2. WHO Histologic Classification of CNS tumors
Neuroepithelial Tumors
Astrocytic tumors
Oligodemdroglial tumors
Ependymal tumors
Mixed gliomas
Choroid plexus tumors
Neurologic tumors
Pineal parenchymal tumors
Embryonal tumors
Tumors of cranial/spinal nerves
Mesenchymal tumors, benign
Mesenchymal tumors, malignant
Uncertain histogenesis
Hemopoietic neoplasms
Cysts/tumorlike lesions
Sellar tumors

3. Incidence of primary brain tumors (benign or malignant) 12.8/100,000
10%–15% of cancer patients develop
brain metastases
Second leading cause of death from a neurological cause after stroke

4. Primary – unknown Genetic – hereditary Metastatic 35% - lung
20% - breast
10% - kidney
5% - gastrointestinal tract

5. Often unknown Under investigation: Genetic changes Heredity
Errors in fetal development
Ionizing radiation
Electromagnetic fields (including cellular phones)
Environmental hazards (including diet)
Viruses
Injury or immunosuppression

6. Tissue of origin
Location
Primary or secondary (metastatic)
Grading

7. Depends on location, size, and type of tumor Neurological deficit 68%
45% motor weakness
Mental status changes
HA 54%
Seizures 26%

8. General Cerebral edema Increased intracranial pressure
Focal neurologic deficits
Obstruction of flow of CSF
Pituitary dysfunction
Papilledema (if swelling around optic disk)

9. Cerebral Tumors Headache Vomiting unrelated to food intake
Changes in visual fields and acuity
Hemiparesis or hemiplegia
Hypokinesia
Decreased tactile discrimination
Seizures
Changes in personality or behavior

10. Brainstem tumors Hearing loss (acoustic neuroma)
Facial pain and weakness
Dysphagia, decreased gag reflex
Nystagmus
Hoarseness
Ataxia (loss of muscle coordination) and dysarthria (speech muscle disorder) (cerebellar tumors)

11. Cerebellar tumors Pituitary tumors
Disturbances in coordination and equilibrium
Pituitary tumors
Endocrine
dysfunction
Visual deficits
Headache

12. Frontal Lobe Inappropriate behavior Personality changes
Inability to concentrate
Impaired judgment
Memory loss
Headache
Expressive aphasia
Motor dysfunctions

13. Parietal lobe Temporal lobe Occipital lobe Sensory deficits
Paresthesia
Loss of 2 pt discrimination
Visual field deficits
Temporal lobe
Psychomotor seizures – temporal lobe-judgment, behavior, hallucinations, visceral symptoms, no convulsions, but loss of consciousness
Occipital lobe
Visual disturbances

14. Extrinsic tumours – arising from cranial and spinal nerves and dura.
CLASSIFICATION OF CNS TUMOURS
Intrinsic tumours – account for virtually all tumours in children and 60% of primary CNS tumours in adults
Extrinsic tumours – arising from cranial and spinal nerves and dura.
Tumours arising from adjacent structures i.e pituitary gland and metastatic tumours.

15. Gliomas Oligodendroglioma Ependymomas Medulloblastoma CNS Lymphoma
Astrocytoma (Grades I & II)
Anaplastic Astrocytoma
Glioblastoma Multiforme
Oligodendroglioma
Ependymomas
Medulloblastoma
CNS Lymphoma
Intra-axial gliomas originate from glial cells; they affect brain by invasion and infiltration.
Gliomas
Low Grade Glioma (WHO – grade I)
?? Nonenhancing
?? Benign – 5–7 years – dedifferentiate – more aggressive
Astrocytoma (WHO – grade II)
?? Nonenhancing, infiltrative
?? 5–7 years – dedifferentiates – more aggressive
Anaplstic Astrocytoma (WHO – grade III)
?? Enhancing
?? Survival 18–24 months
Glioblastoma Multiforme (WHO – grade IV)
?? Enhancing, necrotic center
?? Survival 8–10 months
Ependymomas
?? Arises from lining of ventricle
?? Benign tumor – causes obstruction of CSF
Medulloblastoma
?? Malignant tissue – infra-tentorial
?? May “seed” spinal cord
CNS Lymphoma
?? Common in immunocompromised patients (e.g., transplant/AIDS)
?? Radiation/decadron or chemotherapy (radiation & chemo effective)
?? Survival 1–4 years

16. Grade I
Non-infiltrating

17. Grade II Infiltrating Slow growing

18. Grade III
Infiltrating
Aggressive

19. Grade IV
Highly infiltrative
Rapidly growing
Areas of necrosis

20. Grades II-IV Mixed astro/glio

21. Slow growing Benign HCP/ICP Surgery, RT, Chemo

22. Small cell embryonal neoplasms Malignant HCP/ICP

23. Primary CNS lymphoma
B lymphocytes
Increased ICP
Brain destruction

24. Acoustic neuromas (Schwannoma) Pituitary adenoma Neurofibroma
Meningioma
Metastatic
Acoustic neuromas (Schwannoma)
Pituitary adenoma
Neurofibroma
Extra-axial originate from supporting structures of CNS.
Meningioma
• Slow-growing, attached to meninges
• Usually benign
Metastatic
?? Usually from lung, breast, kidney and GI
?? Enhancing – necrotic center, peritumoral edema, occurs in gray matter
Acoustic neuroma
• Cranial nerve VIII
• Benign
Pituitary adenoma
?? Classification by hormone secretion
?? Classification by location – adenohypophysis – anterior pituitary
Prolactin-secreting – serum prolactin >500 mU/L
a. Microadenoma
- hyperprolactinemia, galactorrhea, amenorrhea
- infertility; males – impotence
b. Macroadenoma
- mild hyperprolactinemia due to disruption of pituitary stalk
Growth hormone – deficiency
a. Childhood
- dwarfism, slow/absent growth
- absent/delayed sexual development, cephalofacial disproportion
b. Adulthood
- increased body fat, decreased muscle mass
- decreased bone density – increased risk of fractures, impaired glucose tolerance
Neurofibroma
?? Genetic because of autosomal dominant mendelian trait; firm, encapsulated lesions
?? Attach to nerve
?? Benign
?? Occur late in childhood/early adolescence
?? Treated with surgery, radiation

