brain tumors astrocytomas and glioblastomas

7/25/2019 Brain Tumors Astrocytomas and Glioblastomas

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Title Brain tumors: Astrocytomas and Glioblastomas

Authored By Wanda Lockwood RN, BA, MA

Course No BTA110508

Contact Hours 5

Purpose

The goal of this course is to define astrocytomas/glioblastomas and to explain the diagnosis, the causes,

the symptoms, the complications, the treatments, and pre-operative and post-operative management.

Objectives

1. Explain the difference between primary and metastatic tumors.

2. Explain the origin of astrocytic tumors.3. List and discuss symptoms of brain tumors in relation to affected region of the brain.4. List and explain at least 5 diagnostic procedures.

5. List and explain 3 primary types of treatment for astrocytic brain tumors.6. List and explain the 4 WHO categories for tumors.

7. List and discuss general characteristics of 6 astrocytic tumors.

8. Explain 3 open surgical approaches.9. Explain the difference between Gamma Knife and CyberKnife radiosurgery.

10. List at least 5 preoperative nursing interventions.

11. Discuss postoperative nursing interventions.12. List and explain the 3 parameters for the Glasgow Coma Scale.

13. Explain the Monroe-Kellie Hypothesis.

14. List and discuss at least 5 of 8 common postoperative complications.15. Discuss nursing interventions for patient discharge.

Introduction

A brain tumor is a chilling diagnosis for anyone, but new chemotherapeutic and surgical techniques have

increased survival rates for most types of tumors. Approximately 17,000 people in the United States alonedevelop primary brain tumors each year. Primary brain tumors can be either benign or malignant. Benign

brain tumors, such as meningiomas, acoustic neuromas, and pituitary gland tumors, are often slow

growing and can be surgically excised, depending upon their location. Malignant tumors, on the otherhand, are often faster growing and tend to spread into the surrounding brain tissue, making completeremoval difficult or impossible. Primary brain tumors rarely spread to other parts of the body, instead

spreading to other parts of the brain and the spinal axis. Both children and adults can suffer from brain

tumors. The most common age groups are children between the ages of 3 and 12 and adults between 40and 70.

Primary brain tumors arise within the brain tissue itself as opposed to metastatic brain tumors with an

original tumor site outside of the brain. Metastatic brain tumors outnumber primary tumors by about 10 to1, occurring in 20-40% of cancer patients. The most common cancers metastasizing to the brain are lungcancer (50%) and breast cancer (15-20%). Eighty percent of metastatic brain tumors occur in the

cerebral hemispheres, 15% in the cerebellum, and 5% in the brain stem with 70% of these patientshaving multiple brain lesions. Its important to differentiate between primary cancerous lesions andmetastatic lesions. It should not be assumed that a cancerous lesion of the brain is metastatic simply

because the patient has a primary tumor elsewhere. Brain tumors must also be differentiated from otherlesions of the brain, such as abscesses, arteriovenous malformations, and infarction (1, 2, 3).

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While there are many types of brain tumors, astrocytomas account for about 40% of the primary tumors

of the brain and spinal cord. Astrocytomas arise from astrocyte cells, which are part of the supportive, orneuroglial, tissue within the brain; therefore, they are sometimes referred to as gliomas. Astrocytes arenamed for their star-like appearance. Astrocytomas are always infiltrative tumors that act as mass

lesions. Symptoms relate to the area in which the tumor has infiltrated. Astrocytomas can developanywhere within the brain but are most common in the cerebrum of adults, especially males, and the

cerebellum of children. Astrocytomas may occur at the base of the brain in children and young adults.

Glioblastomas are fast-growing astrocytomas that contain areas of necrotic tumor cells. In adults, theymost often occur in the frontal or temporal lobes of the cerebrum, rarely in the cerebellum or brain stem.(1, 2, 3).

The brain

Medial aspect:




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Who is at risk for developing astrocytic tumors?

Patients who receive therapeutic radiation for pituitary adenomas, craniopharyngioma, pineal parenchymaltumors, germinoma, and tinea capitis are at increased risk of developing astrocytic tumors. Additionally,

children who receive prophylactic irradiation of the central nervous system for acute lymphoblastic

leukemia are at increased risk. Recurrent lesions often indicate histologic progression to a higher grade,associated with a cumulative acquisition of genetic alterations (3).

While exact risk factors have not been identified, some studies have indicated that the following may putpeople at increased risk of developing astrocytomas:

Genetic disorders Occupational exposure to:

Radiation Chemicals, such as vinyl chloride

Oil refining Rubber manufacturing

History of neurofibromatosis or tuberous sclerosis (4)

General symptoms of astrocytomas

Initially, a person with an astrocytoma may experience either no or vague symptoms. As the tumor

grows, symptoms develop from increased pressure on the area of the brain that is involved. Symptomsmay include:

Headaches Changes in vision

Nausea and vomiting

Seizures Personality changes

Dementia Memory loss Inability to concentrate

Ataxia

In young children, the growing tumor in the brain may enlarge the head. Swelling may be observed in the

back of the eye. Seizures are more common with slow-growing astrocytomas than with more malignantforms. Usually, the symptoms that develop result from increased pressure within the skull as the tumor

grows and causes inflammation of surrounding tissue and increased intracranial pressure. As pressure

increases, headache is common, often behind the eyes and near the top of the head, usually worsening




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with exertion and at night or in early morning. Nausea is common. As pressure increases, lethargy,

confusion, and disorientation may occur. Changes in cardinal signs, such as, blood pressure, pulse,respiration, and temperature are usually late symptoms.

As the tumor develops, symptoms will vary depending upon the location, causing localized brain

dysfunction:

Complications of tumors

There are a number of serious complications that can develop as the brain tumor grows and damages

surrounding tissue:

Vasogenic (cerebral) edema results when there are changes in the permeability of the capillaryendothelial tissue, allowing plasma to seep into the extracellular spaces. This can lead to increased

intracranial pressure and herniation of the brain tissue.

Cerebral blood vessels may become compressed causing ischemia to the area served by the vessels.

Tumorlocation

Associated symptoms

Frontal lobe Changes in mood and personalityHemiparesis

Temporal lobe Lack of coordination

Speech difficulties

Memory loss

Parietal lobe Lack of sensation

Difficulty writingLoss of fine motor skills

Loss of half-body awareness (patient may shave on one side of face or apply makeup to

one side only)

Cerebellum Lack of coordination

Lack of balance

Occipital lobe Vision disturbances

Visual hallucinations

Brain stem Cranial nerve dysfunctionFacial pain, weakness

Dysphagia




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Numerous focal neurologic developments may occur. The tumor may infiltrate the walls of a vessel, leading to rupture and hemorrhage. Seizure activity may occur. Cerebral spinal fluid flow may be obstructed, leading to increased intracranial pressure and

hydrocephalus.

Pituitary dysfunction may occur if the tumor compresses the pituitary gland, leading to inappropriate

antidiuretic hormone or diabetes insipidus (4, 5).

Diagnostic procedures

Diagnosis usually begins with a complete neurological evaluation, especially if the patient has slowlyincreasing evidence of mental impairment, seizures, headaches, or evidence of intracranial pressure. The

neurologist will order further diagnostic tests as indicated:

Diagnostic procedure Discussion

Computed tomography (CT) Because of its speed (afew minutes), CT isused to evaluate

patients who areclinically unstable. A CTof the head produces an

image from the upperneck to the top of the

head. A contrast dye

may be injectedintravenously as bloodvessels become brighter

with contrast. This dyemay cause a slight

burning sensation in the

arm, a metallic taste inthe mouth, and ageneralized feeling of

warmth. These

sensations subsidewithin a few minutes.

