Prediagnostic Symptomatic Interval Research Articles

Unlocking delays: revealing barriers to early diagnosis of childhood central nervous system tumors in an upper-middle-income country.

Childhood central nervous system (CNS) tumors tend to have a longer time interval until diagnosis than other pediatric malignancies. The aim is to describe the time to diagnosis among Brazilian pediatric patients treated at a tertiary center and explore associated factors. Cross-sectional study; application of questionnaires to parents of children with CNS tumors during outpatient visit or inpatient care. One hundred parents participated between August and November 2023. The median age of the children at diagnosis was 7.2years old. Low-grade glioma (LGG) was the most common tumor type (37%), followed by medulloblastoma (24%). The most frequent symptoms were morning and/or persistent vomiting and headache. The mean prediagnostic symptomatic interval (PSI) was 150days. The mean parental interval was shorter than the medical (58.1days vs 92.8days). LGGs and tumors located in the central area had longer intervals to diagnosis than other tumors (296 vs 54days) (p = 0.005) and (206 vs 155days) (p = 0.007), respectively. Despite 81% of the patients undergoing pediatric routine follow-up, 87% of them had been diagnosed at an emergency department. Children attended by the same physician had a shorter mean interval (18.2 vs 88.3days) than those assisted by different professionals (p = 0.015). The mean time for referral to our specialized center was 23days. This study is a crucial step in recognizing barriers to early diagnosis of CNS tumors in a middle-income country as low awareness of signs/symptoms by parents and health professionals, aiming to provide opportunities for intervention strategies to reduce the time to diagnosis.

Delay in the Diagnosis of Pediatric Brain Tumors in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis.

Vague symptoms and a lack of pathognomonic features hinder the timely diagnosis of pediatric brain tumors (PBTs). However, patients in low- and middle-income countries (LMICs) must also bear the brunt of a multitude of additional factors contributing to diagnostic delays and subsequently affecting survival. Therefore, this study aims to assess these factors and quantify the durations associated with diagnostic delays for PBTs in LMICs. A systematic review of extant literature regarding children from LMICs diagnosed with brain tumors was conducted. Articles published before June 2023 were identified using PubMed, Google Scholar, Scopus, Embase, Cumulative Index to Nursing and Allied Health Literature, and Web of Science. A meta-analysis was conducted using a random-effects model through R Statistical Software. Quality was assessed using the Newcastle Ottawa Scale. A total of 40 studies including 2483 patients with PBT from 21 LMICs were identified. Overall, nonspecific symptoms (62.5%) and socioeconomic status (45.0%) were the most frequently reported factors contributing to diagnostic delays. Potential sources of patient-associated delay included lack of parental awareness (45.0%) and financial constraints (42.5%). Factors contributing to health care system delays included misdiagnoses (42.5%) and improper referrals (32.5%). A pooled mean prediagnostic symptomatic interval was calculated to be 230.77 days (127.58-333.96), the patient-associated delay was 146.02 days (16.47-275.57), and the health care system delay was 225.05 days (-64.79 to 514.89). A multitude of factors contribute to diagnostic delays in LMICs. The disproportionate effect of these factors is demonstrated by the long interval between symptom onset and the definitive diagnosis of PBTs in LMICs, when compared with high-income countries. While evidence-based policy recommendations may improve the pace of diagnosis, policy makers will need to be cognizant of the unique challenges patients and health care systems face in LMICs.

From Weakness to Imaging: Prediagnostic Symptomatic Interval and Characteristics of Patients with Tuberculous Spondylitis (Pott’s Disease): a Multi-Center Experience from an LMIC

From Weakness to Imaging: Prediagnostic Symptomatic Interval and Characteristics of Patients with Tuberculous Spondylitis (Pott’s Disease): a Multi-Center Experience from an LMIC

Predictors of Delayed Diagnosis of Pediatric CNS Tumors in the Emergency Department.

