Factores de mortalidad en niños con tosferina maligna / Mortality risk factors in children with severe pertussis

INTRODUCCIÓN: La hiperleucocitosis y la hipertensión pulmonar son factores de riesgo de mortalidad en niños con tosferina maligna. Las opciones terapéuticas disponibles para estos casos graves no se encuentran bien establecidas. Población y métodos: Se diseñó un estudio ambispectivo que incluía a niños diagnosticados de tosferina ingresados en una Unidad de Cuidados Intensivos Pediátricos (UCIP) de un hospital de tercer nivel en España entre enero de 2007 y octubre de 2015. Se compararon variables clínicas y demográficas entre el grupo de niños que sobrevivieron (grupo de supervivientes [GS]) y los que finalmente fallecieron (grupo exitus [EG]). RESULTADOS: Se identificaron un total de 31 pacientes. La mortalidad global fue del 19% (6/31 pacientes). Cinco niños fueron diagnosticados de hipertensión pulmonar. Cinco de seis niños que finalmente fallecieron precisaron canulación en oxigenación por membrana extracorpórea (ECMO). Ocho pacientes recibieron terapia mediante exanguinotransfusión (ET). La mediana de leucocitos antes de la realización de ET fue mayor (81.300 cél./μL) en EG que en GS (57.400 cél./μL), p= 0,05. Los pacientes que fallecieron tuvieron un mayor recuento pico de leucocitos totales, linfocitos, neutrófilos y niveles de proteína C reactiva (PCR) que los niños que sobrevivieron. Las variables que se identificaron como factores de riesgo de mortalidad fueron: una frecuencia cardiaca mayor de 170 lpm (OR 18; IC del 95%: 1,7-192,0), la presencia de neumonía (OR 16,5; IC del 95%: 1,7-165) y la presencia de hipertensión pulmonar (OR 179,6 [6,4-5.027]). CONCLUSIÓN: El uso de variables sencillas como la frecuencia cardiaca, el recuento total de leucocitos o los valores de PCR pueden servir para identificar de forma precoz a pacientes con riesgo de hipertensión pulmonar y tosferina maligna, de forma que procedimientos invasivos como la ET puedan utilizarse de una forma más precoz

BACKGROUND: Hyperleukocytosis and pulmonary hypertension are risk factors for death in infants with severe pertussis. Treatment options in severe pertussis are not well-established. METHODS: We designed an ambispective study of children with pertussis admitted to the pediatric intensive care unit (PICU) of a tertiary level hospital in Spain from January 2007 to October 2015. Clinical and demographical variables were compared between the group of children who survived (survivors group or SG) and those children who died (exitus group or EG). RESULTS: Thirty-one children were identified. Overall mortality rate was 19% (6/31 patients). Five children had pulmonary hypertension. Five out of 6 infants who eventually died had been placed on ECMO. Eight infants needed exchange transfusion (ET). Median leukocyte count immediately before exchange transfusion was higher (81300 cél./μL) in EG than in SG (57400 cél./μL), p= 0.05. Children who died had higher peak values in white blood cell counts (WBC), lymphocyte count, neutrophil counts and PCR levels than children who survived. The following variables were associated with risk of death: a heart rate above 170 bpm (OR 18, CI 95%: 1.7-192,0), the presence of pneumonia (OR 16.5, CI 95%: 1.7-165) and pulmonary hypertension (OR 179,6 [6,4-5027]. CONCLUSION: Early identification of patients at risk for pulmonary hypertension and fatal pertussis using heart rate, WBC and PCR levels would be appropriate so that invasive procedures such as exchange transfusion could be carried out precociously

Factors associated with severity in invasive community-acquired Staphylococcus aureus infections in children: a prospective European multicentre study.