With the CT, a thin x-ray beam rotates

around the patient. Thecomputer then analyzesthe data to construct a

cross-sectional image,

which can be stacked tocreate a three-

dimensional model oforgans. The CT scan is

more effective than MRI

for detecting these

factors:

Calcification Skull lesions

Hemorrhage less

than 24 hours induration(hyperacute)

CT is helpful in directing

differential diagnosis




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and immediate

management. Childrenare at increased risk of

excessive radiation

exposure from multipleCTs because theyreceive the same

amount of radiation as

an adult even thoughtheir size is smaller (3,

6).

Magnetic resonance imaging (MRI) High quality MRI is theimaging method of

choice in the evaluationof intramedullary andextramedullary spinal

cord lesions and is usedfor diagnosis of otherbrain tumors. Unlike CT,

which uses x-rays, theMRI is based on the

magnetic properties ofatoms, so it is safer forchildren although young

children require

anesthesia. The MRIuses radio waves veryclose in frequency to

those of FM radiostations so the test

must be conducted in a

shielded room to avoidoutside interference.The patient lies on a

table that slides into a

tunnel-like tube thatsome may find

claustrophobic. A smallbody coil may be placed

around the head to sendand receive the radio

wave pulses.

The energy from theradio waves is absorbed

and then released in apattern formed by thetype of tissue and by

certain diseases.

Intravenous contrastdye may also be

administered. Usuallyseveral sets of images

are taken, each

requiring 2-15 minutesso a complete scan maytake up to an hour

although newerscanners with more

powerful magnets may




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require less time. MRI

produces detailedpictures of the brain and

nerve tissues from

multiple planes. It is theprocedure of choice formost brain and

neurological disorders

because it can clearlyshow various types of

nerve tissue, providingclear pictures of thebrainstem and posterior

brain, which are hard to

image with a CT scan. Itcan evaluate blood flow

and the flow ofcerebrospinal fluid.Because high quality

MRI has superior soft-

tissue resolution, it ismore effective than CT

for the following:

Detection ofisodense lesions

Tumor

enhancement Detection of

associated

findings, such asedema

All phases of

hemorrhagicstates (except

hyperacute) andinfarction

Distinguishingtumors or other

lesions fromnormal tissues (3,7, 8)

Magnetic resonance spectroscopy (MRS) Magnetic resonancespectroscopy is donewith an MRI at

specialized facilities toanalyze the chemicalcomposition of proton

(hydrogen)-based

molecules, some ofwhich are specific to

nerve cells, and MRScan identify tissue as

normal or tumor and

may be able todistinguish glial tumorsfrom others. Multi-voxel

magnetic resonancespectroscopy (MRS) is

capable of




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characterizing the

chemical fingerprint ofa brain lesion non-

invasively. It may

differentiate betweenlow-grade and high-grade tumors (4, 9).

Positron emission tomography (PET) PET scans uses IVglucose that contains aradioactive atom tracer.

A special camera candetect the radioactivity.Because cancer cells

have high rates ofmetabolism, theyabsorb high amounts of

the radioactive material.A PET scan shows lessdetail than a CT or MRI,

so the PET scan isusually matched with a

CT or MRI to get a fullpicture. A PET scan issometimes useful in

diagnosing tumors and

evaluating response totreatment. Aftertreatment is completed,

scar tissue may stillremain and this will

show up as an

abnormality on an MRI,but PET scans can helpto differentiate tumor

from scar tissue (8).

Angiography A cerebral angiogram is

usually not indicated fordiagnosis of a braintumor, but one may be

ordered to obtain

additional informationabout the vascular

supply to the tumor.With an angiogram, dyeis injected into the

arteries and then x-rays

are taken that showabnormalities in the

arteries that lead to thebrain (4).

Biopsy, surgical With a biopsy, a sample

of the brain tissue isremoved to test for thepresence of cancer cells.

Biopsy is done by directexcision during a

surgical procedure.

Complications caninclude




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Biopsy, stereotactic Stereotactic brain

biopsy is a biopsyprocedure in which

biopsy forceps are

inserted into a lesionthrough a metal cannulapassed through the

brain parenchyma

rather than in an opensurgical procedure. After

injecting a localanesthetic, mostprocedures require a

frame be affixed to the

head. An MRI is used toguide the neurosurgeon.

An incision is made inthe scalp and then asmall hole drilled into

the skull for passage of

the needle, or cannula.There are some

complications associatedwith this procedure:

Non-diagnostic

results: Fifteen

percent to20% of

biopsyresults are

non-

diagnostic.Because the

amount oftissue taken

is verysmall, its

possible toessentiallymiss the

tumor

because ofsampling

the wrongarea, usingthe incorrect

coordinates,

ormisreading

the imaging. A non-

diagnostic

biopsyshould berepeated

one or twotimes.

Hemorrhage:




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The

trajectory ofthe cannula

or the site of

the biopsymay be toonear large

blood

vessels. The

surgeonstechniquetoo quick or

forceful in

passing thecannula

can tear tinybloodvessels.

Patients

blood maynot clot

properly. Typically

there is a

small degreeofhemorrhage

in almost allstereotacticbiopsies, but

they areusuallyinsignificant;

only 5% are

clinicallysignificant.

Infection: Infection is

a possibility

in anyinvasive

procedure.

Typicallyinfection willpresent with

red, swollentender skin

and scalp

around thecannula

insertionsite. More

severeinfections

can alsooccur within

the skull. Infection

complicates




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Classification of tumors

Tumors can be classified in different ways, and this can lead to confusion, but a common classificationsystem is that of the World Health Organization (WHO), last revised in 2007. The WHO incorporates and

interrelates morphology, cytogenetics, molecular genetics, and immunologic markers in an attempt toconstruct a cellular classification that is universally applicable and prognostically valid (3). The TNM(tumor size, nodal status, and metastatic spread) classification system does not relate well to tumors of

the central nervous system because the size of the tumor is less important than the location, there are nolymphatics so nodal status doesnt apply, and tumors rarely metastasize from the CNS to other parts of

the body (sometimes because death occurs early).

The classification system used is important because treatment is based on staging of the tumor, but other

factors, such as age, location, extent of resection, must be considered:

The histologic grade of the tumor is based on the regions of a tumor demonstrating the most

anaplasia, based on the assumption that the areas of greatest anaplasia determine the degree of

malignancy and progression of the disease. The WHO grading of CNS tumors establishes a malignancy scale based on histologic features of the

tumor and assigns grades I-IV with higher grades the most malignant (2, 3):

Low-grade astrocytomas grow very slowly in comparison to higher-grade malignant tumors. The doublingtime for low-grade tumors is about one-fourth that of anaplastic astrocytomas. With low-grade tumors,

only 5% ofstereotacticbrain

biopsies(10).

Visual field studies Visual field studies may

be ordered if there are

visual problems relatedto the brain tumor in

order to provide more

precise informationabout the extent of

visual field deficits (5,12).

Nursing interventions before diagnostic tests

Patients as well as family members are often anxious and fearful when faced with the possibility or

diagnosis of a brain tumor. Whether the nurse sees the patient in the doctors office or the hospital, heor she should take the time to explain the procedures to the patient and family and encourage

questions. Patients are often reluctant to ask the physician questions but usually have many questions

that they would like answered:

If pictures of the equipment (MRI, CT scanner) are available, its helpful to show them to thepatient so that the patient knows what to expect.

Tell the patient and family approximately how long the procedure will take and advise them of any

required preparations, such as fasting or not drinking fluids.

Question the patient regarding allergies to dyes or shellfish if the patient is to receive a contrastmedium.

If a surgical diagnostic procedure, such as a surgical biopsy or stereotactic biopsy, is to beperformed, explain in detail all preoperative preparation, including anesthesia.

Explain the procedure for preparing the patients head for the procedure if the head is to be

shaved in the area of the surgery (as or biopsy). Some peopleespecially males--may prefer to

shave their entire heads prior to the procedure.

(13)




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several years may pass between initial symptoms and diagnosis. In half of the cases of low-grade tumors,deterioration in condition is quite gradual and a sudden deterioration occurs in only about 15% of cases.