Central nervous system (CNS) tumor diagnoses are frequently delayed in children, which may lead to adverse outcomes and undue burdens on families. Examination of factors associated with delayed emergency department (ED) diagnosis could identify approaches to reduce delays. We performed a case-control study using data from 2014 to 2017 for 6 states. We included children aged 6 months to 17 years with a first diagnosis of CNS tumor in the ED. Cases had a delayed diagnosis, defined as 1 or more ED visits in the 140 days preceding tumor diagnosis (the mean prediagnostic symptomatic interval for pediatric CNS tumors in the United States). Controls had no such preceding visit. We included 2828 children (2139 controls, 76%; 689 cases, 24%). Among cases, 68% had 1 preceding ED visit, 21% had 2, and 11% had 3 or more. Significant predictors of delayed diagnosis included presence of a complex chronic condition (adjusted odds ratio [aOR], 9.73; 95% confidence interval [CI], 6.67-14.20), rural hospital location (aOR, 6.37; 95% CI, 1.80-22.54), nonteaching hospital status (aOR, 3.05, compared with teaching hospitals; 95% CI, 1.94-4.80), age younger than 5 years (aOR, 1.57; 95% CI, 1.16-2.12), public insurance (aOR, 1.49, compared with private; 95% CI, 1.16-1.92), and Black race (aOR, 1.42, compared with White; 95% CI, 1.01-1.98). Delayed ED diagnosis of pediatric CNS tumors is common and frequently requires multiple ED encounters. Prevention of delays should focus on careful evaluation of young or chronically ill children, mitigating disparities for Black and publicly insured children, and improving pediatric readiness in rural and nonteaching EDs.

Factors associated with delayed diagnosis among Filipino pediatric brain tumor patients: a retrospective review.

Aim:Determine delayed diagnosis measured by prediagnostic symptomatic interval (PSI) among Filipino pediatric brain tumor patients and identify associated factors.Methods:Data was collected retrospectively on Philippine General Hospital pediatric brain tumor patients from 2015 to 2019. PSI was calculated. Associated factors were determined.Results:196 patients were included. Median PSI was 80.5 days. Longer PSI was significantly associated with older age, supratentorial and low-grade tumors, more physician consults prior to subspecialist referral, longer interval from neuroimaging request to facilitation, and those presenting with seizures (11-month delay), poor school performance (1-year delay), behavioral changes (1.3-year delay) and secondary amenorrhea (3-year delay).Conclusion:Delayed diagnosis among Filipino brain tumor patients is associated with age, tumor characteristics and symptoms that are uncommon in this condition. Awareness of these symptoms through physician education, close monitoring of patients, early subspecialist referral and better neuroimaging access may lead to earlier diagnosis.

LINC-16. Factors Associated with Delayed Diagnosis Among Filipino Pediatric Brain Tumor Patients: A Retrospective Review

BACKGROUND: Delayed diagnosis is observed greatest among pediatric brain tumors compared to other childhood malignancies. Several factors have been found to influence delay. OBJECTIVE: To determine delayed diagnosis measured by the prediagnostic symptomatic interval (PSI) among Filipino pediatric brain tumor patients and identify associated factors. METHODS: Data was collected retrospectively on pediatric brain tumor patients of Philippine General Hospital from 2015-2019. PSI was calculated. Demographic and clinical data were presented using descriptive statistics. Bivariate and linear regression analyses were used to determine factors. RESULTS: The median overall PSI was 80.5days. The median interval from symptom onset to first physician consult was 22days. The median interval from first consult to subspecialty referral was 23.5days. Majority presented with 2 symptoms at onset (42.3%) and during first physician consult (36.2%). Upon subspecialist referral, 52% have ≥4 symptoms. Most patients (68.4%) consulted with a pediatrician. Most were diagnosed with another condition prior to brain tumor diagnosis. Longer PSI was significantly associated with older age (p=0.005), tumor location (p=0.009), tumor grade (p<0.001), and more physicians consulted prior to subspecialist referral (p=0.001). Significant predictors of delayed diagnosis were supratentorial tumors (4-month delay, p=0.014), and those presenting with seizures (11-month delay, p=0.002), poor school performance (1-year delay, p=0.008), behavioral changes (1.3-year delay, p=0.033), and secondary amenorrhea (3-year delay, p=0.021). Predictors of earlier brain tumor diagnosis include posterior fossa tumors (p=0.041), malignant tumors (p=0.002), and vomiting (p=0.020). CONCLUSION: Delayed diagnosis among Filipino brain tumor patients is associated with age, tumor characteristics and symptoms that are uncommon in this condition. This emphasizes the need for first contact physicians to be aware about these symptoms, and keep a diagnosis of brain tumor as a differential. This, coupled with a detailed history, accurate neurologic examination and early subspecialist referral may lead to earlier diagnosis and treatment for pediatric brain tumor patients.

