Brain tumors and central nervous system (CNS) infections both harm the brain in two ways: local damage (focal deficits, seizures) and increased intracranial pressure from mass effect, edema, or blocked CSF flow.

Brain tumors

• Primary tumors arise from brain tissue or its coverings; metastatic tumors (most common overall in adults) spread from lung, breast, melanoma, kidney, and colon cancers.
• Even a histologically "benign" tumor can be fatal because the skull cannot expand.
• Tumors cause vasogenic edema (leaky vessels), which responds to corticosteroids.

CNS infections

Brain tumor

• Increased ICP: change in LOC is often the earliest sign; headache (worse in the morning, with coughing or bending), vomiting, papilledema.
• Focal signs by location: frontal (personality change, weakness), temporal (seizures, language), parietal (sensory loss, neglect), occipital (visual loss), cerebellar (ataxia).
• New-onset seizure in an adult requires imaging to rule out a tumor.
• Pituitary tumors: visual field loss, headache, hormonal symptoms.

Meningitis

• Classic triad: fever, headache, neck stiffness — plus altered mental status, photophobia, nausea and vomiting.
• Kernig sign: supine, hip and knee flexed to 90°, then extend the knee → pain and resistance.
• Brudzinski sign: neck flexion → involuntary hip and knee flexion.
• Meningococcal disease: petechial or purpuric rash that does not blanch — can progress to septic shock and disseminated intravascular coagulation.
• Seizures, signs of increased ICP.

Encephalitis: fever, headache, confusion, personality or behavior change, seizures, focal deficits; HSV often affects the temporal lobes (memory, speech, smell hallucinations).

Brain abscess: headache, fever (may be absent), focal deficits, seizures — similar to a tumor.

CSF patterns

Brain tumors

• Glioblastoma standard of care: maximal safe surgical resection, then radiation therapy with concurrent temozolomide, followed by maintenance temozolomide. Tumor-treating fields may be added.
  • Temozolomide: myelosuppression (especially thrombocytopenia and neutropenia) — check CBC before each cycle; nausea (give antiemetic); fatigue; Pneumocystis pneumonia prophylaxis during concurrent radiation; teratogenic — effective contraception required.
• Dexamethasone for vasogenic edema. Monitor hyperglycemia, insomnia, mood changes, GI bleeding (give with food; acid suppression as ordered), infection risk, myopathy; taper — never stop abruptly (adrenal insufficiency).
• Antiseizure medication for clients who have had a seizure (e.g., levetiracetam — mood changes, irritability). Routine prophylaxis is not recommended for clients who have never had a seizure.
• Meningioma: observation, surgery, or radiation. Metastases: surgery, stereotactic radiosurgery, systemic therapy.
• Pituitary adenoma: transsphenoidal surgery (through the nose/sphenoid sinus); prolactinomas are usually treated first with dopamine agonists (cabergoline).
• Acoustic neuroma: observation, microsurgery, or stereotactic radiosurgery.

Bacterial meningitis — do not delay antibiotics

• Give empiric IV antibiotics as soon as possible; obtain blood cultures first only if they do not delay therapy. If CT is needed before LP, give antibiotics before sending the client to CT.
• Typical adult regimen: ceftriaxone (or cefotaxime) + vancomycin, plus ampicillin for Listeria coverage in adults over 50, pregnancy, or immunocompromise. Vancomycin: trough or AUC monitoring, nephrotoxicity, infusion reaction (flushing if infused too fast). Ceftriaxone: allergy (cross-reactivity with penicillin is low); do not mix with calcium-containing IV solutions in neonates.
• Dexamethasone (0.15 mg/kg every 6 hours for 2–4 days) given before or with the first antibiotic dose in suspected pneumococcal meningitis — reduces hearing loss and death. It is not started after antibiotics have already been given — ask the provider if the first dose was missed. Continue only if pneumococcus is confirmed.
• Droplet precautions for suspected bacterial meningitis until meningococcus is excluded or until 24 hours of effective antibiotics.
• Close contacts of meningococcal disease receive chemoprophylaxis (rifampin, ciprofloxacin, or ceftriaxone); ceftriaxone is preferred in pregnancy (avoid rifampin and ciprofloxacin). Rifampin turns body fluids orange and reduces the effect of hormonal contraceptives.

Encephalitis

• IV acyclovir 10 mg/kg every 8 hours — start immediately when HSV encephalitis is suspected; also first-line for VZV encephalitis. Hydrate well and monitor creatinine (crystal nephropathy); adjust dose for kidney function; watch for neurotoxicity (confusion, tremor) in kidney impairment.

