Traumatic Brain Injury, Brain Tumors & Intracranial Surgery

Student ObjectivesAt the completion of this unit, the student will

be able to:Discuss the pathophysiology, signs &

symptoms, and diagnostic tests associated with brain injury & tumors

Explain the therapeutic interventions and nursing care associated with the care of patients with brain injury & tumors.

Traumatic Brain InjuryEtiology & Pathophysiology

The results of TBI range from undetectable to persistent vegetative state

Causes: hemorrhage, contusion, laceration, cellular damage

MVA, falls, sports injuries, violence

Traumatic Brain InjuryEtiology & Pathophysiology

Classifications of InjuriesDefine each term (page 1148)

1) Closed Head Injury (nonpenetrating injury)2) Open head injury (penetrating injury)3) Acceleration injury4) Deceleration injury

Traumatic Brain InjuryEtiology & Pathophysiology

Define & Describe the following brain Injuries (use page 1148 for help)

1)Concussion:

2)Contusion:

Brain Injuries: HematomasSubdural Hematomas

•Bleeding is between the dura and arachnoid space•May be acute or chronicAcute: symptoms onset within 24 hoursBleeding is most often venous S&S increase in severity as hematoma enlargesOlder adults and alcoholics more prone because of changes in brain tissue

Brain Injuries: Hematomas

Subdural Hematoma S&Ss•Forgetfulness, lethargy, irritability, HA•If hematoma persists or increases in size hemiparesis, pupillary changes, altered levels of consciousness•S&S may be abrupt or gradual depending on the extent of injury and amount of bleeding

Brain Injuries: Hematomas

Epidural Hematoma•Collection of blood between the dura mater and the skull•Usually arterial in nature quicker onset of SXs: seizures, hemiparesis, LOC changes complete unresponsiveness•If ICP is not controlled rapidly permanent brain tissue damage or death•Develops dilated pupil & paralyzed EOMs on side of hematoma

Brain Injuries: HematomasEpidural Hematoma: Diagnosis

•CT scan: patient usually has multiple injuries•Neurophysiological testing: performed when PT stable; identifies problems with memory, judgment, learning, & comprehension. Rehabilitation strategies are then planned.

Brain Injuries: HematomasTherapeutic Measures

•Goal: control of ICP; often require ICP monitoring devices and drainage of CSF•Osmotic diuretics: mannitol (Osmitrol) utilize osmosis to pull fluid from tissue into the intravascular space eliminated. •Hyperventilation via mechanical ventilator cerebral vasoconstriction less blood flow to head lowered ICP (now controversial)

Brain Injuries: HematomasTherapeutic Measures

Barbiturate coma: induces therapeutic coma decreased metabolic needs; requires complete care and mechanical ventilation.

TBI: ComplicationsBrain Herniation

•Displacement of brain tissue out of its normal location•Displacement causes lack of function and pressure on other structures. •Herniation of brain tissue through the foreman magnum is common and occurs when ICP is not controlled

TBI: ComplicationsDiabetes insipidus: edema or injury affects the pituitary gland or hypothalamus inadequate release of antidiuretic hormone polyuria & polydipsiaHydrocephalus: Cerebral edema interferes with the circulation of CSF. This may require the insertion of a ventriculoperitoneal shunt drains CSF from the brain to the peritoneum lowered ICP

TBI: Complications

Post-Traumatic Syndrome: Patients report vague symptoms of headache, fatigue, depression, difficulty concentrating, & memory impairment.

These symptoms often interfere with work, school and relationships.

Neuropsychological testing establishes need for cognitive rehabilitation

TBI: ComplicationsCognitive & Personality Changes

•Short-term memory impairment: limits ability to learn new information, ability to function, & to make judgments•Emotional Liability: loss of inhibitions. Behavior may become violent, profane, or bizarre disintegration of relationships•Motor & speech impairments

TBI: Nursing ProcessData Collection & Assessment: ICP

monitoring (review box 48.1, p. 1137), Glasgow coma scale, pupil responses, muscle strength, vital signs.

Once patient is stable, neurological damage is assessed: physical/cognitive deficits, neuropsychological testing, rehabilitation needs, referral to appropriate services.

TBI: Nursing Process: Nursing Diagnosis

Risk for ineffective cerebral tissue perfusion related to increased ICP

•Assess S&S of Increased ICP: posturing, Glasgow coma scale, responses to pain tactile stimuli, LOC•Review Measures to prevent increased intracranial preasure (table 48.4, p. 1141)

TBI: Nursing Process: Nursing Diagnosis

Ineffective airway clearance related to reduced cough reflex and decreased LOC•Respiratory assessments•Use discretion: suctioning increases ICP•Keep HOB elevated, reduce risk of aspirating oral secretions•Turn frequently to mobilize respiratory secretions and prevent complications of immobility

Brain TumorsPathophysiology & Etiology

• 80 to 90% of brain tumors are primary• Tumors infiltrate and invade brain tissue• Cause is unknown• Primary brain tumors rarely metastasize• Benign tumors may be fatal

Brain TumorsPathophysiology & Etiology

Common Tumor TypesIntra-axial VS. Extra-axial tumors

(Classifications)MeningiomaGlioblastoma multiformeAstrocytomaAcoustic Neuroma

Brain TumorsPathophysiology & Etiology

Intra-axial TumorsNeoplasms that arise from cells within the

cerebrum, cerebellum, or brain stem

Brain TumorsPathophysiology & Etiology

Meningioma (Extra-axial)Slow growing neoplasms arising for the

meningesOccur most commonly in adultsExtra-axial tumor

Brain Tumors & Intracranial SurgeryPathophysiology & Etiology

Glioblastoma (Intra-axial)A malignant and rapidly growing

tumor of the cerebrum or spinal cord

Brain Tumors & Intracranial Surgery

Pathophysiology & EtiologyAstrocytoma (Extra-axial)

Composed of astrocytes & characterized by slow growth and invasion into surrounding structures

Complete surgical resection is possible during the early development of it.

