ONCOLOGIC DISORDERS OF THE BRAIN AND SPINAL CORD

Oncologic disorders in the brain and spinal cord include several types of
neoplasms, each with its own biology, prognosis, and treatment options.

PRIMARY BRAIN TUMORS

 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 neoplasms occur from the compression and
infiltration of tissue.
 A variety of physiologic changes result, causing any or all of the following
pathophysiologic events:
o Increased intracranial pressure (ICP) and cerebral edema
o Seizure activity and focal neurologic signs
o Hydrocephalus
o Altered pituitary function
 Primary brain tumors originate from cells and structures within the brain.
 Secondary, or metastatic, brain tumors develop from structures outside the
brain. Brain tumors rarely metastasize outside the CNS, but metastatic
lesions to the brain occur commonly from the lung, breast, lower
gastrointestinal tract, pancreas, kidney, and skin (melanomas).
 The cause of primary brain tumors is unknown. The only known risk factor
is exposure to ionizing radiation. Additional possible causes have been
investigated, but results of studies are conflicting and unconvincing;
suggested causes have included use of cellular telephones, exposure to high-
tension wires, use of hair dyes, head trauma, dietary exposure to such factors
as nitrates (found in some processed and barbecued foods), and other
sources.
 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 the fifth, sixth, and
seventh decades, with a slightly higher incidence in men. In adults, most
brain tumors originate from glial cells (glial cells make up the structure and
support system of the brain and spinal cord) and are supratentorial (located
above the covering of the cerebellum).
Pathophysiology
 Brain tumors may be classified into several groups: those arising from the
coverings of the brain (eg, dural meningioma), those developing in or on the
cranial nerves (eg, acoustic neuroma), those originating within brain tissue
(eg, gliomas), and metastatic lesions originating elsewhere in the body.
Tumors of the pituitary and pineal glands and of cerebral blood vessels are
also types of brain tumors.
 Tumors may be benign or malignant.

Gliomas
Glial tumors, the most common type of brain neoplasm, are divided into many
categories.
 Astrocytomas are the most common type of glioma and are graded from I to
IV, indicating the degree of malignancy.
 Oligodendroglial tumors are another type of glial tumor, representing 20% of
gliomas. These tumors are categorized as low-grade and highgrade
(anaplastic).

Meningiomas
Meningiomas, which represent 20% of all primary brain tumors, are common
benign encapsulated tumors of arachnoid cells on the meninges. They are slow-
growing and occur most often in middle-aged adults (more often in women).
Meningiomas 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.

Acoustic Neuromas
An acoustic neuroma is a tumor of the eighth cranial nerve, the cranial nerve
most responsible for hearing and balance. The patient usually experiences loss
of hearing, tinnitus, and episodes of vertigo and staggering gait. As the tumor
becomes larger, painful sensations of the face may occur on the same side as a
result of the tumor’s compression of the fifth cranial nerve. With improved
imaging techniques and the use of the operating microscope and microsurgical
instrumentation, even large tumors can be removed through a relatively small
craniotomy.

Pituitary Adenomas
Pituitary tumors represent about 8% to 12% of all brain tumors and cause
symptoms as a result of pressure on adjacent structures or hormonal changes
(hyperfunction or hypofunction of the pituitary).

Angiomas
Brain angiomas (masses composed largely of abnormal blood vessels) are found
either in or on the surface of the brain. They occur in the cerebellum in 83% of
cases. Some persist throughout life without causing symptoms; others cause
symptoms of a brain tumor. Because the walls of the blood vessels in angiomas
are thin, these patients are at risk for a cerebral vascular accident (stroke). In
fact, cerebral hemorrhage in people younger than 40 years of age should suggest
the possibility of an angioma.

