Symptoms and signs of brain tumor in children with and without brain tumors were compared in a UK population-based retrospective analysis of primary care records by researchers at University of York and other centers in the UK. Participants were 195 children, mean age 7.31 (range 1-14 years), newly diagnosed with brain tumors and 285 controls. Between birth and diagnosis with brain tumor symptoms and signs, cases with tumor consulted more often than controls, and their consultation rate with >1 suggestive symptom increased in the 2 years before diagnosis Symptom prevalence was higher among cases than controls, with 3.29 times as many consultations with >1 suggestive symptom. Suggestive symptoms in case children in order of prevalence included vomiting (74% cases), headache (59%), visual problems (44%), unsteadiness (42%), and anorexia (31%). In controls, suggestive symptoms were vomiting (43%), anorexia (18%), headache (15%), and visual (15%) and hearing (11%) problems. In 4 years before diagnosis, cases had at least twice as many consultations with >1 suggestive symptom in each 6 month period, and 20.81 times as many in the 6 months before diagnosis. Cases with combination of symptoms had an increased probability of tumor. Symptoms of brain tumor cases not observed in control children included head tilt, odd head movements, odd posture, back or neck stiffness, and unsteadiness. Recognition of unusual symptoms or specific symptom patterns and combinations is the key to identifying the child who needs prompt investigation. 
COMMENT. Brain tumors in children are rare (2.4 per 100,000) and the average pediatrician or family practitioner will see few such cases in a lifetime of practice. With the advent of improved diagnostic methods and therapy, early diagnosis and prompt referral offer the potential for cure and a good quality of life. Knowledge of presenting symptoms of brain tumor should alert the primary care physician to suspect the diagnosis and refer the patient for neurological evaluation . The account of the UK primary care experience emphasizes the early symptoms and signs suggestive of brain tumor and their increased prevalence and need for consultation with time. The importance of symptom combinations, unusual symptoms or specific symptom patterns is also stressed as the key to diagnosis. Early symptoms of brain tumor not addressed in the UK study include changes in affect, energy, motivation, or behavior. Indifference to playmates, listlessness, and somnolence should alert suspicion. The clinical course of a child with cerebellar medulloblsatoma, as portrayed by Cushing is worth review (Cohen and Duffner, 1984). Initial manifestations are nonlocalizing (changes in school work, vomiting, headache, enlarged head, and diplopia). These are followed by signs of a midline cerebellar syndrome, and terminally, tonsillar herniation, cerebellar fits, and decerebrate rigidity.
Seizures occurred in 50 (17%) of 291 children with intracranial tumor treated at the Mayo Clinic from 1950 through 1959 . EEG was of localizing value in 75% of supratentorial tumors and in 88% of those involving cerebral cortex. Seizures were not included in the list of symptoms observed in the UK primary care study.