This document provides information about space occupying lesions (SOLs) such as brain tumors and abscesses. It defines SOLs as tumors or abscesses within the skull that compress brain tissue. The document discusses the epidemiology, types, risk factors, signs and symptoms, diagnostic evaluation, medical and surgical management, nursing care and complications of different SOLs. It provides detailed information about various brain tumors and abscesses, including definitions and characteristics.

1. SPACE OCCUPYING LESIONS
PRESENTED BY:
MISS.SHWETA SHARMA
M.SC. NURSING
2nd YEAR
AIIMS, JODHPUR

2. INTRODUCTION
Intracranial space occupying
lesions are tumors or abscesses
present within the cranium or
skull. These lesions put pressure
on the adjacent brain tissue
causing its damage. These are
lesions which expand in volume
to displace normal neural
structures & may lead to increase
in intra – cranial pressure.

3. EPIDEMIOLOGY
• The incidence of CNS tumors in
India ranges from 5 to 10 per
100,000 population with an
increasing trend and accounts
for 2% of all malignancies.

4. TYPES OF SPACE OCCUPYING LESIONS
TUMORS
ABSCESS

5. • Non-malignant tumors make up
a majority of this type of space-
occupying lesion. According to
the American Brain Tumor
Association, just one third of
tumors diagnosed in adults are
found to be malignant.

6. HISTOLOGICAL CLASSIFICATION OF
BRAIN TUMOR
Intrinsic tumors
1. Gliomas
• Astrocytoma- Grade I and II are low grade
Grade III is malignant
Grade IV is glioblastoma (high grade malignant tumor)
• Oligodendrogliomas
• Ependymoma
• Mixed gliomas
2. Medulloblastoma

8. Tumors arising from supporting
structures
• Meningioma
• Neuroma
• Schwannoma
Developmental (congenital
tumors)
• Craniopharyngiomas
• Dermoids

9. Pituitary tumors
• Chromophobic or functioning
and non-functioning
• Eosinophilic
• Basophilic
Metastatic tumors
• Lung, breast
• Malignant melanomas

10. DEFINITION OF DIFFERENT TUMORS
• Gliomas: Originating from
neuroglial cells.
• Astrocytoma: Gliomas from
astrocytes.
• Glioblastoma: Gliomas otherwise
called astrocytoma Grade III and IV
arising from cerebral hemispheres.

11. • Oligodendrogliomas: Glioma arising from
oligo dendroglia.
• Ependymoma: Arising from the lining of
ventricles of brain (Ependymol cells). It
can give signs of hydrocephalus.
• Medulloblastoma: Rapid growing tumors
of neuroepithelial origin occurring in
childhood and usually seen near 4th
ventricles of the brain from cerebellum.

12. • Neuromas: Benign tumor composed of
fibrous tissue and nerve fibers.
• Meningioma: They grow often slowly,
but are highly vascular. Commonly
seen on the convexity of dura mater of
the brain.
• Schwannoma: They are tumors of
Schwann cells around the nerves,
commonly seen from 8th cranial
nerve.

13. • Hemangioblastoma: Tumor arises from the brain or spinal
cord consisting of proliferate cells around blood vessels. They
are vascular.

14. • Craniopharyngioma: Congenital sellar/suprasellar tumor, appearing most often in
children and adolescents, that arise in cells derived from Rathke's pouch or the
hypophyseal stalk.
• The lesion, a solid or cystic body ranging in size from 1 to 8 cm, may expand into the
third ventricle or temporal lobe, frequently becomes calcified. This tumor may
interfere with pituitary function, damage optic chiasm, disrupt hypothalamic control
of autonomic nervous system and result in hydrocephalus.
• Development of tumor after puberty can cause amenorrhea in women, loss of
potency in men. Other names are ameloblastoma, pituitary adamantinoma,
Rathke's pouch tumor.

15. Craniopharyngioma

17. Pituitary Tumor
• Chromophobic: It is a non-secreting tumor of pituitary gland.
• Basophilic: It is a secreting tumor producing adrenocorticotropic
hormones causing hyperplasia of adrenal gland. This tumor can
grow fast causing enlargement of sella.
• Eosinophilic: Secreting tumor causing extra production of gland's
hormone.

