Transcript Seizures and Brain Tumors

SEIZURES
Jane E. Binetti DNP MSN RN
Seizure Disorders
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Paroxysmal electrical activity in the brain
Usually symptomatic of other illnesses
Not everyone with seizures have Epilepsy
Can be caused by:
 Metabolic
disorders:
 Electrolyte
imbalances, hypoglycemia, hypoxia, ETOH,
barbiturate withdrawal, dehydration, water intoxication
 Organ diseases
Seizure Disorders
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Epilepsy
 In
US >3 million people have it
 Spontaneous recurrence of seizures
 Males > females
 Highest new onset >60
 More
common in AA and disadvantaged
 Alzheimer's,
stroke have higher risk
 Parent with Epilepsy
Etiology/Pathophysiology
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Causes by age:
0
- 6 mo most commonly birth/congenital
 2-20 can be birth injury, infection, trauma or genetics
 20-30 – structural lesions: trauma, brain tumors, vascular
disease
 >50, CVA, and mets to the brain
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~30% of seizures are idiopathic!
Genetics?? Predisposition?? Astrocytes??
What do you see?
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Several phases of seizures:
 Prodromal
phase
 Aural phase
 Ictal phase
 Post ictal phase
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Classified as:
 Generalized
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or Partial
Symptoms depend on type
Generalized Seizures
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Involve both sides of the brain
Loss of consciousness in seconds to minutes
Tonic-Clonic Seizures
 “Gran
Mal” seizure – loss of consciousness, stiffening then
jerking
 Cyanosis
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Hypersalivation
Incontinence
Generalized Seizures
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Absence Seizures
 “Petit
Mal” seizures
 Most common in preadolescent children
 Peak and wave pattern on EEG
 Brief staring episodes, or loss of consciousness
 Precipitated
by flashing lights, hyperventilation
Generalized
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Atypical Absence Seizures
 Brief
warning prior, odd behavior during seizure
 Staring off, and confusion after
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Other Generalized Seizures
 Myoclonic
 Atonic
 Tonic
 Clonic
Partial Seizures
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“partial focal seizures”
Specific foci in the cortex
 Sx
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depend on focal area
May evolve to a generalized tonic clonic seizure
(secondary generalized)
 Tonic-Clonic
seizures that begin with an aura are
typically partial that evolve
 Todd’s paralysis – secondary generalized
 Transient
post ictal residual weakness
Other Partial Seizures
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Simple Partial
Complex Partial
 Temporal
lobe seizures
 Clouding or loss of consciousness, confusion
 Automatisms
 Psychosensory sx:
 Memory
issues
 Vertigo, auditory and visual distortion, déjà vu
 Psychogenic
seizures
Complications
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Status Epilepticus
 Rapid
recurrence
 Caused by any type
 Neurons burn out
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Subclinical seizures
 Sedation
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Epileptics mortality 2-3X greater
 SUDEP
Diagnostics
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Accurate description and history
EEG
Within 24 hours of seizure
 Only small percentage of pts with disorders have abnormal
EEG
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Magnetoencephalography
CT, MRI r/o structural lesion
Cerebral angiography, SPECT, MRS, PET
Bloodwork
Accurate classification is crucial
Collaborative Care
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Most seizures are self limiting
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Pts note occurrence
Medical care required if:
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First episode
Bodily injury
Prolonged or recurrent
 Tonic
clonic most likely
Therapy
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Cure is not possible, control is the goal
70% of pts controlled by medication
Stabilize nerve cell membranes
 Best control with least side effects
 1/3 of pts require combination therapy
 Serum levels checked and if seizures continue
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Compliance?
