Lecture 7.2: Brain Tumors and Seizures

how are brain and spinal cord tumors named

based on the type of cell they formed in

primary brain tumors that are malignant

1. astrocytic tumors (38% of primary brain tumors)

- glioblastoma multiforme

- astrocytoma

2. primary CNS lymphoma

primary brain tumors that are benign

1. meningeal tumors (27% of primary brain tumors)

2. pituitary tumors

3. schwannomas (acoustic neuroma)

"stage" of primary brain tumor

describes if cancer has spread

- stage I (localized) -> IV (spread to distant sites)

**no standard staging system for primary CNS tumors

"grade" of primary brain tumor

describes how well organized the tumor cells are

- gd I (low, well organized) -> IV (highly disorganized

- low grade tumors have better survival rates than high grade

clinical presentation of impairments of the brain tumor

- will improve as cancer treatment progresses

- but will be limited by the capacity of the neural tissue to recover

clinical presentation of impairments related to brain tumor treatments

- gets worse as cumulative dose of treatment increases

- recovery depends on type of treatment

(chemo acute effects that mostly resolve when treatment ends BUT radiation-late and persistent effects)

survival rates childhood brain tumor

- 70% will survive more than 5 years after diagnosis

- depends mainly on tumor type and grade

- long term sequalae related to the tumor and its treatment are common

initial clinical presentation in adult and children

- headache and/or seizure are the most common

other early sx depend on:

- where tumor is located in CNS

- size of tumor and rate of tumor growth

- number of tumors

diagnosis of brain tumor

- CT, MRI, or PET CT scan to identify mass

- biopsy to identify type of cancer by its cellular characteristics

once cancer has been identified, pts will do this for treatment

start high dose steroids to reduce CNS edema

- will see increase in function and decrease in impairment

medical treatment includes on or all of the following depending on tumor type and characteristics

- active surveillance for slow growing tumors

- surgery

- radiation therapy

- chemotherapy

- targeted therapy

glioblastoma multiform

- most common malignant primary brain tumor

- median age is 64 y/o

- cure rate is very low (less than 5%)

- all considered grade IV

- rapidly adapts and become resistant to treatment

clinical presentation of tumor compressing neural tissue

- ICP increases due to space occupying tumor causing mass effect -> results in seizures or headaches

treatment glioblastoma multiform

- methylation of MGMT (gene encodes a DNA repair enzyme)

- combo of steroids, surgery, chemoradiation and/or chemotherapy

- sx isn't performed due to the fragile area

methylated GBM vs non-methylated GBM

- methylated predicts a better response to treatment

- non-methylated GBM carries a worse prognosis

most common treatment sequence

1. steroids started immediately at diagnosis and not tapered until part way through chemoradiation

2. surgery if indicated (no infiltration)

3. 6 weeks of concurrent chemoradiation

- temodar: oral chemotherapy drug taken 1xday

- radiation 5 days/wk

4. 6 more cycles of Temodar after completing chemoradiation

effects of surgery on mobility

- worse mobility due to post-surgical edema

- as edema resolves will have a steady improvement of neurologic impairments

- intensive post-op rehab to maximize a pt mobility during period before they start chemo/radiation

when does oncology start chemoradiation

wait 4-6 weeks after surgery

effects of steroids on mobility

mobility will improve once steroids start

- due to long-term effects of steroids, the oncology team will taper pt away from steroids once they start chemoradiation

**common to see a regression in mobility, increase in fatigue and increase in cognitive sx when steroids are TAPERED

- need to educate that this is normal

adverse effects of Temodar

- nausea and vomiting

- constipation

- headache

- fatigue

radiation effects on mobility

most common acute side effect: fatigue

- moderate and increases as dose increases

- decreases functional mobility and neurologic impairments magnify

what is the last adverse effect on high-dose radiation?