Staphylococcus aureus is the main pathogen responsible for bone and joint infections worldwide and is also capable of causing pneumonia and other invasive severe diseases. Panton-Valentine leukocidin (PVL) and methicillin-resistant S. aureus (MRSA) have been studied as factors related with severity in these infections. The aims of this study were to describe invasive community-acquired S. aureus (CA-SA) infections and to analyse factors related to severity of disease. Paediatric patients (aged 0-16 years) who had a CA-SA invasive infection were prospectively recruited from 13 centres in 7 European countries. Demographic, clinical and microbiological data were collected. Severe infection was defined as invasive infection leading to death or admission to intensive care due to haemodynamic instability or respiratory failure. A total of 152 children (88 boys) were included. The median age was 7.2 years (interquartile range, 1.3-11.9). Twenty-six (17%) of the 152 patients had a severe infection, including 3 deaths (2%). Prevalence of PVL-positive CA-SA infections was 18.6%, and 7.8% of the isolates were MRSA. The multivariate analysis identified pneumonia (adjusted odds ratio (aOR) 13.39 (95% confidence interval (CI) 4.11-43.56); p 0.008), leukopenia at admission (<3000/mm(3)) (aOR 18.3 (95% CI 1.3-259.9); p 0.03) and PVL-positive infections (aOR 4.69 (95% CI 1.39-15.81); p 0.01) as the only factors independently associated with severe outcome. There were no differences in MRSA prevalence between severe and nonsevere cases (aOR 4.30 (95% CI 0.68- 28.95); p 0.13). Our results show that in European children, PVL is associated with more severe infections, regardless of methicillin resistance.

Herpes zóster en inmunocompetente vacunada frente a varicela / Herpes zoster in a varicella-vaccinated immunocompetent patient

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Cojera no dolorosa como forma de presentación de una artritis tuberculosa / Painless limp as a presentation of tuberculous arthritis

La coxalgia unilateral puede representar un importante reto diagnóstico en pediatría. Aunque la causa más frecuente es la sinovitis transitoria de cadera, hay otros diagnósticos que deben tenerse en cuenta, como la artritis séptica, las formas de inicio de artritis inflamatoria, en especial las asociadas a entesitis, las enfermedades ortopédicas (Perthes y epifisiolisis de cadera) y las neoplasias (AU)

The unilateral hip pain can be a major diagnostic challenge in pediatrics. Although the most common cause is transient synovitis, there are other diagnoses that should be taken into consideration as septic arthritis, onset forms of inflammatory arthritis, especially those associated with enthesitis, orthopedic disease (Perthes and epiphysiolysis hip) and neoplasms (AU)

Carga viral indetectable tras la adición de raltegravir al tratamiento de una adolescente con virus de la inmunodeficiencia humana embarazada de 36 semanas y en fracaso virológico / Undetectable viral load after the addition of raltegravir in a 36 week pregnant adolescent with high-level HIV viraemia

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Traumatismo craneal infligido o no accidental / Abusive head trauma or nonaccidental head injury

El traumatismo craneal infligido, o traumatismo craneal no accidental, es la variante de maltrato infantil con mayor mortalidad y morbilidad neurológica. Se caracteriza por la presencia de hemorragia subdural, hemorragias retinianas y edema cerebral, y puede ir acompañado de fracturas óseas ocultas. La clínica es variada e inespecífica, y suele haber escasos o nulos signos traumáticos externos. Los indicadores de la historia clínica deben hacer sospechar una etiología no accidental. En todos los casos se deberían realizar pruebas de neuroimagen, una serie ósea y un fondo de ojo. El maltrato infantil requiere un abordaje en equipo y, si hay sospecha, se debe realizar un parte judicial y un informe a los trabajadores sociales. Lo más importante es el diagnóstico precoz, ya que puede evitar futuros episodios de maltrato y muertes por esta causa. Por tanto, es imprescindible que el pediatra conozca esta patología(AU)

Abusive head trauma (inflicted traumatic brain injury or non-accidental head injury) is the leading cause of neurological morbidity and death from child abuse. Injuries associated with abusive head trauma include subdural and retinal hemorrhage, parenchymal injury, as well as skeletal fractures. Infants usually present with nonspecific clinical features without a history of trauma. Therefore, any unexplained neurological sign or symptom must alert paediatricians. Computed tomography, skeletal survey and eye examination should be performed inevery child with suspected abusive head injury. A multidisciplinary evaluation should be made, and include communication with law enforcement and social workers. Early diagnosis is essential and may be life-saving. Therefore, paediatricians should be aware of this pathology(AU)

Manchas de Bitot por déficit de vitamina A / Bitot's spots in vitamin A deficiency

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Estudio de la calidad de las prescripciones médicas en un servicio de urgencias pediátricas / Study on the quality of the medical prescriptions in a Pediatrics Emergency Service

