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

ADULT

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


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

  • Acute trauma
  • Change in conscious 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
    • bilateral nerve pain (leg pain below knees)
    • unexplained or unexpected loss of bladder or bowel function
    • perineal anaesthesia
    • progressive weakness
  • Spinal tumour with significant pain and/or neurological deficit
  • Clinical signs spinal nerve root compression or spinal cord compression with rapidly progressive neurological signs/symptoms
  • Spinal trauma with significant pain and/or neurological deficit
  • Spinal fractures demonstrated on imaging
  • Clinical suspicion of 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

 

  • 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

Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)
    • Intracerebral space-occupying lesion, (suspected or confirmed on CT) with minimal and/or slowly progressing symptoms
    • Symptomatic small benign intracranial tumours (e.g. acoustic neuroma/vestibular schwannoma, meningioma, craniopharyngioma epidermoid cyst, arachnoid cyst) without cerebral oedema
    • Pituitary tumour associated with visual field deficits and/or symptomatic hyper/hypopituitarism
  • Category 2
    (appointment within 90 calendar days)
    • Functioning or non-functioning pituitary adenoma, pituitary tumours with slowly progressive visual field deficit
    • Incidental finding on imaging e.g. epidermoid cyst, arachnoid cyst and/or unusual pathology e.g. adults with newly diagnosed chiari malformation, empty sella, temporal lobe herniation, venous angioma
  • Category 3
    (appointment within 365 calendar days)
    • Pituitary tumours with no visual impairment, normal pituitary function and/or mild hyper-prolactinemia

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

2. Essential referral information Referral will be returned without this

  • CT/MRI results
  • Pituitary function tests including prolactin if suspected pituitary tumour (e.g. prolactin, random cortisol, growth hormone and IGF1, TFT's)

3. Additional referral information Useful for processing the referral

  • Details of previous malignancy including treatment/any relevant imaging results

4. Request

Patient's Demographic Details

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander

Referring Practitioner Details

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

Relevant clinical information about the condition

  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

Reason for request

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

Clinical modifiers

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
  • Please note that where appropriate and available, the referral may be streamed to an associated public allied health and/or nursing service. This may include initial assessment and management by associated public allied health and/or nursing, which may either expedite or negate the need to see the public medical specialist.
  • A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.
  • Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.