Brain Tumors Astrocytomas and Glioblastomas

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Brain tumors: Astrocytomas and Glioblastomas

Wanda Lockwood RN, BA, MA
BTA110508
5
Purpose
The goal of this course is to define astrocytomas/glioblastomas and to explain the diagnosis, the causes,
the symptoms, the complications, the treatments, and pre-operative and post-operative management.
Objectives
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Explain the difference between primary and metastatic tumors.

Explain the origin of astrocytic tumors.
List and discuss symptoms of brain tumors in relation to affected region of the brain.
List and explain at least 5 diagnostic procedures.
List and explain 3 primary types of treatment for astrocytic brain tumors.
List and explain the 4 WHO categories for tumors.
List and discuss general characteristics of 6 astrocytic tumors.
Explain 3 open surgical approaches.
Explain the difference between Gamma Knife and CyberKnife radiosurgery.
List at least 5 preoperative nursing interventions.
Discuss postoperative nursing interventions.
List and explain the 3 parameters for the Glasgow Coma Scale.
Explain the Monroe-Kellie Hypothesis.
List and discuss at least 5 of 8 common postoperative complications.
Discuss nursing interventions for patient discharge.
Introduction
A brain tumor is a chilling diagnosis for anyone, but new chemotherapeutic and surgical techniques have
increased survival rates for most types of tumors. Approximately 17,000 people in the United States alone
develop primary brain tumors each year. Primary brain tumors can be either benign or malignant. Benign
brain tumors, such as meningiomas, acoustic neuromas, and pituitary gland tumors, are often slow
growing and can be surgically excised, depending upon their location. Malignant tumors, on the other
hand, are often faster growing and tend to spread into the surrounding brain tissue, making complete
removal difficult or impossible. Primary brain tumors rarely spread to other parts of the body, instead
spreading to other parts of the brain and the spinal axis. Both children and adults can suffer from brain
tumors. The most common age groups are children between the ages of 3 and 12 and adults between 40
and 70.
Primary brain tumors arise within the brain tissue itself as opposed to metastatic brain tumors with an
original tumor site outside of the brain. Metastatic brain tumors outnumber primary tumors by about 10 to
1, occurring in 20-40% of cancer patients. The most common cancers metastasizing to the brain are lung
cancer (50%) and breast cancer (15-20%). Eighty percent of metastatic brain tumors occur in the
cerebral hemispheres, 15% in the cerebellum, and 5% in the brain stem with 70% of these patients
having multiple brain lesions. Its important to differentiate between primary cancerous lesions and
metastatic lesions. It should not be assumed that a cancerous lesion of the brain is metastatic simply
because the patient has a primary tumor elsewhere. Brain tumors must also be differentiated from other
lesions of the brain, such as abscesses, arteriovenous malformations, and infarction (1, 2, 3).
http://www.myfreece.com/Public/Course_PrinterFriendly.asp?CourseId=1845&OrderDeta... 8/13/2009
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While there are many types of brain tumors, astrocytomas account for about 40% of the primary tumors
of the brain and spinal cord. Astrocytomas arise from astrocyte cells, which are part of the supportive, or
neuroglial, tissue within the brain; therefore, they are sometimes referred to as gliomas. Astrocytes are
named for their star-like appearance. Astrocytomas are always infiltrative tumors that act as mass
lesions. Symptoms relate to the area in which the tumor has infiltrated. Astrocytomas can develop
anywhere within the brain but are most common in the cerebrum of adults, especially males, and the
cerebellum of children. Astrocytomas may occur at the base of the brain in children and young adults.
Glioblastomas are fast-growing astrocytomas that contain areas of necrotic tumor cells. In adults, they
most often occur in the frontal or temporal lobes of the cerebrum, rarely in the cerebellum or brain stem.
(1, 2, 3).
The brain
Medial aspect:
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Who is at risk for developing astrocytic tumors?

Patients who receive therapeutic radiation for pituitary adenomas, craniopharyngioma, pineal parenchymal
tumors, germinoma, and tinea capitis are at increased risk of developing astrocytic tumors. Additionally,
children who receive prophylactic irradiation of the central nervous system for acute lymphoblastic
leukemia are at increased risk. Recurrent lesions often indicate histologic progression to a higher grade,
associated with a cumulative acquisition of genetic alterations (3).
While exact risk factors have not been identified, some studies have indicated that the following may put
people at increased risk of developing astrocytomas:

Genetic disorders
Occupational exposure to:
Radiation
Chemicals, such as vinyl chloride
Oil refining
Rubber manufacturing
History of neurofibromatosis or tuberous sclerosis (4)
General symptoms of astrocytomas

Initially, a person with an astrocytoma may experience either no or vague symptoms. As the tumor
grows, symptoms develop from increased pressure on the area of the brain that is involved. Symptoms
may include:

Headaches
Changes in vision
Nausea and vomiting
Seizures
Personality changes
Dementia
Memory loss
Inability to concentrate
Ataxia
In young children, the growing tumor in the brain may enlarge the head. Swelling may be observed in the
back of the eye. Seizures are more common with slow-growing astrocytomas than with more malignant
forms. Usually, the symptoms that develop result from increased pressure within the skull as the tumor
grows and causes inflammation of surrounding tissue and increased intracranial pressure. As pressure
increases, headache is common, often behind the eyes and near the top of the head, usually worsening
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with exertion and at night or in early morning. Nausea is common. As pressure increases, lethargy,
confusion, and disorientation may occur. Changes in cardinal signs, such as, blood pressure, pulse,
respiration, and temperature are usually late symptoms.
As the tumor develops, symptoms will vary depending upon the location, causing localized brain
dysfunction:
Tumor
location
Associated symptoms
Frontal lobe
Changes in mood and personality

Hemiparesis
Temporal lobe Lack of coordination

Speech difficulties
Memory loss
Parietal lobe
Lack of sensation
Difficulty writing
Loss of fine motor skills
Loss of half-body awareness (patient may shave on one side of face or apply makeup to
one side only)
Cerebellum
Lack of coordination
Lack of balance
Occipital lobe Vision disturbances

Visual hallucinations
Brain stem
Cranial nerve dysfunction

Facial pain, weakness
Dysphagia
Complications of tumors
There are a number of serious complications that can develop as the brain tumor grows and damages
surrounding tissue:
Vasogenic (cerebral) edema results when there are changes in the permeability of the capillary
endothelial tissue, allowing plasma to seep into the extracellular spaces. This can lead to increased
intracranial pressure and herniation of the brain tissue.
Cerebral blood vessels may become compressed causing ischemia to the area served by the vessels.

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Numerous focal neurologic developments may occur.

The tumor may infiltrate the walls of a vessel, leading to rupture and hemorrhage.
Seizure activity may occur.
Cerebral spinal fluid flow may be obstructed, leading to increased intracranial pressure and
hydrocephalus.
Pituitary dysfunction may occur if the tumor compresses the pituitary gland, leading to inappropriate
antidiuretic hormone or diabetes insipidus (4, 5).
Diagnostic procedures
Diagnosis usually begins with a complete neurological evaluation, especially if the patient has slowly
increasing evidence of mental impairment, seizures, headaches, or evidence of intracranial pressure. The
neurologist will order further diagnostic tests as indicated:
Diagnostic procedure
Discussion
Computed tomography (CT)
Because of its speed (a

few minutes), CT is
used to evaluate
patients who are
clinically unstable. A CT
of the head produces an
image from the upper
neck to the top of the
head. A contrast dye
may be injected
intravenously as blood
vessels become brighter
with contrast. This dye
may cause a slight
burning sensation in the
arm, a metallic taste in
the mouth, and a
generalized feeling of
warmth. These
sensations subside
within a few minutes.
With the CT, a thin xray beam rotates
around the patient. The
computer then analyzes
the data to construct a
cross-sectional image,
which can be stacked to
create a threedimensional model of
organs. The CT scan is
more effective than MRI
for detecting these
factors:

Calcification
Skull lesions
Hemorrhage less
than 24 hours in
duration
(hyperacute)
CT is helpful in directing
differential diagnosis
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and immediate
management. Children
are at increased risk of
excessive radiation
exposure from multiple
CTs because they
receive the same
amount of radiation as
an adult even though
their size is smaller (3,
6).
Magnetic resonance imaging (MRI)
High quality MRI is the

imaging method of
choice in the evaluation
of intramedullary and
extramedullary spinal
cord lesions and is used
for diagnosis of other
brain tumors. Unlike CT,
which uses x-rays, the
MRI is based on the
magnetic properties of
atoms, so it is safer for
children although young
children require
anesthesia. The MRI
uses radio waves very
close in frequency to
those of FM radio
stations so the test
must be conducted in a
shielded room to avoid
outside interference.
The patient lies on a
table that slides into a
tunnel-like tube that
some may find
claustrophobic. A small
body coil may be placed
around the head to send
and receive the radio
wave pulses.
The energy from the
radio waves is absorbed
and then released in a
pattern formed by the
type of tissue and by
certain diseases.
Intravenous contrast
dye may also be
administered. Usually
several sets of images
are taken, each
requiring 2-15 minutes
so a complete scan may
take up to an hour
although newer
scanners with more
powerful magnets may
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require less time. MRI

produces detailed
pictures of the brain and
nerve tissues from
multiple planes. It is the
procedure of choice for
most brain and
neurological disorders
because it can clearly
show various types of
nerve tissue, providing
clear pictures of the
brainstem and posterior
brain, which are hard to
image with a CT scan. It
can evaluate blood flow
and the flow of
cerebrospinal fluid.
Because high quality
MRI has superior softtissue resolution, it is
more effective than CT
for the following:

Magnetic resonance spectroscopy (MRS)
Detection of
isodense lesions
Tumor
enhancement
Detection of
associated
findings, such as
edema
All phases of
hemorrhagic
states (except
hyperacute) and
infarction
Distinguishing
tumors or other
lesions from
normal tissues (3,
7, 8)
Magnetic resonance
spectroscopy is done
with an MRI at
specialized facilities to
analyze the chemical
composition of proton
(hydrogen)-based
molecules, some of
which are specific to
nerve cells, and MRS
can identify tissue as
normal or tumor and
may be able to
distinguish glial tumors
from others. Multi-voxel
magnetic resonance
spectroscopy (MRS) is
capable of
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characterizing the
chemical fingerprint of
a brain lesion noninvasively. It may
differentiate between
low-grade and highgrade tumors (4, 9).
Positron emission tomography (PET)
PET scans uses IV

glucose that contains a
radioactive atom tracer.
A special camera can
detect the radioactivity.
Because cancer cells
have high rates of
metabolism, they
absorb high amounts of
the radioactive material.
A PET scan shows less
detail than a CT or MRI,
so the PET scan is
usually matched with a
CT or MRI to get a full
picture. A PET scan is
sometimes useful in
diagnosing tumors and
evaluating response to
treatment. After
treatment is completed,
scar tissue may still
remain and this will
show up as an
abnormality on an MRI,
but PET scans can help
to differentiate tumor
from scar tissue (8).
Angiography
A cerebral angiogram is
usually not indicated for
diagnosis of a brain
tumor, but one may be
ordered to obtain
additional information
about the vascular
supply to the tumor.
With an angiogram, dye
is injected into the
arteries and then x-rays
are taken that show
abnormalities in the
arteries that lead to the
brain (4).
Biopsy, surgical
With a biopsy, a sample

of the brain tissue is
removed to test for the
presence of cancer cells.
Biopsy is done by direct
excision during a
surgical procedure.
Complications can
include
Biopsy, stereotactic
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Stereotactic brain
biopsy is a biopsy
procedure in which
biopsy forceps are
inserted into a lesion
through a metal cannula
passed through the
brain parenchyma
rather than in an open
surgical procedure. After
injecting a local
anesthetic, most
procedures require a
frame be affixed to the
head. An MRI is used to
guide the neurosurgeon.
An incision is made in
the scalp and then a
small hole drilled into
the skull for passage of
the needle, or cannula.
There are some
complications associated
with this procedure:
Non-diagnostic
results:
Fifteen
percent to
20% of
biopsy
results are
nondiagnostic.
Because the
amount of
tissue taken
is very
small, its
possible to
essentially
miss the
tumor
because of
sampling
the wrong
area, using
the incorrect
coordinates,
or
misreading
the imaging.
A nondiagnostic
biopsy
should be
repeated
one or two
times.
Hemorrhage:
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The
trajectory of
the cannula
or the site of
the biopsy
may be too
near large
blood
vessels.
The
surgeons
technique
too quick or
forceful in
passing the
cannula
can tear tiny
blood
vessels.
Patients
blood may
not clot
properly.
Typically
there is a
small degree
of
hemorrhage
in almost all
stereotactic
biopsies, but
they are
usually
insignificant;
only 5% are
clinically
significant.
Infection:
Infection is
a possibility
in any
invasive
procedure.
Typically
infection will
present with
red, swollen
tender skin
and scalp
around the
cannula
insertion
site. More
severe
infections
can also
occur within
the skull.
Infection
complicates
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only 5% of
stereotactic
brain
biopsies
(10).
Visual field studies
Visual field studies may

be ordered if there are
visual problems related
to the brain tumor in
order to provide more
precise information
about the extent of
visual field deficits (5,
12).
Nursing interventions before diagnostic tests

Patients as well as family members are often anxious and fearful when faced with the possibility or
diagnosis of a brain tumor. Whether the nurse sees the patient in the doctors office or the hospital, he
or she should take the time to explain the procedures to the patient and family and encourage
questions. Patients are often reluctant to ask the physician questions but usually have many questions
that they would like answered:

If pictures of the equipment (MRI, CT scanner) are available, its helpful to show them to the
patient so that the patient knows what to expect.
Tell the patient and family approximately how long the procedure will take and advise them of any
required preparations, such as fasting or not drinking fluids.
Question the patient regarding allergies to dyes or shellfish if the patient is to receive a contrast
medium.
If a surgical diagnostic procedure, such as a surgical biopsy or stereotactic biopsy, is to be
performed, explain in detail all preoperative preparation, including anesthesia.
Explain the procedure for preparing the patients head for the procedure if the head is to be
shaved in the area of the surgery (as or biopsy). Some peopleespecially males--may prefer to
shave their entire heads prior to the procedure.
(13)
Classification of tumors
Tumors can be classified in different ways, and this can lead to confusion, but a common classification
system is that of the World Health Organization (WHO), last revised in 2007. The WHO incorporates and
interrelates morphology, cytogenetics, molecular genetics, and immunologic markers in an attempt to
construct a cellular classification that is universally applicable and prognostically valid (3). The TNM
(tumor size, nodal status, and metastatic spread) classification system does not relate well to tumors of
the central nervous system because the size of the tumor is less important than the location, there are no
lymphatics so nodal status doesnt apply, and tumors rarely metastasize from the CNS to other parts of
the body (sometimes because death occurs early).
The classification system used is important because treatment is based on staging of the tumor, but other
factors, such as age, location, extent of resection, must be considered:
The histologic grade of the tumor is based on the regions of a tumor demonstrating the most
anaplasia, based on the assumption that the areas of greatest anaplasia determine the degree of
malignancy and progression of the disease.
The WHO grading of CNS tumors establishes a malignancy scale based on histologic features of the
tumor and assigns grades I-IV with higher grades the most malignant (2, 3):
Low-grade astrocytomas grow very slowly in comparison to higher-grade malignant tumors. The doubling
time for low-grade tumors is about one-fourth that of anaplastic astrocytomas. With low-grade tumors,
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several years may pass between initial symptoms and diagnosis. In half of the cases of low-grade tumors,
deterioration in condition is quite gradual and a sudden deterioration occurs in only about 15% of cases.
In general, patients with grade I and II tumors typically have survival rates that exceed 5 years. Those
with grades III and IV glioblastomas have survival rates of 2-3 years although the outlook for some other
types of tumors has improved markedly with cerebellar medulloblastomas and germ cell tumors (grade
IV) having 5-year survival rates of 60% and 80% if diagnosed early and treated with state-of-the-art
radiation and chemotherapy (2, 3, 4, 14).
Grade Description
Comments
Grade Includes lesions with low proliferative Referred to as low-grade astrocytomas. These tend to
I
potential, a frequently discrete nature, grow slowly and remain localized. They are primarily
and the possibility of cure with
found in children.
surgical resection alone.
Grade Includes lesions that are usually
II
infiltrating and low in mitotic activity
but frequently recur.
Same as Above
Grade Includes lesions with histologic

III
evidence of malignancy, usually in the
form of mitotic activity, clear
infiltrative capabilities, and anaplasia.
Referred to as high-grade tumors and grow rapidly,

spreading through the brain and spinal chord. This is the
most common type of astrocytoma found in adults.
Grade III are called anaplastic astrocytomas. Grade IV
tumors are called glioblastoma multiforme.
Grade Grade IV Includes lesions that are

IV
mitotically active, prone to necrosis,
and usually associated with rapid
evolution of the disease, both preand post-operatively.
Same as Above
Astrocytic tumors
The WHO classifies all astrocytomas according to grade:
Tumor
WHO grade
Subependymal giant cell astrocytoma I

Pilocytic astrocytoma
Pilomyxoid astrocytoma
II
Diffuse astrocytoma
II

Fibrillary
Protoplasmic
Gemistocytic
Pleomorphic xanthoastrocytoma
II
Anaplastic astrocytoma
III
Glioblastoma
IV
Giant cell glioblastoma
IV
Gliosarcoma
IV
Subependymal giant cell astrocytoma (SEGA) (WHO grade I)