Antecedentes: En los últimos años se han publicado algunos trabajos sobre el error médico. Los servicios de urgencias pediátricas (SUP) son especialmente susceptibles al error de prescripción, pero se han escrito pocos artículos específicos al respecto. Objetivos: Determinar la frecuencia y las variables asociadas con las desviaciones de la buena práctica médica en las prescripciones médicas en nuestro SUP. Métodos: Estudio retrospectivo observacional. Revisamos las prescripciones realizadas en 58 días elegidos de forma aleatoria (entre julio de 2003 y marzo de 2004). De cada una de ellas evaluamos la legibilidad, el cálculo de dosis, las unidades, el intervalo y la alergia medicamentosa. Recogimos el día de la semana, el turno y el grado de formación del médico responsable. Resultados: Durante los 58 días revisados se realizaron3.143 prescripciones. Detectamos una o más desviaciones de la buena práctica médica en 1.348 (43%). Ninguna de ellas fue clasificada como grave. La variable donde más desviaciones detectamos fue en la legibilidad, seguida del cálculo de la dosis. En el 11%, al menos uno de los elementos se consideró ilegible. Se encontraron diferencias estadísticamente significativas al analizar las variables correspondientes al día de la semana (fin de semana frente a lunes-viernes; p= 0,0036) y el grado de formación (residente frente a adjunto; p <0,0001). Conclusiones: Los errores en la prescripción médica son frecuentes en nuestro SUP; ninguno de ellos es grave, pero sí limitan el buen cumplimiento del tratamiento. Se pueden identificar circunstancias que hacen más frecuentes las desviaciones y, de esta forma, diseñar intervenciones para mejorar la calidad asistencial (AU)

Background: Several papers related to the medical mistakes have been published over the past years. The Pediatrics Emergency Services are specially susceptible as regards to the prescription mistake but there are few specific articles. Objectives: To determine the frequency and variables associated to the deviations of good medical practice in medical prescriptions in our Pediatrics Emergency Service. Methods: Retrospective observational study. We revised the prescriptions done during fifty eight days on a random basis(from July 2003 to March 2004). From every prescription: legibility, dose assessment, units, intervals and drug allergies were evaluated. The day of the week, shift and level of training of the prescribing physician were documented. Results: During the revised 58 day, 3,143 prescriptions were made. One or more deviations to the good medical practice were detected in 1,348 (43%) of the prescriptions. None of the mistakes were classified as severe. The variable where more deviations were detected was the legibility and dosage assessment. In 11% at least one of the elements were considered illegible. Statistical significant differences were found when analyzing the day of the week variables (week-end vs. Monday-Friday, p= 0.0036) and to the level of training (resident vs. pediatricians, p <0.0001). Conclusions: Medical prescription mistakes are very common in our Pediatrics Emergency Service. None of them were severe but limited the good compliance of the treatment. Some characteristics that make deviations more frequent can be identified in order to design interventions to improve the quality (AU)

Rehidratación intravenosa rápida en urgencias: comparación con la pauta tradicional / Intravenous rapid rehydration in the emergency department

Objetivo: Determinar si la rehidratación rápida es un método efectivo para corregir la deshidratación en niños con gastroenteritis aguda (GEA) y deshidratación leve-moderada, y comprobar si permite restablecer en menos tiempo el estado de hidratación, en comparación con el método tradicional. Métodos: Se trata de un estudio retrospectivo, analítico descriptivo, llevado a cabo en niños atendidos en un servicio de urgencias, con una deshidratación leve-moderada isonatrémica, desencadenada por una GEA. Se recopilaron un total de 42 casos y se compararon dos pautas de rehidratación: rápida (19 casos) y tradicional (23 casos).Resultados: El tiempo empleado para la rehidratación i.v. fue menor con la pauta rápida que con la tradicional, con una media de 3,53 horas (desviación estándar [DE]= 1,3) y 12,04 horas (DE= 4,08), respectivamente. Esta diferencia fue estadísticamente significativa (p <0,01). También se encontraron diferencias estadísticamente significativas en cuanto al tiempo necesario para alcanzar una tolerancia oral exitosa, con una media de 6,37 horas (DE= 3,63) en el grupo de la pauta rápida, frente a 9,35 horas (DE= 5,16) en el de la pauta tradicional (p= 0,04). Por el contrario, a pesar de que el tiempo medio de estancia en el servicio de urgencias fue menor para la pauta rápida y que la ganancia de peso fue mayor que en la pauta tradicional, estas diferencias no fueron estadísticamente significativas. Conclusión: La rehidratación i.v. rápida supone una alternativa a la pauta clásica con una serie de ventajas, como la facilidad de cálculo con menor posibilidad de errores, una mejora más rápida del estado de hidratación y del estado general, que permite una tolerancia oral más precoz, o la corrección más rápida de las alteraciones electrolíticas y del equilibrio ácido base gracias a la restauración precoz de la perfusión renal, y todo ello de forma segura, sin que aumente el riesgo de complicaciones como la hipernatremia (AU)