18. RISK FACTORS
• Trauma
• HIV infection
• Diabetes
• Malignancy
• COPD
• Tuberculosis

19. CAUSES
• Ionizing radiation
• Genetic factors
• Lowered immunity due to
underlying conditions or
medications
• Skull fracture
• Chronic sinus infections
• Meningitis

21. SIGNS AND SYMPTOMS
General symptoms
• Headache
• Sudden personality changes
• Nausea and vomiting
• Papilledema

22. Signs and symptoms related to tumor area
Frontal lobe tumors
• Inappropriate behavior
• Inattentiveness
• Inability to concentrate
• Emotional lability
• Impairment of recent memory
• Difficulty with abstraction

23. Parietal lobe tumors
• Decreased tactile sensitivity
• Loss of right left discrimination
• Construction apraxia
• Seizure activity
Temporal lobe tumors
• Hallucination-auditory, visual, olfactory
• Receptive aphasia
• Irritability, Depression
• Poor judgment, Childish behaviour

24. Occipital lobe tumors
• Visual disturbance
• Visual hallucination
Cerebellum tumors
• Ataxia, incoordination
Bra nstem tumors
• Dysphagia
• Vomiting
• Motor /sensory tract deficits

25. Pituitary tumors
• Gigantism
• Acromegaly
• Cushing’s syndrome
• Hypopituitarism
• Changes in metabolisms of fat,
carbohydrate and water

26. Midbrain tumors
• Cerebellar symptoms
• Deafness
• Decreased light reflex
Ventricular tumors
• Headache
• Vomiting
• Signs of increased intracranial pressure

27. DIAGNOSTIC EVALUATION
• History and physical examination
• Visual field and fundoscopic
examination
• Computed tomography
• Electroencephalogram
• Cerebral angiography
• Lumbar puncture
• Magnetic resonance imaging
• Endocrine studies

28. MEDICAL MANAGEMENT
Chemotherapy:
• Dexamethasone (Decadron)-To
reduce the cerebral edema
• Phenytoin- To prevent or treat the
seizure activity
• Osmotic diuretic- mannitol
• Antibiotics

29. Nursing care of patients on chemotherapy
• Record the vital signs to look for any signs of increased
intracranial pressure.
• Observe any other symptoms of increased intracranial
pressure like headache, vomiting.
• Watch for any seizure activity and keep the record.
• Use all support strategies to keep the patient fit and fine.

30. SURGICAL MANAGEMENT
• Craniotomy of different regions, depending upon the site of
tumor
• Shunt of different types in case of non-communicating
tumors causing hydrocephalus
• Laser surgeries
• Use of gamma knife
• Interventional radiotherapy
• Burr hole for biopsy

31. PRE- AND POSTOPERATIVE CARE OF
PATIENTS UNDERGOING
NEUROSURGERIES
Preoperative Management
For the planned surgery, the preoperative care starts on the day the
patient comes to the hospital for the first time. The preoperative
period can be divided into:
• Care given in outpatient department
• Care given from the day of admission till the day of surgery
• On the day of surgery till the patient reaches the OT
• In the operation theatre till the surgery is started

32. In the outpatient department the following steps are taken:
• History
• Investigation
•Make the patient fit for surgery, physically, mentally
financially and socially
• Here the family also is given support
On admission the patient is given physical orientation:
Orientation to the routine of the ward, orientation to the staff.
Patient is given information about the nature of surgical
procedure, possible complications if the patient is in a position
to understand.

33. The day of surgery: consent, physical preparation, keeping
ready all the investigation report, premedication, keeping
ready the preoperative check list and accompanying the
patient till the operation theatre.
In the operation theatre: the nurse receives the patient with
all records, handover the patient to the anesthetist and
his/her team.

34. Intraoperative Care
Nursing care can be under the following heading:
• Prevention of hypotension
• Prevention of hypothermia and hyperthermia
• Prevention of hyperventilation
• Prevention of air embolism if the patient is in sitting position
• Prevention of any type of burns when diathermy is used

35. Postoperative Care
After surgery the patient is taken to the recovery room or to
the neurosurgical intensive care unit. Here, the environment
allows for close monitoring to meet any emergency. Here, the
nurse should have or obtain the necessary documents like:
• Postoperative notes
• History of preoperative neurological status of patient
• Current (postoperative) baseline neurological assessment
• Review the postoperative order

36. Nursing care following craniotomy is with the objective of:
• Frequent monitoring and recording of neurological signs to identify
the signs of increased intracranial pressure.
• Frequent monitoring of vital signs to prevent the causes for
increased intracranial pressure.
• Look for any seizure activity.
• Observe for any neurological deficit.
Care in Postoperative Ward
Continue the observations and prepare the patient for discharge.
Planning for early rehabilitation is essential, i.e. according to the
condition and need for the individual patient.

37. Special Nursing Care of Patients Undergoing Surgery for
Pituitary Tumors
Preoperative
• Daily weight checking
• 24 hours urine volume for 3 consecutive days
• Intake and output chart for 3 days
• If the approach is oral/nasal, swab is sent for culture and
sensitivity, urine and blood also sent for osmolality.

