Brain Tumor Management 2024-2025 PDF

MANAGEMENT OF PATIENTS WITH BRAIN TUMORS NURS 302 Spring 2024-25 Prepared by Dr. Adra; Revised by SDS 1 ANATOMY OF THE BRAIN 2 3 ETIOLOGY There are more than 120 types of tumors and cysts. Brain t...

MANAGEMENT OF PATIENTS WITH BRAIN TUMORS NURS 302 Spring 2024-25 Prepared by Dr. Adra; Revised by SDS 1 ANATOMY OF THE BRAIN 2 3 ETIOLOGY There are more than 120 types of tumors and cysts. Brain tumors typically occur in 2 distinct categories Primary vs. Secondary Primary brain tumors originate from cells and structures within the brain and the spinal cord. Secondary /metastatic brain tumors develop from structures outside the brain such as breast, lung, skin, GI.. Their incidence is higher than that of primary brain tumors. These tumor cells reach the brain via the blood- stream , CSF or lymphatic system.  EPIDEMIOLOGY The frequency of various tumor types and grades varies by age group. In adolescents and young adults, primary brain tumors are more common than metastatic tumors, and among primary brain tumors, low-grade gliomas predominate. In adults above the age of 30 to 40 years, metastatic brain tumors become increasingly prevalent, accounting for more than half of all brain tumors. Glioblastoma is the most common malignant primary brain tumor in adults, with a median age at diagnosis of 64 years. Meningiomas and glial tumors (eg, glioblastoma, astrocytoma, oligodendroglioma) account for approximately two-thirds of all primary brain tumors in adults 4 INCIDENCE OF BRAIN TUMORS ACCORDING TO LOCATION 5  BRAIN TUMORS MALIGNANT VS BENIGN Benign Malignant Rarely grow back when removed Often life-threatening Well-defined border Do not spread to other parts of body Rapid Growth – Invade nearby Can put pressure on sensitive areas of the healthy brain tissue brain causing problems Can spread to other parts of the Can be life-threatening unlike other benign tumors in the body brain or the spinal cord – rarely to Can become malignant with time other parts of the body 6  The cause of primary brain tumors is largely unknown RISK The most studied and most clearly associated risk FACTORS factor is Ionizing Radiation Other factors are: Genetic, environmental 7  Symptoms depend on the location and size of the lesion and the compression of associated 8 structures Manifestations  Headache CLINICAL  Nausea / Vomiting MANIFESTATIONS  Seizures  Motor weakness ( ataxia, facial paralysis, hemiparesis, aphasia)  Symptoms of increased ICP  Mental status changes; memory loss  Visual disturbances  Hormonal effects with pituitary adenoma  Loss of hearing, tinnitus, and vertigo with acoustic neuroma 9  CLASSIFICATION Grading from least to most malignant ( how Location of the fast, presence of Tissue involved tumor necrosis… - determined by biopsy)  TUMOR GRADING Microscopic appearance Growth rate For CNS, per WHO: GX Grade cannot be assessed (Undetermined) G1 Well-differentiated (Low grade) G2 Moderately differentiated (Intermediate grade) G3 Poorly differentiated (High grade) G4 Undifferentiated (High grade) 11  The cerebrum is divided into four lobes: frontal, parietal, occipital and temporal. 12  CLINICAL PRESENTATION Brain tumors can produce symptoms and signs by local brain invasion, compression of adjacent structures, and increased intracranial pressure (ICP). In addition to the histology of the tumor, the clinical manifestations are determined by the function of the involved areas of the brain. The proper evaluation of the patient with a suspected brain tumor requires a detailed history, comprehensive neurologic examination, and appropriate diagnostic neuroimaging studies. 13  PATHOPHYSIOLOGIC RESULTS OF BRAIN TUMORS Increased ICP Cerebral edema / Inflammation Seizure activity Obstruction of flow of CSF/ hydrocephalus Altered pituitary function/hormonal changes 14  Executive functions Concentrating or (making decisions, Learning and focusing your Controlling emotions solving problems, remembering new attention on and behavior planning and information something organizing) Lack of inhibition (making inappropriate comments during Social cognition, Weakness on the Communication skills conversation or impulse control and opposite side of the and language laughing in sexual behavior body from the tumor production inappropriate Speaking Broca’s area situations) A BRAIN TUMOR LOCATED IN THE FRONTAL LOBE MAY CAUSE DIFFICULTY WITH: 15 A BRAIN TUMOR LOCATED IN THE TEMPORAL LOBE MAY CAUSE DIFFICULTY WITH: Hearing Language processing Wernick’s area Memory loss Correctly identifying emotions in others Identifying and categorizing objects Sensations of strange smells. Learning new information Seizures or blackouts 16 BRAIN TUMOR LOCATED IN THE PARIETAL LOBE MAY CAUSE DIFFICULTY WITH: Bringing together information from your different senses (touch, vision, hearing, smell, taste) and making sense of it Recognizing faces or objects Spatial awareness (judging distances and hand-eye co-ordination) Speaking, understanding words, writing and reading Numbness on the opposite side of the body from the tumor. 