Subependymal giant cell astrocytoma (SEGA) is a benign, slow-growing tumor that usually arises in the
lateral walls of the ventricles. It occurs almost exclusively in 6% to 16% of patients with tuberous
sclerosis complex (TSC) during the first two decades of life. Tuberous sclerosis complex is an autosomaldominant, multisystem neurocutaneous syndrome usually characterized by seizures, mental retardation,
and facial adenoma sebaceum. This benign tumor may occur in various organs, including the brain.
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Patients historically presented with signs of increased intracranial pressure and death rates after surgery
approached 10%, but currently biopsies often identify tumors and they are resected during the non-acute
phase, and this has improved prognosis.
Treatment:
Surgical excision (3, 15)
Link to images (click on images to enlarge):

Pictures of subendymal giant cell astrocytoma
Pilocytic astrocytoma (WHO grade I)

The pilocytic astrocytoma, which occurs primarily in children ages 5-14 (average age 58 months), is a
circumscribed, slow-growing and often cystic tumor. It is generally considered benign because it does not
invade surrounding tissue but can become very large. It represents 10% of cerebral tumors and 85% of
cerebellar astrocytic tumors. Pilocytic astrocytomas occur throughout the neuraxis, especially invading the
optic nerve, optic chiasm/hypothalamus, thalamus, and basal ganglia, cerebral hemispheres, cerebellum,
and brain stemmost commonly the cerebellum, the part of the brain that controls balance. Pilocytic
astrocytomas are sometimes excluded from consideration with other gliomas because they constitute a
distinctive pathological and clinical entity. The most common symptoms are related to increased
intracranial pressure due to increased mass or hydrocephalus. These symptoms include the following,
based on location:

Headache
Nausea/vomiting
Irritability
Ataxia
Visual complaints
This tumor is not usually fatal, having a 1- year survival rate of 90% if the tumor was completely
resected. With partial resection, the 10-year survival rate is 45%. It is associated with neurofibromatosis
type 1 (NF1), which is an autosomal dominant disorder characterized by the development of both benign
and malignant tumors, especially involving the optic nerve.
Treatment:

Surgical excision (or stereotactic radiosurgery) if tumor is completely resectable.

Surgical excision followed by radiation therapy if there is known or suspected residual tumor.
Follow up treatment with recurrence:

Reoperation and radiation therapy if not previously done.

If radiation previously done, patients may be considered for nitrosourea-based chemotherapies, for
temozozlomide, or for clinical trials of new drugs (3, 10, 17, 18, 19).
Link to images (Click images to enlarge):

Pictures of pilocytic astrocytoma
Pilomyxoid astrocytoma (WHO grade II)

The pilomyxoid astrocytoma (PMA), a tumor recently identified, is closely related to pilocytic astrocytoma
but is now classified separately. It occurs in sites that are also affected by pilocytic astrocytomas, such as
the hypothalamic/chiasmatic region, but it is histologically distinctive, and it appears much earlier. It
affects primarily infants and children (median age of 10-18 months), and it has a less favorable outcome
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than pilocytic astrocytomas as it is more prone to have local recurrence (55%-76%) and cerebrospinal
spread and recurrence is earlier than for pilocytic astrocytoma (2). Typically, children present with
indications of increased intracranial pressure or compression of parenchymal tissue with failure to thrive,
delay in development, poor feeding, vomiting, alterations of consciousness, and general weakness.
Children with tumors in the cerebellar area may exhibit gait abnormalities, dysmetria, and nystagmus. If
the tumor extends into the foramen magnum, stiffness of the neck or head tilt may be noticeable. If there
is pressure on the 6th cranial nerve (rare), then strabismus may be evident. The first indication in infants
may be increase in head size, with increased intracranial pressure that may cause split sutures and
bulging fontanelles. Children often become irritable and lethargic with bradycardia and slowed respirations
as the disease progresses.
Treatment:
Definitive treatment is evolving as this tumor is studied. Currently, treatment is similar to that of pilocytic
astrocytoma although radiation is generally avoided in prepubertal patients. The more aggressive nature
of this tumor may affect future protocols for treatment:

Surgical resection (or stereotactic radiosurgery) is the treatment of choice.

Chemotherapy and/or radiation may be indicated despite morbidity. (29)
Link to images (Click images to enlarge)

Pictures of pilomyxoid astrocytoma
(16)
Diffuse astrocytoma (WHO grade II)

The diffuse astrocytoma, a low-grade tumor, is characterized by slow growth and infiltration of adjacent
brain structures. That is, the tumor often grows microscopic tentacles that spread into adjacent tissue,
making complete resection of the tumor very difficult. This type of tumor usually is found in young adults
and may progress to anaplastic astrocytoma and glioblastoma. Diffuse astrocytomas represent 35% of all
astrocytic brain tumors and may be located in any area of the central nervous system but are most
commonly found in the cerebrum, the thinking part of the brain. There are three histologic variants:
fibrillary astrocytoma, gemistocytic astrocytoma, and protoplasmic astrocytoma. These types of tumors
may occur in patients with Fraumeni syndrome, having inherited TP52 germline mutations. These
mutations are present in 60% of cases. The most common chromosomal alteration is the deletion of
chromosome band 17p13.1. Seizures and headaches are usually the earliest sings of this tumor. CT and
MRI scans show the presence of a tumor, which does not enhance (light up) when an intravenous contrast
dye is administered. The average survival time after surgical resection is 6 to 8 years with considerable
individual variation, but most patients will eventually die from their tumors.
There is not yet consensus in regard to correct use of radiation therapy. Some prefer early radiation while
others prefer to wait for the tumor to begin to regrow. While studies show that early radiation may slightly
delay the average time until the tumor begins to regrow, the overall outcome was identical. About twothirds of the deferred group required radiation about 5 years after diagnosis. Recurrent tumors tend to
return as biologically more aggressive tumors, making patients eligible for clinical trials available to
patients with high-grade gliomas.
Treatment:

Surgical resection followed by radiation

Surgical resection alone is preferred by some physicians if the patient is younger than 35 years old
and the tumor does not contrast-enhance on a CT scan.
Follow-up treatment with recurrence:

Participation in clinical trials. Some trials use radiation plus chemotherapy. Others evaluate deferring
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radiation therapy until tumor progression. Some vary the amount of radiation (3, 18, 19).

Pictures of diffuse astrocytoma
Pleomorphic xanthoastrocytoma (WHO grade II)

Pleomorphic xanthoastrocytoma is a rare astrocytic tumor that accounts for fewer than 1% of all
astrocytic neoplasms. It is most commonly found in children and young adults and involves the cerebrum
and meninges. The average age at diagnosis is 12 years. These tumors very rarely undergo
transformation to a more malignant tumor. No genetic predisposition has been identified. Because these
tumors grow slowly, children may have vague symptoms for months before being seen by a physician.
The most common symptom at diagnosis is seizure activity. This tumor has a relatively favorable
prognosis with recurrence-free survivals of 72% at 5 years and 61% at 10 years.
Treatment:
Surgical excision
Treatment after recurrence

Surgical excision
Participation in clinical trials (3, 21)

Pictures of pleomorphic xanthoastrocytoma
Anaplastic astrocytoma (WHO grade III)

Anaplastic astrocytoma, also known as malignant astrocytoma or high-grade astrocytoma, may arise from
a diffuse astrocytoma or on its own without a less malignant precursor. Anaplastic astrocytomas often
progress to glioblastoma. The average age at diagnosis for adults is 41 years; for children, 9 to 10 years
old. The tumor primarily affects the cerebral hemispheres (65%) but 20% may also occur in the area of
the thalamus and hypothalamus or the diencephalon. Another 15% occur in the area of the cerebellum
and brain stem area known as the posterior fossa. Similar to diffuse astrocytomas, anaplastic
astrocytomas have a high frequency of TP53 mutations, but chromosomal abnormalities are non-specific.
Many of the genetic alterations involve genes that regulate cell cycle progression. Some patients suffer a
slow insidious onset of symptoms but others have abrupt symptoms. The most common symptoms are
the following:

Headache and lethargy

With increased pressure in the brain, the headache is usually upon awakening in the morning
Vomiting
Seizures may occur but les frequently than in low-grade tumors
Various symptoms depending upon location of the tumor
The average time to progression of the tumor is 2 years. These tumors have a low cure rate and patients
are candidates for clinical trials. The best-reported survival rates for radically-removed tumors and
adjuvant radiation therapy are about 40% after 5 years; however, most tumors are not completely
removed and the survival rate is then less than 20 percent.
Treatment:

Surgery plus radiation

Surgery plus radiation and chemotherapy, such as temozozlomide

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Carmustine (BCNU)-impregnated polymer may be implanted during surgery.

