PRADEEP'S_ Brain Tumor

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DEFINITION A brain tumor is a localized intracraniallesion that occupies space within theskull. Tumors usually grow as a spherical mass, but they can grow

diffusely and infiltrate tissue. The effects of neoplasms occur from the compression and infiltration of tissue. A variety of

physiologic changes result, causing any or all of the following pathophysiologic events:

Increased intracranial pressure (ICP) and cerebral edemaSeizure activity and focal neurologic signsHydrocephalusAltered pituitary function

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Primary brain tumors originate fromcells and structures within the brain.

Secondary, or metastatic, braintumors develop from structures outside

the brain and occur in 20% to 40% of allpatients with cancer. Brain tumors rarelymetastasize outside the CNS, butmetastatic lesions to the brain occur

commonly from the lung, breast, lowergastrointestinal tract, pancreas, kidney,and skin

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CLASS IFI CA TION B rain tumors may be classified into several groups:

those arising from the coverings of the brain (e.g. Duralmeningioma),

those developing in or on the cranial nerves (eg, acousticneuroma),

those originating within brain tissue (e.g. gliomas), and

Metastatic lesions originating elsewhere in the body.

Tumors of the pituitary and pineal glands and of cerebralblood vessels are also types of\ brain tumors.

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IN C IDEN C E

It is estimated that there are about 17,000 new cases of primary brain tumors per year, 9,600 in men and 7,400 inwomen (American Cancer Society, 2002).Secondary tumors or metastases to the brain from a

systemic primary cancer are more common.The highest incidence of brain tumors in adults occurs in thefifth, sixth, and seventh decades, with a slightly higher incidence in men.In adults, most brain tumors originate from glial cells (glialcells make up the structure and support system of the brainand spinal cord) and are supra,tentorial (located above thecovering of the cerebellum).

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ETIO L OGY

1. The cause of primary brain tumors is unknown.2. The only known risk factor is exposure to ionizing

radiation.3. Both glial and meningeal neoplasms have been linked to

irradiation of the cranium, with a latency period of 10 to 20years after exposure.

4. Additional possible causes have been investigated,& resultsof studies are conflicting and unconvincing; suggestedcauses have included use of cellular telephones, exposureto high-tension wires, use of hair dyes, head trauma,dietary exposure to such factors as nitrates (found in some

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P A THO P HY S IO L OGY

D ue to etiological factors

Growth of intracranial tumors (accompanied by edema)

Compress normal tissue and impair function

Produce neurologic manifestations.

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Figure 65-1 indicates common tumor sites in the brain.

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CL INI CAL M A NIFE S T A TION S I ncreased ICPH eadacheVomitingVisual Disturbances

LOCALIZED SYMPTOMS T he most common focal or localized symptomsare -

H emiparesis,Seizures, andMental status changes.

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WHENSP ECIFIC R EGION S OF T HE BRA IN AR E AFFECTED, ADDITIONAL L OCAL S IGN S A NDSYMP TO MS

OCCUR , SUCHAS :Sensory and motor abnormalities,Visual alterations,

Alterations in cognition, andLanguage disturbances such asaphasia.

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correlating the signs and symptoms toknown areas of the brain-

Although some tumors are not easily localized because they lie in so-called silent areas of the brain (i.e.areas in which functions are not definitely determined),many tumors can be localized by correlating the signs andsymptoms to known areas of the brain, as follows:Amotor cortex tumor produces seizure-like movements

localized on one side of the body, called Jacksonian

seizures .An occipital lobe tumor produces visual manifestations:

contra-lateral homonymous hemianopsia (visual loss inhalf of the visual field on the opposite side of the tumor)

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Acerebellar tumor causes dizziness , an ataxic orstaggering gait with a tendency to fall toward the side of the lesion, marked muscle in-coordination , andnystagmus (involuntary rhythmic eye movements), usuallyin the horizontal direction.

A frontal lobe tumor frequently produces personalitydisorders, changes in emotional state and behavior, and anuninterested mental attitude. The patient often becomesextremely untidy and careless and may use obscenelanguage.