Clinical Manifestations
Brain tumors can produce either focal or generalized neurologic signs and
symptoms.
Generalized symptoms reflect increased ICP.
Increasing ICP
 The skull is a rigid compartment containing essential noncompressible
contents: brain matter, intravascular blood, and cerebrospinal fluid (CSF).
Consequently, any change in volume occupied by the brain (as occurs with
disorders such asbrain tumor or cerebral edema) produces signs and
symptomsof increased ICP.
 Symptoms of increased ICP result from a gradual compression of the brain
by the enlarging tumor. The effect is a disruption of the equilibrium that
exists between the brain, the CSF, and the cerebral blood, all located within
the skull.
 As the tumor grows, compensatory adjustments may occur through
compression of intracranial veins, reduction of CSF volume (by increased
absorption or decreased production), a modest decrease of cerebral blood
flow, and reduction of intracellular and extracellular brain tissue mass.
 When these compensatory mechanisms fail, the patient develops signs and
symptoms of increased ICP. The three most common signs of increased ICP
are headache, nausea and vomiting, and a sixth-nerve palsy
 Headache. Headache, although not always present, is most common in the
early morning and is made worse by coughing, straining, or sudden
 movement. It is thought to be caused by the tumor invading, compressing, or
distorting the pain-sensitive structuresor by edema that accompanies the
tumor.
 Vomiting. Vomiting, seldom related to food intake, is usually due to
irritation of the vagal centers in the medulla.
 Visual Disturbances. Papilledema (edema of the optic nerve) is present in
70% to 75% of patients and is associated with visual disturbances such as
decreased visual acuity, diplopia (double vision), and visual field deficits.

Localized Symptoms
The most common focal or localized symptoms are hemiparesis, seizures, and
mental status changes. When specific regions of the brain are affected,
additional local signs and symptoms occur, such as sensory and motor
abnormalities, visual alterations, alterations in cognition, and language
disturbances such as aphasia.
Although some tumors are not easily localized because they lie in so-called
silent areas of the brain (ie, areas in which functions are not definitely
determined), many tumors can be localized by correlating the signs and
symptoms to known areas of the brain, as follows:
o A motor cortex tumor produces seizure-like movements localized on one
side of the body, called Jacksonian seizures.
o An occipital lobe tumor produces visual manifestations: contralateral
homonymous hemianopsia (visual loss in half of the visual field on the
opposite side of the tumor) and visual hallucinations.
o A 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.
o A frontal lobe tumor frequently 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.
o A 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 (eighth cranial nerve dysfunction). Numbness and tingling of the
face and the tongue occur (due to involvement of the fifth cranial nerve).
Later, weakness or paralysis of the face develops (seventh cranial nerve
involvement). Finally, because the enlarging tumor presses on the
cerebellum, abnormalities in motor function may be present.

Assessment and Diagnostic Findings

 History & Neurologic examination.
 Computed tomography (CT) scans
 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 regions, where bone interferes with CT.
 Positron Emission Tomography (PET)
 Computer-assisted stereotactic (three-dimensional) biopsy is being used to
diagnose deep-seated brain tumors.
 Cerebral angiography provides visualization of cerebral blood vessels and
can localize most cerebral tumors.
 An 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
 A variety of medical treatment modalities, including chemotherapy and
external-beam radiation therapy, are used alone or in combination with
surgical resection.
 Radiation therapy, the cornerstone 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) has had promising results for primary
malignancies. It is generally used as an adjunct to conventional radiation
therapy or as a rescue measure for recurrent disease.
 Corticosteroids may be used before and after treatment to reduce cerebral
edema and promote a smoother, more rapid recovery.

Surgical Management
 In many patients, combinations of these modalities may be used. Most
pituitary adenomas are treated by transsphenoidal microsurgical removal
whereas the remainder of tumors that cannot be removed completely are
treated by radiation.
 Conventional surgical approaches require an incision into the skull
(craniotomy).
 Stereotactic approaches involve use of a three-dimensional frame that allows
very precise localization of the tumor; a stereotactic frame and multiple
imaging studies (x-rays, CT scans) are used to localize the tumor and verify
its position. Lasers or radiation can be delivered with stereotactic
approaches.
 Radioisotopes such as iodine 131 (131I) 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 radiosurgery allows deep,
inaccessible tumors to be treated, often in a single session.

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.
 The nurse performs neurologic checks, monitors vital signs, maintains a
neurologic flow chart.
 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 pupillary size and reaction may be affected by cranial
nerve involvement.

NURSING PROCESS: THE PATIENT WITH CEREBRAL

METASTASES OR INCURABLE BRAIN TUMOR
Assessment
 The nursing assessment includes a baseline neurologic examination and
focuses on how the patient is functioning, moving, and walking; adapting to
weakness or paralysis and to visual and speech loss; and dealing with
seizures.
 Assessment addresses symptoms that cause distress to the patient, including
pain, respiratory problems, bowel and bladder disorders, sleep disturbances,
and impairment of skin integrity, fluid balance, and temperature regulation.
 Nutritional status is assessed because cachexia (weak and emaciated
condition) is common in patients with metastases. The nurse explores
changes associated with poor nutritional status (anorexia, pain, weight loss,
altered metabolism, muscle weakness, malabsorption, and diarrhea) and asks
the patient about altered taste sensations that may be secondary to dysphagia,
weakness, and depression and about distortions and impaired sense of smell
(anosmia).