Participation in clinical trials
Follow-up treatment with recurrence:

Participation in various clinical trials. (3, 9)

Pictures of anaplastic astrocytoma
Glioblastoma (WHO grade IV)

Glioblastoma, also known as glioblastoma multiforme, may develop as a progression from a diffuse
astrocytoma or an anaplastic astrocytoma (then called a secondary glioblastoma) but more commonly
appears without evidence of a lesser grade tumor. Glioblastoma is the most commonly occurring brain
tumor, 12% to 15% of all brain tumors but 50% to 60% of all astrocytic tumors. It is one of the most
devastating tumors. This tumor primarily affects adults (70%), with peak incidence between ages 45 and
70. About 8.8% of glioblastomas occur in children. Glioblastomas primarily occur in the cerebral
hemispheres. There are two histologic variants: giant cell glioblastoma and gliosarcoma. Glioblastomas
have been associated with more genetic abnormalities than any other astrocytic tumor. Chromosomal
abnormalities of chromosome 10 are the most frequently observed chromosome alterations. Advances in
the fields of molecular biology and cellular biology and genomics have provided more knowledge about
glioblastomas, which possess multiple genetic and chromosomal abnormalities that cause these tumors to
grow so rapidly. Glioblastomas are unique in the ability to proliferate uncontrollably and aggressively
invade, infiltrate, and destroy surrounding brain tissue. While some have theorized that high-tension
electrical lines and cell phones may cause glioblastomas, the only consistently identified risk factor is
chronic exposure to petrochemicals. The most common presenting symptoms are the following:

Slowly progressive neurologic deficit, generally motor weakness

Generalized symptoms of increased intracranial pressure, including headaches, nausea and
vomiting, and cognitive impairment
Seizures
Glioblastomas are among the most aggressive malignant human neoplasms with survival rates of less
than a year although some of the newer radiosurgery techniques have extended survival to two years.
Glioblastomas typically contain more than one type of cell. While treatment may kill one type of cell, the
other cell types may continue to multiply, making glioblastomas very difficult to treat. Treatment for
glioblastoma is palliative rather than curative. There have been no significant advancements in treatment
in the last 25 years although current treatment prolongs quality survival. With no treatment, death usually
occurs within 3 months, but is extended to one year with aggressive treatment. Length of survival is
better for those whose tumor is located in the frontal lobe of the brain rather than the temporal or parietal
lobes.
Treatment:

Surgery plus radiation and chemotherapy

To delay recurrence, a large single boost dose of stereotactic radiosurgery may be
administered to a sharply delineated region of the tumor bed after standard resection and
irradiation.
Surgery plus radiation
Surgery with BCNU-impregnated polymer (Gliadel wafer) implanted during initial surgery added 2
months to average survival rate.
Radiation therapy alone or with temozozlomide
Participation in clinical trials (3, 14, 17)
Page 17 of 36
Pictures of glioblastoma
Nursing interventions, preoperatively

Prior to surgery on the brainwhether the procedure be an open craniotomy or closed stereotactic
radiographypatients are anxious and fearful. Part of the nurses responsibility is to help allay this fear
by informing the patient:

Answer questions and allow time for the patient to express feelings.
Explain all pre-operative preparations, such as diagnostic tests.
Explain pre-operative restrictions:
Over-the-counter medications containing aspirin, ibuprofen or any other blood-thinning
medications should be stopped one week prior to surgery.
Fiorinal, Darvon Compound 65, and Percodan should be stopped 7 to 10 days prior to
surgery.
Coumadin needs to be stopped about 5 days prior to surgery and a Prothrombin time
checked on the morning of surgery.
Explain pre-surgical and anesthesia procedures in as much detail as possible, such as when patient
will be taken to the operating room, when IV will be started, and what procedures will be done
while patient is awake.
Explain the procedure for preparing the patients head for surgerywhether the hair will be shaved
and how much.
Discuss the probable length of the surgery and how family members will be notified of progress
and where they can wait.
Explain where patient will be treated post-operatively, for example recovery room, critical care, or
ICU. If patient is to be transferred to a specialized unit, if possible allow the patient to visit the unit
or, if thats not allowed, describe the unit to the patient.
Discuss how the patient will look after the surgery.
Explain post-operative care and assessments.
Treatment Options
There are three treatment options for brain tumors (surgery, radiation, and chemotherapy) although not
all tumors respond to all three treatments. Newer surgical techniques, such as endonasal approaches and
CyberKnife, have made surgical removal of previously inoperable tumors possible. Because grades III
and IV tumors grow rapidly, postoperative radiation and chemotherapy are usually started within 2-4
weeks of surgery.
Surgical excision, craniotomy

Surgery has more than one role in treatment as it may be used for biopsy, treatment of increased
intracranial pressure, and tumor removal. Surgical excision is the therapy of choice as complete removal
of the tumor is the most effective treatment; however, some tumors are located in areas that are not
accessible by surgery. Tumors of the cerebral hemispheres are usually easier to remove than those of the
midline, diencephalic structures. Some tumors have infiltrated adjacent brain structures and tissue to the
degree that complete surgical excision is not possible. Recurrent tumors are usually treated with resurgery.
While some astrocytomas are not cured by surgery because the tumors have infiltrated surrounding
tissue, the surgery may reduce pressure of the tumor against the rest of the brain if the tumor is large.
Relieving this pressure may reduce symptoms, such as headaches, nausea, vomiting, and blurred vision.
Surgery may also prolong life even though it is not curative.
A craniotomy involves making a surgical opening through the skull. After the patient is anesthetized, the
head may be shaved and an incision made through the skin. The scalp is then folded back to expose the
skull and small holes, called burr holes, are drilled in the skull with a power drill. The surgeon then cuts
between the holes with a surgical saw and lifts the piece of skull, exposing the surface of the brain. The
size must be large enough to accommodate instruments and allow viewing of parts of the brain. If the
Page 18 of 36
tumor is within the brain rather than on the surface, a small incision is made into the brain. The surgeon
may operate while viewing through a microscope. With microsurgical equipment and techniques, it is
possible to remove tumors with must less damage to surrounding areas than previously. For example,
tumors at the base of the frontal area may be reached by going under the brain rather than through brain
tissue. The surgeon may use MRI, CT, or ultrasound image guidance to locate and map the area of the
tumor in order to minimize damage to healthy tissue.
The tumor may be removed using different procedures. Some tumors are excised using a scalpel. Suction
with a small vacuum tube and cautery, the use of an electric current to seal blood vessels, may be used.
In some instances, ultrasonic aspiration may be used to remove a brain tumor rather than a scalpel.
Ultrasonic waves fragment the tumor, and the fragments are removed by suction. In some cases, where
patients ability to speak or motor control are issues, awake surgery may be done. The patient is brought
to consciousness after the brain is accessed and is able to respond and react during the surgery (3, 10,
13).
Surgery, endoscopic transnasal brain surgery (ETBS)

Endoscopic transnasal brain surgery (minimally-invasive technique) is a new method of tumor removal in
which access to the base of the brain as well as within the brain and the spinal cord is achieved through
the nose and nasal sinuses. This method of surgery merges the medical specialties of otolaryngology and
neurosurgery. Miniature scopes and surgical tools are threaded through the soft tissue of the nose. This
approach is frequently used for pituitary tumors. Some tumors that were previously thought to be
inoperable because of difficulty of access with a craniotomy can be excised through this method. Baseballsized tumors have been removed without damaging other brain tissue. This method holds the promise of
reducing the need for the more invasive craniotomy for many types of tumors. Because there is little
trauma involved in this type of surgery compared to traditional craniotomy, patients can begin radiation
and/or chemotherapy almost immediately after surgery. The thinnest part of the skull is at the top of the
nasal passage, so access to the brain is relatively easy. A lighted endoscope is advanced through an
opening with the surgeon viewing the tissue on a monitor. This technique can also be used to remove
cerebral aneurysms. The instruments go to the center of the tumor and then tiny pieces are removed one
at a time (5).
Surgery, transorbital
Transorbital craniotomy (accessing the brain through the orbit of the eye) emerged as collaboration
between neurosurgeons and oculoplastic surgeons. Usually, a superbrow approach, with a small incision
over the brow, is used, and the tumor is located using MRI guidance and microscopic tools. Only a small
amount of bone is removed. This approach is most commonly used for benign tumors at present, but it
allows access with less disfigurement and trauma (22).
Stereotactic excision
Image-guided surgery technology lets the surgeon see the brain in three dimensions and pinpoint the
tumor with the aid of CT and MRI. Patients are generally fitted with a lightweight halo frame to keep the
head still. The frame is firmly attached with screws to the external surface of the skull, usually under a
local anesthetic while the patient is awake. Stereotactic excision may be used for the removal of small
tumors as it is less invasive than the traditional craniotomy because it requires only a small opening into
the skull and less damage to the tissue (3, 11, 23).
Stereotactic radiosurgery
Stereotactic radiosurgery uses precisely focused radiation to treat tumors in the brain. Computers create
3-D images of the brain, and these images guide radiation oncologists and surgeons in focusing radiation
at the target area. Patients are generally fitted with a lightweight frame to keep the head still. The
technology allows high doses of radiation to be delivered to the tumor with minimal damage to
surrounding healthy tissue. This procedure is essentially surgery without an incision. Adults usually
require no general anesthesia. Studies have shown that radiosurgery is effective for low-grade gliomas in
children. Because this type of surgery requires no incision, recovery time is minimal as are side effects.
The tumor dies slowly over a fairly long period of timeup to 2 years for benign tumors and months for
Page 19 of 36
malignant or metastatic tumors, which divide at a faster rat. The tumor shrinks and is replaced with scar
tissue, so stereotactic radiosurgery is used for small tumors and is not appropriate for all tumors,
depending on the type of tumor and the location. All forms of radiotherapy pose some risks:

Edema: Swelling may occur as the cells of the irradiated tumor lose their ability to regulator fluids.
This is usually treated with a short course of steroids.
Necrosis: Sometimes, the necrotic tissue that remains after the tumor shrinks can cause problems
and may need to be removed, but this is a rare complication (17).
Gamma Knife
Gamma Knife is one type of stereotactic radiosurgery, used for tumors less than 4cm in diameter. Prior
to the radiosurgery, the patient is fitted with a stereotactic frame that is screwed to the skull to
immobilize the head, and using CT and MRI (preferred because it avoids the high doses of x-ray
associated with CTs), the physician determines the exact location of the tumora process that may take
up to 5 hours. Then the patient is placed in a metal helmet-like device with several ports through which
201 beams of cobalt 60 are directed at the center of the lesion. Only at the point where all the 201 beams
cross is enough radiation delivered to affect the tissue (with an accuracy of about 0.5mm), so surrounding
tissue is spared. The treatment continues for 3 to 10 minutes. Because of the degree of accuracy, a full
dose of radiation can usually be delivered in one treatment rather than the multiple sessions required for
linear accelerators, which use fractionated treatment. The basic design of the Gamma Knife, with the
helmet, limits its use to the head (3, 11, 23, 24).
CyberKnife
Page 20 of 36
CyberKnife is another radiosurgery device, but it does not require a frame for precise targeting. Because
of this, surgeons can divide a large radiosurgical dose into more than one stage or fraction, called staged
radiosurgery. The CyberKnife system was designed to address the limitations of the framed-based
systems. It incorporates a miniature linear accelerator mounted on a flexible, robotic arm. An imageguidance system that can track target location during treatment allows for superior targeting accuracy
without the need for the stereotactic frame; however, it does expose the patient to more general radiation
from the tracking system than Gamma Knife procedures. Some patients may experience transient
dizziness, lightheadedness, or mild headaches after treatment. These symptoms may be treated with a
short course of corticosteroids. Because it does not require a frame, CyberKnife radiosurgery can be
used outside of the head for other types of tumors, so it can be used for wider applications (17).
Radiotherapy, external beam

Most tumors that are not completely removed by surgical excision are treated with high-energy radiation
to kill the remaining cancerous cells. Radiation from an external source is called external beam radiation.
Radiation may be used as a primary treatment to kill cancer cells by altering the cell membrane in order
to shrink tumors. Radiation may also be reserved for recurrence. With whole brain radiation, cognitive
impairment, such as short-term memory loss, was common, but focal radiation therapy, where the
radiation is focused on the tumor and a small margin around the tumor, has minimized radiation to nonaffected parts of the brain and there appears to be no cognitive impairment. However, repeat irradiation
can cause necrosis of tissue; thus, re-irradiation is usually not given to patients with recurrent tumors.
Radiotherapy is individually planned for each patient. Prior to the first treatment, patients will have xrays, scans, or MRI of the area to be treated so that the radiographer can plan the correct position of the
treatment. A newer technique called 3D conformal therapy that uses computers and CT scans to plan
radiation therapy is being used in many cancer centers. With 3D conformal therapy, the radiation beam
can be better matched to the shape of the tumor. Once the treatment area has been finalized, ink
markings are usually made on the skin to pinpoint the area. These markings are not permanent and can
rub or wash off. Additionally, sometimes 2 or 3 permanent pinpoint tattoo marks are also made on the
skin. The advantage to the permanent tattoo marks is that it insures that the treatment will be given to
the same spot each time and it leaves a record of where the radiotherapy was given.
Radiotherapy:
Discussion
Linear Accelerator:
Radiotherapy is usually
administered over a period
of 2 to 7 weeks rather
than one session. The
dosage is neither as high
as with stereotactic
radiosurgery nor as
precisely focused. Because
normal cells may be
damaged by radiotherapy,
administration in
fractionated doses over
time allows the normal
Page 21 of 36
cells to heal. Treatments

are usually administered
Monday through Friday,
leaving patients to rest on
the weekend although
some people will have
treatment fewer days per
week. Each treatment is
called a fraction because
its a fraction of the total
treatment. There are
different types of
radiotherapy machines,
including linear
accelerators, and some are
quicker than others and
may give treatment in a
very short time, such as
seconds, while other make
take a few minutes.
IMRT
Intensity Modulated
Radiation Therapy
(IMRT), a shaped-beam
system, is an important
advance in radiation
therapy. It utilizes a
powerful computer to
evaluate millions of
possible beam
arrangements and
determine a final
treatment plan. This
technology uses real-time
computer control to focus
higher doses of cancerkilling energy on tumors
while sparing surrounding
healthy tissue. IMRT
technology enables a
mechanical device, called a
multi-leaf collimator, which
is generally attached to
most modern
Even with improvements in delivery and newer machines, there are still side effects associated with all
fractionated radiotherapy. Short-term side effects include these symptoms:

Fatigue
Loss of appetite
Nausea
Skin rashes and hair loss over substantial regions of the scalp
There are also some delayed side effects that occur within months to years:

Varying degrees of memory loss and impairment of reasoning or thinking

More rarely, impairment of pituitary function or radiation necrosis.
Children are more sensitive to radiation than adults and, because of longer life expectancy, may exhibit
Page 22 of 36
more long-term damage, so the benefits of radiotherapy must be weighed against potential morbidity.
Children may exhibit facial growth retardation, hypothyroidism, and cognitive impairment as the result of
prepubertal radiotherapy. While radiation is more damaging to cancer cells than normal cells, it is
inevitable that some normal cells will be damaged. Sometimes months or years after irradiation, a mass
of dead tissue forms at the site of the irradiated tumor. This is called radiation necrosis, and it most
cases it includes both cancerous and noncancerous tissue. Patients with radiation necrosis generally do
better than patients with recurrent tumor even though the area of radiation necrosis must be surgically
removed. However, a small number of patients with radiation necrosis do poorly or die. If large areas of
the brain require radiation, significant changes in brain function may result, such as memory loss and
lowered thinking ability (3, 10, 13, 17, 23, 24).
Chemotherapy/Gene therapy
Chemotherapy is drug treatment that interferes with the cancer cells ability to grow or reproduce. It is
often used after surgical removal of a tumor, especially for invasive tumors or if the tumor was only
partially resected. Chemotherapy is more useful for some types of tumors than others. Most
chemotherapy is given intravenously. As with all chemotherapy, there are many side effects associated
with treatment. High-dose chemotherapy also kills bone marrow cells that are needed to produce blood.
This raises the risk of infection and slows down delivery of the chemotherapy.
After tumor removal, BCNU polymer water implants may be inserted at the site of the tumor. These
wafers are biodegradable and release chemotherapeutic agents over time.
There are a number of clinical trials now taking place, using chemotherapy alone or in combination with
radiation to treat brain tumors. Some novel approaches to treatment are now being tested, such as
approaches that involve stimulating the bodys natural immune system and drugs that decrease the
tumors blood supply as well as drugs that target biochemical pathways that are active in tumor cells but
inactive in healthy cells.
Studies are in progress to determine if adding three drugs to radiation improves outcomes: procarbazine,
CNU, and vincristine (PCV). Another therapy uses the oral anti-tumor drug temozozlomide in small daily
doses. Gene therapy approaches are being developed to protect the bone marrow from side effects so that
chemotherapy can be more effective (3, 10).
Brachytherapy (interstitial implantation)

Interstitial radiation treatment, also called brachytherapy, involves implanting radium isotopes directly
into the tumor, often done after incomplete surgical excision of invasive tumors. It is particularly effective
for high-grade tumors with poor prognosis because of local persistence after surgery. Interstitial
implantation may be used as an alternative to external-beam radiation, which poses a risk to healthy
tissue because interstitial implantation allows a higher dose of radiation to be delivered without damaging
surrounding tissue. Typically, a catheter is placed into the brain to allow the radiation source to be
delivered to the tumor. The radioactive source may be left in place for hours or days, depending upon
tumor. Sometimes, the radioactive material is permanently placed into the area of the tumor during
surgery (25).
Nursing interventions, postoperatively

The focus of postoperative care is on monitoring the patients condition, observing changes in condition,
and preventing complications:
Observe for signs of increased intracranial pressure (ICP):

Monitor vital signs q 15-30 minutes initially and then every hour as ordered.
Monitor intracranial pressure.
Position head in midline, neutral position
Elevate head of bed 30 to 45 degrees for supratentorial surgery (in upper part of the brain).
Keep patient flat or elevate head slightly for infratentorial surgery (in posterior fossa).
Monitor fluid intake and output:
Page 23 of 36
Maintain strict intake and output records.

