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Chapter 35:
Common Neurosurgical and
Neurological Disorders
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Care of the Neurosurgical Patient
All of the following patient problems require some type of
cranial surgery to reduce cerebral edema and/or
hemorrhage:
– Brain tumors
– Aneurysm
– Arteriovenous malformation (AVM)
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Brain Tumors: Expansion in a Space That’s
Too Tight
Etiology/Incidence
Neoplasm of cranium; some are from metastasis
Pathophysiology: Increase in brain tissue causes:
• Blood and CSF to be shunted from the brain,
affecting CPP
• Disruption in the blood-brain barrier
• Increased ICP from vasogenic edema
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Brain Tumors
• Signs/Symptoms (clinical manifestations of increased ICP)
– Headache
– Seizures
– Change in level of consciousness (LOC)
-
Focal neurological deficits
• Diagnosis based on history
– CT initially but MRI preferred
– MRA shows vascularity of tumor
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Management and Nursing Care
of Brain Tumors
• Pharmacology
• Radiation Therapy
– Steroids if increased ICP
– Used after biopsy
– Acid blockers
– External beam
– Anticonvulsants
– Stereotactic
• Surgical Management
– Biopsy
– Bradytherapy
• Chemotherapy
– Craniotomy
– Multiple modalities
– Complications
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Question
A patient admitted to the ICU with an intracerebral tumor
has been on long-term steroids to reduce intracranial
pressure. Which of the following findings would be a side
effect of this therapy?
A. Potassium 2.5 mEq/L
B. Blood glucose 250mg/dL
C. Serum sodium 135 mEq/L
D. Creatinine 0.5 mg/dL
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
B. Blood glucose 250 mg/dL
Rationale: Long-term steroid use can increase the serum
glucose level and can cause a steroid-induced diabetes.
All of the other lab values would not be related to
steroids.
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Nursing Care
• Monitor for side effects of steroids
• Care after craniotomy
– Watch for cerebral edema, infection, hyponatremia,
hemorrhage, thromboembolism, seizures
• Care during radiation/chemotherapy
• Patient education
• Hospice and family support for malignant gliomas
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Aneurysms: Weakening of the Artery Wall
• Etiology/Incidence
– Associated with congenital and degenerative processes
– Risk groups are female, smokers, and older
– High risk in age group 35 to 60
• Pathophysiology
– Defect in the media leading to arterial wall weakness
– Berry (saccular) aneurysm
– Subarachnoid hemorrhage (SAH)
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
One of the most common complications of an aneurysm is
a subarachnoid hemorrhage. If this occurs, patients will
state they are having “the worse headache of my life.”
A. True
B. False
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Answer
A. True
Rationale: Bleeding into the subarachnoid space causes a
severe headache associated with SAH. This bleeding also
causes an increased ICP.
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Aneurysms
• Signs/Symptoms (clinical manifestations)
– Half of patients have warning symptoms
– Headache, lethargy, neck pain
– Cranial nerve deficits of 2-4
– Rupture: “worst headache in my life”
– If SAH, then nuchal rigidity, photophobia, blurred
vision
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Subarachnoid Hemorrhage Complication
• Bleeding stops when the ICP = MAP; clot forms a seal
around the aneurysm
• Blood in subarachnoid space can stimulate the autonomic
nervous system to create hypertension, therefore
decreasing CPP
• Hydrocephalus can result if blood clogs the CSF in the
ventricles or arachnoid villi (where reabsorbed)
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Diagnosis and Patient Care
Diagnosis
– History, physical exam, lumbar puncture, cerebral
angiogram
– CT shows hemorrhage in 92% of cases
Management and Nursing Care
– Minimal stimulation and quiet environment
– Observe for vasospasm
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Surgical Care
• Cerebral aneurysm clipping/excision
– Only if area is accessible
– Done in first 48 hours
– Critical care monitoring postop for airway, vasospasm, LOC
changes
• Endovascular thrombosis (coil)
– Thrombogenic platinum alloy that conforms to aneurysm
– Complications are hemorrhage, rehemorrhage, and stroke
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Question
A patient is admitted to the ICU for vasospasm after
aneurysm clipping. VS are 100 – 70 – 22, BP 140/90.
