BRAIN Joyce Minerva S.

Ta
Brain Tumor

- 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.
• Primary brain tumors originate from cells and structures within the
brain.
• Secondary, or metastatic, brain tumors develop from structures
outside the brain and occur in 20% to 40% of all patients with cancer.
Brain Tumor

-The cause of primary brain tumors is unknown.

-The only known risk factor is exposure to ionizing radiation.
-Additional possible causes:
• 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)
Brain Tumor

-Estimation: about 17,000 new cases of primary brain tumors per year
• 9,600 in men and
• 7,400 in women
• Neoplastic lesions in the brain ultimately cause death by impairing
vital functions, such as respiration, or by increasing intracranial
pressure (ICP).
Classification of Adult Brain Tumors

I. Intracerebral Tumors
A. Gliomas—infiltrate any portion of the brain; most common type of brain tumor
1. Astrocytomas (grades I and II)
2. Glioblastoma multiforme (astrocytoma grades III and IV)
3. Oligodendrocytoma (low and high grades)
4. Ependymoma (grades I to IV)
5. Medulloblastoma

II. Tumors Arising From Supporting Structures

A. Meningiomas
B. Neuromas (acoustic neuroma, schwannoma)
C. Pituitary adenomas
III. Developmental Tumors
A. Angiomas
B. Dermoid, epidermoid, teroma, craniopharyngioma
IV. Metastatic Lesions
Pathophysiology
• Glioma
-most common type of brain neoplasm
-begin in the gluey supportive cells (glial cells) that
surround nerve cells and help them function
Types:
• Astrocytomas- most common type of glioma. Grading is
based on cellular density, cell mitosis, and appearance
-spread by infiltrating into the surrounding neural
connective tissue
• Oligodendroglial - more sensitive to chemotherapy
than astrocytomas
-are categorized as low-grade and highgrade (anaplastic)
Pathophysiology
• Meningiomas
- 20% of all primary brain tumors
- common benign encapsulated tumors of
arachnoid cells on the meninges
-slow-growing and occur most often in
middle-aged adults
-more often in women
-most often occur in areas proximal to the
venous sinuses.
-result of compression rather than invasion of
brain tissue
Pathophysiology

• Acoustic neuromas
- tumor of the eighth cranial nerve (most
responsible for hearing and balance)
- arises just within the internal auditory
meatus
- improved imaging techniques and the use of
the operating microscope and microsurgical
instrumentation, even large tumors can be
removed through a relatively small craniotomy.
-Some of these tumors may be suitable for
stereotactic radiotherapy rather than surgery.
Pathophysiology
• Pituitary adenomas
-8% to 12% of all brain tumors
-also called the hypophysis, is a relatively
small gland located in the sella turcica
-cause symptoms as a result of pressure on
adjacent structure or hormonal changes
(hyperfunction or hypofunction of the
pituitary)
-attached to the hypothalamus by a short
stalk (hypophyseal stalk) and is divided into two
lobes: the anterior (adenohypophysis) and the
posterior (neurohypophysis)
Pathophysiology
• Pressure Effects of Pituitary Adenomas
-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
-pressure effects produce:
o headache
o visual dysfunction
o hypothalamic disorders (eg, disorders of sleep,
appetite, temperature and emotions),
o increased ICP, and
o enlargement and erosion of the sella turcica
Pathophysiology
• Hormonal Effects of Pituitary Adenomas
ofemale pt with excessive quantities of
prolactin = amenorrhea or galactorrhea

