Brain Tumor / Intracranial space occupying lesion (ICSOL)

A brain tumor is a collection, or mass, of abnormal cells in your brain. Brain

tumors can be cancerous (malignant) or noncancerous (benign). When benign or
malignant tumors grow, they can cause the pressure inside the skull to increase.
This can cause brain damage, and it can be life-threatening.
Incidence
Brain tumor typically occur in 2 distinct categories
Meningioma, a benign primary tumor - 33.8% of primary brain tumor
Glioblastoma Multiforme, a malignant tumor - 17.1% of adult primary tumor
Age of incidence :Children aged 0-15years, Adults in their 5th to 7th decade

Types of brain tumors

Primary brain tumors
Primary brain tumors originate in your brain. They can develop from

 brain cells
 the membranes that surround your brain, which are called meninges
 nerve cells
 glands

Primary tumors can be benign or cancerous. In adults, the most common types of
brain tumors are gliomas and meningiomas.
Gliomas
Gliomas are tumors that develop from glial cells. These cells normally:
 support the structure of your central nervous system

 provide nutrition to your central nervous system

 clean cellular waste

 break down dead neurons

Gliomas can develop from different types of glial cells.

The types of tumors that begin in glial cells are:
 astrocytic tumors such as astrocytomas, which originate in the cerebrum

 oligodendroglial tumors, which are often found in the frontal temporal lobes
  glioblastomas, which originate in the supportive brain tissue and are the
most aggressive type
Other primary brain tumors

 Pituitary adenomas. These are mostly benign tumors that develop in the
pituitary gland at the base of the brain. These tumors can affect the pituitary
hormones with effects throughout the body.
 Pineal gland tumors, which can be benign or malignant

 Ependymomas, which are usually benign

 Craniopharyngiomas. These rare, noncancerous tumors start near the

brain's pituitary gland, which secretes hormones that control many body
functions. As the craniopharyngioma slowly grows, it can affect the pituitary
gland and other structures near the brain.
 Primary central nervous system (CNS) lymphomas, which are malignant

 Primary germ cell tumors of the brain, which can be benign or malignant
 Meningiomas. A meningioma is a tumor that arises from the membranes
that surround your brain and spinal cord (meninges). Most meningiomas are
noncancerous.
 Acoustic neuromas (schwannomas). These are benign tumors that develop
on the nerves that control balance and hearing leading from your inner ear to
your brain.
 Medulloblastomas. These are the most common cancerous brain tumors in
children. A medulloblastoma starts in the lower back part of the brain and
tends to spread through the spinal fluid. These tumors are less common in
adults, but they do occur.
 Germ cell tumors. Germ cell tumors may develop during childhood where
the testicles or ovaries will form. But sometimes germ cell tumors affect
other parts of the body, such as the brain.
Most meningiomas and schwannomas occur in people between the ages of 40 and
70. Meningiomas are more common in women than men. Schwannomas occur
equally in both men and women. These tumors are usually benign, but they can
cause complications because of their size and location. Cancerous meningiomas
and schwannomas are rare but can be very aggressive.
Secondary brain tumors
Secondary brain tumors make up the majority of brain cancers. They start in one
part of the body and spread, or metastasize, to the brain. The following can
metastasize to the brain:
 lung cancer

 breast cancer

 kidney cancer

 skin cancer

Secondary brain tumors are always malignant. Benign tumors don’t spread from
one part of your body to another.
Risk factors for a brain tumor

 Family history - Only about 5 to 10% of all cancers are genetically inherited,
or hereditary
 Age - Risk for most types of brain tumors increases with age
 Race - Brain tumors in general are more common among Caucasians.
However, African-American people are more likely to get meningiomas.
 Chemical exposure - Being exposed to certain chemicals, can increase your
risk for brain cancer.
 Exposure to radiation - People who have been exposed to ionizing radiation
have an increased risk of brain tumors.
 Genetic changes
 Environmental hazards (including diet , viruses Injury or
immunosuppression