Особенности предиагностического периода клинических проявлений медуллобластом у детей в Республике Татарстан

The article provides up-to-date information on the first clinical symptoms of brain tumors in children and considers the term «pre-diagnostic symptomatic interval» of pediatric medulloblastoma, which is widely used in foreign pediatric and neuro-oncological practice. The authors publish the results of their own retrospective population study revealing the clinical and epidemiological characteristics of the most frequently detected malignant brain tumors in children — medulloblastomas in the pediatric population of the Republic of Tatarstan. The analysis of the pre-diagnostic symptomatic interval of this pathology was carried out through the prism of the LOWorPAY scheme, recommended by neurooncologists as a guide for early detection of tumors for primary care physicians. A probabilistic model of the clinical symptom complex is proposed, which determines the risk of neoplasm of the central nervous system in children. Its use will help increase the oncological alertness of doctors and systematize the tactics of detecting brain and spinal cord tumors in children on an outpatient basis.

SWK-08. DELAYED DIAGNOSIS OF CENTRAL NERVOUS SYSTEM (CNS) TUMORS IN CHILDREN: PERSPECTIVE FROM THE FRONTLINE

Delayed diagnosis of CNS tumors in children is well documented, partially due to challenges in recognizing rare diagnoses. Our objective was to describe Canadian family physicians’ attitudes and confidence in diagnosing and managing pediatric CNS tumors. A standardized questionnaire was administered at a Canadian national family physicians’ conference. Items were based on observations from our institutional study of prediagnostic symptomatic interval in pediatric CNS tumors. 449 surveys were completed. 302/443 (68%) physicians practice in cities. 153/447 (34%) report encountering parents that inquire about their children having brain tumors. 261/449 (58%) have not managed a pediatric brain tumor. 153/447 (34%) report they are not confident, 255/447 (57%) somewhat confident and 39/447 (9%) confident in managing a suspected brain tumor in a stable child. 259/447 (58%) would refer directly to a hospital/specialist. The reported median time for suspicion of a brain tumor was 8–14 days for children with vomiting and/or headache and 1 day for children with seizure and/or ataxia. 410/447 (97%) report not knowing any guidelines to help with management. 235/447 (53%) suggested barriers they experience to include 52/235 (22%) wait times for imaging/specialists, 37/235 (16%) geographical location of the child, 27/235 (12%) knowledge, 25/235 (11%) access to imaging/specialist, and 15/235 (6%) patient-related factors or system barriers, and 8/235 (3%) specialist attitudes. 68/235 (29%) identified no barriers in their practice. This study provides insight into family physicians’ perceived challenges and barriers in diagnosing and managing new suspected pediatric CNS tumors. Educational effort and overcoming systemic perceived barriers may increase physicians’ confidence.

Finding the Needle in the Hay Stack: Population-based Study of Prediagnostic Symptomatic Interval in Children With CNS Tumors.

Central nervous system (CNS) tumors in children are a devastating diagnosis and delay in diagnosis is well documented in the literature. The aim of this study was to document and characterize time to diagnosis of CNS tumors among children 0 to 17 years of age in a pediatric center. A retrospective chart review was conducted of medical records of children with CNS tumors from 2000 to 2016 in British Columbia, Canada and 148 reports were available for review. Average age at diagnosis was 87.8 months (SD=59.7; median=72). One third (30%) were diagnosed after a single visit to a health care provider and 11 (7.7%) after more than 4 visits. Median time to diagnosis (prediagnostic symptomatic interval [PSI]) was 62 days (average 197±341 d; range, 0 to 2047 d). Longest period was time from first symptom to first health care provider visit (PSI1, median 37 d). Tumors in the posterior fossa and symptoms of ataxia or paresis were associated with a significantly shorter PSI. CNS tumors in children continue to pose a diagnostic challenge with variability in time to diagnosis. Our population-based study suggests variability in time to diagnosis with a need for education of families to identify symptoms associated with CNS tumors.

Factors impacting time to diagnosis in pediatric CNS tumors in Chinese children.