In general, patients with grade I and II tumors typically have survival rates that exceed 5 years. Thosewith grades III and IV glioblastomas have survival rates of 2-3 years although the outlook for some othertypes of tumors has improved markedly with cerebellar medulloblastomas and germ cell tumors (grade

IV) having 5-year survival rates of 60% and 80% if diagnosed early and treated with state-of-the-artradiation and chemotherapy (2, 3, 4, 14).

Astrocytic tumors

The WHO classifies all astrocytomas according to grade:

Subependymal giant cell astrocytoma (SEGA) (WHO grade I)

Subependymal giant cell astrocytoma (SEGA) is a benign, slow-growing tumor that usually arises in thelateral walls of the ventricles. It occurs almost exclusively in 6% to 16% of patients with tuberous

sclerosis complex (TSC) during the first two decades of life. Tuberous sclerosis complex is an autosomal-dominant, multisystem neurocutaneous syndrome usually characterized by seizures, mental retardation,

and facial adenoma sebaceum. This benign tumor may occur in various organs, including the brain.

Grade Description Comments

GradeI

Includes lesions with low proliferativepotential, a frequently discrete nature,

and the possibility of cure withsurgical resection alone.

Referred to as low-grade astrocytomas. These tend togrow slowly and remain localized. They are primarily

found in children.

Grade

II

Includes lesions that are usually

infiltrating and low in mitotic activitybut frequently recur.

Same as Above

Grade

III

Includes lesions with histologic

evidence of malignancy, usually in the

form of mitotic activity, clearinfiltrative capabilities, and anaplasia.

Referred to as high-grade tumors and grow rapidly,

spreading through the brain and spinal chord. This is the

most common type of astrocytoma found in adults.Grade III are called anaplastic astrocytomas. Grade IV

tumors are called glioblastoma multiforme.

Grade

IV

Grade IV Includes lesions that are

mitotically active, prone to necrosis,

and usually associated with rapidevolution of the disease, both pre-

and post-operatively.

Same as Above

Tumor WHO grade

Subependymal giant cell astrocytoma I

Pilocytic astrocytoma I

Pilomyxoid astrocytoma II

Diffuse astrocytoma

Fibrillary Protoplasmic Gemistocytic

II

Pleomorphic xanthoastrocytoma II

Anaplastic astrocytoma III

Glioblastoma IV

Giant cell glioblastoma IV

Gliosarcoma IV




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Patients historically presented with signs of increased intracranial pressure and death rates after surgeryapproached 10%, but currently biopsies often identify tumors and they are resected during the non-acutephase, and this has improved prognosis.

Treatment:

Surgical excision (3, 15)

Link to images (click on images to enlarge):

Pictures of subendymal giant cell astrocytoma

Pilocytic astrocytoma (WHO grade I)

The pilocytic astrocytoma, which occurs primarily in children ages 5-14 (average age 58 months), is acircumscribed, slow-growing and often cystic tumor. It is generally considered benign because it does not

invade surrounding tissue but can become very large. It represents 10% of cerebral tumors and 85% ofcerebellar astrocytic tumors. Pilocytic astrocytomas occur throughout the neuraxis, especially invading theoptic nerve, optic chiasm/hypothalamus, thalamus, and basal ganglia, cerebral hemispheres, cerebellum,

and brain stemmost commonly the cerebellum, the part of the brain that controls balance. Pilocytic

astrocytomas are sometimes excluded from consideration with other gliomas because they constitute adistinctive pathological and clinical entity. The most common symptoms are related to increased

intracranial pressure due to increased mass or hydrocephalus. These symptoms include the following,based on location:

Headache Nausea/vomiting Irritability Ataxia Visual complaints

This tumor is not usually fatal, having a 1- year survival rate of 90% if the tumor was completelyresected. With partial resection, the 10-year survival rate is 45%. It is associated with neurofibromatosis

type 1 (NF1), which is an autosomal dominant disorder characterized by the development of both benignand malignant tumors, especially involving the optic nerve.

Treatment:

Surgical excision (or stereotactic radiosurgery) if tumor is completely resectable. Surgical excision followed by radiation therapy if there is known or suspected residual tumor.

Follow up treatment with recurrence:

Reoperation and radiation therapy if not previously done.

If radiation previously done, patients may be considered for nitrosourea-based chemotherapies, fortemozozlomide, or for clinical trials of new drugs (3, 10, 17, 18, 19).

Link to images (Click images to enlarge):

Pictures of pilocytic astrocytoma

Pilomyxoid astrocytoma (WHO grade II)

The pilomyxoid astrocytoma (PMA), a tumor recently identified, is closely related to pilocytic astrocytoma

but is now classified separately. It occurs in sites that are also affected by pilocytic astrocytomas, such as

the hypothalamic/chiasmatic region, but it is histologically distinctive, and it appears much earlier. Itaffects primarily infants and children (median age of 10-18 months), and it has a less favorable outcome




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than pilocytic astrocytomas as it is more prone to have local recurrence (55%-76%) and cerebrospinalspread and recurrence is earlier than for pilocytic astrocytoma (2). Typically, children present with

indications of increased intracranial pressure or compression of parenchymal tissue with failure to thrive,delay in development, poor feeding, vomiting, alterations of consciousness, and general weakness.

Children with tumors in the cerebellar area may exhibit gait abnormalities, dysmetria, and nystagmus. If

the tumor extends into the foramen magnum, stiffness of the neck or head tilt may be noticeable. If thereis pressure on the 6th cranial nerve (rare), then strabismus may be evident. The first indication in infants

may be increase in head size, with increased intracranial pressure that may cause split sutures and

bulging fontanelles. Children often become irritable and lethargic with bradycardia and slowed respirationsas the disease progresses.

Treatment:

Definitive treatment is evolving as this tumor is studied. Currently, treatment is similar to that of pilocytic

astrocytoma although radiation is generally avoided in prepubertal patients. The more aggressive natureof this tumor may affect future protocols for treatment:

Surgical resection (or stereotactic radiosurgery) is the treatment of choice. Chemotherapy and/or radiation may be indicated despite morbidity. (29)

Link to images (Click images to enlarge)

Pictures of pilomyxoid astrocytoma

(16)

Diffuse astrocytoma (WHO grade II)

The diffuse astrocytoma, a low-grade tumor, is characterized by slow growth and infiltration of adjacent

brain structures. That is, the tumor often grows microscopic tentacles that spread into adjacent tissue,

making complete resection of the tumor very difficult. This type of tumor usually is found in young adultsand may progress to anaplastic astrocytoma and glioblastoma. Diffuse astrocytomas represent 35% of all

astrocytic brain tumors and may be located in any area of the central nervous system but are mostcommonly found in the cerebrum, the thinking part of the brain. There are three histologic variants:

fibrillary astrocytoma, gemistocytic astrocytoma, and protoplasmic astrocytoma. These types of tumorsmay occur in patients with Fraumeni syndrome, having inherited TP52 germline mutations. These

mutations are present in 60% of cases. The most common chromosomal alteration is the deletion ofchromosome band 17p13.1. Seizures and headaches are usually the earliest sings of this tumor. CT and

MRI scans show the presence of a tumor, which does not enhance (light up) when an intravenous contrastdye is administered. The average survival time after surgical resection is 6 to 8 years with considerable

individual variation, but most patients will eventually die from their tumors.

There is not yet consensus in regard to correct use of radiation therapy. Some prefer early radiation while

others prefer to wait for the tumor to begin to regrow. While studies show that early radiation may slightlydelay the average time until the tumor begins to regrow, the overall outcome was identical. About two-thirds of the deferred group required radiation about 5 years after diagnosis. Recurrent tumors tend to

return as biologically more aggressive tumors, making patients eligible for clinical trials available to

patients with high-grade gliomas.

Treatment:

Surgical resection followed by radiation

Surgical resection alone is preferred by some physicians if the patient is younger than 35 years oldand the tumor does not contrast-enhance on a CT scan.

