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Brain Tumors and Treatment: NeuroSurgery and SLP Collabora=on Sept 16, 2011 KSHA Annual Conven=on Jamie L Johnson, MA CCC-‐SLP
Objec=ves:
• Describe common tumor types and treatment • Describe the role of the SLP in evalua=on and treatment of brain tumors
Structures of the Brain • Cerebrum – Largest area of the brain – Divided into 2 hemispheres – Outer layer: Cerbral Cortex: Gray MaQer • Nerve cells control brain ac=vity
– Inner por=on is White MaQer • Myelinated nerve cell axons carry info between brain and SC. • Oligodendrocytes and Astrocytes are support cells that help maintain myelin covering of axons and cell bodies.
– Basal Ganglia • Areas of Gray MaQer Deep within the brain
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The Four Lobes: Frontal Lobe • Voluntary Muscle Control opposite side of the body. • Dominant hemisphere SPEECH and WRITING. • Intellectual func=oning, thought processing, behavior and memory. • Execu=ve Func=ons.
Temporal Lobe • Understanding sounds, spoken words, • Emo=on • Memory
Parietal Lobe • • • •
Reasoning Memory Hearing Receives and interprets sensa=on • • • • • • •
Pain Temperature Touch Pressure Size Shape Body Awareness
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Occipital Lobe • Understanding of visual images
• Understanding wriQen words
Cerebellum • Second Largest area of the brain • Consists of 2 hemispheres/halves connected by vermis • Connects to brain stem • Works in coordina=on with THALAMUS and CEREBRUM to achieve skilled muscle coordina=on
Other Specialized Nerve Structures in the Brain: • Ventricles and Choroid Plexus: • Inside each Ventricle CHOROID PLEXUS – Forms Spinal Fluid
• Ventricles: 4 connected cavi=es – 2 Lateral Ventricles, 1 in each hemisphere – 3rd Ventricle beneath CORPUS COLLOSUM and surrounded by THALAMUS – 4th Ventricle between Hemispheres of CEREBELLUM, expansion of MEDULLA OBLONGATA
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Other Specialized Nerve Structures in the Brain: • HYPOTHALAMUS – Wall of the 3rd Ventricle and is the base of the Op=c Chiasm. – Controls emo=ons, water balance, sleep, temperature, appe=te, and blood pressure. – Coordinates paQerns of ac=vity – Control center for PITUITARY GLAND
Other Specialized Nerve Structures in the Brain: • Thalamus – Surrounds the 3rd Ventricle – Monitors input from the senses – Acts a relay sta=on for sensory center of cerebrum
Other Specialized Nerve Structures in the Brain: • Limbic System – Coordinates complex ac=vi=es – Works with Hypothalamus to • Control Hunger • Thirst • Emo=onal reac=ons
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Brain Stem • Pons Re=cular Forma=on – Core of Brain Stem – Connects with all parts of brain and Brain Stem – Controls consciousness, ea=ng, sleeping paQerns, drowsiness and aQen=on.
• Medulla Oblongata Midbrain – Between Pons and Cerebral Hemispheres – Relay center for sight and hearing
12 Pairs of Cranial Nerves • • • • • • • • • • • •
I Olfactory II Op=c III Oculomotor IV Trochlear V Trigeminal VI Abducent VII Facial VIII Ves=bulocochlear IX Glossopharyngeal X Vagus XI Accessory XII Hypoglossal
Posterior Fossa • Houses Cerebellum and Brain Stem • Tentorium separates it from Cerebral Hemispheres – Flap membrane, part of meninges
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Supratentorium • Area above Tentorium • Contains cerebral hemispheres and other brain structures
Pineal Body • Lies below Corpus Collosum – Produces Hormone Melatonin
Sellar Region • Area around Sella Turcica – Hollow of skull bone that contains Pituitary Gland – Pituitary Gland: • AQached to and receives messages from Hypothalamus. • Secretes Important hormones.
