The Brain Imaging pathway has been set up to provide General Practice with options to evaluate the best course of action for their patients dependent on their clinical symptoms and signs at presentation.
How do I refer for brain imaging in reference to a patient with a history of a cancer diagnosis in the past 5 years?
If your patient has had a cancer diagnosis in the last 5 years and you are concerned about a suspected brain cancer or brain metastasis, please refer the patient using the generic oncology email.
This is monitored on a daily basis and the patient’s oncologist will be notified for onward action regarding imaging.
How do I refer for brain imaging if I am quite certain this is most likely a brain cancer (patient has progressive neurological/cognitive symptoms/signs) but the patient is not acutely unwell that requires ED referral? Plus, how long will this take?
If your patient has a progressive focal neurological deficit (e.g. a progressive hemiparesis) or rapidly progressive cognitive decline, then you request a brain scan to be done within two weeks. You would need to complete the unified brain imaging request form (choosing the urgent option) and submit to the radiology department, and it should be done within two weeks of the date of the request.
How do I refer for brain imaging if I suspect it could be a brain cancer, but they do not have progressive neurological/cognitive symptoms/signs, they are not acutely unwell and there is no previous cancer history? Plus, how long will this referral take?
If you, or the patient are concerned that they have a brain tumour then you can request a brain scan via the brain imaging referral form. If the patient fits the criteria for a direct access brain scan, they will be offered one on a routine basis. This will be within six weeks of the date of the request.
If the patient doesn’t fit the routine imaging request criteria, it may still be possible to access a scan. You can submit a request for a brain scan via the neurology advice and refer system at the patient’s local secondary care provider. Once this is approved you will need to submit the Brain Imaging request attaching the advice and refer authorisation.
If I am uncertain what the cause of the headaches could be, can I use advice and guidance to neurology? What is the turnaround time for this? If the response is for me to do a CT or MRI brain scan, is this two stage pathway still open and do I have access to these forms?
Yes, you can still do this.
The turnaround time should be two working days, although the system at Heartlands, Good Hope and Solihull Hospital may be slightly delayed. On average there are approximately 30 A+G requests at each site, therefore, depending on staffing levels, it can take a bit of time to catch up.
Once this is approved you will need to submit the brain imaging request attaching the advice and refer authorisation.
Are there further resources available regarding headache management?
The UHB website has been updated to include a section on headache management.
If a brain cancer is found on brain imaging that I requested who will review and inform the patient?
If a brain tumour is seen on the scan, the Radiology department that has acquired the scan will inform primary care. The Primary Care Physician informs the patient of abnormal findings and that a specialist opinion is required. The Primary Care Physician will email the result to the generic oncology email for a new brain cancer diagnosis BrainTumourSpecialistNurses@uhb.nhs.uk. This is monitored on a daily basis. The Clinical Nurse Specialist (CNS) team will contact the patient within 5 working days. An outpatient appointment will be arranged with a Neurosurgeon who will explain the diagnosis and management plan.
Although in an ideal world the patient would be fed directly into the neuro-oncology MDT by the Radiology department, at the present time the infrastructure and training needed to do this are not in place. As such the results will be fed back to the requesting GP. If the report suggests that the patient does have a brain tumour then please contact the CNS team at: BrainTumourSpecialistNurses@uhb.nhs.uk
What do I do if a pituitary/Vestibular abnormality is found?
Pituitary abnormalities are frequently physiological enlargement and so may not be of any clinical significance. If the report suggests a tumour or there is some uncertainty, the patient can be referred to local endocrinology services. The one potential risk would be to sight if the lesion is large. If the patient with a pituitary abnormality, reports any visual symptoms, then it would be sensible to seek ophthalmology advice.
Vestibular schwannomas need to be referred to local ENT services. Again, if the lesion is very large it may need more urgent attention from the Skull Base team; if in doubt the patient can be referred to the CNS team: BrainTumourSpecialistNurses@uhb.nhs.uk
Patients who need an operation will end up being discussed at one of the MDT’s at QEHB. Patients who require surgery may need to be jointly managed by Neurosurgery and ENT.
What do I do if the patient has new onset unilateral tinnitus and I am concerned about an acoustic neuroma?
The worry with unilateral deafness and tinnitus is a vestibular schwannoma or some other posterior fossa structural abnormality (AVM). These are usually very small, low-grade lesions and management will be surveillance in the first instance. The pathway for these patients is referral to local ENT who will usually recommend audiology and then imaging if indicated. If there is a schwannoma or other structural pathology that needs the skull base service here, the patient may be referred on to QEHB by local services.
How do I treat migraine?
In brief you should:
- make sure that patients are trying eliminate triggers by keeping a headache diary and looking for anything that might be making the headaches worse.
- make sure the patients have a good rescue regime for the acute severe headaches – NSAIDS (unless contra-indicated) and paracetamol and antiemetics and triptans (unless contra-indicated)
- try an established prophylactic agent; propranolol, amitriptyline, candesartan, topiramate, pizotifen
If the patient has tried and failed three prophylactic agents OR if you suspect cluster headache or trigeminal neuralgia, then they can be referred the headache services. More details guidance can be found at:
What are the red flags for brain cancer?
The following can be red flags for brain cancer:
- Focal neurological deficit
- Papilloedema
- Change in the level of consciousness
- Memory impairment
- Loss of consciousness
- Recent onset and rapidly increasing frequency and severity of headaches
- Associated dizziness, lack of co-ordination, tingling or numbness
- Headache precipitated by coughing, sneezing or straining
- Patients with malignancy or who are immunocompromised
Patients with a sudden focal neurological deficit would need to go to ED to rule out a stroke, whereas those with a rapidly progressive deficit would qualify for a ‘2WW’ scan; as would those patients with rapidly progressive memory impairment. In patients with a very slowly progressive hemiparesis do think about Parkinson’s disease, which can present in this way and doesn’t necessarily have an associated tremor.
Patients with papilloedema or a change in the level of consciousness would also likely need to go to ED.
Loss of consciousness needs to be assessed more comprehensively; recurrent syncope needs to be discussed with cardiology, likely seizures should be referred to neurology for a first seizure appointment.
Recent onset and rapidly increasing frequency and severity of headaches would be the most common indication for a direct access scan, although you can be relatively re-assuring with the patient, the incidence of brain tumours in this patient group, especially where the headaches are episodic, is not very high.
Associated dizziness, lack of co-ordination, tingling or numbness is a focal neurological deficit and so where sudden onset, a stroke or TIA needs to be considered. If subacute this would qualify for a 2WW scan. However, you still should see whether it could plausibly be related to a central cause; referring patients for a brain scan when they have carpal tunnel syndrome or BPPV is likely to be counterproductive.
Headaches that are precipitated by coughing, sneezing or straining are more likely to represent mechanosensitivity (neck pain in migraine precipitated by movement) than raised ICP. Headaches that occur just after Valsalva (cough, cough, cough, pause, headache) are more likely to be indicative of something like a chairi malformation. Headaches that get worse on lying down or wake the patient from sleep are more concerning and probably warrant assessment in ED.
Patients with malignancy ought to be referred to the oncology team via the generic email (OncologySecretary2QEH@uhb.nhs.uk), patients who are immunocompromised should be discussed with whichever team is responsible for causing (oncology, transplant, rheumatology, MS etc.) or reversing (GU medicine) this state.
Last reviewed: 03 October 2024