Imaging patients with suspected brain tumour: guidance for primary care

Abstract

The number of referrals by primary care practitioners to secondary care neurology services, particularly for headache, may be difficult to justify. Access to imaging by primary care practitioners could avoid referral without compromising patient outcomes, but the decision to refer is based on a number of complex factors. Due to the paucity of rigorous evidence in this area, available data are combined with expert opinion to offer support for GPs. The study suggests management for three levels of risk of tumour: red flags >1%; orange flags 0.1-1%; and yellow flags <0.1% but above the background population rate of 0.01%. Clinical presentations are stratified into these three groups. Important secondary causes of headache where imaging is normal should not be overlooked, and normal investigation does not eliminate the need for follow-up or appropriate management of headache.

The diagnosis and treatment of chronic migraine

“…With regard to the former, evidence shows that when a diagnosis of migraine can be made on clinical grounds, the chances of the patient having a brain tumour are 0.045% [Kernick et al 2008a]; no investigation is indicated, therefore, not least because there is a 1-2% chance of picking up an incidental intracranial abnormality which may cause anxiety, or even have an adverse influence on life insurance applications. Imaging should be reserved for situations when clinical assessment suggests that the probability of an underlying tumour has exceeded 1%; examples include the finding of papilloedema on fundoscopy, headache with fixed abnormal neurological signs, headaches associated with new onset seizures or significant alterations in consciousness, memory or coordination, or headaches in patients with a history of cancer elsewhere in the body.…”

Primary care access to computed tomography for chronic headache

“…8 The role of imaging in this situation has been extensively reviewed, and guidance has been published for risk which stratifies patients according to presentation. 9,10 Although pathology may be excluded by neuroimaging, the diagnostic yield is low, 9,11,12 and the duration of reassurance for patients is short. 13 Moreoever, there is a risk of finding coincidental abnormalities that may generate more anxiety.…”

The changing relationship between neurology and general practice in the UK

“…DeNDRoN (the Dementias and Neurodegenerative Diseases Research Network) has a clinical study group supporting neurodegenerative research in primary care, and there is an independently funded organisation (Primary Care Neurology Society) that aims to 'generate greater awareness and interest in neurology among professionals with an interest, or working, in primary care'. 22 A recent publication in this journal of red, orange, and yellow flags for imaging in headache was produced by a joint primary and secondary care group; 23 it would be good to see similar initiatives for funny turns, tingly legs, tremor, and memory impairment.…”