Hgb and Hct are 14 and 40%. “Triple H” therapy is
instituted to decrease vasospasm. Which of the following
is an expected outcome after instituting this therapy?
A. BP 120/60
B. BP 160/88
C. Hct 30%
D. Hct 50%
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Answer
B. BP 160/88
Rationale: The BP needs to be higher than normal by 20
mm Hg to ensure cerebral perfusion pressure (CPP).
Lowering the BP too quickly would decrease CPP. Hct is
generally kept below normal by 15%, which in this case
would be 36%.
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Care and Treatment Before Surgery
• Vasospasm in injured areas
– May be due to calcium released from blood cells. Calcium
channel blocker, nimodipine are given to prevent this.
• “Triple H” therapy
– Hypervolemia: Give IV colloids/crystalloids to cause
cerebrodilatation. Use pulmonary artery catheter to
monitor MAP and CO.
– Hemodilution: Decrease blood viscosity to increase CBF.
Keep HCT < 15% normal.
– Hypertension (induced): To keep BP > 20 mm Hg above
normal. Ensures CPP.
• Balloon angioplasty
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Arteriovenous Malformations (AVMs)
• Etiology/Incidence
– A tangled mass of arteries and veins without a capillary
system
– Usually congenital
– 90% in cerebrum
• Pathophysiology
– Can develop aneurysms and rupture, creating a cerebral
hemorrhage (50-60% of cases)
– Can cause hydrocephalus and seizures (unresponsive to
drug therapy)
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AVM (cont.)
• Signs/Symptoms (clinical manifestations)
– Asymptomatic unless hemorrhage
– Headache, seizures, and increased ICP
– Cerebral steal: blood flows from viable tissue into
AVM
• Diagnosis
– MRI, CT
– Can see hemosiderin ring around lesion
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Management and Nursing Care
of AVMs
• Surgery preferred to decrease the risk of complications
– Stereotactic biopsy: with creation of burr holes; done
with MRI, CT contrast
– Craniotomy: incision and resection
– Transsphenoid surgery: sphenoid sinus opened, CSF
leak sealed with abdominal fat
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Care of Patients with Neurological
Disorders
• Stroke
• Seizures
• Guillain-Barré syndrome (GBS)
• Myasthenia gravis
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Stroke: Brain Attack
• Etiology/Incidence
–
Medical emergency to decrease neuron death!
–
75% due to vascular obstruction (thrombi, emboli)
–
25% due to hemorrhage
–
TIA (transient ischemic attack) if symptoms last <24 hrs
• Pathophysiology
–
Blood flow is blocked by a clot forming on top of atherosclerotic
plaque or blood clot formed in the heart or body
–
Decreases oxygen supply and creates ischemic areas (ischemic
penumbra) that can become infarcted
–
Penumbra can be saved if thrombolytic therapy is instituted early
–
Ischemic areas cause cerebral edema and increase ICP
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Identifying and Treating Stroke
• Signs/Symptoms (clinical manifestations)
–
Sudden onset that doesn’t resolve
–
Use of NIHSS stroke scale
–
Neurological deficits include:
• Numbness, tingling
• Visual changes, difficulty talking
• Weakness on opposite side of the body as stroke
Deficits last for >24 hrs.
Diagnosis
–
CT without contrast ASAP (3 hour critical window) to rule out
intracerebral bleed
–
ECG to see if atrial fibrillation or flutter is the cause
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
A CT scan of the brain is critical in identifying a vascular
obstructive stroke.