Follow-up treatment with recurrence:

Participation in clinical trials. Some trials use radiation plus chemotherapy. Others evaluate deferring




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radiation therapy until tumor progression. Some vary the amount of radiation (3, 18, 19).


Pictures of diffuse astrocytoma

Pleomorphic xanthoastrocytoma (WHO grade II)

Pleomorphic xanthoastrocytoma is a rare astrocytic tumor that accounts for fewer than 1% of all

astrocytic neoplasms. It is most commonly found in children and young adults and involves the cerebrumand meninges. The average age at diagnosis is 12 years. These tumors very rarely undergo

transformation to a more malignant tumor. No genetic predisposition has been identified. Because thesetumors grow slowly, children may have vague symptoms for months before being seen by a physician.The most common symptom at diagnosis is seizure activity. This tumor has a relatively favorable

prognosis with recurrence-free survivals of 72% at 5 years and 61% at 10 years.

Treatment:

Surgical excision

Treatment after recurrence

Surgical excision

Participation in clinical trials (3, 21)


Pictures of pleomorphic xanthoastrocytoma

Anaplastic astrocytoma (WHO grade III)

Anaplastic astrocytoma, also known as malignant astrocytoma or high-grade astrocytoma, may arise from

a diffuse astrocytoma or on its own without a less malignant precursor. Anaplastic astrocytomas oftenprogress to glioblastoma. The average age at diagnosis for adults is 41 years; for children, 9 to 10 yearsold. The tumor primarily affects the cerebral hemispheres (65%) but 20% may also occur in the area of

the thalamus and hypothalamus or the diencephalon. Another 15% occur in the area of the cerebellumand brain stem area known as the posterior fossa. Similar to diffuse astrocytomas, anaplasticastrocytomas have a high frequency of TP53 mutations, but chromosomal abnormalities are non-specific.

Many of the genetic alterations involve genes that regulate cell cycle progression. Some patients suffer aslow insidious onset of symptoms but others have abrupt symptoms. The most common symptoms arethe following:

Headache and lethargy With increased pressure in the brain, the headache is usually upon awakening in the morning

Vomiting Seizures may occur but les frequently than in low-grade tumors

Various symptoms depending upon location of the tumor

The average time to progression of the tumor is 2 years. These tumors have a low cure rate and patients

are candidates for clinical trials. The best-reported survival rates for radically-removed tumors and

adjuvant radiation therapy are about 40% after 5 years; however, most tumors are not completelyremoved and the survival rate is then less than 20 percent.

Treatment:

Surgery plus radiation Surgery plus radiation and chemotherapy, such as temozozlomide




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Carmustine (BCNU)-impregnated polymer may be implanted during surgery. Participation in clinical trials

Follow-up treatment with recurrence:

Participation in various clinical trials. (3, 9)


Pictures of anaplastic astrocytoma

Glioblastoma (WHO grade IV)

Glioblastoma, also known as glioblastoma multiforme, may develop as a progression from a diffuseastrocytoma or an anaplastic astrocytoma (then called a secondary glioblastoma) but more commonly

appears without evidence of a lesser grade tumor. Glioblastoma is the most commonly occurring braintumor, 12% to 15% of all brain tumors but 50% to 60% of all astrocytic tumors. It is one of the most

devastating tumors. This tumor primarily affects adults (70%), with peak incidence between ages 45 and

70. About 8.8% of glioblastomas occur in children. Glioblastomas primarily occur in the cerebral

hemispheres. There are two histologic variants: giant cell glioblastoma and gliosarcoma. Glioblastomashave been associated with more genetic abnormalities than any other astrocytic tumor. Chromosomal

abnormalities of chromosome 10 are the most frequently observed chromosome alterations. Advances in

the fields of molecular biology and cellular biology and genomics have provided more knowledge aboutglioblastomas, which possess multiple genetic and chromosomal abnormalities that cause these tumors to

grow so rapidly. Glioblastomas are unique in the ability to proliferate uncontrollably and aggressivelyinvade, infiltrate, and destroy surrounding brain tissue. While some have theorized that high-tensionelectrical lines and cell phones may cause glioblastomas, the only consistently identified risk factor is

chronic exposure to petrochemicals. The most common presenting symptoms are the following:

Slowly progressive neurologic deficit, generally motor weakness

Generalized symptoms of increased intracranial pressure, including headaches, nausea andvomiting, and cognitive impairment

Seizures

Glioblastomas are among the most aggressive malignant human neoplasms with survival rates of less

than a year although some of the newer radiosurgery techniques have extended survival to two years.Glioblastomas typically contain more than one type of cell. While treatment may kill one type of cell, theother cell types may continue to multiply, making glioblastomas very difficult to treat. Treatment for

glioblastoma is palliative rather than curative. There have been no significant advancements in treatmentin the last 25 years although current treatment prolongs quality survival. With no treatment, death usually

occurs within 3 months, but is extended to one year with aggressive treatment. Length of survival is

better for those whose tumor is located in the frontal lobe of the brain rather than the temporal or parietallobes.

Treatment:

Surgery plus radiation and chemotherapy To delay recurrence, a large single boost dose of stereotactic radiosurgery may be

administered to a sharply delineated region of the tumor bed after standard resection and

irradiation.

Surgery plus radiation Surgery with BCNU-impregnated polymer (Gliadel wafer) implanted during initial surgery added 2

months to average survival rate.

Radiation therapy alone or with temozozlomide Participation in clinical trials (3, 14, 17)





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Pictures of glioblastoma

Treatment Options

There are three treatment options for brain tumors (surgery, radiation, and chemotherapy) although not

all tumors respond to all three treatments. Newer surgical techniques, such as endonasal approaches andCyberKnife, have made surgical removal of previously inoperable tumors possible. Because grades IIIand IV tumors grow rapidly, postoperative radiation and chemotherapy are usually started within 2-4

weeks of surgery.

Surgical excision, craniotomy

Surgery has more than one role in treatment as it may be used for biopsy, treatment of increased

intracranial pressure, and tumor removal. Surgical excision is the therapy of choice as complete removal

of the tumor is the most effective treatment; however, some tumors are located in areas that are notaccessible by surgery. Tumors of the cerebral hemispheres are usually easier to remove than those of the

midline, diencephalic structures. Some tumors have infiltrated adjacent brain structures and tissue to thedegree that complete surgical excision is not possible. Recurrent tumors are usually treated with re-surgery.

While some astrocytomas are not cured by surgery because the tumors have infiltrated surrounding

tissue, the surgery may reduce pressure of the tumor against the rest of the brain if the tumor is large.

Relieving this pressure may reduce symptoms, such as headaches, nausea, vomiting, and blurred vision.Surgery may also prolong life even though it is not curative.

A craniotomy involves making a surgical opening through the skull. After the patient is anesthetized, thehead may be shaved and an incision made through the skin. The scalp is then folded back to expose the

skull and small holes, called burr holes, are drilled in the skull with a power drill. The surgeon then cutsbetween the holes with a surgical saw and lifts the piece of skull, exposing the surface of the brain. Thesize must be large enough to accommodate instruments and allow viewing of parts of the brain. If the

Nursing interventions, preoperatively

Prior to surgery on the brainwhether the procedure be an open craniotomy or closed stereotacticradiographypatients are anxious and fearful. Part of the nurses responsibility is to help allay this fear

by informing the patient:

Answer questions and allow time for the patient to express feelings.

Explain all pre-operative preparations, such as diagnostic tests. Explain pre-operative restrictions:

Over-the-counter medications containing aspirin, ibuprofen or any other blood-thinning

medications should be stopped one week prior to surgery. Fiorinal, Darvon Compound 65, and Percodan should be stopped 7 to 10 days prior to

surgery.

Coumadin needs to be stopped about 5 days prior to surgery and a Prothrombin timechecked on the morning of surgery.

