Space occupying lesions

Space occupying lesions- Brain tumors and brain abscess

1. SPACE OCCUPYING LESIONS PRESENTED BY: MISS.SHWETA SHARMA M.SC. NURSING 2 nd YEAR AIIMS, JODHPUR

2. INTRODUCTION Intracranial space occupying lesions are tumors or abscesses present within the cranium or skull. These lesions put pressure on the adjacent brain tissue causing its damage. These are lesions which expand in volume to displace normal neural structures & may lead to increase in intra – cranial pressure.

3. EPIDEMIOLOGY The incidence of CNS tumors in India ranges from 5 to 10 per 100,000 population with an increasing trend and accounts for 2% of all malignancies.

4. TYPES OF SPACE OCCUPYING LESIONS TUMORS ABSCESS

5. Non-malignant tumors make up a majority of this type of space-occupying lesion. According to the American Brain Tumor Association, just one third of tumors diagnosed in adults are found to be malignant.

6. HISTOLOGICAL CLASSIFICATION OF BRAIN TUMOR Intrinsic tumors 1. Gliomas Astrocytoma- Grade I and II are low grade Grade III is malignant Grade IV is glioblastoma (high grade malignant tumor ) Oligodendrogliomas Ependymoma Mixed gliomas 2. Medulloblastoma

7. Tumors arising from supporting structures Meningioma Neuroma Schwannoma Developmental (congenital tumors ) Craniopharyngiomas Dermoids

8. Pituitary tumors Chromophobic or functioning and non-functioning Eosinophilic Basophilic Metastatic tumors Lung, breast Malignant melanomas

9. DEFINITION OF DIFFERENT TUMORS Gliomas: Originating from neuroglial cells. Astrocytoma: Gliomas from astrocytes. Glioblastoma: Gliomas otherwise called astrocytoma Grade III and IV arising from cerebral hemispheres.

10. Oligodendrogliomas: Glioma arising from oligo dendroglia . Ependymoma: Arising from the lining of ventricles of brain ( Ependymol cells). It can give signs of hydrocephalus. Medulloblastoma: Rapid growing tumors of neuroepithelial origin occurring in childhood and usually seen near 4th ventricles of the brain from cerebellum.

11. Neuromas: Benign tumor composed of fibrous tissue and nerve fibers. Meningioma: They grow often slowly, but are highly vascular. Commonly seen on the convexity of dura mater of the brain. Schwannoma: They are tumors of Schwann cells around the nerves, commonly seen from 8th cranial nerve.

12. Hemangioblastoma: Tumor arises from the brain or spinal cord consisting of proliferate cells around blood vessels. They are vascular.

13. Craniopharyngioma: Congenital sellar /suprasellar tumor, appearing most often in children and adolescents, that arise in cells derived from Rathke's pouch or the hypophyseal stalk. The lesion, a solid or cystic body ranging in size from 1 to 8 cm, may expand into the third ventricle or temporal lobe, frequently becomes calcified. This tumor may interfere with pituitary function, damage optic chiasm, disrupt hypothalamic control of autonomic nervous system and result in hydrocephalus. Development of tumor after puberty can cause amenorrhea in women, loss of potency in men. Other names are ameloblastoma, pituitary adamantinoma, Rathke's pouch tumor.

14. Craniopharyngioma

15. Pituitary Tumor Chromophobic: It is a non-secreting tumor of pituitary gland. Basophilic: It is a secreting tumor producing adrenocorticotropic hormones causing hyperplasia of adrenal gland. This tumor can grow fast causing enlargement of sella . Eosinophilic: Secreting tumor causing extra production of gland's hormone.

16. RISK FACTORS • Trauma • HIV infection • Diabetes • Malignancy • COPD • Tuberculosis

17. CAUSES Ionizing radiation Genetic factors Lowered immunity due to underlying conditions or medications Skull fracture Chronic sinus infections Meningitis

18. SIGNS AND SYMPTOMS General symptoms • Headache • Sudden personality changes • Nausea and vomiting • Papilledema

19. Signs and symptoms related to tumor area Frontal lobe tumors • Inappropriate behavior • Inattentiveness • Inability to concentrate • Emotional lability • Impairment of recent memory • Difficulty with abstraction