Nursing Diagnoses
 Self-care deficit (feeding, bathing, and toileting) related to loss or
impairment of motor and sensory function and decreased cognitive abilities.
 Imbalanced nutrition, less than body requirements, related to cachexia due to
treatment and tumor effects, decreased nutritional intake, and malabsorption.
 Anxiety related to fear of dying, uncertainty, change in appearance, altered
lifestyle.
 Interrupted family processes related to anticipatory grief and the burdens
imposed by the care of the person with a terminal illness.

SPINAL CORD TUMORS

 Tumors within the spine are classified according to their anatomic relation to
the spinal cord. They include intramedullary lesions (within the spinal cord),
extramedullary-intradural lesions (within or under the spinal dura), and
extramedullary-extradural lesions (outside the dural membrane). Tumors
occurring within the spinal cord or exerting pressure on it cause symptoms
ranging from localized or shooting pains and weakness and loss of reflexes
above the tumor level to progressive loss of motor function and paralysis.

Assessment and Diagnostic Findings

 Neurologic examination and diagnostic studies are used to make the
diagnosis.
 Helpful diagnostic studies include x-rays, radionuclide bone scans, and MRI.

Management
Surgical intervention is the primary treatment for most spinal cord tumors.
Other treatment modalities include partial removal of the tumor, decompression
of the spinal cord, chemotherapy, and radiation therapy, particularly for
intramedullary tumors and metastatic lesions

Nursing Management
Preoperative Care
 Ongoing assessments for pain control, and management of altered activities
of daily living due to sensory and motor deficits and bowel and bladder
dysfunction.
 The nurse assesses for weakness, muscle wasting, spasticity, sensory
changes, bowel and bladder dysfunction, and potential respiratory problems,
especially if a cervical tumor is present.
 The patient is also evaluated for coagulation deficiencies. A history of
aspirin intake is obtained and reported because the use of aspirin may
impede hemostasis postoperatively.
 Breathing exercises are taught and demonstrated preoperatively.
 Postoperative pain management strategies are discussed with the patient
before surgery.
Post-operative Care
 The patient is monitored for deterioration in neurologic status. Frequent
neurologic checks are carried out, with emphasis on movement, strength, and
sensation of the upper and lower extremities.
 Assessment of sensory function involves pinching the skin of the arms, legs,
and trunk to determine if there is loss of feeling and, if so, determining at
what level.
 Vital signs are monitored at regular intervals.
 The prescribed pain medication should be administered in adequate amounts
and at appropriate intervals to relieve pain and prevent its recurrence.
 The bed is usually kept flat initially. The nurse turns the patient as a unit,
keeping shoulders and hips aligned and the back straight. The side-lying
position is usually the most comfortable because this position imposes the
least pressure on the surgical site. Placement of a pillow between the knees
of the patient in a side-lying position helps to prevent extreme knee flexion.
 Monitoring and managing potential complications: If the tumor was in the
cervical area, the possibility of postoperative respiratory compromise arises.
The nurse monitors the patient for asymmetric chest movement, abdominal
breathing, and abnormal breath sounds. The area over the bladder is palpated
or a bladder scan is performed to assess for urinary retention. The nurse also
monitors for incontinence because urinary dysfunction usually implies
significant decompensation of spinal cord function. An intake and output
record is maintained. Additionally, the abdomen is auscultated for bowel
sounds.

Teaching Patients Self-Care

 Patients with residual sensory involvement are cautioned about the dangers
of extremes in temperature. They should be alert to the dangers of heating
devices (eg, hot water bottles, heating pads, and space heaters).
 The patient is taught to check skin integrity daily.
 Patients with impaired motor function related to motor weakness or paralysis
may require training in activities of daily living and safe use of assistive
devices, such as a cane, walker, or wheelchair.
 The patient and family member are instructed about pain management
strategies, bowel and bladder management, and assessment for signs and
symptoms that should be reported promptly.
 ARTERIOVENOUS MALFORMATIONS