Explain pre-surgical and anesthesia procedures in as much detail as possible, such as when patient

will be taken to the operating room, when IV will be started, and what procedures will be done

while patient is awake. Explain the procedure for preparing the patients head for surgerywhether the hair will be shaved

and how much. Discuss the probable length of the surgery and how family members will be notified of progress

and where they can wait.

Explain where patient will be treated post-operatively, for example recovery room, critical care, or

ICU. If patient is to be transferred to a specialized unit, if possible allow the patient to visit the unitor, if thats not allowed, describe the unit to the patient.

Discuss how the patient will look after the surgery. Explain post-operative care and assessments.




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tumor is within the brain rather than on the surface, a small incision is made into the brain. The surgeonmay operate while viewing through a microscope. With microsurgical equipment and techniques, it ispossible to remove tumors with must less damage to surrounding areas than previously. For example,

tumors at the base of the frontal area may be reached by going under the brain rather than through braintissue. The surgeon may use MRI, CT, or ultrasound image guidance to locate and map the area of the

tumor in order to minimize damage to healthy tissue.

The tumor may be removed using different procedures. Some tumors are excised using a scalpel. Suction

with a small vacuum tube and cautery, the use of an electric current to seal blood vessels, may be used.In some instances, ultrasonic aspiration may be used to remove a brain tumor rather than a scalpel.Ultrasonic waves fragment the tumor, and the fragments are removed by suction. In some cases, where

patients ability to speak or motor control are issues, awake surgery may be done. The patient is broughtto consciousness after the brain is accessed and is able to respond and react during the surgery (3, 10,13).

Surgery, endoscopic transnasal brain surgery (ETBS)

Endoscopic transnasal brain surgery (minimally-invasive technique) is a new method of tumor removal inwhich access to the base of the brain as well as within the brain and the spinal cord is achieved throughthe nose and nasal sinuses. This method of surgery merges the medical specialties of otolaryngology and

neurosurgery. Miniature scopes and surgical tools are threaded through the soft tissue of the nose. This

approach is frequently used for pituitary tumors. Some tumors that were previously thought to beinoperable because of difficulty of access with a craniotomy can be excised through this method. Baseball-

sized tumors have been removed without damaging other brain tissue. This method holds the promise ofreducing the need for the more invasive craniotomy for many types of tumors. Because there is little

trauma involved in this type of surgery compared to traditional craniotomy, patients can begin radiationand/or chemotherapy almost immediately after surgery. The thinnest part of the skull is at the top of the

nasal passage, so access to the brain is relatively easy. A lighted endoscope is advanced through anopening with the surgeon viewing the tissue on a monitor. This technique can also be used to remove

cerebral aneurysms. The instruments go to the center of the tumor and then tiny pieces are removed oneat a time (5).

Surgery, transorbital

Transorbital craniotomy (accessing the brain through the orbit of the eye) emerged as collaborationbetween neurosurgeons and oculoplastic surgeons. Usually, a superbrow approach, with a small incisionover the brow, is used, and the tumor is located using MRI guidance and microscopic tools. Only a small

amount of bone is removed. This approach is most commonly used for benign tumors at present, but itallows access with less disfigurement and trauma (22).

Stereotactic excision

Image-guided surgery technology lets the surgeon see the brain in three dimensions and pinpoint thetumor with the aid of CT and MRI. Patients are generally fitted with a lightweight halo frame to keep thehead still. The frame is firmly attached with screws to the external surface of the skull, usually under a

local anesthetic while the patient is awake. Stereotactic excision may be used for the removal of smalltumors as it is less invasive than the traditional craniotomy because it requires only a small opening into

the skull and less damage to the tissue (3, 11, 23).

Stereotactic radiosurgery

Stereotactic radiosurgery uses precisely focused radiation to treat tumors in the brain. Computers create3-D images of the brain, and these images guide radiation oncologists and surgeons in focusing radiationat the target area. Patients are generally fitted with a lightweight frame to keep the head still. The

technology allows high doses of radiation to be delivered to the tumor with minimal damage tosurrounding healthy tissue. This procedure is essentially surgery without an incision. Adults usually

require no general anesthesia. Studies have shown that radiosurgery is effective for low-grade gliomas in

children. Because this type of surgery requires no incision, recovery time is minimal as are side effects.The tumor dies slowly over a fairly long period of timeup to 2 years for benign tumors and months for




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malignant or metastatic tumors, which divide at a faster rat. The tumor shrinks and is replaced with scar

tissue, so stereotactic radiosurgery is used for small tumors and is not appropriate for all tumors,

depending on the type of tumor and the location. All forms of radiotherapy pose some risks:

Edema: Swelling may occur as the cells of the irradiated tumor lose their ability to regulator fluids.

This is usually treated with a short course of steroids. Necrosis: Sometimes, the necrotic tissue that remains after the tumor shrinks can cause problems

and may need to be removed, but this is a rare complication (17).

Gamma Knife

Gamma Knife is one type of stereotactic radiosurgery, used for tumors less than 4cm in diameter. Prior

to the radiosurgery, the patient is fitted with a stereotactic frame that is screwed to the skull to

immobilize the head, and using CT and MRI (preferred because it avoids the high doses of x-rayassociated with CTs), the physician determines the exact location of the tumora process that may take

up to 5 hours. Then the patient is placed in a metal helmet-like device with several ports through which201 beams of cobalt 60 are directed at the center of the lesion. Only at the point where all the 201 beamscross is enough radiation delivered to affect the tissue (with an accuracy of about 0.5mm), so surrounding

tissue is spared. The treatment continues for 3 to 10 minutes. Because of the degree of accuracy, a full

dose of radiation can usually be delivered in one treatment rather than the multiple sessions required forlinear accelerators, which use fractionated treatment. The basic design of the Gamma Knife, with the

helmet, limits its use to the head (3, 11, 23, 24).

CyberKnife




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CyberKnife is another radiosurgery device, but it does not require a frame for precise targeting. Becauseof this, surgeons can divide a large radiosurgical dose into more than one stage or fraction, called staged

radiosurgery. The CyberKnife system was designed to address the limitations of the framed-basedsystems. It incorporates a miniature linear accelerator mounted on a flexible, robotic arm. An image-guidance system that can track target location during treatment allows for superior targeting accuracy

without the need for the stereotactic frame; however, it does expose the patient to more general radiation

from the tracking system than Gamma Knife procedures. Some patients may experience transientdizziness, lightheadedness, or mild headaches after treatment. These symptoms may be treated with a

short course of corticosteroids. Because it does not require a frame, CyberKnife radiosurgery can be

used outside of the head for other types of tumors, so it can be used for wider applications (17).

Radiotherapy, external beam

Most tumors that are not completely removed by surgical excision are treated with high-energy radiation

to kill the remaining cancerous cells. Radiation from an external source is called external beam radiation.

Radiation may be used as a primary treatment to kill cancer cells by altering the cell membrane in orderto shrink tumors. Radiation may also be reserved for recurrence. With whole brain radiation, cognitive

impairment, such as short-term memory loss, was common, but focal radiation therapy, where theradiation is focused on the tumor and a small margin around the tumor, has minimized radiation to non-affected parts of the brain and there appears to be no cognitive impairment. However, repeat irradiation

can cause necrosis of tissue; thus, re-irradiation is usually not given to patients with recurrent tumors.

Radiotherapy is individually planned for each patient. Prior to the first treatment, patients will have x-rays, scans, or MRI of the area to be treated so that the radiographer can plan the correct position of thetreatment. A newer technique called 3D conformal therapy that uses computers and CT scans to plan

radiation therapy is being used in many cancer centers. With 3D conformal therapy, the radiation beam

can be better matched to the shape of the tumor. Once the treatment area has been finalized, inkmarkings are usually made on the skin to pinpoint the area. These markings are not permanent and can

rub or wash off. Additionally, sometimes 2 or 3 permanent pinpoint tattoo marks are also made on theskin. The advantage to the permanent tattoo marks is that it insures that the treatment will be given tothe same spot each time and it leaves a record of where the radiotherapy was given.

