8.4 Oncologic Emergencies, Symptom Management & Palliative Priorities

Caring for a patient with a neuro-oncologic diagnosis extends far beyond the administration of surgery, radiation, or chemotherapy. The morbidity associated with the tumor itself, as well as the iatrogenic effects of treatments, creates a complex web of symptom management challenges. The neuroscience nurse is central to identifying oncologic emergencies, managing debilitating symptoms, and facilitating difficult conversations regarding goals of care.

Vasogenic Edema and Elevated ICP

Brain tumors disrupt the blood-brain barrier, leading to the leakage of plasma fluid into the extracellular space of the brain parenchyma. This is known as vasogenic edema. Unlike cytotoxic edema (seen in acute stroke), vasogenic edema responds robustly to corticosteroids.

Corticosteroid Management

Dexamethasone (Decadron) is the undisputed corticosteroid of choice in neuro-oncology. It is preferred because it has potent glucocorticoid effects (reducing inflammation and edema) with very little mineralocorticoid effect (minimizing fluid retention compared to other steroids). It also has a long half-life.

While highly effective at reducing ICP and rapidly improving neurological symptoms, chronic dexamethasone use induces a severe side effect profile that requires proactive nursing management:

• Hyperglycemia: Often requires insulin therapy, even in non-diabetics.
• Steroid Myopathy: Proximal muscle weakness (especially in the quadriceps), making standing and walking difficult. Physical therapy and rapid weaning of steroids when possible are essential.
• Immunosuppression: Increased risk of opportunistic infections (e.g., oral candidiasis, Pneumocystis pneumonia if prolonged).
• Gastrointestinal Ulceration: Prophylaxis with proton pump inhibitors (PPIs) or H2 blockers is standard practice.
• Psychiatric Effects: Insomnia, agitation, euphoria, or steroid-induced psychosis.
• Cushingoid Appearance: Moon facies, central obesity, and striae.

Tumor-Related Epilepsy (TRE)

Seizures are a very common complication, presenting in up to 80% of patients with low-grade gliomas and frequently in those with metastases (especially melanoma) or meningiomas. Seizures can be the initial presenting symptom or a sign of tumor progression.

Management of TRE

Prophylactic antiepileptic drugs (AEDs) are generally not recommended for patients who have never had a seizure, except in the immediate perioperative period. However, once a seizure occurs, lifelong AED therapy is usually indicated.

• Levetiracetam (Keppra) is often the first-line agent. It is favored because it does not induce or inhibit hepatic cytochrome P450 enzymes. This is crucial because many chemotherapeutic agents (and corticosteroids) are metabolized by the liver, and avoiding drug-drug interactions is paramount.
• Other Agents: Lacosamide or valproic acid may be used. Enzyme-inducing AEDs (like phenytoin or carbamazepine) are generally avoided if possible due to their interactions with systemic therapies.

Nursing care involves standard seizure precautions, educating the family on seizure first aid, and strict adherence to medication schedules.

Venous Thromboembolism (VTE)

Patients with malignant brain tumors (particularly glioblastoma) exist in a hypercoagulable state due to the release of tissue factor by the tumor cells, combined with immobility from neurological deficits. They are at an extraordinarily high risk for Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE).

Management Challenges

Managing VTE in this population presents a clinical conundrum: the patient has a high risk of clotting, but also a high risk of devastating intracranial hemorrhage if anticoagulated, given the vascular nature of brain tumors.

• Prophylaxis: Mechanical prophylaxis (SCDs) is mandatory. Pharmacological prophylaxis (low molecular weight heparin) is generally safe and recommended post-operatively once hemostasis is confirmed.
• Treatment: If a DVT or PE occurs, therapeutic anticoagulation is typically initiated with careful monitoring. Novel oral anticoagulants (NOACs) or enoxaparin are often used. The nurse must relentlessly monitor for signs of intracranial bleeding (acute worsening of headache, lethargy, new focal deficits).

Hydrocephalus

Tumors located in the posterior fossa (e.g., medulloblastomas, large acoustic neuromas) or near the ventricular system can obstruct the flow of cerebrospinal fluid (CSF), leading to obstructive (non-communicating) hydrocephalus.

Symptoms include severe morning headaches, forceful vomiting, lethargy, and upward gaze palsy (Parinaud syndrome). Emergent management may require the placement of an External Ventricular Drain (EVD) or definitively, a Ventriculoperitoneal (VP) shunt to divert the CSF.

Palliative Care and Goals of Care

Given the historically poor prognosis associated with high-grade gliomas and advanced metastatic disease, palliative care should be integrated early in the disease trajectory, alongside active treatment.

Palliative care is not synonymous with hospice; it is specialized medical care focused on providing relief from the symptoms and stress of a serious illness.

• Symptom Management: Addressing intractable pain, nausea, fatigue, and depression.
• Advance Care Planning: Facilitating conversations about the patient's values, preferences for end-of-life care, and establishing advance directives and healthcare proxies while the patient still possesses cognitive capacity.
• Psychosocial Support: Supporting the immense caregiver burden, as family members often witness profound personality and cognitive changes in their loved one.

The neuroscience nurse acts as an advocate, ensuring that the patient's goals of care dictate the treatment plan, prioritizing dignity and quality of life.