Brain tumour - A brain tumor is an abnormal growth of cells within the brain, which can be cancerous or non-cancerous (benign).

BRAIN TUMOR

 

        A brain tumor is an abnormal growth of cells within the brain, which can be cancerous or non-cancerous (benign).

 

        It is defined as any intracranial tumor created by abnormal and uncontrolled cell division, normally either in the brain itself (neurons, glial cell ( astrocytes, oligodendrocytes, ependymal cells), lymphatic ( ifd, blood vessels), in the cranial nerves (myelin-producing Schwann cells), in the brain envelopes (meninges), skull, pituitary and pineal gland, or spread from cancers primarily located on other organs (metastatic tumors).

 

Classification of Brain Tumors:

 

1)      Primary Brain Tumors- it originates from cell & structure within the brain.

 

a)      Intracerebral tumors- Gliomas are primary common brain tumor. Types of gliomas are – Astrocytoma, brain stem glioma, ependymoma, oligodendroglima and medullablastoma.

b)     Tumor arising from supporting structures e.g. Meningioma, Craniopharygioma, Germ cell tumor of brain, Angiomas & Pineal region tumor.

c)      Secondary Brain Tumor: They develop from structures outside the brain. Most common cancer that spread to brain are those arising from lung, breast and kidney.

 

Clinical Manifestations:

 

1.      Increased intra cranial pressure which present clinically as headache, vomiting altered level of consciousness (somnolence, coma), dilation of the pupil on the side of the lesion (anisocoria, papilledema (edema of optic nerve). Increased intra cranial pressure may result in herniation (displacement) of certain such as the cerebellarge tonsils or temporal uncus, result in brainstem compression.

Local Neurologic Deficits:

         Parietal Lobe: Impaired speech, inability to write, memory disturbance and lack of recognition, seizures, spatial disorders, confusion and depression.

        Frontal Lobe : Personality disturbances, behavioral and emotional changes, impaired judgment, impaired sense of smell, memory loss, paralysis on one side of body (hemiplegia), reduced mental capacity (cognitive functions ) vision loss and inflammation of the optic nerve (papilledema), broca’s aphasia (motor speech loss) and contralteral motor weakness .

        Occipital Lobe: Visual loss in half of visual field on the opposite side of tumor and visual hallucinations.

        Temporal Area: Memory disturbances, auditory hallucinations, complex partial seizures, visual field deficits.

        Cerebellar Area: Co-ordination, gait and balance disturbances & vertigo numbness & tingling, weakness or paralysis of face.

        Brain Stem: Behavioral & emotional changes, difficulty in speaking and swallowing, drowsiness, hearing loss, hemeparesis  muscle weakness on one side of face uncoordinated gait, vision loss, dropping eyelid (ptosis), vomiting, incontinence, cardio-vascular instability, respiratory depression, coma and cranial nerve dysfunction.

Clinical Manifestations:

1.      Increased intra cranial pressure which present clinically as headache, vomiting, altered level of consciousness (somnolence, coma), dilation of the pupil on the side of the lesion (anisocoria, papilledema (edema of optic nerve). Increased intra cranial pressure may result in herniation i.e. (displacement) of the certain parts of brain such as the cerebellar tonsils or temporal uncus, result in brainstem compression.

Diagnosis:

Diagnostic Evaluation:

 

1.      Complete neurologic examination.

2.      CT scan and MRI.

3.      PET (Positron Emission Tomography)

4.      EEG (Electro Encephalography)

5.      Myelogram And Angiogram

6.      Skull X- ray

7.      Spinal tap

8.      Stereotactic Biopsy

9.      Laboratory test : analysis of blood, electrolytes, liver function test and a blood coagulation profile.

 

Management:

             People with brain tumor have several treatment options. Depending on the tumor type and stage, patient may be treated with surgery, radiation therapy, or chemotherapy. Some patients receive a combination of treatment.

 

A.    Surgery: Surgery is the treatment of choice for accessible primary brain tumors, when the patient is in good health. The goal of surgery is to remove as much of the tumor as possible without damaging nearby normal brain tissue. The prognosis improves when more than 90% of a tumor can be removed.

 

1.      Craniotomy: The procedure is performed under general anesthesia and involves opening the skull (cranium). The neurosurgeon makes an incision into the scalp and several holes (called burr holes) are made in the skull. After the tumor has been partially or completely resected, the bone flap is replaced and secured using fine wire. Recovery from the procedure may take as long as 8 weeks.

 

2.      Transsphenoidal Microsurgical Removal: Transsphenoidal surgery is an approach that gains access to pituitary gland though nasal cavity and sphenoidal sinus. This procedure may be used after craniotomy to remove remaining tumor tissue.

 

3.      Brain- Mapping: Brain- mapping is performed under local anesthesia and sedation. Electrodes stimulate nerves in the brain, measure responses, and allow communication with the patient. The surgeon removes as much of the tumor as possible without damaging vital areas of the brain, such as those that control motor function and speech.

 

4.      Debulking Surgery: Removal is often complicated by the nature of the tumor and by its location. Partial removal (debulking) of the tumor can improve quality of life by alleviating symptoms and sometimes improve the effectiveness of radiation therapy of chemotherapy.

 

B.     Radiation Surgery: Radiation therapy (also called radiotherapy) uses high-energy rays to kill tumor cells. The radiation may come from x-rays, gamma rays, or protons.