17  A BRAIN TUMOR difficulty with vision e.g., LOCATED IN identifying objects or colors THE OCCIPITAL LOBE MAY loss of vision on one side. CAUSE: 18  difficulty with balance A BRAIN TUMOR loss of co-ordination LOCATED IN THE CEREBELLUM difficulty walking and speaking MAY CAUSE: stiff neck problems with dexterity (skills in using your hands). 19  Headache A TUMOR unsteadiness and difficulty walking LOCATED IN THE facial weakness on one side of the BRAIN STEM face Abnormalities in eye mvt. double MAY CAUSE: vision difficulty speaking and swallowing. Nausea 20  TYPES OF BRAIN TUMORS  Many types of primary brain tumors exist  Named according to the type of cells or the part of the brain in which they begin  Gliomas account for the great majority of primary tumors that arise within the central nervous system (CNS).  The term "glioma" refers to tumors that have histologic features similar to normal glial cells (ie, astrocytes, oligodendrocytes, and ependymal cells). Each of these types of gliomas contains neoplasms spanning a broad spectrum of biologic aggressiveness. 21  1- GLIOMAS Begin in glial cells (brain supportive tissue) Most common primary brain tumors Graded I –IV (WHO criteria) according to aggressiveness Grade 1 & 2 : Astrocytoma, begins in cells called astrocytes that support nerve cells. Grade 3 & 4 are known as Glioblastomas and have little resemblance to the original cell. Glioblastoma Multiforme (grade IV) Highly infiltrative, Rapidly growing, aggressive, rapid recurrence, has necrotic center - Survival 8– 10 months. Low grade tumors may transform into more aggressive grade 4 tumors 22 23  TYPES OF GLIAL CELLS Glial cells support neurons and maintain their 3. Ependymal cell: type of environment. These cells are subdivided into neuronal support cell (neuroglia) that astrocytes, ependymal cells and oligo-dendroglial forms the epithelial lining of the cells. ventricles (cavities) in the brain and 1. Astrocytes: are star shaped cells the central canal of the spinal cord. that provide nutrients and are Ependymomas- common in children responsible for regulating electrical signals (neurotransmission).Tumors that develop out of astrocytes are 4. Microglial called Astrocytomas and cells: scavenge Glioblastomas. pathogens and dead 2. Oligodendrocytes: they form cells. the myelin sheaths around the axons. They are a form of Tumors that develop from these cells immune cell. are oligo-dendro-gliomas. 24  TYPES OF GLIAL CELLS IN THE PERIPHERAL NS Schwann cells: They help support peripheral nerve fibers and form myelin sheath. Satellite cells: are found in mature muscle. They produce different proteins and provide structural support. 25 OTHER TYPES OF BRAIN TUMORS: 2. Medulloblastoma Malignant tissue Common in children 3) Meningioma Benign encapsulated tumors on the meninges Slow growing Common in middle-aged women 4) Acoustic neuroma: (vestibular schwannomas) Tumor of the eighth cranial nerve (hearing and balance) May grow slowly and attain considerable size before 26 diagnosis 5) Pituitary adenoma: Classified by hormone secretion & by location Adenohypophysis – anterior pituitary Prolactin-secreting – serum prolactin >500 mU/L Treatable with surgery 6) Angioma: or Hemangioblastoma Composed largely of abnormal blood vessels 27 Found in or on the surface of the brain LOCATION OF BRAIN TUMORS 28  DIAGNOSTICS Neurologic exam hx of the illness and how symptoms evolved Computed tomography (CT) Magnetic resonance imaging (MRI) Cerebral Angiography Cytologic studies of CSF analysis brain biopsy Obtained by open surgery Only way to provide definitive diagnosis Hormonal levels: may be abnormal if pituitary is involved CXR, EEG, PET scan 29  Surgery- goal is Craniotomy, to relieve trans-sphenoidal surgery, symptoms and stereotactic decompression procedures MANAGEMENT DEPENDS ON THE Radiation External-beam radiation TYPE, LOCATION, & Brachytherapy (the therapy- surgical implantation of ACCESSIBILITY OF radiation sources to cornerstone txt deliver high doses at a THE TUMOR short distance) used Chemotherapy concurrently with surgery 30  Craniotomy: opening of the skull to gain access to intracranial structures It involves removing a portion of the skull Purposes: remove tumor, relieve elevated ICP, INTRACRANIAL evacuate a blood clot, control hemorrhage SURGERY after a craniotomy, the bone is replaced Burr holes: circular openings for Aspirating a exploration or hematoma or abscess diagnosis, useful for: BURR HOLES CRANIOTOMY  Trans-phenoidal approach: through the mouth and nasal sinuses. This approach offers direct access to the sella turcica with minimal risk of trauma and hemorrhage. It avoids many of the risks of craniotomy.  