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Category Archives: Neurosurgery/Neurology

Effects of long-term Diabetes & newer Therapies for Diabetes Control

Dr Tejal Lathia

India is home to over 50 million adults with Diabetes and this number is likely to increase to over 120 million by 2040. Diabetes Mellitus is characterized by high blood sugar levels. Exposure to high blood sugar leads to weakness, weight loss, increased thirst and frequent urination. The long term complications include damage to eyes, Heart, Kidneys and Nerves resulting in loss of vision, Heart failure, Kidney failure and often, amputation.

There are two main types of Diabetes Mellitus – Type 1 and Type 2. Type 1 Diabetes Mellitus predominantly occurs in children and adolescents, and is characterized by complete deficiency of Insulin (a hormone required to keep blood sugar levels normal) in the body. Such patients are completely dependent on Insulin injections for their survival.

Type 2 Diabetes Mellitus results primarily from an imbalance in the demand and supply of Insulin. Though insulin is present in the body, it is not sufficient to control the blood sugars. However, newer research has caused a paradigm shift in the way we look at Diabetes. Not only insulin but other hormones like Glucagon, GLP-1 play a part in Diabetes. The way the Kidneys handle blood sugar is also of importance. These myriad defects have resulted in the coinage of the term – ‘Ominous Octet’.  Identifying these novel defects has been helpful in the sense that we now have medicines to tackle these individual defects opening up a new era in the treatment of diabetes.

Case study:

A 56 year old gentleman, presented to our hospital for a routine health check-up. He has been diagnosed with Diabetes Mellitus 5yrs ago, for which he has been on medications. Recently, he was also diagnosed with Hypertension. His fasting blood sugar was 150 mg/dl and post-meal blood sugar was 200 mg/dl, which is satisfactory to the patient.

However, on evaluating for complications, it was found that there are changes in his eyes because of Diabetes, which threatens his vision, though he has no symptoms. The nerves of his feet are damaged with reduced perception of pain and temperature. His Serum Creatinine (measure of his Kidney function) is abnormally elevated; this leaves the patient shocked.

Diabetes Mellitus unfortunately is a silent killer. There are no symptoms of the damage it is doing to the body, before it is too late. And once the damage is done, it is irreparable. A common misconception is that if the blood sugar level is below 200 mg/dl, you are safe. A normal person’s fasting blood sugar is below 100 mg/dl and after-meal sugar is less than 140 mg/dl. Any increase in the blood sugar values above this leads to damage of vital organs.

Medications like DPPIV inhibitors, SGLT2 inhibitors, GLP-1 agonists as well as newer insulin co-formulations are the key to the future of Diabetes management. Newer rapid acting and ultra-long acting insulins have further strengthened our armamentarium against Diabetes.

There is no substitute for lifestyle modifications though – regular aerobic exercise like walking, cycling, swimming (at least 150 mins per week) and a diet which eschews refined carbohydrates and excess oil is mandatory. These lifestyle changes need to be followed throughout life. Early diagnosis and aggressive treatment of the disease with medications, is imperative to avoid complications and improve quality of life of a Diabetic.

Is a Consultant Endocrinologist, Hiranandani Hospital, Vashi

 

Why are Youth these-Days More Susceptible to Heart Disease

Dr Zakia Khan

Deaths caused due to heart disease are usually attributed to the adult population. What is less known is that young adults are not spared of this main cause of death worldwide. The Coronary Artery Risk Development in Young Adults (CARDIA) conducted a study to find the reasons for youth being susceptible to heart diseases and what are the reasons that put them to this risk. Around 5,000 young adults from the age of 18-30Yrs were a part of this study and were monitored for up to 15 years to learn about what resulted into them acquiring heart diseases. Every man in the 3rd and 4th decade is affected by this disease. It is noted that the youth who smoke up to 10 cigarettes a day are likely to develop heart diseases by 50%. A rise in cholesterol levels can irk heart rates and the risk increases by 50%; rise in blood pressure levels increase the risk rate to up to 30%.

The increase in heart disease in younger adults are caused due to habits of smoking, stress(work and non-work related), unhealthy diet, lack of sufficient physical activity and excess consumption of salt and packaged food in some cases. To curb these issues, we need to first understand how to minimise these triggers. Parents should help their child to maintain healthy diet and motivate them to excise on a regular basis, so that they can control high blood pressure issues, since it is quiet common among who are overweight. They also need to help them maintain their salt intake. Warn them about the dangers about smoking and the effects nicotine has on the blood vessels, causing the blood vessels to narrow down and make it harder for the blood to flow through the vessels. If after many efforts of controlling the diet and increasing the child’s physical activity it still doesn’t lower their blood pressure, a physician should be consulted to seek immediate intervention.