Newer drugs, less testing
Medications
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For Tonic/Clonic and Partial Seizures:
 Phenytoin
(Dilantin)
 Carbamazepine (Tegretol)
 Phenobarbitol
 Divalproex (Depakote)
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Absence and Myoclonic Seizures:
 Ethosuximide
(Zarontin)
 Divalproex (Depakote)
 Clonazepam (Klonopin)
Other Medications
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Broad Spectrum for Multiple Seizure types:
 Gabapentin
(Neurontin)
 Lamotrigine (Lamictal)
 Topiramate (Topamax)
 Tiagabine (Gabitril)
 Levetiracetam (Keppra)
 Zonisamide (Zonegran)
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Pregabalin (Lyrica) = add on
Felbamate (Felbatol)
Treatments regimens
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Status epilepticus needs IV meds
 Ativan
(lorazepam) or Valium (diazepam)
 Short acting, for immediate use
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Long acting
 Dilantin(phenytoin),
Phenobarb, Zarontin (ethosuximide),
Lamictal (lamotrigine), Topamax (topiramate)
 Side effects typically involve CNS
 Can have rashes, dyscrasias, liver/kidney issues
 Phenytoin commonly causes gingival hyperplasia and
hirsuitism
Gingival Hyperplasia and Hirsutism
Surgical Treatment
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Done to control seizures beyond medication
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Limbic or corpus callosum resection; hemispherectomy
Requirements:
Confirmed epilepsy
 Failed drug trial
 Type of seizures defined
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Other tx:
Vagal Nerve stimulation
 Ketogenic diet
 Biofeedback ?
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What do you do?
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If your patient is seizing…
 Assess
your patient!
 What preceded it? When did it occur? How long?
 Can you denote phases?
 Is there LOC, stiffening, lack of tone?
 Note post ictal behavior
 Do not restrain but ensure safety
 Protect the head and keep airway patent – suction!
Pt/Family Education
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Educate about management:
 Compliance,
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Call 911 if seizure is unrelenting
Realize difficulty with restrictions for pts
 Impact
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track seizures, f/u appts, side effects
to job, Drivers License, stigma
Medic Alert bracelets
Support groups
Nursing Diagnoses
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Ineffective Breathing Pattern
Risk for Injury
Ineffective Coping
Ineffective Self-Health Management
BRAIN TUMORS
Jane E. Binetti DNP MSN RN
Demographic Info
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Affect people of all ages, highest in middle age
20,000+ new cases in US yearly
Deaths related to Brain Tumors ~13,000/yr
5 yr survival for primary Brain Tumor is ~ 36%
Males > Females
 Caucasian
have higher incidence of malignancy
 AA have higher incidence of benign tumors
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Brain is a common site of mets
What is it?
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Mass of abnormal cells inside the cranium
Cranium is a tight container – no room!
Lesions and tumors occupy space
 Increase
ICP
 Cause cerebral edema
 Impair blood flow-ischemia
Types
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Brain tumors can be in the brain or spinal cord
Primary tumors arise from brain
Secondary tumors are metastatic
 Most
common brain tumors are metastatic neoplasms
 Most common primary metastatic sites are
 Lung
cancer
 Breast cancer
Brain Tumors
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More than half of brain tumors are malignant
 Infiltrate
and can’t be removed
 Even if benign, may not be able to be removed
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Primary brain tumors rarely metastasize outside
CNS b/c:
 Meninges
 Blood
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brain barrier
Unless treated brain tumors lead to death from
tumor volume and IICP
Classification of Tumors
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Primary brain tumors arise from different tissues:
 Gliomas
make up
 30+%
of all brain tumors
 80% of all malignant tumors
 Types
of Gliomas:
 Glioblastoma
- glial cells, typically malignant
 Astrocytomas - astrocytes, typically malignant
 Medulloblastoma - typically malignant and aggressive
 Oligodendroglioma - oligodendrocytes, typically benign
More Classification of Tumors
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Meningiomas from meninges
Typically
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Acoustic Neuromas from myelin sheath
 Can
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benign
be malignant, most often benign
Pituitary Adenomas from pituitary gland
 Typically
benign
What do you see?
