DEFINITION

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: Increased intracranial pressure (ICP) and cerebral edema Seizure activity and focal neurologic signs Hydrocephalus Altered pituitary function
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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 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
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CLASSIFICATION
Brain tumors may be classified into several groups: those arising from the coverings of the brain (e.g. Dural meningioma), those developing in or on the cranial nerves (eg, acoustic neuroma), 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 cerebral blood vessels are also types of\ brain tumors.
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INCIDENCE
It is estimated that there are about 17,000 new cases of primary brain tumors per year, 9,600 in men and 7,400 in women (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 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 supra,tentorial (located above the covering of the cerebellum).
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ETIOLOGY
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 20 years after exposure. 4. Additional possible causes have been investigated,& 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.
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PATHOPHYSIOLOGY
Due to etiological factors Growth of intracranial tumors (accompanied by edema) Compress normal tissue and impair function Produce neurologic manifestations.

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Tumors of the brain produce neurologic manifestations through a number of mechanisms. Small, strategically located tumors may damage specific neural pathways traversing the brain. Tumors can invade, infiltrate, and supplant normal parenchymal tissue, disrupting normal function. Because the brain dwells in the relatively restricted repository of the cranial vault, growth of intracranial tumors with accompanying edema may compress normal tissue and impair function. Tumors proximal to the third and fourth ventricles may obstruct the flow of cerebrospinal fluid, leading to hydrocephalus. In addition, tumors generate new blood vessels (ie, angiogenesis), disrupting the normal blood-brain barrier and promoting edema. Prinz 12/22/2010

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

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CLINICAL MANIFESTATIONS
Increased ICP Headache Vomiting Visual Disturbances

LOCALIZED SYMPTOMS The most common focal or localized symptoms are Hemiparesis, Seizures, and Mental status changes.
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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.

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correlating the signs and symptoms to known areas of the brainAlthough 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 and symptoms to known areas of the brain, as follows: A motor 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 in half of the visual field on the opposite side of the tumor) 12/22/2010 Prinz and visual hallucinations.

 A cerebellar tumor causes dizziness, an ataxic or staggering gait with a tendency to fall toward the side of the lesion, marked muscle in-coordination, and nystagmus (involuntary rhythmic eye movements), usually in the horizontal direction.

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.
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 A cerebello-pontine 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.

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DIAGNOSTIC FINDINGS
A neurologic examination indicates the areas of the CNS involved. Computed tomography (CT) scans, enhanced by a contrast agentgives specific information concerning the number, size, and density 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 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) - Is used to supplement MRI. On PET scans, low-grade tumors are associated with hypometabolism and high-grade tumors show hyper-metabolism. This information can be useful in treatment decisions. 12/22/2010 Prinz

 Computer-assisted stereotactic (three-dimensional) biopsy is being 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. 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. Cytologic studies of the CSF may be performed to detect malignant cells because CNS tumors can shed cells into the 12/22/2010 Prinz CSF.

MEDICAL MANAGEMENT
1. Chemotherapy and external-beam radiation therapy 2. Autologous bone marrow transplantation

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SURGICAL MANAGEMENT
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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SURGICAL MANAGEMENT
Trans-sphenoidal microsurgery

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 Craniotomy

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 Radioisotopes -iodine 131 (131I)

131 I

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 Gamma knife

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NURSING MANAGEMENT
Preoperative Medical and Nursing Management.

1. Instruct patient and family about the necessity and importance of diagnostic tests to determine the exact location of the tumor. 2. Monitor and record vital signs and neurological status accurately 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 agents on time. Withholding steroids can result in adrenal crisis. Withholding of antiepileptic agents frequently precipitates seizure.
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Post Operative Nursing Care Considerations.

a.Meticulous nursing management and care aimed at prevention of postoperative complications are imperative for the patient's survival. b.Accurately monitor and record all vital signs and neurological signs.
i. Postoperative cerebral edema peaks between 48 and 60 hours following surgery. ii.Patient may be lucid during first 24 hours, then experience a decrease 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 been removed, can cause irreversible damage in the first 72 hours. 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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h. Maintain body temperature.

Increases of body temperature in the neurosurgical patient may be due to cerebral edema around the hypothalamus. Monitor rectal temperature frequently. Place patient on hypothermia blanket, as ordered.

i. Institute seizure precautions at patient's bedside. (Tongue , blade, airway.) j. Maintain accurate record of intake and output. k. Prevent pulmonary complications associated with bed rest.
i. Cough and deep breathe every 2 hours. ii.Perform gentle chest percussion, with the patient in the lateral decubitus position, if tolerated.
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L. Continuously talk to the patient while providing care, reorienting him to person, place, and time.

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