A. True
B. False
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
B. False
Rationale: A CT scan is vitally important, but the purpose is
to rule out hemorrhagic stroke so the patient can be
considered for thrombolytic therapy. The nurse must
have the CT results that rule out a stroke BEFORE
therapy with “clot busters” is started.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Management and Nursing Care
• Assessment for thrombolytic therapy
– An infarction may not show up for 24 hrs
– The 3-hour window begins from the time the patient
was last seen (not presentation time in the ECU)
– Bolus dose and drip of tPA (tissue plasminogen
activator)
– Contraindications for thrombolytic therapy
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Question
A patient is admitted to the Emergency Care Unit with
stroke symptoms. Which of the following would exclude
this patient from thrombolytic therapy?
A. Atrial fibrillation, new onset
B. An elevated BP of 140/90
C. An INR of 2.5
D. Head trauma over 1 year previous
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Answer
C. An INR of 2.5
Rationale: An INR of greater than 1.7 would increase a
patient’s chance of an intracerebral bleed. Atrial
fibrillation of new onset can cause a stroke. Head trauma
that is relatively new (within 2 months) is a
contraindication, as is a BP over 185/110.
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Nursing Management and Care
• Assessments: initial and ongoing
• Hazards of immobility
• Possible preparation for carotid endarderectomy
– Removal of plaque that forms a bed for the clot
• Communication
– Emotional lability of patient
– Family support and education
• Patient education
• Rehabilitation
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Seizures
• Etiology/Incidence
–
Abnormal excessive neuronal discharge
–
Sudden, usually without warning (can have aura)
–
Epilepsy
–
Non-epileptic seizures
• ETOH withdrawal
• Fever
• Hypoxia
• Drug intoxication
• Poisoning
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Seizures (cont.)
• Pathophysiology
–
Increased permeability makes neurons highly excited
–
60% of seizures have no known cause
• Signs/Symptoms (clinical manifestations)
–
Generalized seizures: affect both hemispheres; affect whole
brain from onset to completion
• Grand mal, tonic, clonic, ataxic, myoclonic and absence
–
Focal: only specific part of brain is affected; motor responses can
travel to whole brain
• Jacksonian, sensory, autonomic
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Seizures (cont.)
• Diagnosis
– Identifying high-risk non-epileptic groups
– CT/MRI to see if lesion is cause
– EEG
– PET to evaluate cerebral perfusion and blood flow
– Epilepsy monitoring unit with scalp electrodes
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Management and Nursing Care for the
Seizure Patient
Treatment for status epilepticus (medical emergency)
– Diazepam
– Lorazepam
– Phenobarbital
– Propofol
• Surgical treatment
• Discharge teaching
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Care of the Patient With Guillain-Barré
Syndrome (GBS)
Etiology/Incidence
– Inflammation of the peripheral nerves
• Pathophysiology
– Triggered by autoimmune system
• Signs/Symptoms (clinical manifestations)
– Ascending symmetrical lower motor weakness
– Ascends to muscles of respiration
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Diagnosis and Treatment of GBS
• Diagnosis
–
Lumbar puncture: elevated protein levels
–
Positive serum immunoglobins
–
Diminished pulmonary function tests
• Management and nursing care
–
Airway and breathing management; possible ventilatory support
–
Plasmapheresis
–
IV immunoglobin
–
Supportive care
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Myasthenia Gravis
• Etiology/Incidence
–
Affects younger women and older men
–
50% have thymus hyperplasia
• Pathophysiology
–
Motor weakness from antibodies impairing nerve function at the
myoneural junction
• Signs/Symptoms (clinical manifestations)
–
Ocular muscles are first affected (diplopia, ptosis)
–
Difficulty swallowing (risk for aspiration)
–
Respiratory muscles are affected; possible need for ventilatory
support
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Diagnosis and Treatment of Myasthenia
Gravis
• Diagnosis
–
Blood for acetylcholine receptor antibodies
–
EMG
–
Tensilon tests
• Management and nursing care
–
Pyridostigmine (Mestinon)
–
Steroids
–
Immunosuppressants
–
Plasmapheresis
–
Thymectomy
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