Radiotherapy: Discussion

Linear Accelerator: Radiotherapy is usually

administered over a period

of 2 to 7 weeks ratherthan one session. The

dosage is neither as highas with stereotacticradiosurgery nor as

precisely focused. Because

normal cells may bedamaged by radiotherapy,

administration infractionated doses overtime allows the normal




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Even with improvements in delivery and newer machines, there are still side effects associated with all

fractionated radiotherapy. Short-term side effects include these symptoms:

Fatigue Loss of appetite Nausea Skin rashes and hair loss over substantial regions of the scalp

There are also some delayed side effects that occur within months to years:

Varying degrees of memory loss and impairment of reasoning or thinking More rarely, impairment of pituitary function or radiation necrosis.

Children are more sensitive to radiation than adults and, because of longer life expectancy, may exhibit

cells to heal. Treatments

are usually administeredMonday through Friday,leaving patients to rest on

the weekend althoughsome people will have

treatment fewer days per

week. Each treatment iscalled a fraction becauseits a fraction of the total

treatment. There are

different types ofradiotherapy machines,

including linearaccelerators, and some arequicker than others and

may give treatment in a

very short time, such asseconds, while other make

take a few minutes.

IMRT Intensity ModulatedRadiation Therapy(IMRT), a shaped-beamsystem, is an important

advance in radiationtherapy. It utilizes apowerful computer to

evaluate millions ofpossible beamarrangements and

determine a finaltreatment plan. Thistechnology uses real-time

computer control to focus

higher doses of cancer-killing energy on tumors

while sparing surroundinghealthy tissue. IMRTtechnology enables a

mechanical device, called amulti-leaf collimator, which

is generally attached to

most modern




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more long-term damage, so the benefits of radiotherapy must be weighed against potential morbidity.Children may exhibit facial growth retardation, hypothyroidism, and cognitive impairment as the result ofprepubertal radiotherapy. While radiation is more damaging to cancer cells than normal cells, it is

inevitable that some normal cells will be damaged. Sometimes months or years after irradiation, a massof dead tissue forms at the site of the irradiated tumor. This is called radiation necrosis, and it most

cases it includes both cancerous and noncancerous tissue. Patients with radiation necrosis generally do

better than patients with recurrent tumor even though the area of radiation necrosis must be surgicallyremoved. However, a small number of patients with radiation necrosis do poorly or die. If large areas of

the brain require radiation, significant changes in brain function may result, such as memory loss andlowered thinking ability (3, 10, 13, 17, 23, 24).

Chemotherapy/Gene therapy

Chemotherapy is drug treatment that interferes with the cancer cells ability to grow or reproduce. It is

often used after surgical removal of a tumor, especially for invasive tumors or if the tumor was only

partially resected. Chemotherapy is more useful for some types of tumors than others. Mostchemotherapy is given intravenously. As with all chemotherapy, there are many side effects associated

with treatment. High-dose chemotherapy also kills bone marrow cells that are needed to produce blood.This raises the risk of infection and slows down delivery of the chemotherapy.

After tumor removal, BCNU polymer water implants may be inserted at the site of the tumor. These

wafers are biodegradable and release chemotherapeutic agents over time.

There are a number of clinical trials now taking place, using chemotherapy alone or in combination withradiation to treat brain tumors. Some novel approaches to treatment are now being tested, such as

approaches that involve stimulating the bodys natural immune system and drugs that decrease thetumors blood supply as well as drugs that target biochemical pathways that are active in tumor cells butinactive in healthy cells.

Studies are in progress to determine if adding three drugs to radiation improves outcomes: procarbazine,CNU, and vincristine (PCV). Another therapy uses the oral anti-tumor drug temozozlomide in small daily

doses. Gene therapy approaches are being developed to protect the bone marrow from side effects so thatchemotherapy can be more effective (3, 10).

Brachytherapy (interstitial implantation)

Interstitial radiation treatment, also called brachytherapy, involves implanting radium isotopes directlyinto the tumor, often done after incomplete surgical excision of invasive tumors. It is particularly effective

for high-grade tumors with poor prognosis because of local persistence after surgery. Interstitial

implantation may be used as an alternative to external-beam radiation, which poses a risk to healthytissue because interstitial implantation allows a higher dose of radiation to be delivered without damagingsurrounding tissue. Typically, a catheter is placed into the brain to allow the radiation source to be

delivered to the tumor. The radioactive source may be left in place for hours or days, depending upontumor. Sometimes, the radioactive material is permanently placed into the area of the tumor during

surgery (25).

Nursing interventions, postoperatively

The focus of postoperative care is on monitoring the patients condition, observing changes in condition,and preventing complications:

Observe for signs of increased intracranial pressure (ICP):

Monitor vital signs q 15-30 minutes initially and then every hour as ordered. Monitor intracranial pressure.

Position head in midline, neutral position Elevate head of bed 30 to 45 degrees for supratentorial surgery (in upper part of the brain). Keep patient flat or elevate head slightly for infratentorial surgery (in posterior fossa).

Monitor fluid intake and output:




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Glasgow coma scale

Based on motor responsiveness, verbal performance, and eye opening to appropriate stimuli, the Glasgow

Coma Scale was designed and used to assess the depth and duration of coma and impairedconsciousness. This scale may be used to assess the degree of trauma the patient has suffered from thetumor both preoperatively and post-operatively.

The GCS is scored between 3 and 15, with 3 being the worst, and 15 the best. It is composed of three

parameters: Best Eye Response, Best Verbal Response, and Best Motor Response.

Maintain strict intake and output records.

Monitor urinary flow. Measure or estimate amount of drainage.

Provide wound care/observe for signs of infection: Observe for drainage on dressingscircle and date. Notify the physician immediately if there is cerebrospinal fluid drainage. Empty and measure drainage from surgical drains, such as Hemovacs, every 8 hours (30-

50cc per shift is typical).

Maintain pain control & provide comfort measures: Give pain medications and document effectiveness.

Provide comfort measures, such as cool compresses and backrubs. Allow patient periods of rest. Provide mouth care.

Provide general care:

Turn, cough, and deep breathe every 2 hours, but do not position on operative side,especially if the bone flap has been removed.

Assist with range of motion exercises every shift. Maintain patent airway:

Limit use of suction to 10 seconds, only 2 passes and pre-oxygenate.

Monitor routine postoperative laboratory studies:

Complete blood countHgb and Hct may fall from blood loss Serum electrolyte levelsespecially observe for hypernatremia and hypokalemia

Coagulation studies Arterial blood gas measurementsto ensure proper cerebral oxygenation

Administer medications as prescribed:

Anticonvulsants Corticosteroids Histamine blockers

Analgesics Antibiotics

Prevent hyperthermia:

Anti-pyretics (acetaminophen) Cooling blanket

Prevent venous thromboembolism

Compression stockings

Intermittent pneumatic compression

Glasgow Coma Scale Parameters Score

Eye opening response:

Spontaneousopen with blinking at baseline 4

To verbal stimuli, command, speech 3

To pain only (not applied to face) 2

No response 1

Verbal response:

Oriented 5

Confused conversation, but able to answer questions 4




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What are common post-operative complications?

Increased intracranial pressure (ICP)

Venous thromboembolism Hematomas/Hemorrhage Hypovolemic shock

Hydrocephalus Respiratory disorders Wound infection

Meningitis Fluid and electrolyte imbalance

Increased intracranial pressure

Increased intracranial pressure (ICP) is the major complication after removal of a brain tumor, so

monitoring of ICP is of critical importance. Normal ICP is 0-15mm HG on transducer or 80-180mm H2O onmanometer. Increased ICP is related to a number of other complications:

Cerebral edema Hemorrhage Obstruction of the normal flow of cerebral spinal fluid (CSF)

Inappropriate words 3

Incomprehensible speech 2

No response 1

Motor response:

Obeys commands for movement 6

Purposeful movement to painful stimulus 5 Withdraws in response to pain 4

Flexion in response to pain (decorticate posturing) 3

Extension response in response to pain (decerebrate posturing 2

No response 1

Total Score:

Head injury classifications in relation to score:

ComaGCS score 3-8 Severe head injuryGCS score of 8 or less

Moderate head injuryGCS score of 9 to 12 Mild head injuryGCS score of 13 to 15

Measure Indications

Temperature Increase can indicate a postoperative infection.

