MS Ch65 Oncologic & Degenerative Neurologic Disorders – Comprehensive Review

Brain Tumors

  • Classification
    • Benign vs. Malignant
    • Benign → slow-growing (e.g., meningioma) yet may compress tissue
    • Malignant → rapid growth, infiltrative, require aggressive therapy
    • Primary vs. Secondary
    • Primary: arise in CNS, do NOT metastasize
    • Secondary (metastatic): spread from lung, breast, kidney, melanoma, etc.
  • Major Primary‐Tumor Types
    • Gliomas – astrocytoma, oligodendroglioma, glioblastoma
    • Meningioma – usually benign but invasive
    • Acoustic neuroma (vestibular schwannoma) – CN VIII, ⇣hearing, tinnitus, vertigo
    • Pituitary adenoma – hormonal syndromes (Cushing, acromegaly)
    • Angioma – vascular malformation ↑ risk of hemorrhage (not true neoplasm)
  • Clinical Manifestations
    • Depend on size, location, compression
    • ↑ICP signs: headache, vomiting, papilledema, \uparrow BP, \downarrow HR/RR (Cushing’s triad)
    • LOC changes: drowsiness → coma, restlessness, purposeless movements
    • Focal deficits: seizures, motor/sensory loss, visual changes, hormonal effects, CN VIII deficits
    • Common summarized S/S: headaches, N/V, seizures, sensory loss, ataxia, cognitive changes
  • Diagnostics
    • Neuro exam, CT (screen/ER), MRI (gold standard), PET, EEG, CSF cytology
    • Surgical biopsy → histology & treatment planning
  • Medical/Surgical Management
    • Goal: total resection w/o new deficits OR decompression
    • Procedures: craniotomy, trans-sphenoidal, stereotactic (biopsy or radiosurgery)
    • Radiation (external beam, stereotactic): DNA damage → cell death; watch for tissue deformation
    • Chemotherapy: IV/systemic; pre-medicate with anti-emetics; alopecia common
    • Adjunct drugs: analgesics, dexamethasone (edema), phenytoin (seizure prophylaxis)
  • Nursing Focus
    • Baseline neuro, ICP monitoring, seizure precautions
    • Promote independence, cognitive orientation, family + hospice referrals
    • Nutrition: oral care, pleasant meals, preferred foods, weight & intake records
    • Encourage advance directives before cognitive decline

Spinal Cord Tumors

  • Anatomy-Based Types
    • Intramedullary – inside cord
    • Extramedullary (intradural/extradural) – outside cord but in canal
  • Manifestations
    • Pain (worse at night/lying), weakness, \downarrow motor/reflexes, sensory loss, para- or tetraplegia (level dependent)
  • Treatment
    • Surgical removal if accessible
    • Dexamethasone + radiation to reduce edema/compress.

Parkinson’s Disease (PD)

  • Key Patho Steps
    1. Degeneration substantia nigra → \downarrow dopamine
    2. Dopamine depletion in nigrostriatal pathway
    3. Relative \uparrow acetylcholine → excitatory dominance
    4. Basal-ganglia circuit imbalance → impaired extrapyramidal tracts
  • Four Cardinal Signs
    • Resting tremor (pill-rolling; worse fatigue, better movement/sleep)
    • Muscle rigidity (cogwheel; ↓ ROM; difficult rising—use raised seats)
    • Bradykinesia/akinesia (slow/frozen; shuffling start-hesitation)
    • Postural instability (stooped, propulsive gait, falls)
  • Other Motor & Autonomic Features
    • Mask-like facies, monotonous speech, dysphagia, drooling
    • Sweating, flushing, orthostatic hypotension, gastric/urinary retention
    • Psychiatric: depression, anxiety, dementia, hallucinations
  • Assessment
    • Observe speech, facial expression, tremor amplitude, swallowing, ROM, cognition, fall risk
  • Goals
    • Maintain mobility & ADLs, bowel regularity, nutrition, communication, coping
  • Nursing Interventions
    • Daily exercise, PT/OT, rocking to initiate movement, rest periods, safe footwear, assistive devices
    • Adaptive utensils, thickened liquids, speech therapy referral
    • Support groups, realistic goals, environmental mods
  • Medical Management
    • Levodopa + Carbidopa (Sinemet) ↑ brain dopamine
    • Additional meds: dopamine agonists, MAO-B inhibitors, anticholinergics
    • Stereotactic surgeries: thalamotomy (tremor), pallidotomy (rigidity), DBS

