BRAIN TUMOURS

Introduction:-
The growth of abnormal cells in the tissues of the brain is called brain tumours.
A brain tumour is a localized intracranial lesion that occupies space within the
skull. Intracranial neoplasm are the results of abnormal proliferation of cells
within the central nervous system.

Classification of brain tumours:-

Tumours in the brain are categorized according to several factors, including where
they are localized, the type of cells involved and how quickly they are growing.
 Tumours in the brain may be benign or malignant. Benign tumours are
slow growing, non-cancerous and do not spread to surrounding tissue
whereas malignant tumours are cancerous, fast-growing and aggressive.
They can invade nearby tissue and more likely to reoccur.
 In adult, most of the brain tumours are malignant.

 Tumours in the brain may be localized or invasive. A localized tumour is

confined to one area and is easier to remove, as long as it’s in an accessible
part of the brain. An invasive tumour has spread to the surrounding areas
and more difficult to remove completely.

 Tumours in the brain may be primary or secondary. Primary brain tumours

originate in brain whereas secondary brain tumours are made-up of cells
that have spread to the brain from somewhere else in the brain.

 Brain tumour may be referred to as intra-axial or extra-axial. Intra-axial

cells tumours are those originated from the glial cells and within the brain
tissue and extra-axial tumours have their origin in the skull, cranial nerves
or pituitary gland.
Table of tumours:-
1) Tumours of Neuroglia ( GLIOMAS)
 Astrocytoma
 Oligodendroglioma
 Ependymoma
 Choroid plexus papilloma

2) Tumours of Neurons
 Neuroblastoma
 Ganglioneuroblastoma
 Ganglioneuroma

3) Tumours of Neurons and Neuroglia

 Ganglioglioma

4) Poorly-differentiated and Embryonal tumours

 Medulloblastoma
 Neuroblastoma
 Primitive neuroectodermal tumour

5) Tumours of meninges
 Meningioma
 Meningeal sarcoma

6) Nerve sheath tumours

 Schwannoma
 Neurofibroma
 Malignant nerve sheath tumours

7) Other primary intraparenchymal tumours

 Hemangioblastoma
 Primary CNS tumour
 Germ cell tumour
8) Miscellaneous tumours
 Malignant melanoma
 Craniopharyngioma
 Pineal cell tumour
 Pituitary tumours

9) Tumour-like lesions
 Epidermal cyst
 Dermal cyst
 Colloid cyst

10) Metastatic tumours

Aetiology:-
Exact cause is unknown. Possible causes and risk factors includes:-
 Age: detected in people aged more than 70 years
 Gender: In general, brain tumours are more common in male than in
female. However, meningiomas are common in females
 Positive family history
 Use of cellular phone and exposure to high sensuous wire
 Use of hair dye and head trauma
 Dietary exposure such as nitrate (some barbecued food)
 Exposure to ionizing radiation or certain chemicals
 Acrylonitrale: people who make textile and plastics may expose to a
acrylonitrale. This exposure may increase the risk of brain tumours

Clinical features:-
Brain tumour symptoms are varying greatly from person to person because of
two- factors: where the tumour is located and its size. The major symptoms seen
are as follows:-
1. Headache – up to half of the people with brain tumours suffer from
headache. Headaches are not usually the initial symptoms of brain
tumours. Headache may be localized or generalized and are most severe in
frontal or occipital region, usually intermittent and increased duration,
frequency and severity. Tends to be worse in the morning and ease during
the day.
2. Nausea and vomiting- these are believed to occur because of pressure on
the medulla, where the vomiting centre is found. Vomiting especially in the
morning and without nausea. Nausea can be present just not as common.
These symptoms may be related to generalize swelling, cerebral oedema,
increased headache.
 3. Seizure/convulsion- may be focal or generalized; are common in client with
intracranial tumours, especially cerebral hemisphere tumours. Seizure
causes the body to shake and tremor in varying intensity, loss of
consciousness can also occur.
4. Personality/mood changes- change in the level of consciousness is often
noted in personality changes that are frustrating, that can interrupt in daily
living activities, sudden increased interest in sex, temper tantrum, social
decline, drowsiness, confusion, disorientation may be found.
5. Cognitive decline- slower processing speed of brain can be a symptom of
brain tumours. It takes longer to complete tasks than it usually does.
Memory loss and difficulty concentrating can be typical with some brain
tumours as well.
6. Papilledema- compression of the second cranial nerve (optic nerve) may
result in papilledema.
7. Hearing problem- hearing disturbances can include one sided hearing loss
and ringing in the ears.
8. Physical changes- an adult may experience weakness on the one side of the
body.
9. Speech changes- can include a wide array of changes, slurring of the word
or slow speech can occur, sentences may have words in the incorrect order
or even include words that have to relevance. This lack of effective
communication can be frustrating symptoms for the people with brain
tumours.
10. Hormonal imbalances
11.Localized manifestations- localized manifestations are caused by
destruction, irritation or compression of the part of brain in or near the
tumour. Blood supply to the affected area is also impaired.