The numbers are not going to decrease unless drastic steps are taken. The problem is that we are leading a very sedentary lifestyle that doesn’t allow us much physical activity. Today’s youth is stressed out mentally as well as physically. A major solution to this is drastic lifestyle modification that will help prevent premature heart attacks. Thrive on healthy food instead of relying on junk food, this is simple to adopt and very effective. Despite having a busy schedule, try and make time to organise, prioritise and balance your lifestyle. Take up either yoga or dance or any other form of exercise that is therapeutic and helps in keeping you physically and mentally healthy.

Is a Interventional Cardiologist, Fortis Hospital, Kalyan

Brain Stroke Increasing At An Alarming Rate

Dr. Rahul Gupta

With approximately 1.5 million new cases reported every year, stroke is becoming an important cause of premature death and disability in India. Stroke in India is increasing at an alarming rate, especially among youth. The main cause for this increase includes stress levels, poor diet and a sedentary lifestyle. If left untreated, it can cause irrepressible damage to brain cells, impeding motor and speech skills.

A stroke attack can happen to anyone and across all age groups, social strata and gender. It is alarming to see the increase in stroke cases and the age bracket for stroke decrease, as almost12% of stroke patients are under the age of 40 years. Those suffering from high blood pressure, diabetes, high blood cholesterol and intake of oral contraceptives are especially at risk. It is important to stress the importance of awareness programs to stress the fact that stroke is treatable and preventable.

A stroke occurs when the blood supply to the brain is cut short due to a clot, known asischemic strokeor rupture of the blood vessels, known as hemorrhagic stroke. While 87% of strokes are ischemic by nature, a majority of them can be treated. It is important to identify the symptoms of this attack, such as – changes in Face, Arms, Speech and Time (FAST). Uneven face like drooping of the mouth, one arm hanging down and slurred speech are some of the common symptoms of a stroke and timely treatment can help them prevent the same from occurring.

When medical treatment is delayed, millions of neurons are damaged and higher functions of the brain are affected. Therefore, it becomes critical to provide the patient with timely medical assistance as stroke requires a prompt multidisciplinary treatment.

Over 20 million people suffer from stroke, out of which five million die and another five million are disabled. According to The National Center for Biotechnology Information (NCBI), stroke is one of the most common cause of mortality after coronary artery disease. Also, it is a common cause of chronic adult disability. The lifetime risk of stroke after 55 years of age is 1 in 5 for women and 1 in 6 for men.

The following 10  things may help one to prevent/avoid stroke:

  • Lower blood pressure-Your goal: Maintain a blood pressure of less than 120 (top number) over less than 80 (bottom number).
  • Lose weight- Keep your body mass index (BMI) at 25 or less.Try to eat no more than 1,500 to 2,000 calories a day (depending on your activity level and your current body mass index).
  • Exercise more- Exercise at a moderate intensity at least five days a week.
  • Drink alcohol in moderation
  • Treat atrial fibrillation- If you have symptoms such as heart palpitations or shortness of breath, see your doctor for an exam.
  • Treat diabetes – Keep your blood sugar under control & monitor your blood sugar as directed by your doctor.
  • Quit smoking-Smoking accelerates clot formation in a couple of different ways. It thickens your blood, and it increases the amount of plaque buildup in the arteries.
  • Maintain Healthy BMI and hip to waist ratio.

 Is the man behind the department of Brain and spine surgeon at Fortis Hospital, Noida. He was trained at Nagoya Japan, which has made him an expert in Endovascular procedures.He worked in many government hospitals including PGIMS, Rohtak, PGIMER Chandigarh & Govind Ballabh Pant institute of Postgraduate Medical Education & Research, New Delhi. Dr. Rahul Gupta has performed surgeries on hundreds of patients with head and spine injury. He has treated numerous complex spine ailments like metastatic tumors, osteoporotic fractures (vertebroplasty), degenerative diseases and listhesis.

Trigeminal Neuralgia (TN) : The Suicide Disease

Dr. Rahul Gupta

Trigeminal neuralgia (TN) also known as `suicide disease’ because of the intense electric shock-like burning or stabbing nerve pain along the side of the face, is considered by many to be among the most excruciatingly painful conditions known to mankind that causes a sudden, sharp and stabbing pain to one side of the face. The pain cannot be described in words and yet many sufferers express it by using their imagination as someone giving them an electric shock or blasting a bomb on their face. These can be spontaneous or triggered by things such as touching the face, chewing, speaking and brushing teeth and may last from a few seconds to several minutes. Some patients experience constant aching, burning feeling that’s less severe than the spasm-like pain. The areas of pain are the areas supplied by the trigeminal nerve, including the cheek, jaw, teeth, gums, lips, or less often the eye and forehead. It is a pain affecting one side of the face at a time, though TN may rarely affect both sides of the face, it could be in one spot or spread in a wider pattern. Sometimes the attacks become more frequent and intense over time. Since it is a chronic condition of acute, ‘out of the blue’ episodes of unbearable and agonising pain, countless people, out of sheer frustration have committed suicide before treatments (and cure) were discovered. That is the reason why it is also known as ‘the Suicide Disease’.