Huntington’s Disease (HD)

  • Autosomal dominant, onset 25!–!35\,\text{yr} (±17)
    • Premature death of cells in striatum & cortex
  • Triad of Progression
    1. Chorea – jerky uncontrolled limb/trunk/face
    2. Cognitive decline – executive dysfunction → dementia
    3. Psychiatric – depression, anxiety, irritability, psychosis, suicidality
  • Motor Complications
    • Balance/falls (helmet), rigidity late, dysarthria, dysphagia (no milk), weight loss, fatigue
  • Diagnostics
    • Genetic test (CAG repeat); CT shows brain shrinkage (≈30% weight loss)
  • Management (No cure)
    • Goals: symptom relief, complication prevention, family support
    • Meds
    • Antipsychotics: haloperidol, chlorpromazine, olanzapine (avoid dystonia)
    • Antidepressants: fluoxetine, sertraline, nortriptyline
    • Anxiolytics/BZDs: diazepam, lorazepam, alprazolam
    • Mood stabilizers: lithium, valproate, carbamazepine
    • Botulinum toxin for dystonia
    • Nutrition: ↑ calories, small frequent meals, thickened liquids, vitamin supplements, feeding tube PRN
    • Exercise, social activity, protective environment, caregiver respite

Amyotrophic Lateral Sclerosis (ALS)

  • Pathophysiology
    • Loss of upper & lower motor neurons → muscle denervation
    • "Amyotrophy" = wasting; "Lateral" = lateral corticospinal tract; "Sclerosis" = gliotic scarring
  • Manifestations
    • Progressive distal → proximal weakness & atrophy; fasciculations, cramps, spasticity, brisk DTRs
    • Bulbar involvement: dysarthria, tongue atrophy, dysphagia, nasal speech
    • Respiratory weakness → failure (major mortality cause)
  • Etiologic Theories
    • Viral, autoimmune, excess glutamate excitotoxicity
  • Priority Problems / Interventions
    • Respiratory: monitor ABGs, spirometry, BIPAP, suction, aspiration prevention
    • Swallowing: thick liquids, PEG tube, speech therapy
    • Musculoskeletal: ROM, preventing contractures, assistive devices
    • Psychosocial: advance directives, support groups
    • Pharmacology: Riluzole (glutamate inhibitor) slows progression; symptomatic meds

Muscular Dystrophy

  • Inherited (e.g., Duchenne X-linked)
  • Progressive skeletal muscle wasting, ↑ CK enzymes
  • No cure; supportive care, PT, orthotics, cardiac/resp monitoring

Degenerative Disc Disease

  • Age/trauma → disc dehydration & herniation
  • Low-back pain; radiculopathy due to nerve root compression
  • Conservative therapy: rest, NSAIDs, PT; surgery if refractory

Post-Polio Syndrome

  • Occurs 30!–!40\,\text{yr} after initial infection
  • New weakness, fatigue, pain; cause unclear (overuse, aging)
  • No definitive treatment; energy conservation, PT, orthoses

Cervical Discectomy

  • Indications: cervical herniation, stenosis, radiculopathy, myelopathy unresponsive to conservative care
  • Pre-Op Assessment
    • Pain onset, radiation, aggravating factors
    • Neuro: paresthesia, motor deficits, bilateral vs unilateral symptoms
    • Palpation → tone, tenderness; ROM limits
    • Review comorbidities, prior spine surgeries; patient education & consent
  • Potential Complications
    • Hematoma → cord/airway compromise: monitor swelling, stridor, neuro changes, urgent evacuation
    • Persistent/recurrent pain: NSAIDs, opioids (short-term), muscle relaxants, PT, possible epidural steroids or revision surgery
  • Post-Op Goals & Nursing Care
    • Pain relief: analgesics, positioning
    • Mobility: brace if ordered, gradual PT
    • Complication surveillance: dysphagia, hoarseness, infection
    • Home care: activity limits (no lifting/twisting), wound care, follow-up

General Ethical / Advance-Directive Considerations

  • Cognitive-decline disorders (brain tumors, PD, ALS, HD) → obtain advance directives early while patient A&O
  • Discuss options: CPR, feeding tubes, ventilatory support, hospice