1. 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.

2. 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

3. 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

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

5. 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

6. 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

7. 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

8. 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.

9. 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)

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

11. 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

12. 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

13. 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

14. 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

15. 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.

16. 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)

17. 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

18. 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

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

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

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

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

23. 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

24. 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.

25. 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:

26. 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

27. 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.

28. 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.

29. 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

30. 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 : Nursing Care for the Patient with a Brain Tumor or Injury

31. 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.

32. 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

33. 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

34. 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

35. 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

36. 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

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

38. 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

39. 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.

40. 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.