Clinical features of brain tumours by location:-

 Frontal lobes – disturbed mental state, apathy, inappropriate behaviour,
dementia, depression, inattentiveness, inability to concentrate, loss of
memory, speech disturbances, bowel and bladder incontinence, motor
disorder, gait disturbances, paralysis and seizure.
  Temporal lobes – aphasia, seizure, visual field changes, personality
changes, headache, increased ICP, recent memory impairment.
 Parietal lobe – sensory deficit, focal seizures, agnosia, parenthesis, visual
field cut, headache disorientation
 Occipital lobe – focal agnosia, hallucinations, headache, nausea/vomiting,
increased ICP, visual field impaired, blindness
 Cerebellar – unsteady gait, ataxia, inco-ordinated tremors, head tilt,
nystagmus, hydrocephalus
 Brain stem – vertigo, dizziness, vomiting, nystagmus, headache, gait
disturbances, motor and sensory deficits, deafness
 Pituitary/hypothalamus – visual deficit, headache, hormonal dysfunction,
sleep disturbances, water imbalance, temperature fluctuation, Cushing
syndrome
 Ventricles – hydrocephalous, rapid increased in ICP, headache

Diagnostic procedure:-
 Complete history taking
 Physical examination including neurological examination
 Chest X-rays to rule out metastasis
 CT-Scan
 MRI
 Myelogram
 Angiography/arteriography
 Spinal tapping
 Biopsy
 Brain-scan- reveals that areas of abnormal growth in the brain and records
them in special film. A small amount of radio-active material injected into a
vein, this dye is absorbed by the tumours and shows up on the film.
Treatment:-
The management and treatment of brain tumour depend on a number of factors
including the type, location and size of the tumours as well as patient’s age and
general health. Depending on the need, several methods may be used to some
patient.
The goal of the management is to remove and reduce the size of the tumour.
1. Surgery
It is the usual treatment for most brain tumours. The operation is called
craniotomy. Surgery is for partial or complete removal of the brain tumours.
 First step of surgery is biopsy which is done for diagnosis
 Second step is de-bulking or resection of the tumours for relieving the
symptoms related to mass effects and increased ICP
 Third step- when the remaining post surgical tumour is small as possible.
Craniotomy with removal of lesion and invaded tissue
 Stereotactic radio surgery employs computer directed radiation to eradicate
the tissue. In this procedure, sometime a biopsy is done to find out the
benign or malignant tumours.
2. Radiation therapy
It is also called radiotherapy. It is used for high power rays to damage cancer
cells and stop them from growing. It is often used to destroy tumour tissue
that cannot be removed with surgery. It may be given in two ways:-
 External radiation comes from a large machine. External radiation treatment is
given five days a week for several weeks. Radiation also can come from
radioactive material placed directly in the tumour or implant radiation
therapy.
 Stereotactic radio surgery is another way to treat brain tumour. High energy
rays are aimed at tumour from many angles. In this way, high dose of
radiation reaches the tumour without damaging other brain tissue.
 3. Chemotherapy
It is the drugs used to kill the cells, may be used just as a drug or a
combination, usually giving drugs orally or by injection in to the blood vessels
or muscle and intrathecal (CSF ). Chemotherapy is usually given in cycles. A
treatment period is followed by a recovery period, then, another treatment
period is started again.
Chemotherapeutic drugs includes methotrexate, vincristine sulphate,
cyclophosphamide, methylprednisolone and 5 Fu (5-flurouracil).