 Arteriovenous malformations (AVMs) are tangled masses of thin-walled,

dilated blood vessels that form abnormal connections between arteries and
veins; AVMs range in size from a few millimetres to large malformations
that extend from the cerebral cortex to the ventricles; typically, more than
one AVM is present
 AVMs are primarily located in the posterior portion of the cerebral
hemispheres
 Most AVMs result from congenital defects in capillary development;
traumatic injury may also be a cause
 Most AVMs are present at birth; however, symptoms typically don’t occur
until young adulthood
 Typically, high-pressured arterial flow moves into the venous system
through the connecting channels to increase venous pressure, engorging and
dilating the venous structures
 If the AVM is large enough, the shunting can deprive the surrounding tissue
of adequate blood flow
 Thin-walled vessels may develop aneurysms and ooze small amounts of
blood or actually rupture, causing hemorrhage into the brain or subarachnoid
space.
 AVMs can occur throughout the brain and have three morphologic
components:
o the feeding artery or arteries
o the draining veins
o the dysplastic nidus (an abnormal connection between arteries and
veins; ie, there is no intervening capillary bed)

Signs and Symptoms

 AVMs can cause persistent headaches unresponsive to treatment
 Other signs and symptoms include changes in mental status and intellectual
acuity, dizziness, and visual disturbances
 Seizures and neurologic deficits may also occur

Diagnosis and Treatment

 Cerebral arteriography confirms the presence of AVMs and evaluates blood
flow
 Doppler ultrasonography of the cerebrovascular system indicates abnormal,
turbulent blood flow
 Computed tomography (CT) scanning and magnetic resonance imaging
(MRI) can help differentiate an AVM from a clot or tumor
 EEG can help localize the AVM

◆ Treatment depends on the size and location of the AVM, the feeder vessels
supplying it, and the patient’s condition
 Treatments include embolization, proton-beam radioablation, laser surgery,
and surgical excision.

Nursing Interventions
 Provide supportive measures, including aneurysm precautions (placing the
patient on bed rest or with limited activity, maintaining a quiet atmosphere,
and keeping the patient calm [with sedatives, if needed]) to prevent possible
rupture
 Institute seizure precautions, and monitor for signs of increased intracranial
pressure
 Prepare for surgery, and administer I.V. fluids and medications as ordered
 Postoperatively, control hypertension, monitor the patient’s neurologic
status, and provide pain relief
 Teach the patient and family about the disorder, including the signs and
symptoms of complications
 If the patient develops deficits from the AVM, provide for adaptive measures

INTRACRANIAL (CEREBRAL) ANEURYSM

 An intracranial (cerebral) aneurysm is a dilation of the walls of a cerebral

artery that develops as a result of weakness in the arterial wall.
 The cause of aneurysms is unknown, it may be due to atherosclerosis,
resulting in a defect in the vessel wall with subsequent weakness of the wall;
a congenital defect of the vessel wall; hypertensive vascular disease; head
trauma; or advancing age.
 Any artery within the brain can be the site of cerebral aneurysms, but they
usually occur at the bifurcations of the large arteries at the circle of Willis.
 The cerebral arteries most commonly affected by an aneurysm are the
internal carotid artery (ICA), anterior cerebral artery (ACA), anterior
communicating artery (ACoA), posterior communicating artery (PCoA),
posterior cerebral artery (PCA), and middle cerebral artery (MCA).

Sign and Symptoms:

 Headache
 Facial Pain
 Meningeal Irritation
 Altered LOC
 Seizures

Diagnostics:
 CT
 MRI
 Angiography
 TRIGEMINAL NEURALGIA (TIC DOULOUREUX)

 Trigeminal neuralgia is a condition of the fifth cranial nerve characterized by

paroxysms of pain in the area innervated by any of the three branches, but it
most commonly occurs in the second and third branches of the trigeminal
nerve.
 The pain ends as abruptly as it starts and is described as a unilateral shooting
and stabbing sensation. Associated involuntary contraction of the facial
muscles can cause sudden closing of the eye or a twitch of the mouth, hence
the name tic douloureux (painful twitch).
 The cause is not certain, vascular pressure from structural abnormalities
(loop of an artery) encroaching on the trigeminal nerve, gasserian ganglion,
or root entry zone has also been suggested as a cause.

 The pain is more often cyclic and affects men with MS at a higher rate than
women with MS.
 Paroxysms can occur with any stimulation of the terminals of the affected
nerve branches, such as washing the face, shaving, brushing the teeth, eating,
and drinking. A draft of cold air and direct pressure against the nerve trunk
may also cause pain. Certain areas are called trigger points because the
slightest touch immediately starts a paroxysm or episode. To avoid
stimulating these areas, patients with trigeminal neuralgia try not to touch or
wash their faces, shave, chew, or do anything else that might cause an attack.