Objective: To determine if the rapid rehydration is an effective method to correct the dehydration in children with acute gastroenteritis and mild to moderate dehydration checking if it allows the restoration of the hydration state in less time in comparison with the traditional method. Methods: It is an analytical-descriptive retrospective study set in the emergency department about children presenting mild to moderate isonatremic dehydration triggered by acute gastroenteritis, and who have needed intravenous rehydration after the failure of oral tolerance. A total of 42 cases were compiled and two protocols of rehydration were compared: rapid rehydration (19 cases) and traditional rehydration (23 cases). Results: The time used for intravenous rehydration was less in the rapid rehydration protocol in comparison to the traditional one, with averages of 3.53 hours (DS: 1.3) and 12.04 hours (DS: 4.08) respectively. This difference was statistically significant (p <0.01). There were also statistically significant differences in the time needed to reach a successful oral tolerance, with an average of 6.37 hours (DS: 3.63) in the rapid protocol group in comparison to 9.35 hours (DS: 5.16) in the group of the traditional protocol (p= 0.04). On the contrary, although the average time of stay in the emergency department was less in the rapid rehydration protocol than in the traditional one and there was an increasing trend in the weight gain in the rapid protocol, these differences were not statistically significant. Conclusion: Rapid intravenous rehydration poses an alternative to the classic protocol with several advantages such as they are: facility of calculation with less possibility of errors; faster improvement of the hydration state and patient well being that allows an early tolerance to oral feeding; faster correction of serum electrolyte abnormalities and acidosis due to the promptrestoration of renal perfusion (AU)

[Presence of parents in the emergency room during invasive procedures: do they prefer to be present?]. / Procedimientos invasivos en urgencias: ¿los familiares prefieren estar presentes?

INTRODUCTION: Parents are not usually present during procedures in the paediatric emergency room (ER), although an increasing number of them would like to. Our goal was to find out how parents felt about them being present in ER during procedures. MATERIAL AND METHODS: This is an observational study. Questionnaires were distributed among parents of patients in the ER during January and February 2007. Data included demographic questions as well as the opinion regarding their preference on being present during venipuncture, stitching, lumbar puncture or cardiopulmonary resuscitation. They were also asked about who should take the decision whether to allow the family to be present or not. RESULTS: A total of 98 questionnaires were analyzed. The median age of participants was 32 years-old, of which 84.5% would prefer to be present for venipuncture, 70.4% for stitching, 66.3% for lumbar puncture and 61.2% for cardiopulmonary resuscitation. Venipuncture was performed on 21% of the children, stitching on 4%, and lumbar puncture on 2%. There was no cardiopulmonary resuscitation. Parents considered that the decision about being present should be taken by the professional in 74% (venipuncture), 75% (stitching), 80% (lumbar puncture) and 81% (cardiopulmonary resuscitation). The mean age of the group that preferred to be present was lower (32 vs. 40 years; p = 0.039). CONCLUSIONS: Most parents surveyed preferred to be present during invasive procedures in ER. The more invasive the procedure is the higher reluctance from parents to be present. Most parents thought the decision should be taken by the health care professional, particularly when the procedure is more invasive.

Procedimientos invasivos en urgencias: ¿los familiares prefieren estar presentes? / Presence of parents in the emergency room during invasive procedures: do they prefer to be present?