PREOPERATIVE CARE Obtain baseline neurologic assessment Assess patient and family understanding of and preparation for surgery Provide information, reassurance, and support and insure consent Preoperative diagnostic procedures may include CT scan, MRI, angiography, blood tests Medications usually given include antibiotics, corticosteroids, and anti-seizures  DRUG THERAPY: For symptom treatment and prevention of complications: Analgesics: paracetamol Steroids: (Decadron, prednisone) Anti-seizure / anti-epileptic medications (phenytoin) Dilantin; valproic acid, levetiracetam Anti-emetics : Ondansetron Muscle relaxants (for spasms) Mannitol for increased ICP  Monitoring ICP & neurologic status Detecting and reducing cerebral edema – mannitol , dexamethasone IV Q 6hrs for 24-72 hrs then tapered Relieving pain: acetaminophen, morphine for POSTOPERATIVE headache and fever CARE Preventing seizures: phenytoin, diazepam (monitor serum blood levels to ensure therapeutic range.) The patient may be intubated and have arterial and central venous lines.  NURSING PROCESS: NURSING DIGNOSES Ineffective cerebral tissue perfusion Risk for imbalanced body temperature Potential for impaired gas exchange Disturbed sensory perception Body image disturbance Impaired communication (aphasia) Risk for impaired skin integrity Impaired physical mobility  Careful, frequent monitoring of respiratory function, RR, SpO2, auscultation, including ABGs Monitor VS and LOC frequently; note any potential signs of fever, increasing ICP Assess dressing for evidence of bleeding or CSF drainage NURSING PROCESS: NURSING Monitor for potential seizures; if seizures occur, carefully record and report. INTERVENTIONS Monitor for signs and symptoms of complications ( infection, bleeding) Monitor fluid status, urine output, and laboratory data ( electrolytes)  POTENTIAL COMPLICATIONS AFTER CRANIOTOMY Fluid and Bleeding and electrolyte Increased ICP hypovolemic disturbances shock ( hypo or hypernatremia) Infection Seizures Hypertension  Monitor respiratory status; even slight hypoxia or hypercapnia can affect cerebral perfusion Assess VS and neurologic status every 15 minutes to every hour Strategies to reduce cerebral edema; cerebral edema INTERVENTIONS: peaks 24 to 36 hours after surgery. MAINTAINING CEREBRAL Strategies to control factors that increase ICP PERFUSION Avoid extreme head rotation HOB may be flat or elevated 30 degrees according to needs related to the surgery and surgeon preference Pain relief Prevent hypoxia Prevent constipation Treat fever Manage agitation  INTERVENTIONS Improving gas exchange Turn and reposition every 2 hours. Encourage deep breathing and incentive spirometry. Suction or encourage coughing cautiously as needed (suctioning and coughing increase ICP). Humidification of oxygen may help loosen secretions. Sensory deprivation Periorbital edema may impair vision, cool compresses over eyes and elevation of HOB may be used to reduce edema if not contraindicated.  Preventing infections Assess incision for signs of hematoma or infection. Assess for potential CSF leak. INTERVENTIONS Instruct patient to avoid coughing, sneezing, or nose blowing, which may increase the risk of CSF leakage. Use strict aseptic technique.  NURSING INTERVENTIONS FOR THE PATIENT WITH METASTATIC BRAIN TUMOR Use palliative care approach: Encourage independence for as long as possible Measures to improve functionality and cognition Allow patient to participate in decision making Seek patient wishes and preferences Allow patient to express fears and concerns Presence of family, friends, spiritual advisor, and health care personnel may be supportive Referral to counselor, social worker, home health care, support groups Referral for hospice care Management of symptoms  NURSING INTERVENTIONS FOR THE PATIENT WITH METASTATIC BRAIN TUMOR Improving nutrition Oral hygiene before meals Plan meals for times when patient is comfortable and well rested Measures to make mealtimes as pleasant as possible Offer preferred foods Dietary supplements Daily weight Record dietary intake THANK YOU Stay safe 49