omale pt with prolactinomas =

impotence and hypogonadism

oexcess growth hormone = Acromegaly

oexcessive production of ACTH = clinical

features of Cushing’s disease
Pathophysiology
• Angiomas
-masses composed largely of abnormal
blood vessels
-found either in or on the surface of the brain
-occur in the cerebellum in 83% of cases
-diagnosis is suggested by the presence of
another angioma somewhere in the head or by
a bruit (an abnormal sound) audible over the skull
-walls of the blood vessels in angiomas are
thin = risk of CVA
Clinical Manifestations
• Increasing ICP
o Headache - although not always present, is most common in the early
morning and is made worse by coughing, straining, or sudden movement
-deep or expanding or as dull but unrelenting
-frontal tumors = bilateral frontal headache
-pituitary gland tumors = radiating between the two temples
-cerebellar tumors = suboccipital region at the back of the head
o Vomiting -due to irritation of the vagal centers in thea medulla
o Visual Disturbances - Papilledema (edema of the optic nerve), 70% to 75% of
pt
-decreased visual acuity, diplopia (double vision), and
visual field deficits.
Localized symptoms
• Motor cortex tumor - seizure-like movements localized on one side of the body
(Jacksonian seizures)
• Occipital lobe tumor - visual manifestations:
- contralateral homonymous hemianopsia (visual loss in half of the
visual field on the opposite side of the tumor)
- visual hallucinations.
• Cerebellar tumor - dizziness, an ataxic or staggering gait with a tendency to fall
toward the side of the lesion, marked muscle incoordination, and nystagmus
usually in the horizontal direction.
• Frontal lobe tumor - personality disorders, changes in emotional state and
behavior, and an uninterested mental attitude, untidy and careless and may use
obscene language
• Cerebellopontine angle tumor -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)
-because the enlarging tumor presses on the
cerebellum, abnormalities in motor function may be present.
Assessment and Diagnostic Findings

• CT Scan -number, size, and density of the lesions and the extent of
secondary cerebral edema
• MRI -smaller lesions, and tumors in the brain stem and pituitary
regions, where bone interferes with CT
• PET scans -low-grade tumors are associated with hypometabolism
and high-grade tumors show hypermetabolism
• Computer-assisted stereotactic (three-dimensional) biopsy -diagnose
deep-seated brain tumors and to provide a basis for treatment and
prognosis
A right frontal oligodendroglioma confi rmed by stereotactic biopsy. (a) The frame has been fi xed to the cranium. (b) The
head of patient have been fi xed at supine position to operating table and the MRI images have been transferred to
monitor. (c and d) The patient and images on LCD data have been adjusted. (e and f) The pantoghraph show that the data
of the patient head and pathology are seen at the same location of their counterpart on LCD.
An occipital cavernous angioma at the tip of left occipital lobe. (a) The frame has been fi xed to the cranium. (b) The
head of the patient have been fi xed to operating table at prone position and the images have been transferred to
monitor. (c and d) The patient and images data have been adjusted. (e and f) The pantoghraph show that the data of the
patient head and pathology are seen at the same location of their counterpart on LCD.
Assessment and Diagnostic Findings
• Cerebral angiography -visualization of cerebral blood vessels and can
localize most cerebral tumors
• Electroencephalogram (EEG) –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 -malignant cells because CNS tumors can
shed cells into the CSF
Gerontologic Considerations
Intracranial tumors can produce personality changes, confusion, speech
dysfunction, or disturbances of gait.
The most frequent tumor types in the elderly are anaplastic astrocytoma,
glioblastoma multiforme, and cerebral metastases from other sites.
The incidence of primary brain tumors and the likelihood of malignancy
increase with age.
Signs and symptoms in the elderly must be carefully evaluated because
10% of brain metastases occur in patients with a history of prior cancer
(Rude, 2000).
Medical Management
• Chemotherapy and
external-beam radiation
therapy -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
Medical management
• Brachytherapy - the
surgical implantation of
radiation sources to
deliver high doses at a
short distance (has had
promising results for
primary malignancies)
-used as an adjunct
to conventional radiation
therapy or as a rescue
measure for recurrent
disease
Radiation therapy
• Using stereotactic or “brain-
mapping” guided approach, a 3-
D computer image fuses the CT
and MRI to pinpoint the exact
location of the brain tumor
• Radioisotopes such as iodine
131 are implanted directly into
the tumor to deliver high doses
of radiation to the tumor while
minimizing effects on
surrounding brain tissue
RAdiation Therapy
• Gamma radiation – 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
-An advantage of this method is that no surgical incision is
needed; a disadvantage is the lag time between treatment and the
desired result
Medical Management

• Intravenous (IV) autologous bone marrow transplantation - 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
• Corticosteroids- may be used before and after treatment to reduce
cerebral edema and promote a smoother, more rapid recovery
Medical Management

• Gene-transfer therapy - uses

retroviral vectors to carry
genes to the tumor,
reprogramming the tumor
tissue for susceptibility to
treatment
SURGICAL MANAGEMENT
• Transsphenoidal microsurgical
removal
-Most pituitary adenomas are
treated by transsphenoidal
microsurgical removal, whereas the
remainder of tumors that cannot be
removed completely are treated by
radiation.
SURGICAL MANAGEMENT
• Craniotomy
-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
-For patients with malignant glioma,
complete removal of the tumor and cure are
not possible, but 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.
Nursing Management

