Brain and CNS cancer referral guidelines

Very urgent referral

Consider very urgent referral (appointment within 48 hours) in children and young people with newly abnormal central neurological or cerebellar function.

Urgent direct access

Consider urgent direct access MRI brain scan (appointment within two weeks) in adults with progressive, sub-acute loss of central neurological function.

A normal investigation does not preclude the need for ongoing follow-up, monitoring or further investigation. In addition, a seemingly ‘normal’ MRI scan may provide false reassurance in people who have neurological pathology that MRI scanning is unable to detect.

Approximately 10% of people may be unsuitable for or unable to tolerate an MRI brain scan, eg people with pacemakers or those with severe claustrophobia. A CT scan may be more appropriate for these people, but potential radiation exposure should be considered.

A small percentage of MRI scans may yield abnormalities in otherwise healthy individuals. This may impact on these people in a number of ways, including the need for further investigation and their health insurance premiums being potentially affected. As incidental findings are not an infrequent result of MRI scanning, people should be offered counselling and information before a scan to make them aware that such findings are possible.

No definition of ‘progressive sub-acute loss of central neurological function’ has been provided for this update, but NICE’s 2005 guidance for suspected cancer states signs or symptoms that should raise concern include:

• progressive neurological deficit
• new-onset seizures
• headaches
• mental changes
• cranial nerve palsy
• recent headaches accompanied by features suggestive of raised intracranial pressure, such as:
  • vomiting
  • drowsiness
  • posture-related headache
  • pulse-synchronous tinnitus
  • or other focal or non-focal neurological symptoms, such as blackout or change in personality or memory.

Consider urgent referral for people with:

• rapid progression of sub-acute focal neurological deficit, unexplained cognitive impairment behavioural disturbance or slowness, or a combination of these
• personality changes there is no reasonable explanation for and which have been confirmed by a witness, even in the absence of the other symptoms or signs of a brain tumour.

Please note, these guidelines aim to share learning and good practice but, out of necessity, they are brief in nature. They are not a substitute for your own clinical judgement or advice provided to you by a specialist.

Macmillan and NICE will not accept any liability for any type of loss caused by someone acting on information contained in the guidelines, unless liability is enforced by law.