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Course: Oncology Nursing

Topic: Nursing Management of

Oncological Emergency - Increased Intracranial Pressure

The Nurses International Community

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Module Goals

Learners will be able to:

Explain the underlying pathophysiology of Increased Intracranial Pressure (ICP).
Describe the scope of the problem including the etiology and risk factors for this oncologic emergency.
List the clinical manifestations associated with this emergency situation.
Explain the nursing assessment for ICP including relevant diagnostic tests.
Characterize the nursing interventions and supportive care important to address this problem in a timely and effective manner.

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Introduction

Brain metastases are the most common type of brain malignancy, occurring in 20-40% of adult cancer patients.
Although any tumors can metastasize to the brain, lung cancer, breast cancer, and melanoma are the most common, accounting for 70-90% of brain metastases.
Brain metastases can lead to neurologic deficits and seizures, and become an oncologic emergency in cases of increased intracranial pressure.

Cancer Care Nova Scotia, 2014

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Definition

Increased ICP is when pressure inside the skull rises.
The pressure in the cranial vault is measured in millimeters of mercury (mm Hg) and is normally less than 20 mm Hg.
The cranium is a rigid structure and has 3 main components: brain, cerebrospinal fluid, and blood.
Any increase in the volume of its contents will increase the pressure within the cranial vault.

Pinto VL et al., 2021

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Review Question:

It is called Increased Intracranial pressure when pressure inside the skull is rises to……………...Select correct answer.

<20 mmHg
>20mmHg
<25 mmHg
>30mmHg

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Pathophysiology

The volume of the cranial vault ranges from 1400 to 1700 cc, of which the brain constitutes approximately 80% of that volume, and CSF and blood, each constitute another 10%.
Since the cranium is rigid and has a fixed volume, an increase in the volume occupied by brain, CSF, or blood:

Results in a decrease in one or both of the other components, or the system's ability to compensate fails giving rise to an increase in ICP.

Lin & Avila, 2017

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Pathophysiology

Brain tumors exert mass effect because the neoplasm occupies space, but also because the tumor increases vascular permeability causing vasogenic edema.
Tumors also increase ICP during the first 3 to 6 months after radiotherapy, as a consequence of a robust inflammatory reaction that disrupts the blood brain barrier.
Another cause of increased ICP is decreased CSF outflow, which is seen in patients with an obstruction of the ventricular system and in patients with decreased CSF absorption.

Lin & Avila, 2017

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Causes of Increased ICP

Canadian Cancer Society, 2021

Increased ICP can develop if the cancer or its treatments cause:

A blockage in CSF pathways so CSF can’t flow normally.
Infection of the brain or the membranes that cover the brain and spinal cord (called the meninges).
Bleeding in the brain.
Cerebral edema.
A reaction in brain tissue to radiation therapy.

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Causes of Increased ICP

Pinto VL et al., 2021

Increase in brain volume

Generalized swelling of the brain or cerebral edema from a variety of causes such as trauma, ischemia, hyperammonemia

Mass effect:

Hematoma
Tumor
Abscess
Blood clots

Increase in cerebrospinal fluid

Increased production of CSF
Choroid plexus tumor

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Causes of Increased ICP

Decreased reabsorption of CSF

Obstructive hydrocephalus
Meningeal inflammation or granulomas

Increase in blood volume

Increased cerebral blood flow during hypercarbia, aneurysm
Venous sinus thrombosis,
Elevated central venous pressures, e.g., heart failure

Other causes

Idiopathic or benign intracranial hypertension
Skull deformities such as craniosynostosis
Hypervitaminosis A, tetracycline use

Pinto VL, Tadi P, Adeyinka A., 2021

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Case Study/Critical Thinking Question/What would the nurse do?

What are the causes of increased ICP in a cancer patient? (Select all that apply)

Brain tumor
Reaction of brain tissue to radiation therapy
Cerebral edema
Infection to the brain tissues

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Symptoms of Increased ICP

Canadian Cancer Society, 2021

A headache is the most common symptom of increased ICP.

Nausea/vomiting
Dizziness
Poor memory
Restlessness
Nervous system problems ( weakness, numbness, vision problems, coordination problems, loss of muscle strength, or difficulty speaking
Lowered consciousness, including drowsiness, lack of energy, confusion or coma

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Symptoms of Increased ICP

Canadian Cancer Society, 2021

Later signs develop as ICP increases, the following signs of increased ICP are called Cushing triad including:

High blood pressure with an increasing difference between the systolic and diastolic blood pressure readings
Slow pulse rate
Abnormal respirations

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Case Study/Critical Thinking Question/What would the Nurse do?

Miss Mona has recently been treated with radiation therapy and has increased ICP. What is the most common symptoms a nurse would see in the Mona case?

Nausea
Vomiting
Headache
Weakness

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Diagnosis

Pinto VL, et al., 2021

History and Physical Examination:

Clinical suspicion should be raised if a patient presents:

Headaches,
Vomiting, and
Altered mental status varying from drowsiness to coma
Visual changes can be blurred vision, double vision, photophobia

Infants in whom the anterior fontanelle is still open may have a bulge overlying the area.

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Diagnosis

Canadian Cancer Society, 2021

Tests done if increased ICP is suspected may include:

CT scan of the head:

Can show edema, reveal causes of increased ICP.