Pulse Compression in the medulla area can affect the cardiac center and cause changes in

heart rate.

Respiration Increase may indicate damage to the midbrain. Decrease may indicate damage to lowerpons and upper medulla.

Bloodpressure

Increase associated with sympathetic stimulation. Decrease associated with increasingintracranial pressure.

Pupils Only one pupil reacting may indicate pressure on the 3rd cranial nerve.Dilated or pinpoint pupils that are slow to react or non-reactive to light may indicate

increased intracranial pressure.




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As intracranial pressure increases, the patient will experience a number of symptoms:

Severe headache Deteriorating level of consciousness Restlessness & irritability

Dilated or pinpoint pupils that are slow to react or non-reactive to light. Seizure activity

Increased motor weakness Bradycardia & hypertension may occur late Cushings Triad (typical changes in vital signs) is a late sign of increasing ICP:

Systolic pressures increases with widened pulse pressure Slowing of heart rate occurs in response to increased systolic pressure Respiration rate decreases

Treatment will be directed at the underlying cause of the increased ICP. Treatment may includemedications, ventilation, and further surgery (5, 22, 28, 29).

Venous thromboembolism

Deep venous thromboembolism (VTE), especially in the calves of the legs, and leading to pulmonary

embolism (PE) is a common complication after craniotomy for brain tumors. Careful observation, range ofmotion, encouraging mobility, and care of compression stocking or intermittent pressure boots is

necessary to prevent this complication. Patients may be asymptomatic or may present with a number of

different symptoms:

Calf or groin tenderness or pain Positive Homans sign

Pain in the calf on dorsiflexion of the foot

Localized edema Compromised circulation Shortness of breath Fever

Studies have indicated that daily prophylactic anticoagulant therapy with enoxaparin, heparin, or

dalteparin along with the use of intermittent pneumatic compression device and graduated compressionstockings was very effective in reducing the incidence of thromboembolism and carries no additional riskof hemorrhage (5, 18).

Hematomas/Hemorrhage

Monroe-Kellie Hypothesis

The Monroe-Kellie Hypothesis states that to maintain a normal ICP, a change in the volume of one

compartment must be offset by a reciprocal change in the volume of another compartment. The brain

consists of three compartments:

Brain tissue Cerebrospinal fluid Blood

Thus, except in neonates, the skull cannot expand easily expand to allow for extra space-occupying fluidor tissue, so if one of three component increase, the other two must decrease in order to compensate.

The cerebrospinal fluid (CSF) and blood volume are the compartments that most easily change to

accommodate changes in pressure. Medical interventions to treat increased ICP and prevent secondarybrain injury follow these principles and focus primarily on cerebral blood flow and drainage.




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There are three types of hematomas/hemorrhage that may occur after craniotomy:

Epidural hematoma (between the dura mater and the skull) Subdural hematoma (between the dura mater and the arachnoid mater) Subarachnoid hemorrhage (in the subarachnoid space)

Patients who suffer from intracranial bleeding may exhibit the following symptoms:

Severe headaches Change in level of consciousness Neurologic deficits Herniation syndromes Sudden cardiovascular and respiratory arrest (with bleeding into the posterior fossa.

Monitoring ICP is especially important to observe for this complication. Treatment varies according to the

location and extent of the bleeding, but hematomas generally necessitate surgical removal to relievepressure. Intracranial hemorrhage may be treated medically with osmotic diuretics and ICP monitoring(5).

Hypovolemic shock

Hypovolemic shock is the result of blood loss both during and after surgery. It can also be caused byinadequate replacement of fluids, dehydration brought on by fluid restriction, or the administration of

osmotic diuretics. Thus, monitoring of intake and output is critically important. A patient usually exhibitsthe typical shock symptoms:

Hypotension Cold, clammy skin Rapid, thready pulse

Pallor

Intravenous fluid replacement is necessary to reverse hypovolemic shock (5, 22).

Compensatory reactions affecting cerebral metabolism

Ischemia/Edema




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Hydrocephalus

Hydrocephalus can result when there is obstruction of the normal cerebrospinal fluid (CSF) for variousreasons:

Edema:

Cerebral edema may be present before surgery and usually reaches a peak within 72 hoursafter surgery.

Expanding lesions, such as hematoma or blood in the subarachnoid space.

Hydrocephalus may produce different symptoms, depending upon the speed of progression. Rapidlyprogressive hydrocephalus produces classic symptoms of ICP:

(See above)

Slowly progressive hydrocephalus causes less severe symptoms:

Headache

Decreased level of consciousness Irritability

Blurred vision

Urinary incontinence

Depending upon the cause of the hydrocephalus, the condition may be self-limiting and controlled by dailylumbar punctures to remove CSF. If the condition persists or worsens, surgical interventionplacing ashunt to drain CSFmay be required. Usually a ventriculoperitoneal shunt is performed, but a

ventriculoatrial or a lumbar peritoneal shunt may be done. Patients who receive a shunt must be observedcarefully for signs of subdural hematoma from tearing of bridging veins (5, 22).

Ventriculoperitoneal shunt:

When cerebral ischemia/anoxia occurs, the brain doesnt get enough oxygen so the brain compensatesby dilating blood vessels to get more oxygen, thus resulting in cerebral edema.

Mean arterial pressure

The mean arterial pressure (MAP) affects cerebral flow.

Normal readings 50mm Hg to 150mm Hg: Below 50mm Hg cerebral flow decreases, leading to ischemia Above 150mm Hg cerebral blood vessels are maximally constricted and the brain barrier is

disrupted, leading to cerebral edema and increased intracranial pressure.

MAP = Diastolic BP (DBP) + 1/3 pulse pressure

Cerebral Perfusion Pressure (CPP)

Cerebral perfusion pressure is that needed to maintain blood flow to the brain:

MAP-ICP= CPP

Normal CPP is 60-100:


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Respiratory disorders

Most respiratory disorders following surgery can be prevented by good general care that includes deepbreathing hourly and turning the patient frequently. The most common respiratory complications includethe following:

Atelectasis Pneumonia

Neurogenic pulmonary edema

Neurogenic pulmonary edema occurs infrequently but most people do not survive this complication. Itssymptoms are the same as acute pulmonary edema, but there is no cardiac problem. Patients who

develop any of the respiratory disorders after surgery must be treated aggressively. Treatment may

include the following:

Humidified air Medications Incentive spirometry Endotracheal or oral tracheal suctioning

Chest physiotherapy

Some of these treatments may cause an increase in ICP but the benefit may outweigh the risk (5).

Wound infection

Wound infections become obvious when the wound site becomes red and puffy, and there may be

purulent or serosanguineous discharge. The patient may be febrile. Proper wound care is important toprevent infections. Wound infections occur most often in patients who are already compromised for avariety of reasons:

Older, debilitated History of diabetes




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Long-term steroid use Obesity

Previous infection

Treatment of localized infection may require only cleansing and topical antibiotics, but a more generalizedinfection may be treated with systemic antibiotics (5).