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Symptoms listed by Tumor Loca=on • Symptoms – Pa=ent reports to MD • Sensa=ons, feelings, descrip=ons
• Signs – MD Observes, directly or as a result of tests
Brain Stem Tumors
(Midbrain, Pons, Medulla Oblongata) • • • • • • • • • • • •
Vomi=ng Clumsy, uncoordinated gait Facial assymetry Dysphagia Dysarthria Vision changes or decreased vision HA aeer waking Head =lt Drowsiness Hearing loss Hemiparesis Personality changes
Acous=c Nerve Tumors Cerebellopon=ne Angle • Ringing or Buzzing in ears • Ver=go • Deafness
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Cerebral Tumors Frontal Lobe • • • • • •
Seizures Hemiplegia Ataxia Memory changes Impaired Judgment Personality changes
• Base of Frontal lobe: – loss of smell, impaired vision
Cerebral Tumors Temporal Lobe • Seizures • Language Disorders
Cerebral Tumors Parietal Lobe
• • • •
Seizures Speech Changes Agraphia Spa=al Disorders
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Cerebral Tumors Occipital Lobe • Seizures • Blindness
Subcor=cal Tumors • Hemiparesis • Thalamus – Sense of Touch
Posterior Fossa Tumors • Headache • n/v • Swollen Op=c Nerve due to increased Intracranial pressure • Ataxia • Tremors • Speech incoordina=on • Nerve irrita=on may cause pain in back of head
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Brainstem Gliomas: 59% presented with CN Involvement • CN III-‐IV • CN V-‐VII
• CN VII • CN V
Oculomotor-‐Trochlear 10.9% Trigeminal, Abducens, Facial and Accous=c 51.5% Facial 25% Trigeminal 22%
Metasta=c Brain Tumors • Depend on loca=on of tumor – Headache, n/v, due to swelling
Brain Tumors Frequently Encountered by Speech-‐Language Pathologists: A Review and Tutorial • Primary Gliomas – Astrocytomas-‐most common 50% – Pilocy=c Astrocytomas-‐most common pediatric – Ependymomas – Oligodendrogliomas
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CNS Neoplasms • • • • •
Acous=c Neuromas Lymphoma Medulloblastoma Meningiomas Metasta=c Tumors – Lung, Breast, Kidney, Colon Cancers and Melanoma
Most Common Deficits • Cogni=ve Deficits
80%
– Visiospa=al and Sensory Deficits
• Cranial Nerve Palsies • Dysarthria, Dysphagia or Aphasia • Dysphagia:
33% 25%
2/3 AdmiQed to Rehab Unit
Brainstem Gliomas: 59% presented with CN Involvement • CN III-‐IV • CN V-‐VII
• CN VII • CN V
Oculomotor-‐Trochlear 10.9% Trigeminal, Abducens, Facial and Accous=c 51.5% Facial 25% Trigeminal 22%
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Rehabilita=on: Augmen=ng the Quality of Life • Achieve Similar Levels of Func=onal Progress compared to TBI and Stroke pa=ents • Extensive Plas=city of Neural System, tailored rehabilita=on programs following resec=on habe the poten=al to induce cor=cal reorganiza=on and maximize outcomes.
ASHA Scope of Prac=ce • Voice
• Fluency
– Phona=on quality – Pitch – Loudness – Respira=on
– StuQering – CluQering
Speech-‐Language Pathology Scope of Prac=ce • Speech Produc=on – Ar=cula=on – Apraxia – Dysarthria – Ataxia – Dyskinesia
• Resonance – Hypernasality – Hyponasality – Cul –de-‐sac resonance – Mixed resonance
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ASHA Scope of Prac=ce • Language – Phonology – Morphology – Syntax – Seman=cs – Pragma=cs – Literacy
• Auditory Comprehension • Verbal Expression • Reading • Wri=ng
ASHA Scope of Prac=ce • Cogni=on
• Swallowing
– AQen=on – Memory – Sequencing – Problem Solving – Execu=ve Func=oning
– Oral, Pharyngeal Esophageal – Orofacial Myology – Oral-‐motor Func=ons
Dysphagia • Dysphagia Outcomes in Pa=ents with Brain Tumors Undergoing Inpa=ent Rehabilita=on, Dysphagia, 18: 203-‐210.