Introducción: tradicionalmente no se ha permitido a los familiares de los pacientes permanecer con su niño durante los procedimientos invasivos en urgencias pediátricas. Se evalúa la opinión de los padres en cuanto a su preferencia de estar o no presentes. Material y métodos: se trata de un estudio observacional descriptivo. Se realizaron encuestas al azar a familiares de pacientes que fueron atendidos en nuestro servicio de urgencias en enero y febrero de 2007. Se preguntó acerca de su preferencia de estar o no durante las siguientes técnicas invasivas: venopunción, sutura de herida, punción lumbar y reanimación cardiopulmonar. Se preguntó también quién creía que debía tomar la decisión de que estuvieran o no presentes. Resultados: se realizó un total de 98 encuestas. La mediana de edad de los participantes fue 32 años. Preferían estar presentes en las técnicas de venopunción el 84,5% de los familiares; en sutura de la herida, el 70,4%; en punción lumbar, el 66,3%, y en reanimación cardiopulmonar, el 61,2%. Se realizó venopunción al 21% de los niños, sutura de herida al 4%, punción lumbar al 2%; no se realizó ninguna reanimación cardiopulmonar. Los encuestados respondieron que la decisión de estar presente debe ser tomada por el personal sanitario en un 74% en venopunción, el 75% en suturas, el 80% en punción lumbar y el 81% en reanimación cardiopulmonar. La media de edad del grupo que prefiere estar presente difiere significativamente de los que no (32 frente a 40 años). Conclusiones: la mayoría de los familiares encuestados preferirían estar presentes durante los procedimientos invasivos en urgencias pediátricas. A mayor invasividad, menor deseo de los padres de estar presentes. La mayoría de los familiares cree que la decisión de estar o no presente debe ser tomada por el personal sanitario, especialmente cuanto más invasivo es el procedimiento (AU)

Introduction: Parents are not usually present during procedures in the paediatric emergency room (ER), although an increasing number of them would like to. Our goal was to find out how parents felt about them being present in ER during procedures. Material and methods: This is an observational study. Questionnaires were distributed among parents of patients in the ER during January and February 2007. Data included demographic questions as well as the opinion regarding their preference on being present during venipuncture, stitching, lumbar puncture or cardiopulmonary resuscitation. They were also asked about who should take the decision whether to allow the family to be present or not. Results: A total of 98 questionnaires were analyzed. The median age of participants was 32 years-old, of which 84.5% would prefer to be present for venipuncture, 70.4% for stitching, 66.3% for lumbar puncture and 61.2% for cardiopulmonary resuscitation. Venipuncture was performed on 21% of the children, stitching on 4%, and lumbar puncture on 2%. There was no cardiopulmonary resuscitation. Parents considered that the decision about being present should be taken by the professional in 74% (venipuncture), 75% (stitching), 80% (lumbar puncture) and 81% (cardiopulmonary resuscitation). The mean age of the group that preferred to be present was lower (32 vs. 40 years; p=0.039). Conclusions: Most parents surveyed preferred to be present during invasive procedures in ER. The more invasive the procedure is the higher reluctance from parents to be present. Most parents thought the decision should be taken by the health care professional, particularly when the procedure is more invasive (AU)

Impétigo bulloso causado por Staphylococcus aureus" resistente a meticilina / Bullous impetigo caused by methicillin-resistant Staphylococcus aureus

El impétigo es una infección cutánea superficial que ocurre sobre todo en la edad pediátrica, más frecuentemente por debajo de los 5 años de edad. SE clasifica en primario, que es el que tiene lugar sobre piel previamente sana, y secundario, que aparece en piel lesionada, principalmente tras un eccema. Existen dos tipos de impétigo: no bulloso, más frecuentemente, y bulloso. el agente causal predominante en todos los tipos de impétigo es Staphylococcus aureus. En los últimos años se ha descrito la emergencia de cepas de S. aureus resistentes a meticilina (SARM) como causantes de infecciones adquiridas en la comunidad, tanto leves como graves. Se presenta el caso de un varón de 8 años que presenta lesiones ampollosas dolorosas de una semana de evolución en la región lumbar. Se recoge cultivo de las lesiones y se identifica el crecimiento de colonias de S. aureus con resistencia a meticilina(AU)

Impetigo is a superficial skin disease that occurs in children, mainly before the age of five years. It is classified as primary if it occurs on previously healthy skin and secondary when it develops on damaged skin, usually following eczema. There are two types of impetigo: non-bullous, which is more frequent, and bullous. The predominant causative agent in both types is Staphylococcus aureus. In recent years, emergent methicillin-resistant strains (MRSA) that provoke mild to severe community-acquired lesions have been described. We report the case of an eight-year-old boy with painful, bullous skin lesions on his back that had developed one week earlier. A skin culture revealed the presence of colonies of methicillin-resistant S. aureaus(AU)

[Initial signs and symptoms of brain tumors in children]. / Síntomas y signos iniciales de los tumores cerebrales pediátricos.