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Acerebello-pontine angle tumor usually originates in thesheath of the acoustic nerve and gives rise to a characteristicsequence of symptoms. T innitus and vertigo appear first ,soon followed by progressive nerve deafness (eighthcranial nerve dysfunction). Numbness and tingling of theface and the tongue occur (due to involvement of the fifthcranial nerve). Later, weakness or paralysis of the facedevelops (seventh cranial nerve involvement). Finally,

because the enlarging tumor presses on the cerebellum ,abnormalities in motor function may be present.

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DI A GNO S TI C FINDING S A neurologic examination indicates the areas of the CNS

involved.

Computed tomography (CT) scans, enhanced by a contrast agent-gives specific information concerning the number, size, anddensity of the lesions and the extent of secondary cerebral edema.

CT scans can provide information about the ventricular system.

Magnetic resonance imaging (MRI) is the most helpful diagnostictool for detecting brain tumors, particularly smaller lesions, andtumors in the brain stem and pituitary regions, where bone

interferes with CT.

Positron emission tomography (PET) - Is used to supplement MRI.On PET scans, low-grade tumors are associated with hypo-metabolism and high-grade tumors show hyper-metabolism. This

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C omputer-assisted stereotactic (three-dimensional)biopsy is being used to diagnose deep-seated brain tumors

and to provide a basis for treatment and prognosis.

C erebral angiography provides visualization of cerebral blood vessels and can localize most cerebral tumors.

An electroencephalogram (EEG) to detect an abnormal brain wave in regions occupied by a tumor and is used to

evaluate temporal lobe seizures and assist in ruling out other disorders.C ytologic studies of the C SF may be performed to detectmalignant cells because CNS tumors can shed cells into theCSF.12/22/2010 Prinz


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MEDI CAL M A N A GEMENT 1. C hemotherapy and external-beam radiation therapy2. Autologous bone marrow transplantation

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SUR GI CAL M A N A GEMENT The objective of surgical management is -

to remove or destroy the entire tumor without

increasing the neurologic deficit (paralysis, blindness) or

to relieve symptoms by partial removal(decompression).

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Trans-sphenoidal microsurgerySUR GI CAL M A N A GEMENT

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C raniotomy

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R adioisotopes -iodine 131 (131I)

131 I

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G amma knife

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N URS ING M A N A GEMENT Preoperative Medical and Nursing Management.1. Instruct patient and family about the necessity and

importance of diagnostic tests to determine the exactlocation of the tumor.

2. Monitor and record vital signs and neurological statusaccurately q2-4h, or as ordered. Report changes to

professional nurse immediately.3. Institute measures to prevent inadvertent increases in

intracranial pressure.1. Elevate head of bed 30.2. Stool softeners to prevent straining at stool (which increases

intracranial pressure).

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4. Institute seizure precautions at patient's bedside. (Tongue blade airway.)

5. Supportive nursing care is given depending upon the patient's symptoms and ability to perform activities of

daily living.

6. Administer all doses of steroids and antiepileptic agentson time.

Withholding steroids can result in adrenal crisis.Withholding of antiepileptic agents frequently

precipitates seizure.

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Post Operative Nursing C areC onsiderations.a.Meticulous nursing management and care aimed at

prevention of postoperative complications are imperativefor the patient's survival.

b.Accurately monitor and record all vital signs andneurological signs.i. Postoperative cerebral edema peaks between 48 and 60 hours

following surgery.

ii.Patient may be lucid during first 24 hours, then experience adecrease in level of consciousness during this time.

c.Administer artificial tears (eye drops) as ordered, to prevent corneal ulceration in the comatose patient.

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d. Maintain skin integrity.e. Bone flap may not have been replaced over surgical site;

turning patient to the affected side, if the flap has beenremoved, can cause irreversible damage in the first 72hours.

f. Maintain head of bed at 30elevation.g. Perform passive range of motion exercises to all

extremities every 2-4 hours.

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L. Continuously talk to the patient while providing care,reorienting him to person, place, and time.

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PRADEEP'S_ Brain Tumor

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