Symptoms of a brain tumor

Symptoms of brain tumors depend on the location and size of the tumor. Some
tumors cause direct damage by invading brain tissue and some tumors cause
pressure on the surrounding brain.
Headaches are a common symptom of a brain tumor. Headaches that:

 are worse in the morning when waking up

 occur while you’re sleeping

 are made worse by coughing, sneezing, or exercise

You may also experience:

  vomiting
 blurred vision or double vision

 confusion

 seizures (especially in adults)

 weakness of a limb or part of the face

 a change in mental functioning

Other common symptoms include:

 clumsiness
 memory loss
 confusion
 difficulty writing or reading
 changes in the ability to hear, taste, or smell
 decreased alertness, which may include drowsiness and loss of
consciousness
 difficulty swallowing
 dizziness or vertigo
 eye problems, such as drooping eyelids and unequal pupils
 uncontrollable movements
 hand tremors
 loss of balance
 loss of bladder or bowel control
 numbness or tingling on one side of the body
 trouble speaking or understanding what others are saying
 changes in mood, personality, emotions, and behavior
 difficulty walking
 muscle weakness in the face, arm, or leg

Location specific symptoms

The brain is divided into lobes and each lobe or area has its own function. A tumor
in any of these lobes may affect the area's performance. The symptoms
experienced are often linked to the location of the tumor, but each person may
experience something different.
 Frontal lobe: Hemiparesis, Seizures, Aphasia & Gait Difficulties. with growth
of tumor there may be personality changes like Disinhibition, Irritability,
Impaired Judgement, & Lack of Initiation
 Temporal lobe:
Ant. lesion - clinically silent until they become very large and causing seizures.
Lateral Side - Auditory and perceptual changes
Medial Side - Changes in cognitive integration, long-term memory, learning,
and emotions may be seen.
Dominant Temporal lobe - Aphasia
Left Temporal lobe lesion - Anomia, agraphia, acalculia, Wernicke aphasia
(Fluent, nonsensical speech)
Bitemporal involvement - It is rare and causes memory deficits & possible
dementia.
 Parietal lobe: Contralateral Sensory loss & hemiparesis, Homonymous visual
deficits or neglect, agnosia, apraxia & visual-spatial disorders.
If Dominant Parital Lobe is involved, Aphasia & may be present.
If Non-Dominant Parietal Lobe is Involved, Contralateral neglect & decresed
awareness of impairements can commonly be found.

 Occipital lobe: Dysfunction of the eye movement & Homonymous

hemianopsia. If parieto- occipital junction is involved, visual agnosia &
agraphia are often present. Bilateral tumor may cause Cortical Blindness.
 Cerebellum: In adults, headache, nausea and vomiting present in 40% of
condition & ataxia in 25% of Cases.
 Lesion of midline - Truncal & Gait Ataxia
 Lesion of Hemispheres - Uni. Appendicular ataxia
 Lesion in cerebellopontine angle - hearing loss, headache, ataxia, dizziness,
tinnitus and facial palsy may occur.
 If tumor invades meninges at foramen magnum causes cerebellar tonsil
herniation, nuchal rigidity and head tilt away from lesion may be seen.
 Brain stem: Tumor have an insidious onset and may include gait disturbances,
diplopia, focal weakness, headache, vomiting, facial numbness and weakness,
and personality changes.
 Dorsal Midbrain - Parinaud Syndrome(Loss of upward gaze, pupillary
areflexia to light, and loss of convergence)
 Reticular System of Pons & Medulla - Apnea, hypo- or hyper- ventilation,
orthostatic hypotension or syncope
Behavior changes
A person's personality may be altered due to the tumor damaging lobes of the
brain. Since the frontal, temporal, and parietal lobes, control inhibition, emotions,
mood, judgement, reasoning, and behavior, a tumor in those regions can cause
inappropriate social behavior, temper tantrums, laughing at things which merit no
laughter, and even psychological symptoms such as depression and anxiety
Personality changes can have damaging effects such as unemployment, unstable
relationships, and a lack of control.

Grades of Brain Tumors

Tumors are graded by how normal or abnormal the cells look. Your doctor will use
this measurement to help plan your treatment. The grading also gives you an idea of
how fast the tumor may grow and spread.

 Grade 1. The cells look nearly normal and grow slowly. Long-term survival is
likely.
 Grade 2. The cells look slightly abnormal and grow slowly. The tumor may
spread to nearby tissue and can recur later, maybe at a more life-threatening
grade.
 Grade 3. The cells look abnormal and are actively growing into nearby brain
tissue. These tumors tend to recur.
 Grade 4. The cells look most abnormal and grow and spread quickly.