Tuberculous meningitis

• Isoniazid, rifampin, pyrazinamide, ethambutol (not vancomycin) for about 2 months, then isoniazid and rifampin for a total of 9–12 months, plus dexamethasone.
  • Isoniazid: hepatotoxicity, peripheral neuropathy (give pyridoxine). Rifampin: hepatotoxicity, orange fluids, many drug interactions. Pyrazinamide: hepatotoxicity, hyperuricemia. Ethambutol: optic neuritis (check vision and color discrimination).

Brain abscess: prolonged IV antibiotics (often 6–8 weeks) plus surgical aspiration or excision; manage ICP and seizures.

Listed in priority order.

1. Airway, breathing, and circulation
   • Decreased LOC or seizures threaten the airway; side-lying, suction ready.
   • Meningococcal sepsis: monitor for shock (hypotension, tachycardia, mottled skin) and bleeding.
2. Immediate treatment of infection
   • Start ordered antibiotics or acyclovir without delay; cultures first only if quick.
   • Initiate droplet precautions for suspected bacterial meningitis until meningococcus is excluded or 24 hours of effective therapy.
3. Monitor neurologic status and ICP
   • LOC, GCS, pupils, motor function, seizures, vital signs.
   • Head of bed 30°, head midline, avoid Valsalva, quiet environment. Do not lower the head of the bed to relieve headache in abscess or tumor — lying flat raises ICP.
4. Seizure precautions — padded rails per policy, suction and oxygen at bedside, antiseizure medications on time.
5. Comfort — dim lights (photophobia), analgesics, antipyretics and cooling for fever (fever raises metabolic demand and ICP).
6. Fluid balance — strict intake and output, sodium levels (SIADH is common in meningitis).
7. After cranial surgery
   • Neuro checks, dressing and drain monitoring, pain control, seizure precautions.
   • Supratentorial surgery: HOB usually 30°; infratentorial surgery: position per surgeon's order (often flat or slightly elevated, side-lying).
8. After transsphenoidal pituitary surgery
   • Diabetes insipidus: monitor hourly urine output and urine specific gravity — report large volumes of dilute urine (specific gravity below about 1.005) and rising serum sodium; desmopressin as ordered.
   • Watch for CSF leak: clear nasal drainage or "postnasal drip," test for glucose; report.
   • No nose blowing, sneezing through the nose, coughing, bending over, or drinking through straws; nasal packing care; mouth care without brushing near the incision per protocol.
   • Monitor for adrenal insufficiency; steroid replacement as ordered.

• Take dexamethasone with food, check glucose as instructed, and never stop it suddenly.
• Temozolomide: take the same way each day (an empty stomach or bedtime dosing may reduce nausea) with the antiemetic; swallow capsules whole — do not open or chew them; caregivers wear gloves when handling; report fever, bleeding, or bruising; use contraception.
• Seizure safety and driving restrictions per local rules.
• Meningococcal and pneumococcal vaccination as recommended; Hib vaccination for children.
• Family members and close contacts of meningococcal cases: take prophylaxis as prescribed.
• Rehabilitation and support services for cognitive, speech, or motor deficits; palliative care discussions for high-grade tumors.
• After transsphenoidal surgery: avoid nose blowing and straining for the period advised; report excessive thirst and urination, clear nasal drainage, or fever.

• Earliest sign of increased ICP from a tumor: change in LOC.
• Glioblastoma: maximal resection → radiation + concurrent temozolomide.
• Dexamethasone treats vasogenic edema from tumors; monitor glucose; taper.
• Pituitary adenoma → bitemporal hemianopia; after transsphenoidal surgery watch for DI (hourly urine output, specific gravity) and CSF leak; no nose blowing.
• Acoustic neuroma → progressive unilateral hearing loss and tinnitus.
• Meningitis: fever, headache, neck stiffness; Kernig (hip and knee 90°, extend knee) and Brudzinski signs.
• Bacterial meningitis: antibiotics without delay — cultures first only if no delay; dexamethasone before or with first dose.
• Droplet precautions for suspected meningococcal disease until 24 hours of therapy; prophylaxis for close contacts.
• HSV and VZV encephalitis → IV acyclovir; hydrate, monitor creatinine.
• TB meningitis: isoniazid, rifampin, pyrazinamide, ethambutol + dexamethasone — vancomycin is not a TB drug.
• Brain abscess: HOB elevated — never lower the head to ease headache.