primary brain tumor

BRAIN TUMOR

• A primary brain tumor is a group (mass) of abnormal cells that start In the brain.

• A brain tumor is a localized intracranial lesion that occupies space within the skull. Tumors usually grow as a spherical mass, but they can grow diffusely and infiltrate tissue. The effects of neoplasm occur from the compression and infiltration of tissue.

pathophysiologic events• Increased

intracranial pressure (ICP) and cerebral edema

• Seizure activity and focal neurologic signs

• Hydrocephalus• Altered pituitary

function

CAUSE

• unknown

RISK FACTORS

• Exposure to ionizing radiation• Head injuries• Smoking

SPECIFIC TUMOR TYPES

SPECIFIC TUMOR TYPES Gliomas-the most common type of brain

neoplasm Astrocytomas

- are graded from 1 to 4, indicating the degree of malignancy- usually these tumors spread by infiltrating into the surrounding neural connective tissue and therefore cannot be totally removed without causing considerable damage to vital structures

Oligodendroglial- are more sensitive to chemotherapy than astrocytomas

SPECIFIC TUMOR TYPES Meningiomas• are common benign

encapsulated tumors of arachnoid cells on the meninges

• they are slow-growing and occur most often in middle-aged adults

• most often occur in areas proximal to the venous sinuses

• manifestations depend on the area involved and are the result of compression rather than invasion of brain tissue

• standard treatment is surgery with complete removal or partial dissection

SPECIFIC TUMOR TYPES Acoustic neuromas• tumor of the eight cranial nerve, the

cranial nerve most responsible for hearing and balance.

• it usually arises just within the internal auditor meatus, where it frequently expands before filling the cerebllopontine recess

• an acoustic neuroma may grow slowly and attain considerable size before it is correctly diagnosed

• the patient usually experiences:-Loss of hearing-Tinnitus-Episodes of vertigo-Staggering gait

SPECIFIC TUMOR TYPESPituitary adenomas

-a result of pressure on adjacent structures or hormonal changes (hyperfunction or hypofunction of the pituitary)

Pressure effects of pituitary adenomas- pressure from a pituitary adenoma may be exerted on the optic nerves, optic chiasm, or optic tracts or on the hypothalamus or the third ventricle when the tumor invades the cavernous sinuses or expands into the sphenoid bone- These pressure effects produce headache, visual dysfunction, hypothalamic disorders, increased ICP, enlargement and erosion of the sella turcica

SPECIFIC TUMOR TYPES Hormonal effects of pituitary adenomas

- Functioning pituitary tumors can produce one or more hormones normally produced by the anterior pituitary- these hormones may cause prolactin secreting pituitary adenomas (prolactinomas), growth hormone secreting pituitary adenomas that produce acromegaly in adults, and adrenocorticotropic hormone (ACTH)-producing pituitary adenomas that result in Cushing disease- adenomas that secrete thyroid-stimulating hormone or follicle-stimulating hormone and luteinizing hormone occur infrequently, whereas adenomas that produce both growth hormone and prolactin are relatively common- Female patient whose pituitary gland is secreting excessive quantities of prolactin presents with amenorrhea or galactorrhea (excessive or spontaneous flow of milk)- Male patients with prolactinomas may present with impotence and hypogonadism- acromegaly, caused by excess growth hormone, produces enlargement of the hands and feet, distortion of the facial features, and pressure on peripheral nerves (entrapment syndrome)- clinical manifestation of Cushing disease include a form of obesity with redistribution of fat to the facial, supraclavicular, and abdominal areas; hypertension; purple striae and ecchymoses; osteoporosis; elevated blood glucose levels; and emotional disorders

SPECIFIC TUMOR TYPESAngiomas• masses composed largely of abnormal

blood vessels are found either in or on the surface of the brain

• some persists throughout life without causing symptoms; others cause symptoms of a brain tumor

• occasionally, the diagnosis is suggested by the presence of another angioma somewhere in the head or by bruit (an abnormal sound) audible over the skull

• because the walls of the blood vessels in angiomas are thin, these patients are at risk for a cerebral vascular accident (stroke)

CLINICAL MANIFESTATION

CLINICAL MANIFESTATION

• Increasing ICP• Headache• Vomiting• Visual disturbances

(papilledema)• Hemiparesis• Seizures• Mental status changes

CLINICAL MANIFESTATION• Motor cortex tumor

-Produces seizure-like movements localized on one side of the body, called Jacksonian seizures

• Occipital lobe tumor-Produces visual manifestations: contra lateral homonymous hemianopsia (visual loss in half of the visual field on the opposite side of the tumor) and visual hallucinations

CLINICAL MANIFESTATION

• Cerebellar tumor-Causes dizziness, an ataxic or staggering gait with a tendency to fall toward the side of the lesion, marked muscle incoordination, and nystagmus (involuntary rhythmic eye movements) usually in the horizontal direction

• Frontal lobe tumor-Produces personality disorders, changes in emotional state and behavior, and an uninterested mental attitude-the patient often becomes extremely untidy and careless and may use obscene language