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Symptoms will depend on location
 Headache
is a common sx
 Constant,
dull, throbbing
 Worse at night, insomnia
 Seizures
with gliomas and mets
 Vomiting from IICP
 Cognitive dysfunction, memory, mood
 Muscle weakness, aphasia, temp alterations
 Hydrocephalus
Areas of the Brain
Motor
activity
Decision making, inhibition,
motivation, word choice
Broca’s area
Intellect
Calculation, perception, spelling,
learned skills, gestures, touch,
sensation
Visual processing,
color, shape, motion
Motor speech
Reading
Memory
Memory of facts, events, and
language; Wernicke’s; hearing
smell and taste
Motor control, balance
Diagnostics
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H and P
Physical Exam, MRS, MRI, PET, CT, SPECT
Angiography - blood flow to tumor
Endocrine studies for pituitary
Histological sample is reliable dx
 Stereotactic
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MIB-1
bx
Collaborative Goals
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Goals are:
 Identify
location and type of tumor
 Remove or minimize the mass and damage
 Manage the increased ICP
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Surgery reduces tumor size, ICP, and reduces
symptoms, improves quality of life
 Open
or stereotactic
Types of Cranial Surgery
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Craniotomy
 Incision
into any lobe of the cranium
 Burr holes and saws to create bone flap
 Allows for microscopes, drains, implants
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Stereotactic
 Frame
is used, computer guided
 Biopsy, tumors, hematomas, ablation
 Reduced damage to collateral tissue
 Examples are cyber knife, gamma knife
Crani and Stereotactic
Collaborative Care
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Ventricular Shunts
 Hydrocephalus
 Catheter
with one way
valve with one end in
lateral ventricle and
the other in the
jugular vein or the
peritoneum
Ventricular shunts
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ICP drained too fast causes headache
 Pt
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HOB raised gradually
Shunt malfunction
 IICP
– decreased LOC, vomiting, restlessness, HA,
blurred vision
 Shunt
revision
 Infection
– high fever, headache, nuchal rigidity
 Antibiotics
 Shunt
replacement
Radiation
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Radiation Therapy
 Usually
a follow up tx
 Concern is cerebral edema
 High
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dose steroids
Stereotactic Radiation
 High
dose radiation to specific site
 Used for failure of other treatment or locale
 Pt is typically awake
Chemo
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Chemotherapy
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Limitations
Blood-brain barrier
 Heterogeneity of tumors
 Resistance
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Malignancies can break down blood-brain barrier at
tumor sites
Types of chemo
Nitrosoureas
 Implanted wafers
 Ommaya reservoirs
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Oral and Targeted therapy
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Temodar (temozolmide) first oral chemo to cross the
blood brain barrier
 Does
not interact with anti-seizure meds, steroids and
anti-emetics
 Can cause myelosuppression
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Targeted therapy
 Avastin
(bevacisumab) – targets endothelial growth
factor for vasculature
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In spite of advancements, outcomes are poor
What do you do?
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Pre-op Assess your patient!
 GCS
– know their baseline
 Level of consciousness
 Motor abilities
 Balance, proprioception
 Sensory ability, pain response
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Bowel and bladder
Signs of IICP
What will you see with IICP
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Headache
Changes in level of consciousness
Ocular changes – oculomotor nerve
Vomiting
Diminished motor function
 Ataxia,
hemiplegia, paralysis, decorticate and
decerebrate
What else will you do??
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Pre-op teaching
 Do
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not encourage coughing or valsalva
Anti microbial wash, prepare pt to be shaved
Prepare pt and family for ICU post-op
Address physical and emotional concerns
Ensure spiritual support if requested
You are not done yet!
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Post-op Care
Assess your pt!!!!! Frequent VS and NS
 Check dressing
 Careful monitoring of ICP, F & E
 Nausea (post-op) and vomiting
 Careful pain control
 According to orders HOB at 30 degrees or less
 If no bone flap – protect the brain!
 Support patient and family
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Conscious or unconscious, engage your patient!
 Outcomes often uncertain
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Nursing Diagnoses
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Risk for Ineffective cerebral tissue perfusion
Acute pain
Self care deficits
Anxiety
Goals:
 Maintain
normal ICP
 Maximize neuro functioning
 Control pain
 Long term planning
Parting Thoughts