20. Parietal lobe tumors • Decreased tactile sensitivity • Loss of right left discrimination • Construction apraxia • Seizure activity Temporal lobe tumors • Hallucination-auditory, visual, olfactory • Receptive aphasia • Irritability, Depression • Poor judgment, Childish behaviour

21. Occipital lobe tumors • Visual disturbance • Visual hallucination Cerebellum tumors • Ataxia, incoordination Bra nstem tumors • Dysphagia • Vomiting • Motor /sensory tract deficits

22. Pituitary tumors • Gigantism • Acromegaly • Cushing’s syndrome • Hypopituitarism • Changes in metabolisms of fat, carbohydrate and water

23. Midbrain tumors • Cerebellar symptoms • Deafness • Decreased light reflex Ventricular tumors • Headache • Vomiting • Signs of increased intracranial pressure

24. DIAGNOSTIC EVALUATION History and physical examination Visual field and fundoscopic examination Computed tomography Electroencephalogram Cerebral angiography Lumbar puncture Magnetic resonance imaging Endocrine studies

25. MEDICAL MANAGEMENT Chemotherapy: • Dexamethasone (Decadron)-To reduce the cerebral edema • Phenytoin- To prevent or treat the seizure activity • Osmotic diuretic- mannitol • Antibiotics

26. Nursing care of patients on chemotherapy Record the vital signs to look for any signs of increased intracranial pressure. Observe any other symptoms of increased intracranial pressure like headache, vomiting. Watch for any seizure activity and keep the record. Use all support strategies to keep the patient fit and fine.

27. SURGICAL MANAGEMENT • Craniotomy of different regions, depending upon the site of tumor • Shunt of different types in case of non-communicating tumors causing hydrocephalus • Laser surgeries • Use of gamma knife • Interventional radiotherapy • Burr hole for biopsy

28. PRE- AND POSTOPERATIVE CARE OF PATIENTS UNDERGOING NEUROSURGERIES Preoperative Management For the planned surgery, the preoperative care starts on the day the patient comes to the hospital for the first time. The preoperative period can be divided into: • Care given in outpatient department • Care given from the day of admission till the day of surgery • On the day of surgery till the patient reaches the OT • In the operation theatre till the surgery is started

29. In the outpatient department the following steps are taken: • History • Investigation •Make the patient fit for surgery, physically, mentally financially and socially • Here the family also is given support On admission the patient is given physical orientation: Orientation to the routine of the ward, orientation to the staff. Patient is given information about the nature of surgical procedure, possible complications if the patient is in a position to understand.

30. The day of surgery: consent, physical preparation, keeping ready all the investigation report, premedication, keeping ready the preoperative check list and accompanying the patient till the operation theatre. In the operation theatre: the nurse receives the patient with all records, handover the patient to the anesthetist and his/her team.

31. Intraoperative Care Nursing care can be under the following heading: • Prevention of hypotension • Prevention of hypothermia and hyperthermia • Prevention of hyperventilation • Prevention of air embolism if the patient is in sitting position • Prevention of any type of burns when diathermy is used

32. Postoperative Care After surgery the patient is taken to the recovery room or to the neurosurgical intensive care unit. Here, the environment allows for close monitoring to meet any emergency. Here, the nurse should have or obtain the necessary documents like: • Postoperative notes • History of preoperative neurological status of patient • Current (postoperative) baseline neurological assessment • Review the postoperative order

33. Nursing care following craniotomy is with the objective of: • Frequent monitoring and recording of neurological signs to identify the signs of increased intracranial pressure. • Frequent monitoring of vital signs to prevent the causes for increased intracranial pressure. • Look for any seizure activity. • Observe for any neurological deficit. Care in Postoperative Ward Continue the observations and prepare the patient for discharge. Planning for early rehabilitation is essential, i.e. according to the condition and need for the individual patient.

34. Special Nursing Care of Patients Undergoing Surgery for Pituitary Tumors Preoperative • Daily weight checking • 24 hours urine volume for 3 consecutive days • Intake and output chart for 3 days • If the approach is oral/nasal, swab is sent for culture and sensitivity, urine and blood also sent for osmolality.

