Increased Intracranial Pressure (ICP)

1. Increased Intracranial Pressure (ICP)

2. Objectives • The learner will be able to: • Identify the cancers most likely to metastasize to the brain and cause increased ICP. • Identify two early and two late signs of increased ICP. • Discuss the role of surgery, chemotherapy, and radiation therapy in the management of increased ICP.

3. Definition • Sustained intracranial pressure above 1520 mm Hg

4. Causes of Increased ICP • Primary brain tumor • Metastasis to brain from another site • Increased vascularity related to tumor • Hemorrhage • Edema of the brain tissue • Obstruction of cerebral spinal fluid (CSF) flow

5. Primary Brain Tumors • Gliomas • Astrocytomas (most common brain tumor) • Glioblastomas (40%50% of astrocytomas) • Oligodendrogliomas • Ependymomas • Medulloblastomas

6. Metastasis • 20%40% of patients with cancer have brain metastases (single or multiple lesions). • Common sources • Lung • Breast • Also testes, thyroid, kidney, or colon/rectum

7. Increased Vascularity • Cancers require a nutrient source. • Many cancers produce growth factors to stimulate the production of blood vessels to bring a blood supply, which increases brain volume. • Blood vessels in cancer cells tend to “leak” plasma.

8. Hemorrhage • Disseminated intravascular coagulation (DIC) • Leukemias • Clients receiving myelosuppressive therapies • Spontaneous bleeding from straining • Greatest risk when platelets are below 20,000 cells/cubic mm

9. Edema of Brain Tissue • Infection • Bacterial, fungal, and viral • Water intoxication • Increased intracellular sodium and water • Radiation/chemotherapy to head/brain • Leaking of plasma-like fluid into extracellular space

10. Obstruction of CSF Flow • Obstruction by tumor cells of CSF reabsorption • Obstruction by tumor on critical structures responsible for CSF outflow

11. Significance of ICP • Increased pressure creates a downward displacement on critical brain structures (brain stem) and compromises blood flow. • Results in rapid neurologic decline and death

12. Early Manifestations • Persistent headache (worse in the am; briefly better after vomiting) • Nausea or vomiting (unrelated to food intake; often projectile) • Visual changes (blurring; double vision) • One-sided muscle weakness • Memory or personality changes • Drowsiness or lethargy

13. Late Manifestations • Papilledema • Bradycardia • Widening pulse pressure • Abnormal breathing patterns • Temperature elevations • Coma/seizures • Abnormal posturing

14. Assessment • History • Neurologic exam • Glasgow Coma Scale • Neurologic exam • Orientation, memory, attention, and thought processes • Speech, vision acuity, EOMs, pupils, and facial symmetry • Gait, coordination, and fine motor skills • Ability to follow commands

15. Diagnostics • Computed tomography (CT) • Magnetic resonance imaging (MRI) • Angiography • Stereotactic biopsy

16. Management • Surgery for emergent ICP • Craniotomy to relieve pressure • Ventriculostomy to drain CSF • Radiation therapy after pressure normalized • Chemotherapy after pressure normalized

17. Supportive Therapies • Administer dexamethasone. • Use hyperventilation therapy. • Elevate head of bed to 30 degrees. • Maintain blood pressure and temperature. • Monitor ICP.

18. Supportive Therapies (cont.) • Maintain sodium level. • Administer diuretics, cautiously. • Restrict fluid intake, cautiously. • Osmotic therapy (mannitol) • Administer anticonvulsants. • CNS depressants

19. Nursing Care • Complete bed rest • Passive movements only • No lifting, pulling, or pushing • Control activities requiring straining. • Coughing, vomiting, and constipation • Facilitate quiet, restful environment. • Space activities evenly throughout day.

20. References Belford, K. (2005). Central nervous system cancers. In C.H. Yarbro, M.H. Frogge, & M. Goodman (Eds.), Cancer nursing: Principles and practice (6th ed., pp. 10891136). Sudbury, MA: Jones and Bartlett. Camp-Sorrell, D. (2005). Myelosuppression. In J.K. Itano & K.N. Taoka (Eds.), Core curriculum for oncology nursing (4th ed., pp. 259274). St. Louis, MO: Elsevier Saunders. Clancey, J.K. (2006). Increased intracranial pressure. In M. Kaplan (Ed.), Understanding and managing oncologic emergencies: A resource for nurses (pp. 99121). Pittsburgh, PA: Oncology Nursing Society. Hickey, J.V. (2003). Intracranial hypertension: Theory and management of increases in intracranial pressure. In J.V. Hickey (Ed.), The clinical practice of neurological and neurosurgical nursing (5th ed., pp. 286315). Philadelphia, PA: Lippincott Williams and Wilkins.

21. References (cont.) Hunter, J.C. (2005). Structural emergencies. In J.K. Itano & K.N. Taoka (Eds.), Core curriculum for oncology nursing (4th ed., pp. 422439). St. Louis, MO: Elsevier Saunders. Jarvis, C. (2008a). Eyes. In C. Jarvis (Ed.), Physical examination and health assessment (5th ed., pp. 299342). St. Louis, MO: Elsevier Saunders. Jarvis, C. (2008b). Mental status assessment. In C. Jarvis (Ed.), Physical examination and health assessment (5th ed., pp. 97119). St. Louis, MO: Elsevier Saunders. Kearn, S. (2005). Nursing care of the client with cancers of the neurologic system. In J.K. Itano & K.N. Taoka (Eds.), Core curriculum for oncology nursing (4th ed., pp. 656675). St. Louis, MO: Elsevier Saunders. Lee, E.T., & Armstrong, T.S. (2008). Increased intracranial pressure. Clinical Journal of Oncology Nursing, 12, 3741. Merkle, C.J., & Loescher, L.J. (2005). Biology of cancer. In C.H. Yarbro, M.H. Frogge, & M. Goodman (Eds.), Cancer nursing: Principles and practice (6th ed., pp. 325). Sudbury, MA: Jones and Bartlett.