Medical Management
Antiseizure agents, such as carbamazepine (Tegretol), relieve pain in most
patients with trigeminal neuralgia by reducing the transmission of impulses at
certain nerve terminals. Carbamazepine is taken with meals. Gabapentin
(Neurontin) and baclofen (Lioresal) are also used for pain control. If pain
control is still not achieved, phenytoin (Dilantin) may be used as adjunctive
therapy
Surgical Management
Microvascular Decompression of the Trigeminal Nerve: An intracranial
approach can be used to decompress the trigeminal nerve. The pain may be
caused by vascular compression of the entry zone of the trigeminal root by an
arterial loop and occasionally by a vein. With the aid of an operating
microscope, the artery loop is lifted from the nerve to relieve the pressure, and a
small prosthetic device is inserted to prevent recurrence of impingement on the
nerve. This procedure relieves facial pain while preserving normal sensation,
but it is a major procedure, involving a craniotomy.

Percutaneous Radiofrequency Trigeminal Gangliolysis: Percutaneous

radiofrequency interruption of the gasserian ganglion, in which the small
unmyelinated and thinly myelinated fibers that conduct pain are thermally
destroyed, is the surgical procedure of choice for trigeminal neuralgia. In the
patient with trigeminal neuralgia and MS who is refractory to medical pain
management, the surgical treatment of choice is trigeminal rhizotomy.

Nursing Management
 Preoperative management of a patient with trigeminal neuralgia occurs
mostly on an outpatient basis and includes recognizing factors that may
aggravate excruciating facial pain, such as food that is too hot or too cold or
jarring the patient’s bed or chair. Even washing the face, combing the hair,
or brushing the teeth may produce acute pain.
 Providing cotton pads and room-temperature water for washing the face,
instructing the patient to rinse with mouthwash after eating when tooth-
brushing causes pain, and performing personal hygiene during pain-free
intervals are all effective strategies.
 The patient is instructed to take food and fluids at room temperature, to chew
on the unaffected side, and to ingest soft foods.
 The nurse recognizes that anxiety, depression, and insomnia often
accompany chronic painful conditions and uses appropriate interventions and
referrals.

Postoperative Care
 Postoperative neurologic assessments are conducted to evaluate the patient
for facial motor and sensory deficits in each of the three branches of the
trigeminal nerve.
 If the surgery results in sensory deficits to the affected side of the face, the
patient is instructed not to rub the eye, because pain will not be felt if there is
injury.
 The eye is assessed for irritation or redness. Artificial tears may be
prescribed to prevent dryness in the affected eye.
 The patient is cautioned not to chew on the affected side until numbness has
diminished. The patient is observed carefully for any difficulty in eating and
swallowing foods of different consistency.

BELL’S PALSY

 Bell’s palsy (facial paralysis) is due to unilateral inflammation of the seventh

cranial nerve, which results in weakness or paralysis of the facial muscles on
the affected side.
 The cause is unknown, although possible causes may include vascular
ischemia, viral disease (herpes simplex, herpes zoster), autoimmune disease,
or a combination of all of these factors.
 There is distortion of the face from paralysis of the facial muscles; increased
lacrimation (tearing); and painful sensations in the face, behind the ear, and
in the eye. The patient may experience speech difficulties and may be unable
to eat on the affected side because of weakness or paralysis of the facial
muscles.

Management
 Early administration of corticosteroid therapy appears to diminish the
severity of the disease, relieve the pain, and prevent or minimize
denervation.
 Facial pain is controlled with analgesic agents.
 Heat may be applied to the involved side of the face to promote comfort and
blood flow through the muscles.
 Electrical stimulation may be applied to the face to prevent muscle atrophy.
Although most patients recover with conservative treatment, surgical
exploration of the facial nerve may be indicated in patients who are
suspected of having a tumor or for surgical decompression of the facial nerve
and for surgical treatment of a paralyzed face.

Teaching Patients Self-Care

 While the paralysis lasts, the involved eye must be protected. Frequently, the
eye does not close completely and the blink reflex is diminished, so the eye
is vulnerable to dust and foreign particles. Corneal irritation and ulceration
may occur if the eye is unprotected. Distortion of the lower lid alters the
proper drainage of tears. To prevent injury, the eye should be covered with a
protective shield at night. Wrap-around sunglasses or goggles may be worn
to decrease normal evaporation from the eye.