4. Drugs
Steroid, anti-convulsant and osmotic diuretics to control symptoms.
Analgesics and anti-emetic is used.
Immunotherapy

Nursing management:-
Nursing assessment
 Complete history taking
 Physical examination
 Assess the neurological status of the patient
 Assess the vital signs at regular interval
Nursing diagnosis:
 Acute pain related to excessive growth of new cells
 Risk for injury related to impaired sensory and motor functions
 Anxiety related to lack of exposure to new disease
 Imbalanced nutrition related to decreased amount of intake
 Impaired cerebral perfusion related to increased intra-cranial perfusion.
Nursing management
 It is difficult to be specific about the nursing management of the patient with
a brain tumour. The basis for nursing management is the history and
neurological assessment. Nursing care (physical) will depend on the deficits
experienced by the patient.
 The responses of the patient and family to a brain tumour are influenced by
the type, grade, location and presenting symptoms of the tumour. They are
also influenced by the age, disabilities, family dynamics and coping skills of
the patient and family.
 Patients and families have an ongoing need for information and emotional
support which should be addressed by the nurse as a part of the
management plan.

1) Pain management
 Provide analgesics around the clock at regular intervals that will not mask
neurological changes
 Maintain the head of bed at 15-30 degree to reduce cerebral venous
congestion
 Minimizes direct sunlight by provide a darkened room for photophobic
patient
 Maintain quite environment to increase patients pain tolerance
 Collaborate with patients on alternative ways to reduce pain such as use of
diversional therapy e.g. listening music ,talking with patient.
 Keep the patient in comfortable position as with operative side up

2) Preventing injury
 Perform baseline physical assessment and neurological assessment and
report any signs of increased ICP or worsening condition immediately
 Adjust care to reduce risk for increased ICP
 Monitor intake and output, electrolytes regularly.
 Initiate seizure precautions-keep the side rails of the bed to prevent injury if
seizures occurs, keep suction ready to work
 Initiate fall precautions-keep the side rails up all the time assist in toileting
and other as necessary avoid slippery floor
 If the patient is dysphasic or unconscious, initiate aspiration precaution,
elevate head up to 30 degree and keep NPO as needed.
 If the patient is dysphasic: instruct the sequence swallowing to maintain
feeding function.
 Maintain oxygen and suction in case of aspiration

3) Minimizing anxiety
 Observe the patient for verbal and nonverbal cues indicating anxiety
 Provide a safe environment in which the patient may verbalize fear and
anxiety
 Encourage patient to ask the question and answers the questions and
provide written information
 Anticipate need of the patient
 Introduce stress management techniques
 Provide consistency in care ,continually provide emotional supports
 Assess the patients usual coping behaviour and provide support in these
areas
 Refer and consult with resource person as necessary

4) Optimizing nutrition
 Assess the patients nutrition intake on a 24hours basis
 Assess the patient dietary intake/likes and dislikes
 Offers small meals frequently as tolerated
 Provide frequent month care to enhance intake
 Medicate for nausea vomiting before radiation ,chemotherapy and positive
changes
 Consult with dietician to evaluate food choices and provide adequate caloric
needs through parental nourishment if unable to take oral nutrition
5) Promote cerebral perfusion
 Assess the patients neurological signs periodically which will be identified
early and definitive action taken to control deterioration
 Identify any signs of neurological deterioration , report any such changes to
the physician and document finding in record
 Elevate the head of bed 30 degree
 Administer drugs and other protocols as necessary
 Continue to monitor the patient’s conditions.

6) Minimize fatigue which is induced by chemotherapy /radiation

 Allow the patient to express his/her feeling about general malaise
 Encourage and plan a schedule that allow for frequent rest periods
 Assess the patient’s ability to prefers activities for daily livings
 Provide frequently rest periods

7) Patient education and health maintenance

 Explain the adverse effects of treatment
 Encourage close follow up after diagnosis and treatment
 Explain about need for frequent mouth care for management of altered
oral mucous and administer glycerine swab as needed
 Avoid irritating foods such as citrus fruits and provide a soft balance diet.