“Patients usually go from doctor to doctor in search of a cure. Initially, drugs can control symptoms, but over time they become less effective. So patients continue to suffer episodes of fierce pain and live a miserable life,” he said.

While the nerve disorder has no reason of occurrence in elders, in the middle age groups the disease can have multiple reasons. There are no specific reasons for the disease in elderly, but in middle age group the possible reasons for the disease can be nerve tumor, vascular loop and erosion of nerves.

It happens when the trigeminal nerve is disturbed, compressed or for some reason loses its insulation. In most of the cases the problem is contact between a normal blood vessel and the trigeminal nerve at the base of our brain. This contact puts pressure on the nerve causing excruciating pain. TN can also occur as a result of ageing, or it can be related to multiple sclerosis or a similar disorder that damages the myelin sheath protecting certain nerves. In a few cases, trigeminal neuralgia can be caused by a tumor putting pressure on the trigeminal nerve. In other cases, brain lesions, brain abnormalities, surgical injuries, stroke or facial trauma may be responsible for trigeminal neuralgia.

It can be noted that Bollywood Actor Salman Khan had also undergone a surgery as he was suffering from “Trigeminal Neuralgia”. But he is not the only one suffering from this peculiar disease. According to estimate, one in 15,000 people suffer from trigeminal neuralgia, but in all likelihood, the numbers may be significantly higher due to frequent misdiagnoses. It usually develops after the age of 40 (though, it can also happen to children and younger adults) and affects more women than men, in perhaps 2:1 ratio.

The disorder is quite common and he gets a number of cases of Trigeminal Neuralgia. He himself performed micro vascular decompression (MVD) procedure on 8 patients during last one year. Two patients were from abroad, one patient was from Himachal Pradesh and one patient was from Delhi. Other 4 patients were from Uttar Pradesh. “I get around five to six cases in a month. Initially most patients confuse the pain with dental problem. This surgery is performed with neurosurgical microscope and if done in time and by experienced team, it gives excellent results in 98 percent of the patients. This surgery has a great potential to give a long term relief from pain and permanently cure the patients”, said Dr. Gupta.

Because of the variety of treatment options available, having trigeminal neuralgia doesn’t necessarily mean one is doomed to a life of pain. Doctors usually can effectively manage trigeminal neuralgia with medications, injections or surgery. Certain medicines sometimes help reduce pain and the rate of attacks and these include, anti-seizure drugs, muscle relaxants and tricyclic antidepressants. Others can be treated by relieving the pressure on the nerve. Medicines can be given to reduce the pain. Sometimes injections are also given to paralyze the affected nerve. In extreme cases brain surgery is required.

Micro vascular decompression

Now Trigeminal Neuralgia can be successfully treated with Micro vascular Decompression (MVD) technique. Micro vascular Decompression is the most beneficial surgical treatment for permanently treating the condition. It is the only procedure which treats the basic cause of the trigeminal neuralgia in most cases – compression of nerve by blood vessels. This procedure is performed under the neurosurgical microscope and it is effective in 98% patients.

While drugs and surgery were the only treatment earlier now there are new therapies available like Micro vascular decompression (MVD) which involved the placing of a teflon piece between the nerve and blood vessel interventionally .

Performing this procedure requires a lot of expertise and skill. Usually the success rates of the surgery are excellent with full recovery.

The other therapies are desensitising of the nerve causing the pain through radio-frequency ablation. Balloon decompression in which a balloon was placed between the nerve and blood vessel was an alternative to MVD. This was also done interventionally. Gamma Knife is an alternative to radio frequency ablation. Interventional medication applied with the help of C-Arm or CT-Scan and also radio-frequency ablation were new developments in pain management.

Administering pain medication interventionally was more effective in reducing inflammation. It was more effective in ultimately reducing inflammation and also the dosage of the pain-killers that caused severe side-effects after prolonged use, Dr. Rahul Gupta explained.

 Is the man behind the department of Brain and spine surgeon at Fortis Hospital, Noida. He was trained at Nagoya Japan, which has made him an expert in Endovascular procedures. Dr. Gupta has rich experience of working as faculty in teaching government institutes. He has performed thousands of complex vascular, endo-vascular, skull base and minimally invasive brain surgeries. He has mastery in dealing with spine ailments. He had been actively involved in teaching and research activities in the Department of Neurosurgery at PGIMER, Chandigarh and at G B Pant Hospital, Delhi.