CLINICAL MANIFESTATION

• Cerebellopontine angle tumor-usually originates in the sheath of the acoustic nerve and gives rise to a characteristic sequence of symptoms-tinnitus and vertigo appear first, soon followed by progressive nerve deafness (eight cranial never dysfunction)-numbness and tingling of the face and tongue occur (due to involvement of the fifth cranial never)-later, weakness or paralysis of the face develops (seventh cranial nerve involvement)-finally, because the enlarging tumor presses on the cerebellum, abnormalities in motor functions may be present

DIAGNOSTIC TEST

DIAGNOSTIC TEST• Computed tomography (CT) scan

-can give specific information concerning the number, size, and density of the lesions and the extent of secondary cerebral edema-can provide information about the ventricular system

• Magnetic resonance imaging (MRI)

-is the most helpful diagnostic tool for detecting brain tumors, particularly smaller lesions, and tumors in the brain stem and pituitary region, where bone interferes with CT

• Positron emission tomography (PET)

-it is used to supplement MRI-low grade tumors are associated with hypometabolism and high-grade tumors show hypermetabolism-this information can be useful in treatment decisions

DIAGNOSTIC TEST• Computer-assisted stereotactic (three-

dimensional) biopsy-used to diagnose deep-seated brain tumors and to provide a basis for treatment and prognosis

• Cerebral angiography-provides visualization of cerebral blood vessels and can localize most cerebral tumors

• Electroencephalogram (EEG)-can 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

• Cytologic studies of the CSF-may be performed to detect malignant cells because CNS tumors can shed cells into the CSF

MEDICAL MANAGEMENT

MEDICAL MANAGEMENT• Chemotherapy• Radiation Therapy

- The corner-stone of treatment of many brain tumors, decreases the incidence of recurrence of incompletely resected tumors

• Brachytherapy-the surgical implantation of radiation sources to deliver high doses at a short distance-had promising results for primary malignancies-it is used as an adjunct to conventional radiation therapy or as a rescue measure for recurrent disease

• Intravenous (IV) autologous bone marrow transplant-is used in some patients who will receive chemotherapy or radiation therapy because it has the potential to “rescue” the patient from the bone marrow toxicity associated with high doses of chemotherapy and radiation-a fraction of the patient’s bone marrow is aspirated, usually from the iliac crest, and stored-the patient receives large doses of chemotherapy or radiation therapy to destroy large number of malignant cells-the marrow is then reinfused intravenously after treatment is completed

MEDICAL MANAGEMENT• Corticosteroids

-may be used before and after treatment to reduce cerebral edema and promote a smoother, more rapid recovery

• Gene-transfer therapy-uses retroviral vectors to carry genes to the tumor, reprogramming the tumor tissue for susceptibility to treatment

• Photodynamic therapy-this is a treatment of primary malignant brain tumors that delivers a targeted therapy while conserving healthy brain tissue- combines a drug (called a photosensitizer or photosensitizing agent) with a specific type of light to kill cancer cells

SURGICAL MANAGEMENT

SURGICAL MANAGEMENT• Transsphenoidal microsurgical removal

-treatment for most pituitary adenomas-whereas the remainder of tumors that cannot be removed completely are treated by radiation-an untreated brain tumor ultimately leads to death, either from increasing ICP or from the damage to brain tissue it causes

• Craniotomy-is used in patients with meningiomas, acoustic neuromas, cystic astrocytomas of the cerebellum, colloid cysts of the third ventricle, congenital tumors such as dermoid cyst, and some of the granulomas-the rationale for resection includes relieving ICP, removing any necrotic tissue, and reducing the bulk of the tumor, which theoretically leaves behind fewer cells to become resistant to radiation or chemotherapy

SURGICAL MANAGEMENT• Radioisotopes

-such as iodine 131 can also be implanted directly into the tumor to deliver high doses of radiation to the tumor (brachytherapy) while minimizing effects on surrounding brain tissue-the use of the gamma knife to perform radio surgery allows deep, inaccessible tumors to be treated, often in a single session-precise localization of the tumor is accomplished using the stereotactic approach and by minute measurements and precise positioning of the patient-multiple narrow beams then deliver a very high dose of radiation

NURSING MANAGEMENT

NURSING MANAGEMENT

• The patient with a brain tumor may be at an increased risk for aspiration due to cranial nerve dysfunction

Preoperatively, the gag reflex and ability to swallow are evaluated

NURSING MANAGEMENT• In patients with

diminished gag response Teach the patient to

direct food and fluids toward the unaffected side

Having the patient sit upright to eat

Offering a semisoft diet Having suction readily

available

NURSING MANAGEMENT• Function should be reassessed

postoperatively because changes can occur

The nurse performs neurologic checks

Monitors vital signs Maintains a neurologic flow

chart Spaces nursing interventions to

prevent rapid increase in ICP Reorients the patient when

necessary to person, time and place

NURSING MANAGEMENT

• Patients with changes in cognition caused by the lesion

Frequent reorientation and the use of orienting devices (personal possessions, photographs, lists, clock)

Supervision of and assistance with self-care

Ongoing monitoring and intervention for prevention of injury

NURSING MANAGEMENT• Patients with seizures Are carefully monitored and

protected from injury Motor function is checked at

intervals because specific motor deficits may occur, depending on the tumor’s location

Sensory disturbances are assessed

Speech is evaluated Eye movement and papillary size

and reaction may be affected by cranial nerve involvement

END