Traumatic Brain Injury, Brain Tumors & Intracranial Surgery Student Objectives At the completion of this unit, the student will be able to: Discuss the pathophysiology, signs & symptoms, and diagnostic tests associated with brain injury & tumors Explain the therapeutic interventions and nursing care associated with the care of patients with brain injury & tumors.

Traumatic Brain Injury Etiology & Pathophysiology The results of TBI range from undetectable to persistent vegetative state Causes: hemorrhage, contusion, laceration, cellular damage MVA, falls, sports injuries, violence

Traumatic Brain Injury Etiology & Pathophysiology Classifications of Injuries Define each term (page 1148) 1) Closed Head Injury (nonpenetrating injury) 2) Open head injury (penetrating injury) 3) Acceleration injury 4) Deceleration injury

Traumatic Brain Injury Etiology & Pathophysiology Define & Describe the following brain Injuries (use page 1148 for help) Concussion: Contusion:

Brain Injuries: Hematomas Subdural Hematomas Bleeding is between the dura and arachnoid space May be acute or chronic Acute: symptoms onset within 24 hours Bleeding is most often venous S&S increase in severity as hematoma enlarges Older adults and alcoholics more prone because of changes in brain tissue

Brain Injuries: Hematomas Subdural Hematoma S&Ss Forgetfulness, lethargy, irritability, HA If hematoma persists or increases in size  hemiparesis, pupillary changes, altered levels of consciousness S&S may be abrupt or gradual depending on the extent of injury and amount of bleeding

Brain Injuries: Hematomas Epidural Hematoma Collection of blood between the dura mater and the skull Usually arterial in nature  quicker onset of SXs: seizures, hemiparesis, LOC changes  complete unresponsiveness If ICP is not controlled rapidly  permanent brain tissue damage or death Develops dilated pupil & paralyzed EOMs on side of hematoma

Brain Injuries: Hematomas Epidural Hematoma: Diagnosis CT scan: patient usually has multiple injuries Neurophysiological testing: performed when PT stable; identifies problems with memory, judgment, learning, & comprehension. Rehabilitation strategies are then planned.

Brain Injuries: Hematomas Therapeutic Measures Goal: control of ICP; often require ICP monitoring devices and drainage of CSF Osmotic diuretics: mannitol (Osmitrol)  utilize osmosis to pull fluid from tissue into the intravascular space  eliminated. Hyperventilation via mechanical ventilator  cerebral vasoconstriction  less blood flow to head  lowered ICP (now controversial)

Brain Injuries: Hematomas Therapeutic Measures Barbiturate coma: induces therapeutic coma  decreased metabolic needs; requires complete care and mechanical ventilation.

TBI: Complications Brain Herniation Displacement of brain tissue out of its normal location Displacement causes lack of function and pressure on other structures. Herniation of brain tissue through the foreman magnum is common and occurs when ICP is not controlled

TBI: Complications Diabetes insipidus: edema or injury affects the pituitary gland or hypothalamus  inadequate release of antidiuretic hormone  polyuria & polydipsia Hydrocephalus: Cerebral edema interferes with the circulation of CSF. This may require the insertion of a ventriculoperitoneal shunt  drains CSF from the brain to the peritoneum  lowered ICP

TBI: Complications Post-Traumatic Syndrome: Patients report vague symptoms of headache, fatigue, depression, difficulty concentrating, & memory impairment. These symptoms often interfere with work, school and relationships. Neuropsychological testing  establishes need for cognitive rehabilitation

Cognitive & Personality Changes TBI: Complications Cognitive & Personality Changes Short-term memory impairment: limits ability to learn new information, ability to function, & to make judgments Emotional Liability: loss of inhibitions. Behavior may become violent, profane, or bizarre  disintegration of relationships Motor & speech impairments

TBI: Nursing Process Data Collection & Assessment: ICP monitoring (review box 48.1, p. 1137), Glasgow coma scale, pupil responses, muscle strength, vital signs. Once patient is stable, neurological damage is assessed: physical/cognitive deficits, neuropsychological testing, rehabilitation needs, referral to appropriate services.

TBI: Nursing Process: Nursing Diagnosis Risk for ineffective cerebral tissue perfusion related to increased ICP Assess S&S of Increased ICP: posturing, Glasgow coma scale, responses to pain tactile stimuli, LOC Review Measures to prevent increased intracranial preasure (table 48.4, p. 1141)

TBI: Nursing Process: Nursing Diagnosis Ineffective airway clearance related to reduced cough reflex and decreased LOC Respiratory assessments Use discretion: suctioning increases ICP Keep HOB elevated, reduce risk of aspirating oral secretions Turn frequently to mobilize respiratory secretions and prevent complications of immobility

Brain Tumors Pathophysiology & Etiology 80 to 90% of brain tumors are primary Tumors infiltrate and invade brain tissue Cause is unknown Primary brain tumors rarely metastasize Benign tumors may be fatal

Brain Tumors Pathophysiology & Etiology Common Tumor Types Intra-axial VS. Extra-axial tumors (Classifications) Meningioma Glioblastoma multiforme Astrocytoma Acoustic Neuroma