MRI of the head:

Can reveal signs of raised ICP such as enlarged ventricles, herniation, or mass effect from causes such as tumors, abscesses, and hematomas.

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Diagnosis

Canadian Cancer Society, 2021

A lumbar puncture, or spinal tap:

A measurement greater than 20 mm Hg is suggestive of raised ICP.
Brain imaging should precede an LP because LP can cause a sudden and rapid decrease in ICP and the sudden change in volume can lead to herniation.

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Case Study/Critical Thinking Question/What would the Nurse do?

Miss Maya has brain cancer, and has developed symptoms of severe headache, nausea and vomiting. The nurse suspects her to have a increased ICP. What the diagnostic tests would confirm ICP?

CT Scan of brain
MRI of brain
Lumbar puncture
X-ray of chest

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Management of Increased ICP

Management principles should be targeted toward:

Maintenance of cerebral perfusion pressure by raising MAP
Treatment of the underlying cause
Lowering of ICP

Pinto VL, et al., 2021

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Management of Increased ICP

Initial treatment of elevated ICP:

Dexamethasone, 10-24 mg IV, followed by 4 mg IV every 6 hours should be administered.

In the most severe cases:

Mannitol 0.25-1g/ kg/dose IV over 30 minutes (may be given over 5-10 minutes in critical situations).
Intubation and controlled hyperventilation may be used to decrease cerebral edema, but this is reserved for critical cases in patients with rapidly declining clinical states.

Cancer Care Nova Scotia, 2014

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Management of Increased ICP

Canadian Cancer Society, 2021

Cancer treatment: can help lower ICP:

Radiation therapy or intrathecal chemotherapy to treat the tumour.
Intrathecal chemotherapy is given by a lumbar puncture to deliver chemotherapy drugs directly into the CSF around the brain and spinal cord.

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Management of Increased ICP

Canadian Cancer Society, 2021

Surgery

May need to have surgery to remove as much of the tumor as possible (called debulking surgery).
May needed to have a cerebral shunt placed to drain CSF and relieve ICP.
The extra CSF is drained from the brain to the abdomen.

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Management of Increased ICP

Measures to lower ICP include:

Elevate of the head of the bed to greater than 30 degrees.
Keep the neck midline to facilitate venous drainage from the head.
Hyperventilation to lower pCO2 to around 30 mm Hg can be transiently used to increase cerebral fluids.
3% hypertonic saline to decrease cerebral edema can be administered as a 5 ml/kg bolus or a continuous infusion, (considered safe if serum sodium is < than 160mEq/dl or serum osmolality is less than 340 mOsm).

Pinto VL et al., 2021

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Management of Increased ICP

Carbonic anhydrase inhibitor class (acetazolamide) to decrease the production of CSF.
Lumbar punctures, can be used to drain CSF thus reducing the ICP.
Optic nerve fenestrations for patients with chronic idiopathic hypertension at a risk of blindness.
Ventriculoperitoneal or lumbar-peritoneal shunts can divert CSF to another part of the body.
A decompressive craniectomy, wherein a part of the skull is removed, and dura lifted, allowing the brain to sell without causing compression.

Pinto VL et al., 2021

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Nurse’s Role in Increased ICP

History:

Onset severe headache is often all that is needed to make one suspicious of intracranial hypertension.

Physical examination:

In many circumstances, the patient has a severe headache, and nausea and vomiting.
Visual complaints, including double or blurry vision, are seen in conjunction with the headache.
Examination of the oculomotor nerves may reveal difficulty moving the eyes vertically up or horizontally and laterally.

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Nurse’s Role in Increased ICP

Assess and monitor Cushing triad including:

High blood pressure, slow pulse rate, abnormal respiration.

Nursing Measures to lower ICP:

Assess airway, breathing and vital signs
Raise head of bed and remove obstructions/restrictions to jugular venous outflow
Keep the neck midline to facilitate venous drainage from the head
Transiently hyperventilate by bag ventilation (20-30 breaths per minute) until other ICP reduction maneuvers are begun

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Case Study/Critical Thinking Question/What would the Nurse do?

The nurse is looking after a 50 yr old woman with cancer in an Oncology ward. During her shift, the patient complains of a severe headache and vomiting. and the nurse suspects ICP. How would the nurse position her patient? (Select all that apply)

Raise the head of the bed greater than 30 degree
Keep the neck midline to facilitate venous drainage from the head
Keep the client in supine position
keep the patient in recovery position

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References:

Cancer Care Nova Scotia (2014). Guidelines for the Management of Oncologic Emergencies in Adult Patients – Full Version. © Crown copyright, Province of Nova Scotia. Retrieved from:http://www.cdha.nshealth.ca/system/files/sites/77/documents/full-version-oncologic-emergencies-final.pdf

Canadian Cancer Society (2021). Increased Intracranial Pressure. Retrieved from:https://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/managing-side-effects/increased-intracranial-pressure-icp/?region=on

Dunn. L.T.,(2002).Raised Intracranial Pressure.Journal of Neurology Neurosurgery and Psychiatry. Retrieved from: https://jnnp.bmj.com/content/73/suppl_1/i23

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References:

Lin, A. L., & Avila, E. K. (2017). Neurologic Emergencies in the Patients With Cancer. Journal of intensive care medicine, 32(2), 99–115. https://doi.org/10.1177/0885066615619582

Pinto VL, Tadi P, Adeyinka A (2021). Increased Intracranial Pressure. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482119/

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