Sunday, March 21, 2010
10:15–11:05 am
(301) Journey to the Center of the Brain: Exploring Adult Intraventricular Tumors
Deanna Glass-Macenka, RN BSN CNRN
Although quite rare and very often histologically benign, intraventricular tumors require complex management skills. A wide range of tumor types can arise from within the ventricles. The location of these tumors within the ventricles can potentially cause disruption in normal cerebral spinal fluid circulation (CSF) leading to obstructive hydrocephalus and increased intracranial pressure. The deep location of intraventricular tumors poses a unique challenge for removal. Careful surgical planning and meticulous peri-operative care can provide for optimal patient outcomes. The goal of this session will be to provide an overview of adult intraventricular tumors and histological sub-types. Case studies will be used to discuss presenting signs and symptoms, radiographic characteristics, surgical approaches, and patient management.
(302) Cerebral Hyperperfusion Syndrome After Carotid Endarterectomy
Jonathan Jehle, BSN
Carotid artery stenosis (CAS) is an intravascular narrowing caused by plaque formation, reducing bloodflow in one or both carotid arteries. CAS is a significant risk factor for acute ischemic stroke (AIS), due to cerebral hypoperfusion. Plaque removal via carotid endarterectomy (CEA) can re-establish bloodflow to brain tissue, decreasing the risk for AIS. A potential risk factor from CEA is cerebral hyperperfusion syndrome (CHS). CHS results from an increase in cerebral blood flow after plaque removal in the affected artery. CHS can present as headache, seizure, or focal neurological changes. CHS, although rare, can lead to life threatening side effects such as cerebral edema, or intracerebral hemorrhage. Utilizing a case study approach, we will describe the effects of CHS in a patient who had a CEA, as well as the nursing interventions utilized in the care of this critically ill patient.
(303) Innovative CSF Biomarkers and Evidence-Based Therapy for Opsoclonus-Myoclonus Syndrome
Elizabeth Tate, C-FNP MN
The purpose was to evaluate the role of state-of-the-art cerebrospinal fluid (CSF) biomarkers in the evaluation and treatment of opsoclonus-myoclonus syndrome (OMS), an autoimmune neurological disorder afflicting children with neuroblastoma. Removal of the tumor is insufficient to reverse OMS, which acutely consists of opsoclonus, action myoclonus, gait ataxia, irritability, sleep disturbance, and, later, ADHD and cognitive impairment. B cells permeate the CSF space and brain, resulting in inflammation and autoantibody production. CSF B and T cell biomarkers correlate with OMS severity, and relate to disease duration. Anti-B cell therapy with rituximab ablates the B cell response in blood and in CSF. In conjunction with immunosuppressive and immunomodulatory therapy, the clinical response is excellent, improving on conventional agents alone (see video clips). B cells repopulate in the peripheral blood over 12-18 months, but stay within normal limits in the CSF. Anti-B cell therapy affords a new therapeutic avenue to neuroscience nurses.
11:15 am–12:05 pm
(305) Long-Term Effects of Childhood Brain Tumors: Multiple Treatment Sequelae in a Single Case Study
Jean Arzbaecher, RN MS APN
Brain tumors are the most common solid tumors of childhood. Therapy for children with central nervous system tumors often includes surgical resection and a combination of radiation and chemotherapy. With advances in treatment resulting in improved overall survival, long term complications are common. This presentation will identify potential long term complications in treated childhood brain tumors. Discussion of a 44 year old female with multiple treatment sequelae from an ependymoma at age 8 will illustrate many potential long term complications including secondary malignancies, neurovascular disorders, growth retardation and developmental delay.
(306) Now or Later? The Hemicraniectomy Debate
Carey Heck, RN MSN ACNP CCRN CNRN
Patients with large MCA strokes or severe traumatic brain injury are at increased risk for massive cerebral edema causing intractable intracranial hypertension. Successful outcomes for these patients are a challenge despite maximal medical and surgical interventions. The use of decompressive hemicraniectomy may provide an opportunity to improve these outcomes. This potentially life saving intervention however, is not the current standard of care in the neurosurgical community and controversy abounds over its impact on patient outcomes. This presentation will identify patient populations which may benefit from this intervention and the pros and cons of the procedure will be discussed. Current research findings and emerging clinical guidelines will be reviewed which will facilitate the neuroscience nurse's ability to advocate best practices at the bedside. Case studies will highlight the importance of interdisciplinary collaboration and the role of the bedside neuroscience nurse in this process.