Brain Tumors Pathophysiology & Etiology Intra-axial Tumors Neoplasms that arise from cells within the cerebrum, cerebellum, or brain stem

Brain Tumors Pathophysiology & Etiology Meningioma (Extra-axial) Slow growing neoplasms arising for the meninges Occur most commonly in adults Extra-axial tumor

Brain Tumors & Intracranial Surgery Pathophysiology & Etiology Glioblastoma (Intra-axial) A malignant and rapidly growing tumor of the cerebrum or spinal cord

Brain Tumors & Intracranial Surgery Pathophysiology & Etiology Astrocytoma (Extra-axial) Composed of astrocytes & characterized by slow growth and invasion into surrounding structures Complete surgical resection is possible during the early development of it. Astrocyte: a large star-shaped neurological cell with many branches that is found in certain nervous system tissues. Astrocytes

Brain Tumors & Intracranial Surgery Pathophysiology & Etiology Acoustic Neuroma A benign unilateral or bilateral tumor arising from the vestibulocochlear (VIII) cranial nerve that grows within the auditory canal. Depending on the size of the neoplasm, tinnitus, hearing loss, headache, facial numbness, papilledema, dizziness, and unsteady gait may occur.

Brain Tumors Signs & Symptoms S&S are related to the location of the tumor Common symptoms: motor & sensory deficits, visual changes, seizures, headaches, hemiparesis Pituitary gland involvement symptoms:

Brain Tumors Diagnostic Testing MRI: clearest images Angiogram: performed when neoplasm lies in close proximity to major blood vessels If pituitary gland involvement is suspected, serum hormone levels are evaluated

Brain Tumors Therapeutic Interventions Medical Treatment Control symptoms ICP and cerebral edema Seizures Pain control Surgical Treatment Removal of tumor, or of as much of the tumor as possible.

Brain Tumors Therapeutic Interventions Radiation Therapy Standard treatment Brachytherapy: a means of delivering radiation directly to a tumor. Stereotaxic radiosurgery: small amounts of radiation are directed at a tumor from different angles.

Brain Tumors Therapeutic Interventions Chemotherapy Standard chemotherapeutic agents do not cross the blood-brain barrier New procedures are aimed at delivering chemotherapeutic directly to the brain tumor . Many new procedures being investigated i.e.: Gene therapy

Brain Tumors Therapeutic Interventions Difficult to distinguish between symptoms of a brain tumor and complications of treatment. May experience hemiparesis or aphasia following surgery or treatment Patient gradually becomes comatose with untreatable brain tumors. Nursing care of the patient with a brain tumor is similar to the patient with brain injury. Review p. 1062-1064: Nursing Care for the Patient with a Brain Tumor or Injury

Intracranial Surgery Purpose: to remove a mass or lesion Lesions include: hematomas, neoplasms, diseased brain tissue, arteriovenous malformations, seisure foci, removal of foreign body, or removal of infectious debris/material.

Intracranial Surgery Procedure Types Burr holes: holes drilled into the skull to drain or irrigate materials Craniotomy: surgical opening into the skull Craniectomy: removal of part of a cranial bone Cranioplasty: repair of cranial bone or the placement of prosthetic bone to repair a cranial defect. Bone flap: refers to the piece of bone that was removed during a craniectomy

Intracranial Surgery Surgical goal: removal of all of the tumor. Debulking: removal of as much of a tumor mass as possible Appropriateness of intracranial surgery is dependent upon location of lesion and patient’s condition

Intracranial Surgery Preoperative Care Routine pre-surgical work ups and evaluations Complete neurological & cognitive baseline function Management of anxiety & fear Patient & family education: Prepare patient and family for ICU environment Many brain surgeries can last for up to 12 hours Hair is shaved Facial & periorbital edema

Intracranial Surgery Nursing Process Frequent neurological & routine post-operative assessments Changes need to be reported promptly Planning depends on the deficits and functional level of the client Planning requires an interdisciplinary approach

Nursing Process: Nursing Diagnoses Intracranial Surgery Nursing Process: Nursing Diagnoses Risk for ineffective cerebral tissue perfusion related to edema at the operative site Risk for infection related to surgical procedure

Nursing Process: Nursing Diagnoses Intracranial Surgery Nursing Process: Nursing Diagnoses III. Knowledge deficit related to treatment regimens

Brain Tumors & Intracranial Surgery Review Questions What is the goal of chemotherapy when it is given for an inoperable brain tumor? State two examples of extra-axial tumors that effect neurological function Describe a glioblastoma Describe a craniectomy and a bone flap

Brain Tumors & Intracranial Surgery Review Questions 5) Your patient has had a craniectomy and you note there is a wet mark next to his ear. How do you determine if this wet mark was caused by a CSF leak? 6) Why are seizure precautions implemented for a client with a brain tumor? 7) List interventions you may offer to help a post-operative craniectomy patient cope with a shaved head.

TBI Injury Review Questions List measures that can be implemented to prevent increased intracranial pressure List signs and symptoms related to increased intracranial pressure Compare and contrast subdural and epidural hematomas.