This study aimed to investigate the factors impacting time to diagnosis in pediatric central nervous system tumors. A descriptive, cross-sectional design was used in this study. A self-developed questionnaire for health-seeking behavior and influencing factors was used in children with intracranial tumors. The factors related to time to diagnosis and the long-term prognosis of children were analyzed. A total of 433 families replied to the questionnaire. The median parental interval was 50 days (range 0 ~ 884), the median diagnostic interval was 97 days (range 4 ~ 1646), and the median prediagnostic symptomatic interval (PSI) was 123 days (range 8 ~ 1844). Higher education was associated with a shorter parental interval (mother: P = 0.048; father: P = 0.035). The diagnostic interval was shortened in patients with dizziness (P = 0.022), abnormal eye movement (P = 0.034), or drowsiness (P = 0.021). A shorter PSI was observed in patients who presented with high intracranial pressure such as headache (P = 0.016), dizziness (P = 0.009), or drowsiness (P = 0.023) and those who went to a higher-level health institution or patients who went to neurology or neurosurgery department as the first medical consultation. No statistically significant difference was found in the interval time (parental interval, diagnostic interval, and PSI) regarding patients' outcomes. Different time intervals showed different factors influencing the long delay in diagnosing central nervous system tumors, highlighting the need for increased awareness to improve the treatment efficacy.

CT scans in childhood predict subsequent brain cancer: Finite mixture modelling can help separate reverse causation scans from those that may be causal

BackgroundExcess brain cancers observed after computed tomography (CT) scans could be caused by ionizing radiation. However, as scans are often used to investigate symptoms of brain cancer, excess cancers could also be due to reverse causation bias. We used finite mixture models (FMM) to differentiate CT exposures that are plausibly causal from those due to reverse causation. MethodsPersons with at least one CT scan exposure and a subsequent diagnosis of brain cancer were selected from a cohort of 11 million young Australians. We fitted FMMs and used the posterior probability to inform the choice of exclusion periods. We validated our findings using a separate clinical dataset describing the time between first symptoms and brain cancer diagnosis (pre-diagnostic symptomatic interval; PSI). ResultsThe cohort included 1028 persons with a diagnosed brain tumor and exposed to a total of 1,450 CT scans. The best-fitting model was a generalized linear mixture model using the exponential distribution with three latent classes and two covariates (age at exposure and year of exposure). The 99th percentile classifier cutoff was 18.9 months. The sample-size weighted mean of the 99th percentile of the PSI, derived from clinical data, was 15.6 months. ConclusionsTo minimize reverse causation bias in studies of CT scan and brain cancer, the optimal exclusion period is one to two years (depending on the choice of classifier). This information will inform the interpretation of current and future studies.

From Symptom to Diagnosis—The Prediagnostic Symptomatic Interval of Pediatric Central Nervous System Tumors in Austria

BackgroundChildren with central nervous system (CNS) tumours may present with a multitude of symptoms, ranging from elevated intracranial pressure to focal neurological deficit. In everyday practice, some signs may be misleading, thereby causing prolonged prediagnostic symptomatic intervals. Prediagnostic symptomatic intervals are longer for pediatric brain tumors than for other childhood malignancies. This study evaluated prediagnostic symptomatic intervals and parental and diagnostic intervals for pediatric patients with CNS tumours in Austria. It also considered socioeconomic factors. MethodsPatients ≤ 19 years of age treated at the Medical University of Vienna and diagnosed during the years 2008 to 2013 were included. Patients diagnosed incidentally or by screening were excluded. ResultsTwo hundred twelve consecutive patients were included in the study. They reflected the expected spectrum of CNS tumors. Patients presented with a median of five symptoms at diagnosis, most frequently with signs of elevated intracranial pressure. The median prediagnostic symptomatic interval was 60 days (0 days to seven years), the median parental interval was 30 days (0 days to 6.7 years), and the median diagnostic interval was three days (0 days to 6.5 years). In spinal tumors alone (n = 7), the median prediagnostic symptomatic interval was 70 days (ten days to seven years), and three of seven patients had a prediagnostic symptomatic interval longer than 320 days. Young age, higher tumor grade, and ataxia were associated with a shorter prediagnostic symptomatic interval. Localization in the supratentorial midline, histology of craniopharyngioma, and endocrine symptoms prolonged the prediagnostic symptomatic interval. There was a clear trend for longer prediagnostic symptomatic interval in non-native speakers. ConclusionsResults are comparable to other industrialized countries. However, long delays in diagnosis of central nervous system tumors still occur, urging increased awareness.

Posterior cranial fossa tumours in children at National Cancer Institute, Sudan: a single institution experience.