Diagnosis
Diagnosis of a brain tumor begins with a physical exam and medical history.
The physical exam inc ludes a very detailed neurological examination.
Evaluate : muscle strength, coordination, memory, ability to do mathematical
calculations
CT scan ,MRI ,PET Scan, SPECT, Angiography, Skull X-rays, Biopsy

Treatment of brain tumors

Factors considered in planning treatment include:

 the person’s age

 their general health status
 their medical history
  the location, size, and type of tumor
 the risk of the tumor spreading
 the person’s tolerance for certain treatments

Surgery

The most common treatment for malignant brain tumors is surgery. The goal is to
remove as much of the cancer as possible without causing damage to the healthy
parts of the brain. The purposes of surgery in the management of brain tumors
include the following :

1. Biopsy to establish a diagnosis

2. Partial resection to decrease the tumor mass to be treated by other methods
3. Complete resection of the tumor

Biopsies are performed through open, needle, and stereotactic needle

techniques.
‒
Open biopsies involve exposure of the tumor followed by removal of a
sample through surgical excision.
‒
Needle biopsies involve insertion a needle into the tumor through a hole in
the skull and the excision of the tissue sample drawn through the needle.
‒
Stereotactic needle biopsies use computers and MRI or CT scanning
equipment to assisst in directing the needle into the tumor.

Partial & Complete Resections are accomplished through craniotomy.

–
Craniotomy involves removal of a portion of the skull and separation of the
dura mater to expose the tumor.
–
Stereotactic craniotomy uses technologyto guide neurosurgeon during the
procedure.
–
Awake craniotomy allows for intra-op brain mapping.
Risks of brain surgery include infection and bleeding. Clinically dangerous benign
tumors are also surgically removed. Surgery can be combined with other
treatments, such as radiation therapy and chemotherapy.

Preoperative Management : Before surgery, clients are evaluated for general

surgical risks and the possibility of tumors in additional locations. Unless
medically contraindicated, steroids & anticonvulsant medications are administered
before surgery

Intraoperative Management : During surgery, precautions are taken to prevent an

increase in edema or ICP. Mannitol (vasodiuretic) &Hyperventilation is used to
decrease ICP, Steroid use is continued and Antibiotics are administered to prevent
infection.

Postoperative Management : Patients are observed in an intensive care unit for at

least 24 hours for possible intracranial bleeding or seizures. Blood pressure is
monitored continuously. Post-op these patients are more prone to DVT but due to
the risk of intracranial bleeding, acoagulants cannot be given so Compression
stockings are used prophylactically. Steroids are tapered in 5-10 days post-op.

Physical therapy, occupational therapy, and speech therapy can help you to recover
after neurosurgery.

 steroid drug, such as dexamethasone (Decadron), to relieve swelling.

 Treat with an anticonvulsant drug to relieve or prevent seizures.
 CSF drainage

Radiation Therapy for Brain Cancer

Radiation therapy (also called radiotherapy) is the use of high-energy rays to kills
tumor cells, thereby stopping them from growing and multiplying.
External-beam radiation therapy can be directed at a brain tumor in the following
ways:
 Conventional radiation therapy.
 3-dimensional conformal radiation therapy (3D-CRT).
 Intensity modulated radiation therapy (IMRT).
 Proton therapy.
 Stereotactic radiosurgery.
 There are many different types of stereotactic radiosurgery equipment,
including:
o A modified linear accelerator is a machine that creates high-energy
radiation by using electricity to form a stream of fast-moving
subatomic particles.

o A gamma knife is another form of radiation therapy that concentrates

highly focused beams of gamma radiation on the tumor.

 A cyber knife is a robotic device used in radiation therapy to guide radiation

to the tumor, particularly in the brain, head, and neck regions.

 Fractionated stereotactic radiation therapy. Radiation therapy is

delivered with stereotactic precision but divided into small daily doses called
fractions and given over several weeks, in contrast to the 1-day radiosurgery.
This technique is used for tumors located close to sensitive structures, such
as the optic nerves or brain stem.

 Radiosurgery
Radiosurgery is the common name for stereotactic radiosurgery (SRS). SRS is a
specialized form of radiation therapy and is not a surgical procedure.
SRS allows a healthcare provider to administer a precise dose of radiation in the
form of an X-ray beam. They can focus the radiation only on the area of the brain
where the tumor is present. This reduces the risk of damage to healthy tissue.