Monitor urinary flow.
Measure or estimate amount of drainage.
Provide wound care/observe for signs of infection:
Observe for drainage on dressingscircle and date.
Notify the physician immediately if there is cerebrospinal fluid drainage.
Empty and measure drainage from surgical drains, such as Hemovacs, every 8 hours (3050cc per shift is typical).
Maintain pain control & provide comfort measures:
Give pain medications and document effectiveness.
Provide comfort measures, such as cool compresses and backrubs.
Allow patient periods of rest.
Provide mouth care.
Provide general care:
Turn, cough, and deep breathe every 2 hours, but do not position on operative side,
especially if the bone flap has been removed.
Assist with range of motion exercises every shift.
Maintain patent airway:
Limit use of suction to 10 seconds, only 2 passes and pre-oxygenate.
Monitor routine postoperative laboratory studies:
Complete blood countHgb and Hct may fall from blood loss
Serum electrolyte levelsespecially observe for hypernatremia and hypokalemia
Coagulation studies
Arterial blood gas measurementsto ensure proper cerebral oxygenation
Administer medications as prescribed:
Anticonvulsants
Corticosteroids
Histamine blockers
Analgesics
Antibiotics
Prevent hyperthermia:
Anti-pyretics (acetaminophen)
Cooling blanket
Prevent venous thromboembolism
Compression stockings
Intermittent pneumatic compression

Glasgow coma scale

Based on motor responsiveness, verbal performance, and eye opening to appropriate stimuli, the Glasgow
Coma Scale was designed and used to assess the depth and duration of coma and impaired
consciousness. This scale may be used to assess the degree of trauma the patient has suffered from the
tumor both preoperatively and post-operatively.
The GCS is scored between 3 and 15, with 3 being the worst, and 15 the best. It is composed of three
parameters: Best Eye Response, Best Verbal Response, and Best Motor Response.
Glasgow Coma Scale Parameters
Score
Eye opening response:

Spontaneousopen with blinking at baseline
To verbal stimuli, command, speech
To pain only (not applied to face)
No response
Verbal response:
Oriented
Confused conversation, but able to answer questions
Page 24 of 36
Inappropriate words
Incomprehensible speech
No response
Motor response:
Obeys commands for movement
Purposeful movement to painful stimulus
Withdraws in response to pain
Flexion in response to pain (decorticate posturing)
Extension response in response to pain (decerebrate posturing 2
No response
Total Score:
Head injury classifications in relation to score:

ComaGCS score 3-8

Severe head injuryGCS score of 8 or less
Moderate head injuryGCS score of 9 to 12
Mild head injuryGCS score of 13 to 15
What are common post-operative complications?

Increased intracranial pressure (ICP)

Venous thromboembolism
Hematomas/Hemorrhage
Hypovolemic shock
Hydrocephalus
Respiratory disorders
Wound infection
Meningitis
Fluid and electrolyte imbalance
Measure
Indications
Temperature
Increase can indicate a postoperative infection.
Pulse
Compression in the medulla area can affect the cardiac center and cause changes in
heart rate.
Respiration
Increase may indicate damage to the midbrain. Decrease may indicate damage to lower
pons and upper medulla.
Blood
pressure
Increase associated with sympathetic stimulation. Decrease associated with increasing

intracranial pressure.
Pupils
Only one pupil reacting may indicate pressure on the 3rd cranial nerve.
Dilated or pinpoint pupils that are slow to react or non-reactive to light may indicate
increased intracranial pressure.
Increased intracranial pressure

Increased intracranial pressure (ICP) is the major complication after removal of a brain tumor, so
monitoring of ICP is of critical importance. Normal ICP is 0-15mm HG on transducer or 80-180mm H2O on
manometer. Increased ICP is related to a number of other complications:

Cerebral edema
Hemorrhage
Obstruction of the normal flow of cerebral spinal fluid (CSF)
Page 25 of 36
As intracranial pressure increases, the patient will experience a number of symptoms:

Severe headache
Deteriorating level of consciousness
Restlessness & irritability
Dilated or pinpoint pupils that are slow to react or non-reactive to light.
Seizure activity
Increased motor weakness
Bradycardia & hypertension may occur late
Cushings Triad (typical changes in vital signs) is a late sign of increasing ICP:
Systolic pressures increases with widened pulse pressure
Slowing of heart rate occurs in response to increased systolic pressure
Respiration rate decreases
Monroe-Kellie Hypothesis
The Monroe-Kellie Hypothesis states that to maintain a normal ICP, a change in the volume of one
compartment must be offset by a reciprocal change in the volume of another compartment. The brain
consists of three compartments:

Brain tissue
Cerebrospinal fluid
Blood
Thus, except in neonates, the skull cannot expand easily expand to allow for extra space-occupying fluid
or tissue, so if one of three component increase, the other two must decrease in order to compensate.
The cerebrospinal fluid (CSF) and blood volume are the compartments that most easily change to
accommodate changes in pressure. Medical interventions to treat increased ICP and prevent secondary
brain injury follow these principles and focus primarily on cerebral blood flow and drainage.
Treatment will be directed at the underlying cause of the increased ICP. Treatment may include
medications, ventilation, and further surgery (5, 22, 28, 29).
Venous thromboembolism
Deep venous thromboembolism (VTE), especially in the calves of the legs, and leading to pulmonary
embolism (PE) is a common complication after craniotomy for brain tumors. Careful observation, range of
motion, encouraging mobility, and care of compression stocking or intermittent pressure boots is
necessary to prevent this complication. Patients may be asymptomatic or may present with a number of
different symptoms:

Calf or groin tenderness or pain

Positive Homans sign
Pain in the calf on dorsiflexion of the foot
Localized edema
Compromised circulation
Shortness of breath
Fever
Studies have indicated that daily prophylactic anticoagulant therapy with enoxaparin, heparin, or
dalteparin along with the use of intermittent pneumatic compression device and graduated compression
stockings was very effective in reducing the incidence of thromboembolism and carries no additional risk
of hemorrhage (5, 18).
Hematomas/Hemorrhage
Page 26 of 36
There are three types of hematomas/hemorrhage that may occur after craniotomy:

Epidural hematoma (between the dura mater and the skull)

Subdural hematoma (between the dura mater and the arachnoid mater)
Subarachnoid hemorrhage (in the subarachnoid space)
Patients who suffer from intracranial bleeding may exhibit the following symptoms:

Severe headaches
Change in level of consciousness
Neurologic deficits
Herniation syndromes
Sudden cardiovascular and respiratory arrest (with bleeding into the posterior fossa.
Monitoring ICP is especially important to observe for this complication. Treatment varies according to the
location and extent of the bleeding, but hematomas generally necessitate surgical removal to relieve
pressure. Intracranial hemorrhage may be treated medically with osmotic diuretics and ICP monitoring
(5).
Hypovolemic shock
Hypovolemic shock is the result of blood loss both during and after surgery. It can also be caused by
inadequate replacement of fluids, dehydration brought on by fluid restriction, or the administration of
osmotic diuretics. Thus, monitoring of intake and output is critically important. A patient usually exhibits
the typical shock symptoms:

Hypotension
Cold, clammy skin
Rapid, thready pulse
Pallor
Intravenous fluid replacement is necessary to reverse hypovolemic shock (5, 22).
Compensatory reactions affecting cerebral metabolism

Ischemia/Edema
Page 27 of 36
When cerebral ischemia/anoxia occurs, the brain doesnt get enough oxygen so the brain compensates
by dilating blood vessels to get more oxygen, thus resulting in cerebral edema.
Mean arterial pressure

The mean arterial pressure (MAP) affects cerebral flow.
Normal readings 50mm Hg to 150mm Hg:

Below 50mm Hg cerebral flow decreases, leading to ischemia
Above 150mm Hg cerebral blood vessels are maximally constricted and the brain barrier is
disrupted, leading to cerebral edema and increased intracranial pressure.
MAP = Diastolic BP (DBP) + 1/3 pulse pressure
Cerebral Perfusion Pressure (CPP)

Cerebral perfusion pressure is that needed to maintain blood flow to the brain:

MAP-ICP= CPP
Normal CPP is 60-100:
<100 = hyperperfusion and increased ICP
<60 = hypoperfusion
<30 = incompatible with life
Hydrocephalus
Hydrocephalus can result when there is obstruction of the normal cerebrospinal fluid (CSF) for various
reasons:
Edema:
Cerebral edema may be present before surgery and usually reaches a peak within 72 hours
after surgery.
Expanding lesions, such as hematoma or blood in the subarachnoid space.
Hydrocephalus may produce different symptoms, depending upon the speed of progression. Rapidly
progressive hydrocephalus produces classic symptoms of ICP:
(See above)
Slowly progressive hydrocephalus causes less severe symptoms:

Headache
Decreased level of consciousness
Irritability
Blurred vision
Urinary incontinence
Depending upon the cause of the hydrocephalus, the condition may be self-limiting and controlled by daily
lumbar punctures to remove CSF. If the condition persists or worsens, surgical interventionplacing a
shunt to drain CSFmay be required. Usually a ventriculoperitoneal shunt is performed, but a
ventriculoatrial or a lumbar peritoneal shunt may be done. Patients who receive a shunt must be observed
carefully for signs of subdural hematoma from tearing of bridging veins (5, 22).
Ventriculoperitoneal shunt:
Page 28 of 36
Respiratory disorders
Most respiratory disorders following surgery can be prevented by good general care that includes deep
breathing hourly and turning the patient frequently. The most common respiratory complications include
the following:

Atelectasis
Pneumonia
Neurogenic pulmonary edema
Neurogenic pulmonary edema occurs infrequently but most people do not survive this complication. Its
symptoms are the same as acute pulmonary edema, but there is no cardiac problem. Patients who
develop any of the respiratory disorders after surgery must be treated aggressively. Treatment may
include the following:

Humidified air
Medications
Incentive spirometry
Endotracheal or oral tracheal suctioning
Chest physiotherapy
Some of these treatments may cause an increase in ICP but the benefit may outweigh the risk (5).
Wound infection
Wound infections become obvious when the wound site becomes red and puffy, and there may be
purulent or serosanguineous discharge. The patient may be febrile. Proper wound care is important to
prevent infections. Wound infections occur most often in patients who are already compromised for a
variety of reasons:

Older, debilitated
History of diabetes

Page 29 of 36
Long-term steroid use

Obesity
Previous infection
Treatment of localized infection may require only cleansing and topical antibiotics, but a more generalized
infection may be treated with systemic antibiotics (5).
Meningitis
Meningitis is an inflammation of the meninges of the brain, involving the arachnoid and pia mater as well
as the spinal cord. Meningitis can be caused by a variety of organisms, but post-surgical meningitis is
generally caused by bacteria. In the case of surgery, the direct route of entry by bacteria into the brain
occurs. The organism invades the central nervous system through the subarachnoid space. This produces
an inflammatory reaction in the pia mater, the arachnoid, the CSF, and the ventricles. An exudate,
consisting of bacteria, fibrin, and leukocytes, forms in the subarachnoid space and accumulates in the
CSF, causing it to thicken and interfering with the normal flow of CSF around the brain and spinal chord.
This can lead to a number of complications:

Hydrocephalus (see above)

Further inflammatory reaction
ICP (see above)
Rapid vasodilation of the cerebral vessels, leading to engorgement, rupture, or thrombosis of the
vessel walls
Infarcted brain tissue
Vascular dysfunction from septic emboli
Signs of meningeal irritation may include these symptoms:

Nuchal rigidity
Stiff neck and soreness
Positive Kernigs sign (indicates bacterial infection rather than viral):
Flex the patients leg at the hip, and bring the knee to a 90-degree angle, and then attempt to
extend the knee and straighten the leg. This will cause pain and spasm of the hamstring
muscle, secondary to meningeal irritation and spinal nerve root inflammation caused by
exudates.
Positive Brudzinskis sign (indicates bacterial infection rather than viral):
Flex the patients head and neck onto the chest. A positive response causes flexion of the hips
and knees.
Seizure activity
Analysis of cerebrospinal fluid is the most significant laboratory test for diagnosis of meningitis, but it is
not usually done with ICP because this can lead to herniation of the brain tissue onto the medulla and
cardiopulmonary arrest. Treatment must be instituted immediately and often includes the following:

Medications:
Broad spectrum antibiotics
Hyperosmolar agents
Steroids
Anticonvulsants
Isolation procedures:
Often for the first 24 hours, depending upon hospital policy
Neurologic assessment:
This should include complete cranial nerve testing
6th cranial nerve defectinability to move eyes laterallymay indicate hydrocephalus
Vascular assessment:
Assessment of temperature, color, pulses, and capillary refill (normal capillary refill occurs
within 3 seconds)
Seizure precautions
Pain control:
Page 30 of 36
Pain:
Combination of drug and non-drug measures, such as ice cap for relief of headache,
keeping room quiet
Photophobia:
Keep lights dimmed, close blinds or curtains (5, 28)
Fluid and electrolyte imbalance

Both diabetes insipidus and the syndrome of inappropriate antidiuretic hormone (SIADH) are
complications related to fluid and electrolyte imbalance. Maintaining correct intake and output reports are
essential in order to diagnose these complications and to treat them.
Diabetes insipidus:
Most common after surgery on pituitary gland or in the area of the hypothalamus or third
ventricle.
Urinary output increases dramatically and specific gravity drops below 1.005.
Treated with fluid replacement and medications.
SIADH:
Occurs when the pituitary gland secretes too much ADH, causing water retention.
Urinary output decreases or ceases.
Serum sodium levels fall, but sodium concentration is normal or elevated in the urine.
Treated with medication.
Nursing interventions, discharge

Discharge planning will vary depending upon the age of the patient and the degree of residual disability.
Discharge planning after removal of a brain tumor should always include:

Information about follow up appointments

Instruction in wound care
Instruction on all medications, including a review of the proper dosage, the frequency, and any
side effects
Information about seizure precautions and what to do if a seizure occurs
Information about any follow up treatments, such as radiotherapy or chemotherapy
Instructions about activity restrictions, such as not bending over, keeping head above heart, or not
turning to operative side.
For those with residual physical impairment, such as hemiparesis or cognitive or emotional changes, the
patient and family may need further planning:

Assistance for patient and family to develop strategies for dealing with residual problems
Home preparation, such as making the environment safe by removing throw rugs and installing
grab bars
Referral to rehabilitation center or physical therapist
Some patients (and family) who face prolonged recovery or impending death may need help dealing with
multiple problems, including financial and emotional:

Referral to social worker

Referral to support groups or counseling
Information about disease and prognosis, including brochures, handouts, and internet resources
Information about healthcare resources, such as the American Cancer Society, National Cancer
Institute, and the Association for Brain Tumor Research
Summary
Primary brain tumors arise within the brain tissue as opposed to metastatic brain tumors, which originate
outside of the brain. Primary brain tumors may be either benign or malignant. Malignant tumors tend to
Page 31 of 36
grow faster and spread into the surrounding brain tissue, making complete removal difficult. Astrocytomas
arising from neuroglial tissue account for about 40% of primary tumors of the brain and spinal cord.
Astrocytomas are classified according to the World Health Organization (WHO) into 4 grades (I, II, III,
and IV) depending on a number of factors related to the degree of malignancy. There is no clear cause for
astrocytic tumors, but patients who receive therapeutic radiation for other tumors and children who
receive irradiation of the central nervous system for acute lymphoblastic leukemia are at increased risk.
Lower grade tumors may progress to more malignant forms. Some people may be at genetic risk for
developing tumors. Occupational exposure to chemicals may also increase risk. Symptoms can vary
widely depending upon the portion of the brain affected by the tumor, but general presenting symptoms
include headache, changes in vision, nausea and vomiting, seizures, personality changes, dementia,
memory loss, inability to concentrate, and ataxia. As the tumor grows, it can lead to a number of
complications, such as cerebral edema, ischemia, focal neurologic developments, hemorrhage, seizure
activity, obstruction of CSF, and pituitary dysfunction leading to inappropriate antidiuretic hormone or
diabetes insipidus. Diagnosis of astrocytic tumors is based on a number of different procedures, including
neurological examination, CT, MRI, MRS, PET, angiography, surgical biopsy, stereotactic biopsy, and visual
field studies. Astrocytic tumors comprise pilocytic astrocytoma, diffuse astrocytoma, anaplastic
astrocytoma, glioblastoma, pleomorphic xanthoastrocytoma, and subependymal giant cell astrocytoma.
There are 3 types of treatment options for brain tumors: surgery, radiotherapy, and chemotherapy.
Surgery may involve traditional surgical excision, stereotactic excision, or non-invasive stereotactic
radiosurgery. Treatment for all of these tumors involves removal of the tumor by surgery alone or
combined with radiotherapy and/or chemotherapy. The focus on postoperative care is to monitor the
patients condition, observe changes, and prevent complications. Common postoperative complications
include increased intracranial pressure (ICP), venous thromboembolism, hematomas/hemorrhage,
hypovolemic shock, hydrocephalus, respiratory disorders, wound infection, meningitis, and fluid and
electrolyte imbalance. Nursing care, including the monitoring of ICP is of critical important in the postoperative period. Nurses must also help to prepare the patient and family to deal with residual problems
upon discharge.
References
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http://www.medifocus.com/guide_detail.asp?
gid=OC009&a=a&assoc=Google&keyword=glioblastoma
2. Louis, D.N., Ohgaki, H., Wiestler, O.D, et al. (2007, August).The 2007 WHO classification of tumours
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http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1929165
3. U.S. National Institutes of Health. (2008, August 1). Adult Brain Tumors (PDQ): Index. National
Cancer Institute. Retrieved October 25, 2008, from
4. http://www.cancer.gov/cancertopics/pdq/treatment/adultbrain/healthprofessional
5. Badash, M. & Lucas, R. (2007, November). Astrocytoma: Brain tumor, Glioma. Swedish Medical
Center. Retrieved October 25, 2008, from http://www.swedish.org/14169.cfm
6. Smeltzer, S. C., Bare, B., Hinkle, J.L., & Cheever, K. H. (2008). Brunner & Suddarths Textbook of
Medical-Surgical Nursing, 11th ed. New York: Lippincott, Williams, & Wilkins.
7. Bentley-Hibbert, S. (2006, October 23). CT scan. Merck Source. Retrieved October 25, 2008, from
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8. Bentley-Hibbert, S. (2006, October 25). MRI. Merck Source. Retrieved October 25, 2008, from
http://www.mercksource.com/pp/us/cns/cns_hl_adam.
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Society, Inc. Retrieved October 25, 2008, from
http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_
How_is_brain_and_spinal_cord_tumors_diagnosed_4. asp?sitearea=
10. Anaplastic astrocytomas. (2007). Bostons Children Hospital. Retrieved October 25, 2008, from
http://www.childrenshospital.org/az/Site565/mainpageS565P0.html
11. Radiosurgery practice guidelines: Index. (2008). IRSA. Retrieved October 25, 2008, from
http://www.irsa.org/index.html
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12. Stereotactic radiosurgery at Mayo Clinic. (2008). Mayo Clinic. Retrieved October 25, 2008, from
http://www.mayoclinic.org/stereotactic-radiosurgery/
13. Expanded endonasal approach. (2008). UPMC. Retrieved October 25, 2008, from
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14. Radiation therapy. (2008, August 6). American Cancer Society. Retrieved October 25, 2008, from
http://www.cancer.org/docroot/CRI/content/CRI_2_4_4X_Radiation_Therapy_3.asp?sitearea=
15. Bruce, J. N., & Cronk, K. (2006, August 4). Glioblastoma Multiforme. EMedicine. Retrieved October
25, 2008, from http://www.emedicine.com/med/topic2692.htm
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subependymal giant cell astrocytomas. Neurosurgical Focus 20 (1). Retrieved October 25, 2008,
from http://thejns.org/doi/pdf/10.3171/foc.2006.20.1.6
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from http://www.emedicine.com/MED/topic2693.htm
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20. Lo, S., & Kish, K.K. (2008, September 10). Juvenile Pilocytic Astrocytoma. EMedicine. Retrieved
October 25, 2008, from http://www.emedicine.com/RADIO/topic367.htm
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review. Medscape General Medicine. Retrieved October 26, 2008, from
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from http://www.childrenshospital.org/az/Site1454/mainpageS1454P0.html
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Course Exam
1.
Primary brain tumors rarely metastasize outside of the central nervous system.
True
2.
If a patient has a primary cancer elsewhere, it can be assumed that a brain tumor is a metastasis of
that primary cancer.
True
3.
False
False
Astrocytomas account for about 40% of the primary tumors of the brain and spinal cord.
True
4.
False
MRIs and CTs expose the patient to about equal amounts of radiation.
True
9.
False
Tumor growth may result in vasogenic edema, compression of cerebral blood vessels, and seizure
activity.
True
8.
False
Tumors of the frontal lobe and occipital lobes are often associated with lack of coordination.
True
7.
False
Common symptoms of astrocytomas include headaches, vision changes, nausea and vomiting,
personality changes, memory loss, and ataxia.
True
6.
False
Recurrent lesions are usually the same type, rarely progressing to more malignant tumors.
True
5.
Page 33 of 36
False
PET scans are matched with CT or MRI because PET scans show less detail.
True
False
10. Surgical biopsies of brain tumors are often not necessary because of better imaging.
True
False
11. Patients may have many questions that they are afraid to pose to physicians.
True
False
12. The TNM (tumor, nodal status, and metastatic spread) is not appropriate for classifying brain tumors.
True
False
13. The WHO tumor classification system classifies tumors as Grade I to IV based on histological
features.
True
False
14. Patients with grade III and IV tumors usually have survival rates that exceed 5 years.
True
False
15. Low-grade astrocytomas double faster than high-grade astrocytomas.

True
False
16. Grade II astrocytomas often recur.

True
False
17. Grade I and II astrocytomas occur most often in adults.

True
False
18. Subependymal tumors are rapidly growling.

True
False
19. Pilocytic astrocytoma is a cystic tumor that does not usually invade adjoining tissue.
True
False
Page 34 of 36
20. Recurring tumors are usually re-treated with radiation even if radiation was given after tumor
removal.
True
False
21. Pilomyxoid astrocytoma is closely related to pilocytic astrocytoma and occurs in similar sites but is
histologically different and recurs more frequently.
True
False
22. Diffuse astrocytomas are low-grade tumors, but they spread into adjacent tissue with microscopic
tentacles, making complete excision difficult.
True
False
23. Pleomorphic xanthoastrocytomas often transform into more aggressive tumors.

True
False
24. Anaplastic astrocytoma may arise from diffuse astrocytomas and may progress to glioblastoma, so
they have a low cure rate.
True
False
25. Glioblastomas progress slowly with life expectancy of 5-10 years.

True
False
26. Glioblastomas are usually treated by surgery alone.

True
False
27. Patients should be cautioned to avoid OTC medications containing aspirin, ibuprofen or other bloodthinning medications for one week prior to surgery.
True
False
28. Patients should be given as much information as possible about presurgical, surgical, and postsurgical procedures in preparation for surgery.
True
False
29. There are 3 primary treatments for brain tumors: surgery, chemotherapy, and radiotherapy.
True
False
30. If a tumor cannot be completely removed, surgery is usually deferred in favor of radiation or
chemotherapy.
True
False
31. Endoscopic transnasal brain surgery involves little trauma so radiation/chemotherapy can start
almost immediately after surgery.
True
False
32. Transorbital craniotomy is usually performed below the eyeball.

True
False
33. Stereotactic radiosurgery uses precisely focused radiation to treat tumors of the brain.
True
False
34. Gamma Knife can be used on tumors of the brain and tumors in other parts of the body.
True
False
Page 35 of 36
35. CyberKnife requires a stereotactic frame to immobilize the head.

True
False
36. External beam radiation is given in fractionated doses because healthy tissue is radiated along with
the tumor.
True
False
37. Intensity modulated radiation therapy (IMRT) uses a computerized system to focus higher doses of
radiation but it is not as spatially precise as radiotherapy.
True
False
38. Radiation necrosis is a mass of dead tissue that forms at the site of the irradiated tumor.
True
False
39. Chemotherapy is often used after removal of invasive tumors.

True
False
40. Brachytherapy involves implanting radioactive isotopes directly into a tumor.

True
False
41. Electrolytes should be monitored postoperatively, especially K levels.

True
False
42. The Glasgow Coma scale is used to assess the depth and duration of coma and impaired
consciousness.
True
False
43. An intracranial pressure (ICP) reading of 190 mm per manometer is within normal range.
True
False
44. Cushings Triad is an early sign of increasing ICP.

True
False
45. The Monroe-Kellie Hypothesis states that to maintain a normal ICP, a change in the volume of one
compartment must be offset by a reciprocal change in another compartment.
True
False
46. A positive Homans sign, pain in the calf on dorsiflexion of the foot, is indicative of venous
thromboembolism.
True
False
47. Three types of hemorrhage may occur after craniotomy: subdural, epidural, and subarachnoid.
True
False
48. Symptoms of hypovolemic shock include hypotension, cold clammy skin, rapid thready pulse, and
pallor.
True
False
49. Mean arterial pressure (MAP) = Systolic BP (SBP) + 1/3 pulse pressure
True
False
50. If hydrocephalus occurs postoperatively a ventriculoperitoneal shunt may be inserted.
True
Page 36 of 36
False

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