Metastatic Intracranial Tumors

Risk factors:
1. Exposure to ionizing radiation
2. Genetic mutations- rare
3. Familial tendencies from astrocytoma ( glioma that develops from star-shaped glial cells (astrocytes)
that support nerve cells. An anaplastic astrocytoma is classified as a grade III tumor.)

Types of Brain Tumors:

A. Primary Brain tumor
- is a localized intracranial lesion that occupies space within the skull.
- can grow as a spherical mass but can also grow diffusely and infiltrate the tissue
- Effects of the neoplasms are caused by the compression and infiltration of the tissue
- originate from the cells and structures within the brain
- Brain tumors rarely metastasize outside the CNS

B. Secondary brain tumors (cerebral metastases)

- develop from the structures outside the brain and occur in 10%-20% of patients with cancer.
- Metastatic lesions to the brain can occur from the following:
a. Lung- most common source
b. breast primary sites
c. GIT
d. kidney
e. pancreas
f. skin (melanomas)
- most cerebral metastases occur supratentorially (tumors of the brain located above the
tentorium cerebelli, a fold of dura mater separating the cerebellum and brain stem from the

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 cerebral hemispheres and diencephalon (i.e., thalamus and hypothalamus and related
structures).

C. Leptomeningeal metastases
-Leptominges (literally thin meninges) is a term used to refer to the pia mater and arachnoid
mater, two of the membranes that surround the brain and the spinal cord.
-Leptomeningeal metastases refers to the spread of malignant cells through the CSF space

Neoplasms metastasizing most commonly to the leptomeninges:

1. Breast cancer
2. Lymphomas
3. Leukemia

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Shiver images indicates presence of leptomeningeal spread

Pathophysiologic events:
1. Increased intracranial pressure (ICP) and cerebral edema
2. Seizure activity and focal neurologic signs
3. Hydrocephalus (Tumor-associated non-communicating hydrocephalus)

4. Altered pituitary function

1.Hormone-producing pituitary adenomas produce an active hormone in excessive
amounts.
 Prolactin-secreting pituitary adenoma (prolactinoma)
 Growth hormone-secreting pituitary adenoma
 ACTH-secreting pituitary adenoma
2.Hormone-inactive (non-functional) pituitary adenomas typically cause problems related
to the size of the tumor pushing on surrounding brain structures
A. Visual Loss
*When large pituitary adenomas ("macroadenomas") grow upward, the tumor
can elevate and compress the optic chiasm.
1. Bitemporal hemianopsia
2. Other visual problems can include:
a. Loss of visual acuity
b. Changes in color perception

B. Pituitary Failure
1. Hypopituitarism –due to the compression of the pituitary gland. Symptoms can
include:
 Sexual dysfunction and/or loss of sex drive
 Inadequate body cortisol levels, causing low blood pressure,
fatigue, and inability to handle stressful situations
 Low thyroid functioning (hypothyroidism)

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 2. Sudden onset Headache and visual loss due to Pituitary Apoplexy

Diagnostic Tests:
1. CT scan/ MRI- with gadolinium enhancement to:
 Detect the lesion and define its location, shape, size
 The extent to which normal anatomy is distorted,
 The degree of any associated cerebral edema or mass effect
2. Arteriography
- may show stretching or displacement or normal cerebral vessels by the tumor and
the presence of tumor vascularity.
* if avascular: may indicate presence of a tumor, hematoma, abscess or
any space-occupying lesion
3. Mammography in women cerebral metastases
4. Germ cell origin in men under 50
5. Lumbar puncture and cytologic studies to examine the CSF to its:
o Pressure
o Pleocytosis
o Increased protein concentration
1. Moderately increased (150-200 mg/dl): occurs in inflammatory diseases
of meninges (meningitis, encephalitis), intracranial tumors,
subarachnoid hemorrhage, and cerebral infarction.
2. Marked Increase (may rise to 500 mg/dl): In bacterial meningitis
3. Severe increase occurs in the Guillain-Barré syndrome and acoustic and
spinal schwannoma
o Decreased glucose concentration
6. Positron Emission tomography (PET)
- Low-grade tumors are associated with hypometabolism
- High-grade tumors show hypermetabolism
7. Computer-assisted stereotactic (three-dimensional) biopsy- to identify deep-seated brain
tumors and provide basis for treatment and prognosis
8. Cerebral Angiography- provides visualization of cerebral blood vessels and can localize most
cerebral tumors
9. Electroencephalogram- detect abnormal brain wave regions occupied by a tumor
- used to evaluate temporal lobe seizures and assist in ruling out other disorders.