(307) Dude, Sweet Synapse! An Inside Look at the Teenage Brain
Holly Watson-Evans, RN MS
Excitability, angst, randomness and risk-taking. It's all a part of being a teenager. Long dreaded by parents and educators, the teenage years are actually a critical time during brain development. Recent scientific findings have revealed that the teenage brain is truly a "work in progress" during the teen years. In fact, growth and development extend well into the 20's. Brain structure evolves and physiologic functions emerge amidst a flush of hormones and newly "wired" synapses to create the unique adults each of us becomes. Understanding the changing structure and three major development processes within the teenage brain (proliferation, pruning and myelinization) will make many of us smile, nod our heads and say, "Oh—THAT's why." Behind each eye-rolling teenager whose favorite expressions include "Dude," "Emo," "Sick," and "Whatever," is an amazing person who will one day grow with hopes to change the world.
1:30–2:20 pm
(308) Skull-Base Meningiomas: Malignant by Location
Marylyn Kajs-Wyllie, RN MSN CCRN CNRN
Skull base meningiomas constitute 30-40% of brain meningiomas. These slow growing, benign tumors present with minimal mild symptoms even when they are large. Left untreated, they grow and cause symptomatic deterioration. The petroclival region is located in the skull base; petroclival/clival tumors are especially rare and are among one of the most difficult tumors for which to obtain surgical cure. Cautious subtotal resection has become the preferred treatment because of the tumor's close proximity to the cranial nerves, vertebrobasilar arterial system and brainstem; follow up with stereotactic radiosurgery is done to prevent tumor progression. New cranial nerve deficits constitute the main post operative complication, and are a challenge for recovery. A case study of a woman with a clival meninigoma who underwent subtotal resection and suffered disabling cranial nerve involvement will be presented. The nurse's role in the interdisciplinary approach to care for these post op challenges will be discussed.
(309) Critical Illness Neuropathy: a Multidisciplinary Approach
Jennifer Woods, MSN CCNS CNRN
Critical Illness Neuropathy (CIN) was clinically defined in the 1980's. There is a growing body of literature to support its existence in conjunction with Systemic Inflammatory Response Syndrome (SIRS) and Multiple Organ Dysfunction (MOD). In many instances, the neurological complications of these processes are unidentified because examination of the neuromuscular system is difficult in this patient population; therefore, the incidence of CIN is felt to be much higher than studies report. The pathogenesis of CIN is complex and diagnosis requires thorough neuromuscular examination, electrodiagnostic testing, and muscle biopsy. Those patients, who develop CIN and survive their illness, face many months of rehabilitation. Currently, treatment of CIN is supportive; however, a multidisciplinary approach is crucial to identifying and modifying risk factors in the critically ill patient in addition to implementing treatment modalities including ongoing neuromuscular examination, limiting neuromyopathic drug use, tight glycemic control, and early mobilization.
(310) Developing a CPG for New Onset Acute Nonfebrile Seizure in Pediatrics
Lisa Duffy, PhD CPNP-PC CNRN
Children who present with new seizures often undergo extensive diagnostic procedures and often require hospitalization for management of their condition. Currently, because there are no standard guidelines, treatment regimens vary between institutions. Unnecessary tests and procedures may result in emotional and financial burdens for the family who is already experiencing the stress associated with an unplanned hospitalization. The nurse/nurse practitioner has a vital role in facilitating the coping of the child and family in this situation by providing education to both the family and healthcare team about best practice when caring for a child with a new seizure diagnosis. After an evidence based review of the literature, a clinical practice guideline (CPG) for the management of a new onset afebrile seizure in a pediatric patient was developed. The purpose of this presentation will be to discuss the development and implementation of the CPG in a large metropolitan teaching hospital.