Posterior cranial fossa tumours (PCF) comprise 54-70% of childhood brain tumours. The clinical profile and outcomes of these tumours differ in area of the world. The aim of this study is to describe clinical characteristics, treatment and outcome of posterior cranial fossa tumours in Sudan. A retrospective study of children diagnosed with posterior cranial fossa tumours and treated between January 1998 and December 2015 at National Cancer Institute, Sudan. A total of 31 paediatric patients with a posterior cranial fossa brain tumour were identified over the study period. The mean age was 7.9years (standard deviation (SD)=3.37). Females were slightly more affected (51%) than males (49%), and the majority of patients were from rural areas (71%). Brainstem tumours were the most frequent tumour type (48%) followed by medulloblastoma (36%). The mean pre-diagnostic symptomatic interval was 3.6months (SD=3.95). Overall survival rate of our total study population at 1, 2 and 5years was 23, 19 and 13%, respectively. Overall, this study draws attention to the situation of paediatric brain tumours in Sudan. Late presentation, misdiagnosis and limited diagnostic and treatment resources are challenges that may contribute to poor outcome in these patients.

Duration between onset and diagnosis in central nervous system tumors: impact on prognosis and functional outcome.

The initial presentation of central nervous system (CNS) tumors in children frequently mimics other more common and less serious conditions, resulting in diagnostic difficulty and a prolonged time to diagnosis. Yet whether early diagnosis contributes to better life prognosis and functional outcome has not been elucidated. Only a few such reports have originated from Japan, where neuroimaging techniques are the best in the world. We examined the time to diagnosis, the so-called prediagnostic symptomatic interval (PSI), and its impact on prognosis and functional outcome in children with CNS tumors. We reviewed the records of 127 patients aged <15 years with CNS tumors, who were treated at our two institutions between November 1993 and October 2011. The median age at diagnosis was 7.2 years (range, 3 weeks-14.9 years). The male-to-female ratio was 63:64. Median PSI was 1.5 months (0-36 months). Overall survival and progression-free survival did not differ significantly between the groups, regardless of whether the PSI was longer than the median PSI. The PSI was significantly longer in patients with long-lasting clinical signs after the initial treatment than in patients with temporary symptoms only at onset. Both univariate and multivariate analysis showed that high histological grading was statistically correlated with short PSI. A short PSI was significantly associated with high-grade tumors. Earlier diagnosis did not lead to better life prognosis, but possibly to better functional outcome in children with CNS tumors.

Time to diagnosis of brain tumors in children: A single‐centre experience

The aim of the study was to analyze the pre-diagnostic symptomatic interval (PSI) of children with brain tumors with regard to the parental and doctor's delay and the clinical symptoms. A retrospective review of all children with brain tumors diagnosed in a single centre over a period of 11 years was carried out. Seventy-nine patients (35 boys, 44 girls), with a mean age of 9.2 years (0.2-23.5 years), were analyzed. PSI was 28 weeks with a parental delay of 11.1 weeks and a doctor's delay of 16.9 weeks. Main clinical symptoms were headache (66.7%), vomiting (57.7%), vision (46.2%) and gait (41.6) disorders and fatigue (41.0%) followed by other neurological signs. Diagnosis of pediatric brain tumors is often delayed in relation to the presenting symptoms. If parents report a combination of headache with other neurological abnormalities, a brain tumor should always be considered.

A long duration of the prediagnostic symptomatic interval is not associated with an unfavourable prognosis in childhood medulloblastoma

BackgroundDue to the lacking specificity of symptoms making a correct diagnosis can be a challenge in children with medulloblastoma. This can lead to prediagnostic symptomatic intervals (PSIs) of several weeks to months. It is unknown whether the length of the PSI is associated with an inferior survival outcome in this population. MethodsTo study the association of PSI with disease stage at diagnosis, tumour control and survival in children with medulloblastoma, prospectively collected data on PSI, clinical, and biological features were analysed in 224 patients diagnosed at the age of 3–18years and treated within the prospective randomised multicentre trial HIT’91. ResultsPatients with lower-stage disease tended towards a longer median PSI than those with higher-stage disease (M0 stage, 2.0months; M1 stage, 2.0months; M2/M3 stage, 1month; p=0.094. M0/1 stage versus M2/3 stage; p=0.025). The patient group with the longest PSI had the best survival outcome (PSI ⩾4.0months: 10-year overall survival rate (OS), 71%; PSI <4.0months, 10-year OS, 61%; p=0.056). Age at diagnosis was positively correlated with PSI (p=0.027). No associations were found between PSI and sex histological subtype, presence of postoperative residual tumour, or c-myc and TrkC mRNA expression. ConclusionContrary to a common belief that a longer PSI may adversely affect prognosis, a longer PSI was associated with a trend towards lower metastatic stage and better survival probabilities. Nevertheless these findings do not obviate the importance of a timely diagnosis in paediatric patients with medulloblastoma.