35. Postoperative • Weight to be checked daily • Strict intake and output chart-watch for negative balance and inform • Nasal drops to be put If nasal pack is there • Head end to be elevated • Bedrest to be advised • Instruct not to sneeze • Instruct not to cough • Oral respiration to be advised

36. Operative approaches in neurosurgery

37. NURSING DIAGNOSIS Ineffective cerebral tissue perfusion related to cessation of blood flow by SOL. Pain (acute / chronic) related to physical injury, nerve compression by SOL, increased ICP. Risk for ineffective breathing pattern related to neurovascular damage, cognitive impairment.

38. BRAIN ABSCESS A brain abscess is a collection of pus enclosed in the brain tissue, caused by a bacterial or fungal infection.

39. Brain abscess (or cerebral abscess) is an abscess caused by inflammation and collection of infected material, coming from local (ear infection, dental abscess, infection of paranasal sinuses, infection of the mastoid air cells of the temporal bone, epidural abscess) or remote (lung, heart, kidney etc.) infectious sources. The infection may also be introduced through a skull fracture following a head trauma or surgical procedures.

40. EPIDEMIOLOGY It may occur at any age but is most frequent in the third decade of life. The incidence of brain abscess among intracranial masses varies from 1-2% in western countries, to about 8% in developing countries.

41. CAUSES AND RISK FACTORS Nearly anyone can get a brain abscess, but certain groups of people are at a higher risk than others: • A compromised immune system due to HIV • Cancer and other chronic illnesses • Congenital heart disease • Major head injury or skull fracture • Meningitis • Immunosuppressant drugs, such as those used in chemotherapy • Chronic sinus or middle ear infections

42. CLINICAL MANIFESTATIONS Triad of fever, headache and focal neurologic findings Headache, drowsiness, confusion, seizures, hemiparesis or speech difficulties together with fever with a rapidly progressive course. Headache is characteristically worse at night and in the morning, as the intracranial pressure naturally increases when in the supine position. This elevation similarly stimulates the medullary vomiting center and area postrema, leading to morning vomiting. Decreased sensation, loss of coordination, loss of muscle function, typically on one side, stiff neck and vision changes.

43. DIAGNOSTIC EVALUATION Neurological examination Blood cultures Chest x-ray Complete blood count (CBC) Head CT scan- Within 4-5 days the inflammation and the concomitant dead brain tissue are surrounded with a capsule, which gives the lesion the famous ring-enhancing lesion appearance on CT examination with contrast. Electroencephalogram (EEG)

44. MRI of head Testing for the presence of antibodies to organisms such as Toxoplasma gondii and Taenia solium A needle biopsy is usually performed to identify the cause of the infection. Lumbar puncture is contraindicated because it can cause the brain tissue to move across structures within the skull (brain herniation).

45. MANAGEMENT Medication is recommended if patient have: • Several abscesses (rare) • A small abscess (less than 2 cm) • An abscess deep in the brain • An abscess and meningitis • Shunts in the brain for hydrocephalus (in some cases the shunt may need to be removed temporarily or replaced) • Toxoplasma gondii infection in a person with HIV

46. Broad spectrum antibiotics Antifungal medications Hyperbaric oxygen therapy (HBO2 or HBOT) Reduces intracranial pressure High partial pressures of oxygen act as a bactericide and thus inhibits the anaerobic and functionally anaerobic flora common in brain abscess Optimizes the immune function thus enhancing the host defense mechanisms Found to be of benefit when brain abscess is concomitant with cranial osteomyelitis.

47. Surgery is needed if: • Increased pressure in the brain continues or gets worse • The brain abscess does not get smaller after medication • The brain abscess contains gas (produced by some types of bacteria) • The brain abscess might break open (rupture)

48. PROGNOSIS If untreated, a brain abscess is almost always deadly. With treatment, the death rate is about 10 - 30%. The earlier the treatment is received, the better is prognosis. Some patients may have long-term neurological problems after surgery.

49. COMPLICATIONS Brain damage Meningitis that is severe and life threatening Recurrence of infection Seizures

50. Nursing Management & Interventions • Nursing interventions should support the medical treatment. • Patients and families need to be advised of neurologic deficits that may remain after treatment (hemiparesis, seizures, visual deficits, and cranial nerve palsies). • Frequently assess neurologic status, especially LOC, speech and sensorimotor and cranial nerve functions. • Assess the family’s ability to express their distress at the patient’s condition, cope with the patient’s illness and deficits, and obtain support. • Always provide safety measures.