• Risk for aspiration due to cranial nerve dysfunction

• Increased ICP
• Assess or check:
-Motor function
-Sensory disturbances
-Speech
-Eye movement and pupillary size
CEREBRAL METASTASES
• Metastatic lesions to the brain constitute the most common
neurologic complication, occurring in 20% to 30% of patients with
cancer.
• Neurologic signs and symptoms include headache, gait disturbances,
visual impairment, personality changes, altered mentation (memory
loss and confusion), focal weakness, paralysis, aphasia, and seizures.
Medical Management
• The treatment of metastatic brain cancer is palliative and involves eliminating
or reducing serious symptoms.
• The median survival for patients with no treatment for brain metastases is 1
month; with corticosteroid treatment alone it is 2 months; radiation therapy
extends the median survival to 3 to 6 months
• The therapeutic approach includes radiation therapy (the foundation of
treatment), surgery (usually for a single intracranial metastasis), and
chemotherapy; more often some combination of these treatments is the
optimal method. Gamma knife radiosurgery is considered when three or fewer
lesions are present.
PHARMACOLOGIC THERAPY
• Corticosteroids are useful in relieving headache and alterations in level of
consciousness.
• Osmotic agents eg. Mannitol or glycerol - to decrease the fluid content of the
brain, which leads to a decrease in ICP
• Antiseizures eg. Phenytoin- are used to prevent and treat seizures
• Pain is managed in a stepladder progression in the doses and type of analgesic
agents needed for relief
morphine can be infused into the epidural or subarachnoid space through a spinal
needle and a catheter as near as possible to the spinal segment where the pain is
projected
NURSING PROCESS

THE PATIENT WITH CEREBRAL

METASTASES OR INCURABLE
BRAIN TUMOR
Assessment
• baseline neurologic examination
• nutritional status
• dietary history
• nurse works with other members of the health care team to assess
the impact of the illness on the family in terms of home care, altered
relationships, financial problems, time pressures, and family
problems.
Diagnosis
• 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
Planning and Goals
• The goals for the patient may include compensating for self-care
deficits, improving nutrition, reducing anxiety, enhancing family
coping skills, and absence of complications.
Nursing Interventions
COMPENSATING FOR SELF-CARE DEFICITS
-encourage the family to keep the patient as independent as
possible for as long as possible
-Increasing assistance with self-care activities is required
-Because the patient with cerebral metastasis and the family live
with uncertainty, they are encouraged to plan for each day and to make
the most of each day
- referral for home or hospice care may be necessary
Nursing Interventions
IMPROVING NUTRITION
• nurse teaches the family how to position the patient for comfort during
meals
• Meals are planned for the times the patient is rested and in less distress
from pain or the effects of treatment
• Oral hygiene before meals helps to improve intake.
• Offensive sights, sounds, and odors are eliminated
• Creative strategies may be required to make food more palatable,
provide enough fluids, and increase opportunities for socialization
during meals.
Nursing Interventions
RELIEVING ANXIETY
• The presence of family, friends, a spiritual advisor, and health professionals
may be supportive. Support groups such as the Brain Tumor Support Group
may provide a feeling of support and strength.
• Spending time with patients allows them time to talk and to communicate
their fears and concerns.
• Open communication and acknowledging fears are often therapeutic.
• Touch is also a form of communication.
• These patients need reassurance that continuing care will be provided and
that they will not be abandoned.
Nursing Interventions
ENHANCING FAMILY PROCESSES
• The family needs to be reassured that their loved one is receiving
optimal care and that attention will be paid to the patient’s changing
symptoms and to their concerns.
• When the patient can no longer carry out self-care, the family,
additional support systems (social worker, home health aid, home care
nurse, hospice nurse) may be needed. A nursing goal is to keep anxiety
at a manageable level.
QUIZ
1. ___________ originate from cells and structures within the brain.
2. ___________ most common type of glioma. Grading is based on cellular
density, cell mitosis, and appearance. spread by infiltrating into the
surrounding neural connective tissue
3. ____________ tumor of the eighth cranial nerve (most responsible for
hearing and balance)
4-6. three most common signs of increased ICP
7. ____________ diagnose deep-seated brain tumors and to provide a basis
for treatment and prognosis
8. ____________ allows deep, inaccessible tumors to be treated, often in a
single session. Multiple narrow beams then deliver a very high dose of
radiation
9. One nursing diagnosis
10. One nursing intervention