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ASHA Roles of Speech-‐Language Pathologists • • • • • • • •
Iden=fica=on Assessment Interven=on Counseling Collabora=on Case Management Educa=on Preven=on
Evidence Based Prac=ce Map • www.ncepmaps.org/TBI-‐Adults-‐Flowchart.php
Trauma&c Brain Injury (Adults)
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Pre and Post Opera=ve Role
Intra-‐Opera=ve Role Goal: To preserve speech and language, while achieving maximum tumor resec=on.
Pre-‐opera=ve • Phone Call – Conversa=on – Dentures – Glasses/Contacts
• Formalized Evalua=on – BDAE
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Medica=ons • Fentenyl – Pain Reliever
• Propofol – Short ac=ng Benzo oeen giving amnesia to event
• Versed – Anesthe=c
• Dilan=n – Levels checked during procedure
Different Disciplines Involved: • • • • • •
NeuroSurgery Anesthesiology Nursing Neurology EEG Tech SLP
Intra-‐opera=ve • Localiza=on/Mapping – “This is a___________.”
• Resec=on – Verbal Expression-‐Naming, Auditory Comprehension, Apraxia, Assymetry
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Intra Opera=ve Language Evalua=on • Naming Tasks – LARK Cards – Por=ons of BDAE
• Automa=c, Structured and Conversa=onal speech Tasks • Reading Tasks
Post-‐Opera=ve Language Mapping • Re-‐evalua=on • Considera=ons: – Edema – Inpa=ent, Outpa=ent or Home Therapy
End Of Life Considera=ons
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Collabora=on????
Resources and References • • • • • • • • • • • •
American Brain Tumor Associa=on. (2004). A Primer of Brain Tumors, A Pa9ent’s Reference Manual. (8th ed). www.abta.org American Cancer Society. (2008). Cancer facts and figures. www.cancer.org Na=onal Brain Tumor Founda=on www.braintumor.org American Speech and Hearing Associa=on www.asha.org Abou-‐Khalil, R. and Abou-‐Khalil, B. 2003. Cor=cal S=mula=on Mapping and Speech Produc=on Perspec9ve on Neurophysiology and Neurogenic Speech and Language Disorders. 13. 10-‐15. Cherney, L. (2003).Cor=cal S=mula=on and Aphasia: The State of the Science. Perspec9ve on Neurophysiology and Neurogenic Speech and Language Disorders. 18. 33-‐39. Mayer, J. (2008). Brain Tumors Frequently Encountered by Speech-‐Language Pathologists: A Review and Tutorial. Perspec9ve on Neurophysiology and Neurogenic Speech and Language Disorders. 18. 129-‐135. Leestma. (1980). Brain Tumors. American Journal of Pathology. 100. No 1. 248-‐316. Lesser, R.P. (1986). Electrical S=mula=on of Wernicke’s Area Interferes with Comprehension. Neurology. 36, 658-‐663. Oberndorfer, et al. (2008). The End of Life Hospital Serng in Pa=ents with Glioblastoma. Journal of Pallia9ve Medicine. 11, No 1. 26-‐30. Ojemann, G. (1979). Individual Variability in Cor=cal Localiza=on of Language. Journal of Neurosurgery, 50, 164-‐169. Wesling, et al. (2003. Dysphagia Outcomes in Pa=ents with Brain Tumors Undergoing Inpa=ent Rehabilita=on. Dysphagia. 18. 203-‐210.
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