilateral radicular pain
      • And/or dermatomal reduced sensation
      • And/or myotomal weakness
      • Reduced saddle sensation (subjective or objective pin prick)
      • unexplained or unexpected loss or change of bladder or bowel function
      • Sexual disturbance
      • perineal anaesthesia
  • Presentations that increase the probability of acute threatened Cauda Equina:
    • Back Pain with:
      • Presence of new saddle anaesthesia, bladder or bowel disturbance.
      • Age < 50
      • Unilateral onset progressing to bilateral leg pain
      • Alternating leg pain
      • Presence of new motor weakness
  • Spinal tumour with significant pain and/or neurological deficit
  • Lumbar Spine Stenosis (LSS) presenting with clinical symptoms of the following:
    • Recurring and insidiously but increasing back pain with gradual onset of unilateral or bilateral lower limb sensory disturbance and/or motor weakness
    • Incomplete bladder emptying, urinary hesitancy, incontinence, nocturia or urinary tract infections. Bladder and/or bowel dysfunction may progress gradually over time.
  • Clinical signs of spinal nerve root compression or spinal cord compression with rapidly progressive neurological signs/symptoms
  • Spinal fractures demonstrated on imaging
  • Clinical suspicion spinal infections
  • High risk of irreversible deficit if not assessed urgently

  Peripheral nerve compression including carpal tunnel syndrome, ulnar nerve entrapment neuropathy, common peroneal and lateral cutaneous nerve of thigh compression syndromes

  • Acute development of peripheral nerve compression symptoms following trauma

  Other referrals to emergency not covered within conditions:

  Adult

  • Collapse/altered level of consciousness/new neurological deficit
  • Suspected subarachnoid haemorrhage or other intracranial haemorrhage
  • Headache with concerning features:
    
    • sudden onset/thunderclap headache
    • severe headache with signs of systemic illness (fever, neck stiffness, vomiting, confusion, drowsiness)
    • first severe headache age over 50 years
    • severe headache associated with recent head trauma
  • Symptomatic benign or malignant space-occupying lesion
  • Suspected or proven blocked or infected VP shunt
  • Acute hydrocephalus
  • Head injuries/trauma including extensive scalp laceration or suspected traumatic brain injury
  • Trigeminal neuralgia – severe uncontrollable pain

  Paediatric

  • Benign or malignant space occupying lesion associated with midline shift, hydrocephalus, neurological or endocrine deficit
  • Acute hydrocephalus
  • Suspected or proven blocked or infected VP shunt
  • Vascular disorders – suspected subarachnoid haemorrhage or other intracranial haemorrhage e.g. Thunderclap headache, collapse/altered level of consciousness, headache with vomiting, new neurological deficit
  • Cranial trauma – extradural, subdural haematoma, large cerebral contusion, concussion injuries, diffuse axonal injury, skull fractures, CSF fistula/leakage spinal trauma or other spinal conditions with severe or rapidly progressive deficit e.g. Loss of sensation, muscular weakness or cauda equina syndrome
  • Generalised seizures, prolonged focal seizures and persistent neurological deficits

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  Other useful information for referring practitioners Not and exhaustive list

  • Monitor neurological function
  • CT+/-contrast and/or MRI for patients with suspected space-occupying lesion;
    • headache suspicious for raised intracranial pressure i.e. morning headache, vomiting and papilloedema and/or
    • associated neurological features i.e. new onset seizures, cognitive, behavioural or personality changes, neurological deficits
  • Consider endocrinology referral for any of the following:
  • functioning pituitary adenoma
  • pituitary tumours with slowly progressive visual field deficit
  • marked hyper-prolactinemia serum prolactin > 5000 mU/L
  • pituitary tumours with no visual impairment