INTRODUCTION: This is a study of the presenting features of brain tumors in children, their localization and histology which is aimed at describing the most frequent symptoms at the beginning and at the moment of diagnosis and minimize the time needed to reach a diagnosis. METHODS: Retrospective and descriptive study. Data were collected from the medical records of the patients (aged: 0-16) operated on for a brain tumor in our Department from 1999 to 2004. All analyses were conducted with the SPSS 11.0. RESULTS: In our study, the prevalence of brain tumors was higher in males (58%) older than five years. Of these, 52% were supratentorial and the most frequent one was astrocytome. Median time to diagnosis was 30 days. A total of 75% were diagnosed during the first 60 days of the onset of the symptoms. We found a statistically significant relationship between age and mean time to d i a gnosis. The most frequent initial symptom was increased head circumference and nausea/vomiting in children younger than 2 years, vomiting and headache in children aged 2-5, and headache in older than 5 years. In all groups, 83% of headache was accompanied by vomiting. CONCLUSIONS: Mean time to diagnosis in our study is similar to other series. Presenting features vary based on age and they are not pathognomonic of the brain tumors. This hinders early diagnosis. In order to make an early diagnosis, it is important to pay attention to the associated symptoms and chronology.

Síntomas y signos iniciales de los tumores cerebrales pediátricos / Initial signs and symptoms of brain tumors in children

tumores cerebrales en niños, sus características histológicasy su localización con el fin de conocer los síntomasmás habituales al inicio y en el momento del diagnóstico eintentar disminuir el tiempo hasta éste.Métodos. Estudio retrospectivo, descriptivo. Informaciónrecogida de las historias clínicas de 50 pacientes pediátricosintervenidos en nuestro centro de tumor cerebral primarioentre 1999 y 2004 analizada con SPSS 11.0.Resultados. En nuestra serie los tumores cerebralesfueron más prevalentes en niños (58%) mayores de 5 años,un 52% era supratentorial y el astrocitoma fue el más frecuente.La mediana de tiempo al diagnóstico fue de 30 díasy el 75% se diagnosticaron en los 60 días siguientes a la primeraconsulta. Encontramos una relación estadísticamentesignificativa entre el tiempo transcurrido hasta el diagnósticoy la edad. La clínica más frecuente en el diagnóstico eraaumento del perímetro craneal y náuseas/vómitos en losmenores de 2 años, náuseas/vómitos y cefalea en los niñosde 2 a 5 años y cefalea en los mayores de 5 años. En todoslos grupos el 83% de las cefaleas se acompañaban de náuseas/vómitos.Conclusiones. El tiempo medio hasta el diagnóstico ennuestra serie es aceptable comparado con otras. La clínicavaría en función de la edad y no es patognomónica de lostumores cerebrales, lo que dificulta el diagnóstico precoz.Para un diagnóstico precoz es importante fijarse en la asociaciónde síntomas y en la cronología (AU)

Introduction. This is a study of the presenting featuresof brain tumors in children, their localization andhistology which is aimed at describing the most frequentsymptoms at the beginning and at the moment of diagnosisand minimize the time needed to reach a diagnosis.Methods. Retrospective and descriptive study. Datawere collected from the medical records of the patients(aged: 0-16) operated on for a brain tumor in our Departmentfrom 1999 to 2004. All analyses were conductedwith the SPSS 11.0.Results. In our study, the prevalence of brain tumorswas higher in males (58%) older than five years. Of these,52% were supratentorial and the most frequent onewas astrocytome. Median time to diagnosis was 30 days.A total of 75% were diagnosed during the first 60 daysof the onset of the symptoms. We found a statisticallysignificant relationship between age and mean time to diagnosis.The most frequent initial symptom was increasedhead circumference and nausea/vomiting in childrenyounger than 2 years, vomiting and headache in childrenaged 2-5, and headache in older than 5 years. In allgroups, 83% of headache was accompanied by vomiting.Conclusions. Mean time to diagnosis in our study issimilar to other series. Presenting features vary based onage and they are not pathognomonic of the brain tumors.This hinders early diagnosis. In order to make anearly diagnosis, it is important to pay attention to theassociated syntoms and chronology (AU)