(311) Vasospasm in the Subarachnoid Hemorrhage Patient
Dawn Tymianski, ANP
Approximately 200 subarachnoid hemorrhage (SAH) patients are admitted to a quaternary teaching Canadian neurosurgical center. Although outcomes vary, a proportion of SAH patients develop vasospasm, (VSP) which can cause cerebral infarction, neurological deficits or death. Nursing understanding and assessment of patient risks, symptoms and initial management may play a key role in limiting VSP sequelae. A patient quality initiative was undertaken. All intensive care unit SAH patients were assigned a ‘VSP Risk Card' by the Nurse. 8" x 11", coloured red (high risk), yellow (moderate) and green (low) each patient's risk was assessed per shift and assigned the appropriate coloured card, with a ‘red card' indicating high risk. Each card included signs and symptoms and a hospital developed protocol for urgent VSP care and management. Developed and implemented by nursing, the goal is to alert the nurse that any neurological change could suggest VSP, warranting earlier intervention.
2:50–3:40 pm
(312) Advances in Operative Technology: Treating the Brain Tumor Patient
Marilynn Maida, RN MSN APN CNRN
Advances in technology have made the operative experience more precise and safer for the brain tumor patient. Pre-operative Magnetoencephalography (MEG) as well as intra-operative MRI provide pertinent anatomical and functional details for the neurosurgeon. Eloquent areas of the brain are mapped with these technologies. Utilization of these technologies results in decreased complications and improved patient outcomes. MEG will be discussed and specific brain mapping will be shown with respect to different tumor locations. Full details of Intra-operative MRI will be discussed. Novel intra-operative angiogram techniques will be reviewed. Patient cases will be presented to illustrate key aspects.
(313) Brain Death: Myths and Methods
Mary Guanci, MS RN CNRN
The concept of brain death has come under scrutiny leading those who are involved in the care of these patients to question our current criteria and practices. Variability in hospital guidelines throughout the country contribute to questions about the accuracy of diagnosis. Debate surrounding whole brain death versus the brain stem death present a challenge to those caring for patients with devastating brain injury,especially stroke. The brain death diagnosis has ethical and legal implications that influence care. Brain death organ donation has come under attack from those who continue to question the validity of testing. Families continue to struggle with the finality of the diagnosis when looking at a loved one who is warm and has a beating heart. The nurse who guides the family must understand the accepted criteria, the evidence that drives it and the controversies that may impede it's acceptance as a practice standard.
(314) Pediatric Multiple Sclerosis: Caring for a Growing Population
Jennifer Boyd, RN MHSc MSCN
Although the onset of Multiple Sclerosis (MS) usually occurs in young adulthood, approximately 5% of people with MS are diagnosed before age 18. The number of children and adolescents presenting with MS appears to be growing and increasingly, nurses are caring for this patient population. This presentation will provide an overview of pediatric MS including symptoms, diagnosis and treatment. The issues and challenges specific to children and adolescents with MS and their families and the nursing care involved with respect to education, support and advocacy will be highlighted. Case examples will help illustrate the needs and care of these patients. Theories behind the apparent increase in pediatric MS will also be discussed.
(315) Sugar and Stroke: the IRIS Trial
Mary Amatangelo, RN MS ACNP-BC CCRN
Despite current treatments, 27% of patients with a recent ischemic stroke will have a recurrent stroke or myocardial infarction within 4 years. The greatest impact on stroke as a public health issue is via preventive measures. However, current preventive measures are insufficient. For the most part, by the time risk factors are identified, the damage is done. The Insulin Resistance Intervention after Stroke (IRIS) trial is a randomized secondary stroke prevention trial evaluating the effectiveness of pioglitazone (Actos®) and best preventive care, compared with optimal routine prevention strategies, for the prevention of recurrent stroke and myocardial infarction among non-diabetic men and women with a recent ischemic stroke or TIA and insulin resistance. IRIS is one of the largest trials ever funded by the National Institutes of Neurological Disorders and Stroke. Identifying patients with insulin resistance, before diabetic vascular damage has accumulated, may be our window to future stroke prevention.