*Multifocal neurologic deficits are caused by the following factors:

1. Infiltration of the cranial and spinal nerve roots
2. Direct invasion of the brain or spinal cord
3. Obstructive hydrocephalus
4. Combination of the factors

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Clinical manifestations:
A. Generalized
1. Increased ICP
Monro-Kellie hypothesis states:
If any one of the skull components increases in volume, ICP increases unless one of the
other components decreases in volume.
Related signs and symptoms:
1. Headache
2. Vomiting
3. Visual Disorders
B. Localized
1. Hemiparesis
2. Seizures
3. Mental changes

The following, more specific symptoms are due to a tumor's effect on specific brain structures. Because
the tracts of the central nervous system cross near the base of the skull, a tumor on the right side of the
brain may cause symptoms on the left side of the body, and vice-versa, depending on the specific brain
structure affected.

Tumor Site Signs and Symptoms

Brain Stem - the Midbrain, Pons,  vomiting (usually just after awakening)
Medulla Oblongata  clumsy, uncoordinated walk
 Muscle weakness on one side of the face causes a one-sided
*The brain stem controls basic smile or drooping eyelid
life functions including blood  Difficulty in swallowing and slurred or nasal speech
pressure, heart beat, and  double vision with an inability to fully move one or both eyes
breathing. The reticular Headache, usually just after awakening
formation (the central core of  Head tilt
the brain stem) controls  Drowsiness
consciousness, eating and  hearing loss
sleeping patterns, drowsiness  Personality changes can also be present.
and attention.

*Symptoms may develop

gradually.
Cerebellum Changes in muscular coordination, including walking and speech.

Located in the posterior fossa,

the cerebellum together with

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the thalamus and cerebrum
Cerebellopontine Angle  ringing or buzzing in the ear -earliest symptom
 dizziness occurring less often
 Deafness
 loss of facial sensation and/or facial weakness
 Other symptoms similar to those of a brain stem tumor.

Cerebral Hemispheres
Frontal Lobe
*The frontal lobe of each Tumors in the frontal lobe may initially be "silent."
hemisphere controls voluntary one-sided paralysis
movement, usually on the seizures
opposite side of the body. The short-term memory loss
frontal lobe of the dominant impaired judgment and personality or mental changes
hemisphere controls language Urinary frequency and urgency
and writing. (The dominant Gait disturbance
hemisphere is the left communication
hemisphere in all right-handed *If the tumor is at the base of the frontal lobe, loss of smell,
and some left-handed impaired vision, and a swollen optic nerve can occur.
individuals and the right
hemisphere in most left-handed
people.) Other frontal lobe
activities include intellectual
functioning, thought processes,
behavior, and memory.

Occipital Lobe
The occipital lobe is involved in Blindness in one direction or other visual disturbances
the understanding of visual seizures
images and the meaning of
written word.

Parietal Lobe
The parietal lobe receives and Seizures
interprets sensations including Language disturbances (if a tumor is in the dominant hemisphere)
pain, temperature, touch, Loss of ability to read
pressure, size, shape, and body- Spatial disorders (such as difficulty with body orientation in space or
part awareness. Other activities recognition of body parts)
of the parietal lobe are hearing, Numbers may be read, but there may be difficulty with calculations.
reasoning and memory. Difficulty knowing left from right sentences containing comparisons
The parietal lobe also controls or cross-references may not be understood.
language and the ability to do
arithmetic.

Temporal Lobe
The temporal lobe is involved in
the understanding of sounds and Seizures are the most common symptom

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spoken words, as well as The ability to recognize sounds or the source of sounds may be
emotion and memory. Depth affected.
perception and the sense of Vision can be impaired
time are also controlled by the
temporal lobe.
Basal Ganglia  One-sided paralysis is the most common symptom. This tumor
might invade other areas of the cerebral hemispheres and
produce symptoms common to tumors in those locations.
 * Seizures are uncommon.
Corpus Callosum  Impaired judgment and defective memory are frequent symptoms
behavioral changes are common with a tumor in the rear part.
 A tumor in the middle of the corpus callosum might cause few, if
any, symptoms until it grows quite large.
 This tumor might invade other lobes of the cerebral hemispheres
and produce symptoms common to tumors in those locations.
Seizures are uncommon.

Hypothalamus
The hypothalamus controls Abnormalities in the urinary function, temperature regulation
thirst and urination, sleep, body Sleep and eating difficulties
temperature, appetite, and Alteration in BP levels
blood pressure. The Emotional lability
hypothalamus coordinates
patterns of activity and controls
emotions. It is also the control
center for the pituitary gland.

