1. Lisa Randall, RN, MSN, ACNS-BC
RNSG 2432

2. Classify brain tumors according to type and location
Discuss unique characteristics of primary and metastatic brain tumors
Recognize common signs and symptoms
Discuss nursing care re: management of S/S and treatment interventions

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. Microscopic appearance Growth rate Different for other types of CA
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)

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

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

10. 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

11. 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)

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

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

15. 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

17. 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

18. Grade I
Non-infiltrating

19. Grade II Infiltrating Slow growing

20. Grade III
Infiltrating
Aggressive

21. Grade IV
Highly infiltrative
Rapidly growing
Areas of necrosis

22. Grades II-IV Mixed astro/glio

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

24. Small cell embryonal neoplasms Malignant HCP/ICP

25. Primary CNS lymphoma
B lymphocytes
Increased ICP
Brain destruction

26. 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

27. Usually benign
Slow growing
Well circumscribed
Easily excisable

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

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

30. Benign
Anterior pituitary
Endocrine dysfxn

31. Cystic tumor
Hypothalamic-pituitary axis dysfunction

33. 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

34. 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

35. 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

36. Pre-op care Post-op care Patient teaching Activity Wound care Diet
Meds
F/U

37. Neuro assessment Vital signs H & P Teaching Diagnostic test info
Pre & Post-op care
ICU
Dressings, edema, bruising, hair removal
Sensations if done partially awake
Emotional support
Avoid false hope

38. Anxiety
Risk for infection
Risk for injury: seizures
Pain (Acute)
Impaired cognitive ability
Impaired physical mobility
Altered nutrition: less than body requirements
Urinary retention
Risk for constipation
Disturbed self-esteem

39. Wound infection
Seizures
CSF leak
Edema
Increased ICP
Hematoma
Hypovolemic shock
Hydrocephalus
Atelectasis
Pulmonary edema
Meningitis
Fluid and electrolyte imbalances (ADH)

40. Follow-up appointments and procedures Medications Exercise Diet
Patient may need referral to dietician to help with diet planning while undergoing chemotherapy
Seizures
Are a risk for 1 or more years following surgery
If expecting long term changes, coordinate discharge planning with appropriate members of health care team

41. 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.

42. Side Effects Patient teaching Radiation necrosis
Skin burns, hair loss, fatigue, local swelling
Patient teaching
Do not erase markings
Steroids
S/S of cerebral edema
Radiation necrosis

43. 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)

44. Side effects Patient teaching
Oral mucositis, bone marrow suppression, fatigue, hair loss, nausea/vomiting, anxiety, peripheral neuropathy
Patient teaching
Meds/MV
Nutrition/hydration/activity
Avoid pregnancy
Resources

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

46. Subjective data?
Interventions?
Goals?
Evaluation?

47. 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

48. 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

50. 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.