 Chemotherapy
It can be used independently or as an adjuvant to surgery or radiation.
Chemotherapy can be administered in a number of different ways.
• Most agents are given intravenously through a peripheral intravenous line or
through a catheter such as a peripherally inserted central catheter (PICC).
• Methotrexate (Highly neuro-toxic) is admnistered with Leucovorin
(Antidote)
• Temozolomide is orally available chemotherapeutic agent for the R x of
Gliomas.

 Targeted therapy can be used to treat certain types of brain tumors. These
drugs attack specific parts of cancer cells and help stop tumors from growing
and spreading. This type of treatment blocks the growth and spread of tumor
cells while limiting the damage to healthy cells.

Bevacizumab is an anti-angiogenesis therapy used to treat glioblastoma

multiforme. Anti-angiogenesis therapy is focused on stopping
angiogenesis, which is the process of making new blood vessels. Because
a tumor needs the nutrients delivered by blood vessels to grow and
spread, the goal of anti-angiogenesis therapy is to “starve” the tumor.

 Larotrectinib (Vitrakvi) is a type of targeted therapy that is not

specific to a certain type of tumor but focuses on a specific genetic
change .This type of genetic change is found in a range of tumors,
including some brain tumors.

Symptom management and nursing considerations

 Vasogenic edema : Corticosteroids are given to decrease edema
by decreasing the permeability of tumor capillaries.
Dexamethasone is the drug of choice. Nurses should be aware of
the potential side effects of steroids and provide ongoing
assessment of symptoms.
 Seizures : Seizures can increase morbidity, provoke anxiety,
decrease independence, interfere with the ability to work, require
additional medications, and decrease a patient’s overall quality of
life. Nurses should be familiar with the dosing and potential side
effects of AEDs used for patients with tumors. Patient and
caregiver/family education should include correct use, potential
side effects, and what to do in the event of a seizure.
 Venous ThromboEmbolism (DVT and Pulmonary Embolism) - Risk
factors include immobility, poor performance status, older age, prior
history of VTE, smoking, obesity, and a hypercoagulable state related to
cancer. Anticoagulation prophylaxis is recommended. Intermittent
pneumatic compression device use and graduated compression stockings
are recommended. Avoid prolonged bed rest or immobility by
encouraging ambulation, alternative exercises for nonambulatory
patients, correct use of graduated compression stockings, and adequate
 hydration. Educate regarding the correct injection technique for LMWH
or heparin. Monitor INR results per institutional protocol
 Nausea and vomiting - effective antiemetic prophylaxis. Progressive
muscle relaxation may be effective . Nonpharmacologic interventions a.
Acupuncture, acupressure, guided imagery, music therapy, progressive
muscle relaxation, and psychosocial support and education likely may be
effective
 Cognitive dysfunction - Cognitive dysfunction is estimated to occur in
50%–90% of people with brain tumor. Encourage referrals and
participation in occupational therapy, speech therapy, and cognitive
rehabilitation programs . Encourage cognitive exercises that are fun,
relevant, and appropriate to the individual. Taper to their personal needs.
If possible, patients should not wake to take their medication. d. Discuss
appropriate sleep patterns, and safety. Nurses should assess for cognitive
dysfunction as a symptom of the overall disease state . Nurses should
recommend neuropsychological testing in specific cases . Nurses need to
be aware of interventions that will help patients cope with cognitive
changes.
 Fatigue - Cancer-related fatigue is multifactorial, including effects of the
tumor, surgery, chemotherapy, radiation, and medication. Fatigue may be
part of a symptom cluster including emotional and cognitive factors.
Nonpharmacologic management a. A moderate exercise program within
limits of b. Energy conservation techniques c. Cognitive behavioral
therapy for sleep d. Avoid overdoing things; patients cannot “push
through” cancer-related fatigue. b. Encourage appropriate therapy for
insomnia, emotional distress, and pain.
 Body image - Patients with brain tumors may experience a range of
physical changes including skull defects, hair loss, cushinoid facies,
weight gain, weakness, and impaired mobility. Allow the opportunity to
discuss concerns and coping with loss b. Use scarves or hats to cover
scars, skull defects, or hair loss. c. Stress that many changes will improve
with time, especially the effects of steroids or RT. Nurses should be
aware of the effect of physical changes and offer strategies to decrease
the impact of changes on the patient.