Meninges A tumor in this location usually causes symptoms by pressure and

The meninges are the thin compression rather than by growth into brain tissue.
covering layers of the brain and Seizures are common
spinal cord. Additional symptoms depend on the location of the tumor
Midline Headaches, nausea and a swollen optic nerve are the most common
The "midline" is where the two symptoms associated with this area and are due to increased
cerebral hemispheres meet. intracranial pressure
abnormal eye movements and vision
alteration of personality or consciousness
impairment of glandular functions can cause either delayed or
accelerated growth
Problems with water balance
Optic Tract eye movement disorders
abnormal pupil reactions
impaired vision.
production of hormones can be affected due to the tumor's effect on
the nearby pituitary
Pineal Region hydrocephalus with the symptoms of increased intracranial pressure.
Problems with eye movement
In children, hormonal disturbances such as precocious puberty may

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 occur.
Pituitary Headache
The pituitary is called the vision changes
"master gland." It secretes diabetes insipidus
several important hormones. Because these tumors often secrete hormones inappropriately,
other symptoms vary depending on the type of hormone secreted.
Breast enlargement and secretion are common.

Posterior Fossa Headaches due to the tumor and/or hydrocephalus, nausea and
The posterior fossa contains the vomiting and a swollen optic nerve due to increased intracranial
fourth ventricle, cerebellum and pressure are the most common symptoms
brain stem. clumsy, uncoordinated walk, swaying, and staggering
Dizziness
tremors
difficulty with coordination and speech, are also frequent symptoms.
Double vision
Nerve irritation can cause pain in the back of the head or neck or
tilting of the head.

Skull Base Symptoms depend on the specific structure affected:

Cranial nerves are often affected causing slurred speech, swallowing
difficulties, double vision and facial weakness
Balance problems

Thalamus sensory loss such as the sense of touch on the side of the body
The thalamus monitors input opposite the side of the tumor
from the senses and acts as a muscle weakness
relay station for the sensory decreased intellect
center of the cerebrum. vision problems
speech difficulties
loss of urinary control
Headache, nausea and vomiting and difficulties in walking due to the
increased pressure caused by obstructive hydrocephalus.

Third Ventricle Hydrocephalus due to the blockage of cerebrospinal fluid causing

symptoms of increased intracranial pressure
Leg weakness
fainting spells
impaired memory
hypothalamic dysfunction

Medical Management:
*treatment of metastatic brain cancer is palliative
* This involves eliminating or reducing serious symptoms
1. Radiation Therapy- foundation of treatment
2. Surgery- usually for a single intracranial metastasis
3. Gamma knife radiosurgery

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4. Chemotherapy
a. Corticosteroids
- dexamethasone (Decadron) and prednisone to reduce edema around tumors
b. Osmotic diuretics- decrease the fluid content of the brain
c. Antiseizure agents- phenytoin (Dilantin)
d. Multidrug regimens
- carmustine (BCNU)
- lomustine (CCNU)
- PCV (procarbazine Hcl, lomustine, vincristine)
- topotecan (Hycamtin)
e. Analgesics for pain
* Pain is managed by means of stepped progression in the doses and type of analgesic agents
needed for relief
- Morphine
- infused into the epidural or subarachnoid space through a spinal needle to
manage severe pain.

Nursing Interventions:
A. Compensating for Self-care Deficits
1. Encourage the family to keep the patient as independent as possible
2. Increase assistance with self-care if needed.

B. Improving Nutrition
1. Position patient comfortably during meals
2. Meals should be planned for times when the patient is rested and in less distress from pain or the
effects of treatment.
3. Oral hygiene before meals improves appetite
4. Utilize creative strategies to make the food palatable. Provide enough fluids.
5. Increase opportunities for socialization.
6. Ask the family to keep a daily weight chart and to record the quantity of food eaten to determine the
daily calorie count.
7. Dietary supplements can be provided as ordered.
8. Use other forms of nutritional support if patient show marked deterioration (Eg, Tube feeding,
parenteral nutrition)
9. Course of action regarding selection, initiation, maintenance and discontinuation of nutritional
support must be congruent to the wishes and choices of the patient and family.

C. Relieving Anxiety
1. be sensitive to the patient’s concerns and fears
2. Encourage to utilize support systems
3. Spend time with the patient to allow for open communication of fears and concerns.
4. Give therapeutic reassurances on the provision of continuing care.
5. Utilize counseling of spiritual advisers, social workers and mental health professionals if patient’s
emotional reactions are very intense or prolonged.

D. Enhancing Family Processes

1. Provide reassurance to the family on the continuance of optimal health care to their patient.
2. Communicate the plan of care with the family.

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3. End-of-life care should be provided with respect.

E. Promoting Home and Community-based Care

1. Teach patients about self care
2. Home care nursing and hospice services are valuable resources that should be made available to the
patient and family early in the course of terminal illness.
3. Home care should focus on the following;
 Palliation of symptoms and pain control
 Assistance in self-care
 Control of treatment complications
 Administration of specific forms of treatment

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