38. Postoperative
• Weight to be checked daily
• Strict intake and output chart-watch for negative balance and inform
• Nasal drops to be put
If nasal pack is there
• Head end to be elevated
• Bedrest to be advised
• Instruct not to sneeze
• Instruct not to cough
• Oral respiration to be advised

39. Operative approaches in neurosurgery

41. NURSING DIAGNOSIS
• Ineffective cerebral tissue perfusion related to cessation of
blood flow by SOL.
• Pain (acute / chronic) related to physical injury, nerve
compression by SOL, increased ICP.
• Risk for ineffective breathing pattern related to
neurovascular damage, cognitive impairment.

42. BRAIN ABSCESS
• A brain abscess is a collection
of pus enclosed in the brain
tissue, caused by a bacterial
or fungal infection.

43. • Brain abscess (or cerebral abscess) is an abscess
caused by inflammation and collection of infected
material, coming from local (ear infection, dental
abscess, infection of paranasal sinuses, infection
of the mastoid air cells of the temporal bone,
epidural abscess) or remote (lung, heart, kidney
etc.) infectious sources.
• The infection may also be introduced through a
skull fracture following a head trauma or surgical
procedures.

44. EPIDEMIOLOGY
• It may occur at any age but is most frequent in the third
decade of life.
• The incidence of brain abscess among intracranial masses
varies from 1-2% in western countries, to about 8% in
developing countries.

45. CAUSES AND RISK FACTORS
Nearly anyone can get a brain abscess, but certain groups of people
are at a higher risk than others:
• A compromised immune system due to HIV
• Cancer and other chronic illnesses
• Congenital heart disease
• Major head injury or skull fracture
• Meningitis
• Immunosuppressant drugs, such as those used in chemotherapy
• Chronic sinus or middle ear infections

48. CLINICAL MANIFESTATIONS
• Triad of fever, headache and focal neurologic findings
• Headache, drowsiness, confusion, seizures, hemiparesis or
speech difficulties together with fever with a rapidly progressive
course.
• Headache is characteristically worse at night and in the morning,
as the intracranial pressure naturally increases when in the
supine position. This elevation similarly stimulates the medullary
vomiting center and area postrema, leading to morning vomiting.
• Decreased sensation, loss of coordination, loss of muscle
function, typically on one side, stiff neck and vision changes.

49. DIAGNOSTIC EVALUATION
• Neurological examination
• Blood cultures
• Chest x-ray
• Complete blood count (CBC)
• Head CT scan- Within 4-5 days the
inflammation and the concomitant dead brain
tissue are surrounded with a capsule, which
gives the lesion the famous ring-enhancing
lesion appearance on CT examination with
contrast.
• Electroencephalogram (EEG)

50. • MRI of head
• Testing for the presence of antibodies to
organisms such as Toxoplasma gondii and
Taenia solium
• A needle biopsy is usually performed to
identify the cause of the infection.
• Lumbar puncture is contraindicated because
it can cause the brain tissue to move across
structures within the skull (brain herniation).

51. MANAGEMENT
Medication is recommended if patient have:
• Several abscesses (rare)
• A small abscess (less than 2 cm)
• An abscess deep in the brain
• An abscess and meningitis
• Shunts in the brain for hydrocephalus (in some cases the shunt may
need to be removed temporarily or replaced)
• Toxoplasma gondii infection in a person with HIV

52. • Broad spectrum antibiotics
• Antifungal medications
• Hyperbaric oxygen therapy (HBO2 or HBOT)
Reduces intracranial pressure
High partial pressures of oxygen act as a bactericide and thus
inhibits the anaerobic and functionally anaerobic flora common in
brain abscess
Optimizes the immune function thus enhancing the host defense
mechanisms
Found to be of benefit when brain abscess is concomitant with
cranial osteomyelitis.

54. Surgery is needed if:
• Increased pressure in the brain continues or gets worse
• The brain abscess does not get smaller after medication
• The brain abscess contains gas (produced by some types of
bacteria)
• The brain abscess might break open (rupture)

56. PROGNOSIS
• If untreated, a brain abscess is almost always deadly.
• With treatment, the death rate is about 10 - 30%. The earlier
the treatment is received, the better is prognosis. Some
patients may have long-term neurological problems after
surgery.

57. COMPLICATIONS
• Brain damage
• Meningitis that is severe and life threatening
• Recurrence of infection
• Seizures

58. Nursing Management & Interventions
• Nursing interventions should support the medical treatment.
• Patients and families need to be advised of neurologic deficits that
may remain after treatment (hemiparesis, seizures, visual deficits,
and cranial nerve palsies).
• Frequently assess neurologic status, especially LOC, speech and
sensorimotor and cranial nerve functions.
• Assess the family’s ability to express their distress at the patient’s
condition, cope with the patient’s illness and deficits, and obtain
support.
• Always provide safety measures.