 

 

CyberKnife Effectively Treats Brain Tumors Without Surgery

Dr. Aditya Gupta

Indu, a young 32-year old housewife noticed whistling sounds in her left ear 1 year before she consulted her physician in Agra. One thing led to another, and an MRI scan of her brain showed a benign tumor involving her hearing nerve, an Acoustic Neuroma. Her neurosurgeon advised her to undergo open surgery, but she was treated using radiosurgery, which is a new and advanced method that is totally non-invasive. After radiosurgery procedure she went back home to her normal daily activities the same day! There were no risks, scars, no pain, no ICU stay or a week stay in the hospital, and no anxious husband waiting outside the operating room. Now, her MRI scans done 5 years later have shown us that this treatment was a cure, and her hearing remains the same.

The above case shows that Cyber Knife radiosurgery system used as an alternative to surgery, or in conjunction with other treatments plays a significant role in the management both non-cancerous and cancerous brain tumors.

The technique that has been around in India for about 3-4 years has been mostly used to treat a range of cancerous and non cancerous/benign tumors in the body including the prostate, lung, liver, etc., is now being commonly used to kill tumors of brain and spine as well.

What is CyberKnife?

Basically, CyberKnife radiation surgery is the most advanced, non invasive radiation therapy tools available to treat especially non-cancerous as well as cancerous and other diseases with the help of precise beams of high-dose radiation. It is a no pain and a no risk day-care treatment wherein patients are discharged as soon as the session gets over and therefore, no hospitalisation is required. The treatment uses a sophisticated image guidance system to beam high doses of radiation directly to your tumor.

The Cyber Knife radiation therapy has clinically proven success rates, however, it works the best for a tumors that’s upto 2-2.5 cm in size. However, in a few rare cases it is also used as an treatment option to cure brain tumors that either cannot be operated because of their location in the head, or the patients who cannot undergo brain cancer surgery due to their poor medical condition, etc. And, the success of the treatment largely depends and increases beyond 90% upon choosing the right patient.

The next generation of Cyber Knife – M6 is highly precise when compared to the earlier ones used in India as this offers some of the exceptional features and delivers a maximum dose of radiation directly to the tumor from many different angles with sub-millimeter precision for the higher success rates. Also, the emitted focused beams of intense energy destroy cancer cells and shrink/control the growth of tumors. It further prevents the cancerous cells from multiplying. Infact, the objective of radiation therapy is to destroy the harmful cells while minimising damage to healthy cells.

Besides, the CyberKnife system automatically adjusts itself and tracks the tumor which aids in minimising radiation exposure to healthy organs and tissues. The CyberKnife radiation surgery offers multiple benefits compared to conventional radiation treatments and surgery.

Cyber Knife Vs conventional Gamma Knife 

For brain tumor or cancer patients, Gamma Knife treatment is not as convenient or comfortable, largely because Gamma Knife requires an invasive head frame be bolted into the skull. Besides, the entire treatment process; right from imaging to planning to treatment itself has to happen on the same day. Typically, the head frame is mounted to the patient’s skull in the morning, followed by imaging scans which take place. The patient has no choice but to wait in the hospital during the treatment planning process with the metal head frame bolted to their skull.

Compared to this, the CyberKnife is a non-invasive, real-time motion tracking technology for accurate delivery of high-dose radiation therapy. Instead of a bulky head frame, CyberKnife patients are provided with a soft, mesh mask during the treatment.

Moreover, treatment with CyberKnife is flexible; imaging is performed few days in advance, thereby leaving the radiation oncologist with enough time to design and finalise a customised treatment plan. Once the plan is set in place, the patient will return for a non-invasive, pain-free experience. Using advanced tumor-tracking technology, the CyberKnife system is able to either deliver one single high-dose treatment, or smaller doses (upto 5) over the course of two to five days. This approach limits side effects and enables most patients to return to their regular routine the same day. Additionally, clinical studies have shown that patients with certain cancerous and non-cancerous conditions in the brain, neck and spine have a better outcome with a lower dose of two to five fractionated radiation treatments than a single, large dose.

Nothing is required of patients during treatment with CyberKnife, except to relax and lie as still as possible. The treatment is usually completed in four to five treatment sessions, over a week’s time. The treatment through CyberKnife is cost effective and it is almost similar to the cost of other surgeries.

CyberKnife Brain Cancer Treatment At A Glance 

The procedure is non-invasive and therefore, requires no anesthesia.

The flexibility of the robotic arm allows to direct multiple beams of radiation to attack cancerous cells from any angle.

It causes no harm or damage to the surrounding cells/tissues.

CyberKnife radiosurgical treatments may be given in short intervals of three to five sittings.

Side-effects are minimal and patients are back to regular activity within an hour or two of their treatment.

The treatment is done on outpatient basis.

 Is a Neurosurgeon at Agrim institute of neurosciences, Artemis Hospital, Gurugram.