 

1.      External-beam radiation: External radiation to tumor decreases the incidence of recurrence of incompletely resected tumor. Conventional therapy is 5000 to 6000 rads (6000 centrigray) of external radiation over 5 to 6 weeks.

 

2.      Brachytherapy – The surgical implantation of radiation sources (radioisotopes) to deliver high – dose at a short distance for high – grade malignant tumors. Radioisotopes such as iodine 131 can also are implanted to tumor while minimizing effects on surrounding brain tissue.

 

3.      Stereotactic radiation therapy: Narrow beams of radiation are directed at the tumor from different angles. For this procedure the patient wears a rigid head frame. An MRI or CT scan creates pictures of tumor’s exact location. The doctor uses a computer to decide on the dose of radiation needed, as well as the sizes and angles of the radiation beams. The therapy may be given during a single visit or over several visits.

 

4.      Stereotactic radiosurgery: Stereotactic radiosurgery delivers radiation to the tumor in a single dose and does not involve surgery, as the term may imply. In this procedure, a head frame supporting a CT or MRI scanner may be attached to the skull. With the aid of computer imaging, the radiologist is able to pinpoint the exact location of the tumor and aim the beam of radiation directly at it. Types of machine are used to perfume stereotactic radiosurgery include modified linear accelerators (LINAC scalpel; e.g., Cyber Knife) and Gamma knife.

 

C.    Chemotherapy: Chemotherapy, the use of drugs to kill cancer cells, is sometimes used to treat brain tumors. The drugs may be given by mouth of by injection. Either way, the drugs enter the bloodstream and travel throughout the body. The drugs are usually given in cycle so that a recovery period follows each treatment period. A single drug or a combination may be used.

 

Agent that commonly work in patient with high-grade gliomas include procarbazine, platinum analogs (cisplatin, carboplatin), taxol, nitrosureas, irinotecan, topotecan, and an oral medication called Temodar (temozolomide). Other chemotherapeutic agent for the treatment of recurrent gliomas include interferon and retinoic acid.

 

One chemotherapeutic agent that has proved to be effective is BCNU. The neurosurgeon places a wafer soaked with BCNU into the surgical cavity after the tumor has been removed. By applying it directly to the diseased area of the brain, side effect are limited and the drug has a more beneficial effect.

 

D.    Supportive Care: At any stages of disease, people with brain tumors receive supportive care to prevent or control problems and to improve their comfort and quality of life during treatment. Patients may have treatment to control pain and other symptoms of a brain tumor, to relieve the side effects of therapy, and to ease emotional problems.

 

These are common types of supportive care for people with brain tumors:

1.      Steroids- Most patients with brain tumors need steroids to help relieve swelling of the brain. Dexamethaxone may be used before and after treatment to reduce cerebral edema.

2.      Anticonvulsant medicine – Brain tumors can cause seizures. Patient may take an anticonvulsant medicine to prevent or control seizures.

3.      Shunt – If fluid builds up in the brain, the surgeon may place a shunt to drain the fluid.

 

Many people with brain tumors receive supportive care along with treatments intended to slow the progress of the disease. Some decide not to have antitumor treatment and receive only supportive care to manage their symptoms.

 

Nursing Management:

 

1.      Decreasing Intracranial Pressure:

 

·         Continually assess patient’s neurologic status.

·         Monitor and record vital signs and neurological status accurately q2-4h, or as ordered.

·         Monitor ICP and cerebral perfusion pressure.

·         Use strict aseptic technique with ICP monitoring

·         Observe for signs of increased ICP: decreased level of consciousness, restlessness, visual and other sensory disturbances, headache, vomiting, seizures and papilledema.

·         Ensure proper positioning of the head. Elevate the head 30⁰.

·         Stool softeners to prevent straining at stool (Which increases intracranial pressure)

·         Administer mannitol as ordered to reduce intracranial pressure.

 

2.      Maintaining Normal Respiratory Pattern:

 

·         Assess respiratory parameters and monitor ABGs as indicated.

·         Assess the client’s level of consciousness and neurologic status for change.

·         Suction mouth and throat if needed to maintain the airway.

·         Perform gentle chest percussion, with the patient in the lateral decubitus position, if tolerated.

·         Administer oxygen therapy. Hyper oxygenation prevents increased intracranial pressure.

 

3.      Preventing Injury:

 

·         Report any signs of increased ICP & neurologic deficits.

·         Initiate seizure precautions – Pad the side rails of bed.

·         Maintain body position without flexion of head, reduce hip flexion.

·         For patient with visual field deficits, place material in visual field.

·         Provide appropriate care and teaching for chemotherapy.

·         Maintain the client as comfortable as possible with analgesics and antiemetics as ordered.

 

4.      Improving Nutrition:

 

·         Medicate for nausea before position changes, radiation or chemotherapy as needed.

·         Maintain adequate hydration and nutrition.

·         Perform oral hygiene before and after meals to improve intake.

·         Maintain accurate intake and output records.

 

5.      Compensating For Self-Care Deficits:

 

·         Provide for total self – care requirement.

·         Maintain range of – motion exercise for all joints.

·         Encourage planning for each day.

·         Supportive nursing care is given depending upon the patient’s symptoms and ability to perform activities of daily living.