25. Usually benign
Slow growing
Well circumscribed
Easily excisable

26. Peritumoral edema Necrotic center
Most common site is breast and lung
•Seed to brain by lymphatic system or blood vessels

27. Benign Schwannoma cells CN VIII •Arises from the meninges
•Slightly higher incidence in women
•Very bloody
•Benign

28. Benign
Anterior pituitary
Endocrine dysfxn

29. Cystic tumor
Hypothalamic-pituitary axis dysfunction

31. Radiological Imaging LP/CSF analysis Pathology
Computed Tomography scan (CT scan) with/without contrast
Magnetic Resonance Imaging (MRI) with/without contrast
Plain films
Myelography
Positron Emission Tomography scan (PET scan)
LP/CSF analysis
Pathology
Diagnostic Procedures
Computed Tomography (CT) Scan
?? Evaluate bony lesions, hemorrhages with enhancement – enhancing tumors
?? May miss smaller parenchymal lesions
Magnetic Resonance Imaging (MRI)
?? Structures shown in three planes
?? With and without contrast – enhancing lesions
?? Document smaller parenchymal lesions
?? MRI technology variations
MRI angiography – visualization of vascular structures
MR spectroscopy – documents chemical composition, brain metabolites, increased
choline peak, tumor lactate peak
- tumor necrosis diagnostic and prognostic tool
Positron Emission Tomography scan (PET scan)
?? F-18 fluorodeoxyglucose (FDG)
?? Measures tissue metabolism
?? Differentiates treatment-related necrosis vs. tumor necrosis

32. Resection Craniotomy Stereotaxis Surgery Biopsy Transsphenoidal
?? Brain surgery, partial resection, resection of tumor
Steriotactic Surgery
??MRI–CT guided surgery to remove small superficial tumor
Biopsy
?? To remove piece of tumor to determine type of tumor
Transsphenoidal
??Approach through nasal passage to remove pituitary tumor

33. Drug therapy – Palliative
Done for symptom treatment and to prevent complications
NSAIDs
Analgesics – Vicodin, Lortab, MS Contin
Steroids (Decadron, medrols, prednisone)
Anti-seizure medications (phenytoin) Dilantin & Cerebyx
Histamine blockers
Anti-emetics
Muscle relaxers (for spasms)
Mannitol for ICP –New Hypertonic saline

34. Damages DNA of rapidly dividing cells 4000–6000 Gy total dose
Duration of 4–8 weeks
Brachytherapy
Stereotactic radiosurgery
Radiation is sensitive to cells that rapidly divide (e.g., brain tumors) and normal tissue too.
Low-grade radiation
Daily radiation doses of 150–200 Gy … goes +2 cm margin beyond tumor bed
Types of Radiation
??External beam radiation
??Stereotactic radiosurgery (gamma, linac, cyberknife)
??Interstitial brachytherapy – isotopes inserted into tumor bed, removed in 4–5 days
Considerations
•Skin burns are a big concern and reddened skin from beam of radiation.
•Corticosteroids are given during radiation to control cerebral edema
•Radiation necrosis may occur after treatments are completed; may need to be surgically
removed.

36. Roles of Radiotherapy in Brain Tumor
Incomplete surgery
Deep seated tumor: midbrain, pons
Radiosensitive tumor: medulloblastoma
Pituitary adenoma
Palliation: metastatic lesions

37. Slows cell growth Cytotoxic drugs Gliadel wafers Ommaya Reservoir
CCNU, BCNU, PCV, Cisplatin, Etoposide, Vincristine, Temozolomide (Temodar)
Gliadel wafers
Ommaya Reservoir
Cancer cells are rapidly dividing cells.
A combination of drugs is sometimes used.
Chemotherapeutic drugs are administered by the PO, IV or intrathecal routes
Acute side effects include the following:
•Oral mucositis: Provide mouth care on regular basis
•Check for bone marrow suppression: WBC with differential; Neurtrophils >1500
•Fatigue: Rest, check hemoglobin >10, platelets >10,000
•Hair loss: Encourage patients to wear scarves and use makeup; review cause of hair
loss and that it will regrow
•Nausea/vomiting: Antiemetics
•Anxiety: Reassure positive attitude
•Peripheral neuropathy: Non-narcotics, opioids, adjuvant (e.g., antidepressants,
anticonvulsants, anxiolytics)

38. Ineffective Tissue Perfusion
Ineffective Airway Clearance
Impaired Communication
Decreased Intracranial Adaptive Capacity
Activity Intolerance
Disturbed Sensory disturbance
Acute Confusion

39. A patient is being directly admitted to the medical-surgical unit for evaluation of a brain mass seen in the frontal lobe on a diagnostic CT scan. Which of the following signs and symptoms would the patient most likely present with?
Personality changes
Visual field cuts
Difficulty hearing
Difficulty swallowing

40. The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits
a. A positive Brudzinski’s sign
b. A negative Kernig’s sign
c. Absence of nuchal rigidity
d. A Glascow Coma Scale score of 15

41. Greenberg, Mark. (2006). Handbook of
AANN Core Curriculum for Neuroscience Louis, MO. Nursing, 4th Ed Saunders. St.
Greenberg, Mark. (2006). Handbook of
Neurosurgery. Greenberg Graphics,
Tampa, Florida.