Astrocyte: a large star-shaped neurological cell with many branches that is found in certain nervous system tissues.

Astrocytes

Brain Tumors & Intracranial Surgery

Pathophysiology & EtiologyAcoustic Neuroma

A benign unilateral or bilateral tumor arising from the vestibulocochlear (VIII) cranial nerve that grows within the auditory canal.

Depending on the size of the neoplasm, tinnitus, hearing loss, headache, facial numbness, papilledema, dizziness, and unsteady gait may occur.

Brain TumorsSigns & Symptoms

S&S are related to the location of the tumor

Common symptoms: motor & sensory deficits, visual changes, seizures, headaches, hemiparesis

Pituitary gland involvement symptoms:

Brain TumorsDiagnostic TestingMRI: clearest imagesAngiogram: performed when

neoplasm lies in close proximity to major blood vessels

If pituitary gland involvement is suspected, serum hormone levels are evaluated

Brain TumorsTherapeutic Interventions

Medical TreatmentControl symptoms

ICP and cerebral edemaSeizuresPain control

Surgical TreatmentRemoval of tumor, or of as much of the

tumor as possible.

Brain TumorsTherapeutic Interventions

Radiation TherapyStandard treatmentBrachytherapy: a means of delivering

radiation directly to a tumor. Stereotaxic radiosurgery: small amounts of

radiation are directed at a tumor from different angles.

Brain TumorsTherapeutic Interventions

ChemotherapyStandard chemotherapeutic agents do

not cross the blood-brain barrier New procedures are aimed at delivering

chemotherapeutic directly to the brain tumor .

Many new procedures being investigatedi.e.: Gene therapy

Brain Tumors Therapeutic InterventionsDifficult to distinguish between symptoms of a

brain tumor and complications of treatment.May experience hemiparesis or aphasia

following surgery or treatmentPatient gradually becomes comatose with

untreatable brain tumors. Nursing care of the patient with a brain tumor

is similar to the patient with brain injury. Review p. 1062-1064: Nursing Care for the

Patient with a Brain Tumor or Injury

Intracranial SurgeryPurpose: to remove a mass or lesionLesions include: hematomas, neoplasms,

diseased brain tissue, arteriovenous malformations, seisure foci, removal of foreign body, or removal of infectious debris/material.

Intracranial SurgeryProcedure Types

Burr holes: holes drilled into the skull to drain or irrigate materials

Craniotomy: surgical opening into the skullCraniectomy: removal of part of a cranial boneCranioplasty: repair of cranial bone or the

placement of prosthetic bone to repair a cranial defect.

Bone flap: refers to the piece of bone that was removed during a craniectomy

Intracranial SurgerySurgical goal: removal of all of the tumor. Debulking: removal of as much of a tumor

mass as possibleAppropriateness of intracranial surgery is

dependent upon location of lesion and patient’s condition

Intracranial SurgeryPreoperative Care

Routine pre-surgical work ups and evaluationsComplete neurological & cognitive baseline functionManagement of anxiety & fearPatient & family education:

Prepare patient and family for ICU environmentMany brain surgeries can last for up to 12 hoursHair is shavedFacial & periorbital edema

Intracranial SurgeryNursing Process

Frequent neurological & routine post-operative assessments

Changes need to be reported promptlyPlanning depends on the deficits and

functional level of the clientPlanning requires an interdisciplinary

approach

Intracranial SurgeryNursing Process: Nursing Diagnoses

I.Risk for ineffective cerebral tissue perfusion related to edema at the operative site

II.Risk for infection related to surgical procedure

Intracranial SurgeryNursing Process: Nursing Diagnoses

III. Knowledge deficit related to treatment regimens

Brain Tumors & Intracranial Surgery

Review Questions1)What is the goal of chemotherapy when it is

given for an inoperable brain tumor? 2)State two examples of extra-axial tumors that

effect neurological function3)Describe a glioblastoma4)Describe a craniectomy and a bone flap

Brain Tumors & Intracranial Surgery

Review Questions5) Your patient has had a craniectomy and you note

there is a wet mark next to his ear. How do you determine if this wet mark was caused by a CSF leak?

6) Why are seizure precautions implemented for a client with a brain tumor?

7) List interventions you may offer to help a post-operative craniectomy patient cope with a shaved head.

TBI Injury Review Questions1) List measures that can be

implemented to prevent increased intracranial pressure

2) List signs and symptoms related to increased intracranial pressure

3) Compare and contrast subdural and epidural hematomas.