radiation necrosis

- permanent death of brain tissue resulting in decreased neural function

emerging therapies for GBM

combination of genetic profile and functional profile

- allows physician to select the treatment that will be MOST likely to cause the tumor cells to go into apoptosis

- allows bypass the tumor's ability to become resistant to treatment

classification of pediatric primary brain tumors

1. supratentorial - more common in kids younger than 3 y/o

2. posterior fossa tumors (brainstem/cerebellum) - common between ages 4-10 y/o

what can cancer treatment affect to pediatrics

mobility, growth and development

late or persistent impairments from treatment will have a negative impact on

pediatric brain tumor survivors mobility as adults

adult survivors of childhood brain tumor

- debilitating effects on growth and neurologic development after radiation

- secondary tumors

- chemotherapy effects

decreased balance is associated w/

- infratentorial tumor

- increased body fat (due to being inactive?)

- hearing loss

- CIPN

- cognitive impairments

are metastatic brain tumors or primary brain tumors more common

metastatic

half of metastatic brain tumors are from

lung cancer

leptomeningeal metastases

cancer cells circulate through venous system and cross into CNS, circulate in CSF and spread into leptomeninges (innermost membranes)

clinical presentation of metastatic brain tumor

- headache due to tumor blocking CSF is the main

- often multifocal

treatment of metastatic brain tumors

can extend life by months to years

1. radiation to whole brain

2. stereotactic radiosurgery (if less than 4 tumors)

3. chemotherapy or immunotherapy

treatment when tumors have spread to leptomeninges

- chemotherapy (systemic and/or intrathecal)

- radiation

- supportive care

**difficult to treat and often w/ poor prognosis

seizure

abnormal unregulated electrical discharge that occurs within brain's cortical gray matter and interrupts normal brain function

- possibly due to a disruption of normal balance of excitation and inhibition of neurons in cortex

common causes of seizures

- TBI

- stroke

- brain tumors

- withdrawal of alcohol

diagnosis of seizure disorder

- clinical hx

- physical exam

- MRI of medial temporal, cortical and subcortical structures

- EEG

classification of seizures

1. focal onset seizures

- focal aware seizures w/ motor onset

- focal aware seizures w/ nonmotor onset

- focal impaired awareness w/ motor onset

- focal impaired awareness w/ motor onset

2. generalized onset seizures

- motor generalized onset tonic-clonic seizure

- nonmotor typical absence seizures

- nonmotor other

focal onset seizures

- originate in networks in one hemisphere (possibly subcortical)

- localized but may spread and evolve

- motor and nonmotor onset

generalized onset seizures

- originate in bilateral hemispheres

- always cause impaired awareness

- generalized onset of motor seizure and tonic-clonic seizure

- typical absences of nonmotor seizures (zone-outs) **most common seizure type

aura

indicator that the individual might experience a large seizure

- specific sensation tied to location of seizure (i.e. unpleasant odors, deja vu, fear/panic)

post-ical

time period immediately after seizure

- extreme fatigue w/ possible cognitive or language impairments

behavioral management strategies for seizures

- good sleep hygiene

- avoid stress

- decrease alcohol

- exercise

post traumatic brain injury seizure management

- anti-seizure drugs to prevent seizures in individuals after TBI w/ a GCS <10 (for the first week and stopped unless seizures occur)

- if seizures begin > 1 wk after TBI, long term anti-seizure medication

injury prevention for seizures

- loose clothing around neck

- placing pillow under head

- roll pt onto side to prevent aspiration

- DON'T hold the person down to stop movements

- DON'T put anything in the person's mouth to protect tongue

only call 911 for seizures if one more more is true

- person has never had a seizure before

- person has difficulty breathing or walking after seizure

- seizure lasts 5+ min

- person has a health condition like diabetes/heart disease

don't leave anyone alone after a seizure until

- can answer the 4 W's: who, what, when and where

- can talk or communicate

- breathing normally

- can wake if they fall asleep post seizure