Does diagnostic delay result in decreased survival in paediatric brain tumours?

To study the hypothesis that a delay in the diagnosis of paediatric brain tumours results in decreased survival outcome probability, we compared the prediagnostic period of 315 brain tumour patients (median age 6.7 years, range, 0 to 16 years) with progression-free and overall survival. The median prediagnostic symptomatic interval was 60 days (range, 0 to 3,480 days), with a median parental delay of 14 days (range, 0 to 1,835 days) and a median doctor's delay of 14 days (range, 0 to 3,480 days). The prediagnostic symptomatic interval correlated significantly with the patient age, tumour histology, tumour location and year of diagnosis, but not with gender. We then grouped the patients according to histology (low-grade glioma [n=77], medulloblastoma [n=57], high-grade glioma [n=40], craniopharyngioma [n=27], ependymoma [n=20] and germ cell tumours [n=18]). Contrary to common belief, long prediagnostic symptomatic interval or long doctor's delay did not result in decreased survival outcome probability in any of these groups. The effect of tumour biology on survival seems to be dominant and overwhelms any possible opposing effect on survival of a delay in diagnosis.

Clinical features of children's brain tumors according to location

Purpose:This study evaluated the clinical characteristics of brain tumors in children according to their location, the parental delay and the doctor's delay between the onset of symptoms and the diagnosis of a pediatric brain tumor. In addition, this study compared the relationship between the pre-diagnostic symptomatic interval and the tumor location. Methods:A retrospective study was undertaken of 45 children with primary brain tumors admitted to Inha Hospital from July, 1986 to June, 2004. A diagnosis of the tumor location was made using brain MRI. Results:The male to female ratio was 1:0.67. The median age at diagnosis was 6.0 years in supratentorial tumors, 7.0 years in infratentorial tumors. Twenty four cases(53.3 percent) were located in the supratentorial area, 21 cases(46.6 percent) were located in the infratentorial area. The distribution of supratentorial tumors were 14(58.3 percent) in the cerebral hemisphere and temporal lobe, seven (29.1 percent) in the suprasellar area, and three(12.5 percent) in the pineal gland and posterial lateral ventricle. The distributions of the infratentorial tumors were 12(57.1 percent) in the cerebellar vermis and fourth ventricle, four(19.1 percent) in the brain stem, and five(23.8 percent) in the cerebellar hemisphere. The most common initial symptom was seizure(37.5 percent) in the supratentorial tumor and headache(38.0 percent) in infratentorial tumors. The median pre-diagnostic symptomatic interval (PSI) was 21 days(range 0-240 days). The median PSI with a parental delay in supratentorial tumor was six days(range 1-240 days), and 30 days(range 1-40 days) in the infratentorial tumor. We immediately diagnosed most cases after visiting the hospital. There was no significant relationship between the tumor location and the pre-diagnostic symptomatic interval. Conclusion:The most common symptom of supratentorial tumors and infratentorial tumors was seizure and headache, respectively. Although, the median pre-diagnostic symptomatic interval was shorter than in previous studies, a detailed medical history and a correctly interpreted neurological examination should lead to an earlier diagnosis of pediatric brain tumors.

Delay in the diagnosis of paediatric brain tumours.

The pre-diagnostic period of 252 children (median age 6.3 years, range 0-16.9 years) with primary brain tumours was assessed to analyse their clinical presentation and reasons for any delay in diagnosis. The median pre-diagnostic symptomatic interval (PSI) was 60 days (range 0-3010 days) with a parental delay of 14 days (range 0-2310 days) and a doctor's delay of 30 days (range 0-3010 days). Only 33% of brain tumours were diagnosed within the 1st month after the onset of signs/symptoms. PSI correlated significantly with patients' age and tumour histology, but not with gender, year of diagnosis or tumour location (supratentorial hemispheric, supratentorial midline, infratentorial). In children older than 2 years, most common initial signs/symptoms were headache, nausea/vomiting, seizures, squint/diplopia, ataxia and behavioural changes. In children younger than 2 years, most common initial signs/symptoms were seizures, vomiting, head tilt and behavioural changes. These signs/symptoms are by no means pathognomonic features of brain tumours, making the diagnosis in the early course often difficult. given the fact that the vast majority of patients (88% in the present study) develop further signs/symptoms, a high level of awareness, a detailed medical history and repeated correctly interpreted neurological examinations should lead to an earlier diagnosis and to a higher probability of total tumour resection.