Meningitis

Meningitis is an inflammation of the meninges of the brain, involving the arachnoid and pia mater as wellas the spinal cord. Meningitis can be caused by a variety of organisms, but post-surgical meningitis is

generally caused by bacteria. In the case of surgery, the direct route of entry by bacteria into the brain

occurs. The organism invades the central nervous system through the subarachnoid space. This producesan inflammatory reaction in the pia mater, the arachnoid, the CSF, and the ventricles. An exudate,

consisting of bacteria, fibrin, and leukocytes, forms in the subarachnoid space and accumulates in theCSF, causing it to thicken and interfering with the normal flow of CSF around the brain and spinal chord.This can lead to a number of complications:

Hydrocephalus (see above) Further inflammatory reaction

ICP (see above) Rapid vasodilation of the cerebral vessels, leading to engorgement, rupture, or thrombosis of the

vessel walls Infarcted brain tissue

Vascular dysfunction from septic emboli

Signs of meningeal irritation may include these symptoms:

Nuchal rigidity Stiff neck and soreness

Positive Kernigs sign (indicates bacterial infection rather than viral):

Flex the patients leg at the hip, and bring the knee to a 90-degree angle, and then attempt toextend the knee and straighten the leg. This will cause pain and spasm of the hamstring

muscle, secondary to meningeal irritation and spinal nerve root inflammation caused by

exudates. Positive Brudzinskis sign (indicates bacterial infection rather than viral):

Flex the patients head and neck onto the chest. A positive response causes flexion of the hips

and knees. Seizure activity

Analysis of cerebrospinal fluid is the most significant laboratory test for diagnosis of meningitis, but it isnot usually done with ICP because this can lead to herniation of the brain tissue onto the medulla and

cardiopulmonary arrest. Treatment must be instituted immediately and often includes the following:

Medications: Broad spectrum antibiotics Hyperosmolar agents Steroids Anticonvulsants

Isolation procedures: Often for the first 24 hours, depending upon hospital policy

Neurologic assessment: This should include complete cranial nerve testing 6th cranial nerve defectinability to move eyes laterallymay indicate hydrocephalus

Vascular assessment:

Assessment of temperature, color, pulses, and capillary refill (normal capillary refill occurs

within 3 seconds) Seizure precautions Pain control:




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Pain:

Combination of drug and non-drug measures, such as ice cap for relief of headache,keeping room quiet

Photophobia:

Keep lights dimmed, close blinds or curtains (5, 28)

Fluid and electrolyte imbalance

Both diabetes insipidus and the syndrome of inappropriate antidiuretic hormone (SIADH) are

complications related to fluid and electrolyte imbalance. Maintaining correct intake and output reports areessential in order to diagnose these complications and to treat them.

Diabetes insipidus: Most common after surgery on pituitary gland or in the area of the hypothalamus or third

ventricle.

Urinary output increases dramatically and specific gravity drops below 1.005.

Treated with fluid replacement and medications. SIADH:

Occurs when the pituitary gland secretes too much ADH, causing water retention. Urinary output decreases or ceases. Serum sodium levels fall, but sodium concentration is normal or elevated in the urine.

Treated with medication.

Summary

Primary brain tumors arise within the brain tissue as opposed to metastatic brain tumors, which originateoutside of the brain. Primary brain tumors may be either benign or malignant. Malignant tumors tend to

Nursing interventions, discharge

Discharge planning will vary depending upon the age of the patient and the degree of residual disability.Discharge planning after removal of a brain tumor should always include:

Information about follow up appointments

Instruction in wound care

Instruction on all medications, including a review of the proper dosage, the frequency, and anyside effects

Information about seizure precautions and what to do if a seizure occurs Information about any follow up treatments, such as radiotherapy or chemotherapy

Instructions about activity restrictions, such as not bending over, keeping head above heart, or notturning to operative side.

For those with residual physical impairment, such as hemiparesis or cognitive or emotional changes, the

patient and family may need further planning:

Assistance for patient and family to develop strategies for dealing with residual problems Home preparation, such as making the environment safe by removing throw rugs and installing

grab bars Referral to rehabilitation center or physical therapist

Some patients (and family) who face prolonged recovery or impending death may need help dealing with

multiple problems, including financial and emotional:

Referral to social worker Referral to support groups or counseling Information about disease and prognosis, including brochures, handouts, and internet resources Information about healthcare resources, such as the American Cancer Society, National Cancer

Institute, and the Association for Brain Tumor Research




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grow faster and spread into the surrounding brain tissue, making complete removal difficult. Astrocytomasarising from neuroglial tissue account for about 40% of primary tumors of the brain and spinal cord.

Astrocytomas are classified according to the World Health Organization (WHO) into 4 grades (I, II, III,and IV) depending on a number of factors related to the degree of malignancy. There is no clear cause forastrocytic tumors, but patients who receive therapeutic radiation for other tumors and children who

receive irradiation of the central nervous system for acute lymphoblastic leukemia are at increased risk.Lower grade tumors may progress to more malignant forms. Some people may be at genetic risk for

developing tumors. Occupational exposure to chemicals may also increase risk. Symptoms can vary

widely depending upon the portion of the brain affected by the tumor, but general presenting symptomsinclude headache, changes in vision, nausea and vomiting, seizures, personality changes, dementia,memory loss, inability to concentrate, and ataxia. As the tumor grows, it can lead to a number of

complications, such as cerebral edema, ischemia, focal neurologic developments, hemorrhage, seizureactivity, obstruction of CSF, and pituitary dysfunction leading to inappropriate antidiuretic hormone or

diabetes insipidus. Diagnosis of astrocytic tumors is based on a number of different procedures, including

neurological examination, CT, MRI, MRS, PET, angiography, surgical biopsy, stereotactic biopsy, and visualfield studies. Astrocytic tumors comprise pilocytic astrocytoma, diffuse astrocytoma, anaplasticastrocytoma, glioblastoma, pleomorphic xanthoastrocytoma, and subependymal giant cell astrocytoma.

There are 3 types of treatment options for brain tumors: surgery, radiotherapy, and chemotherapy.

Surgery may involve traditional surgical excision, stereotactic excision, or non-invasive stereotacticradiosurgery. Treatment for all of these tumors involves removal of the tumor by surgery alone or

combined with radiotherapy and/or chemotherapy. The focus on postoperative care is to monitor thepatients condition, observe changes, and prevent complications. Common postoperative complications

include increased intracranial pressure (ICP), venous thromboembolism, hematomas/hemorrhage,hypovolemic shock, hydrocephalus, respiratory disorders, wound infection, meningitis, and fluid and

electrolyte imbalance. Nursing care, including the monitoring of ICP is of critical important in the post-operative period. Nurses must also help to prepare the patient and family to deal with residual problems

upon discharge.

References

1. Glioblastoma. (2008). Medifocus. Retrieved October 25, 2008, from

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Course Exam

1. Primary brain tumors rarely metastasize outside of the central nervous system.

True False

2. If a patient has a primary cancer elsewhere, it can be assumed that a brain tumor is a metastasis of

that primary cancer.

True False

3. Astrocytomas account for about 40% of the primary tumors of the brain and spinal cord.




33/36

True False

4. Recurrent lesions are usually the same type, rarely progressing to more malignant tumors.

True False

5. Common symptoms of astrocytomas include headaches, vision changes, nausea and vomiting,

personality changes, memory loss, and ataxia.

True False

6. Tumors of the frontal lobe and occipital lobes are often associated with lack of coordination.

True False

7. Tumor growth may result in vasogenic edema, compression of cerebral blood vessels, and seizure

activity.

True False

8. MRIs and CTs expose the patient to about equal amounts of radiation.

True False

9. PET scans are matched with CT or MRI because PET scans show less detail.

True False

10. Surgical biopsies of brain tumors are often not necessary because of better imaging.

True False

11. Patients may have many questions that they are afraid to pose to physicians.

True False

12. The TNM (tumor, nodal status, and metastatic spread) is not appropriate for classifying brain tumors.

True False

13. The WHO tumor classification system classifies tumors as Grade I to IV based on histologicalfeatures.

True False

14. Patients with grade III and IV tumors usually have survival rates that exceed 5 years.

True False

15. Low-grade astrocytomas double faster than high-grade astrocytomas.

True False

16. Grade II astrocytomas often recur.

Tr

brain tumors astrocytomas and glioblastomas

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