Our Treatments

 

 Adult brain tumor

Brain tumors are named based on the type of cell they formed in and where the tumor first formed in the CNS. The grade of a tumor may be used to tell the difference between the fast growing and slow growing tumors.

Tumors are graded as Grade I, II, III, IV, of which Grade I, II are low grade tumors and they spread slowly. Whereas Grade III, IV are high grade tumors which tends to spread rapidly into the nearby tissue. Grade IV tumors usually cannot be completely removed by surgery.

Astrocytic tumors

Astrocytic tumors arises from  star shaped brain cells called astrocytes, which are helper cells in nervous system. It is a type of glial cell. It forms tumors called gliomas. It includes brainstem glioma (usually high grade), pineal glioma, pilocytic astrocytoma (grade I), diffuse astrocytoma (grade II), anaplastic astrocytoma (grade III) and glioblastoma (grade IV).

Oligodendroglioma

Oligodendroglial cells are another helper cells which keeps nerve cells healthy. They usually develop as oligodendroglioma (grade II), Anaplastic oligodendroglioma (grade III) tumors.

Ependymoma

Ependymal tumors arise from the ependymal linings that lines the fluid filled spaces in the brain and spinal cord. They are graded as Ependymoma (grade I, II), Anaplastic ependymoma (grade III).

Pineal parenchymal Tumors

A pineal parenchymal tumor forms in parenchymal cells or pineocytes, which make up most of the pineal gland. Pineocytoma (grade II), Pineoblastoma (grade IV), are the 2 types.

Meningeal tumors

A meningeal tumor arises from the thin layers of tissue that cover the brain and spinal cord. The various types of meningeal tumors are meningiomas grade I, meningiomas grade II and meningiomas grade III.

Pituitary gland tumor

Pituitary gland tumor originates from the cells of the pituitary gland, situated in the sellar region. Usually presents with diminution of vision, milk discharge from breast, tachycardia, abnormal changes in facial features, thickness of palm, need for change in the footware size, palpitation, headache.

Genetic Syndromes

Various genetic syndromes may increase the risk of developing brain tumors. It includes

Neurofibromatosis type I, II. Von hippel- lindau disease, tuberous sclerosis, Li Fraumeni syndrome, Turcot syndrome type I and II, nevoid basal cell carcinoma syndrome.

 

 

Signs and Symptoms

Signs and symptoms depend on the location of the tumor

Most of the patients present with early morning headaches or headache that goes away after vomiting, seizures, visual, hearing or speech problems, loss of appetite, frequent nausea, vomiting, personality changes, loss of balance, limb weakness, unusual sleepiness or change in activity level.

 

Tests

After preliminary history, physician may perform

1. Neurological examination: It includes questions to assess the orientation, memory, language, attention, calculation. He may also check power of the limbs, the tone, reflexes, sensations, visual assessment, hearing examination, swallow assessment.
2. Visual field examination: It is performed to assess the diminution of the vision.
3. MRI/CT scan: It help to confirm the diagnosis, provide localization of the tumor if any.

Treatment

For brain tumor patients it is essential to have a tissue diagnosis prior to any adjuvant treatment.

1. Stereotactic biopsy: In patients with deep seated tumors which cannot be excised, stereotactic biopsy is essential.
2. Open biopsy: A part of the skull is removed in an operation called a craniotomy. A sample of brain tissue is removed and viewed under a microscope. If cancer cells are found, some or all of the tumor may be removed during the same surgery.
3. SRS: Stereotactic radiation surgery, It is used for the treatment of small size tumors or the tumors which cannot be resected.
4. Proton therapy: It uses radiation of high intensity to treat inaccessible tumors.
5. Chemotherapy/Radiation: Post surgery, if the tumor is a high grade than the physician may advice for further chemotherapy along with radiation to treat the tumor. Even with complete treatment grade IV tumors tends to recur after short duration of time.

Immunohistochemistry, cytogenetic analysis are performed to assess the grading of the tumor.

 

The prognosis and treatment depends on

• The type and grade of the tumor
• Location of tumor
• Whether the tumor can be removed by surgery
• Whether cancer cells remain after surgery
• Whether there are certain changes in the chromosomes
• Whether the cancer has just been diagnosed or her recurred
• The patient’s general health

 

The prognosis and treatment options for metastatic brain and spinal cord tumors depend on the following:

• Whether there are more than two tumors in the brain or spinal cord.
• Where the tumor is in the brain or spinal cord.
• How well the tumor responds to treatment.
• Whether the primary tumor continues to grow or spread.

It is essential to evaluate oneself in case if any of the symptoms persists. As early treatment has a better outcome.

Left frontal tumor with mass effect

Tumor in the suprasellar region with solid and cystic component

Our Treatments

Adult Hydrocephalus

The term hydrocephalus is derived from two words: “hydro,” meaning water, and “cephalus,” referring to the head.

CSF(Cerebrospinal Fluid) has three crucial functions:

1. It acts as a “shock absorber” for the brain and spinal cord;
2. It acts as a vehicle for delivering nutrients to the brain and removing waste; and
3. It flows between the cranium and spine to regulate changes in pressure within the brain.

Hydrocephalus is a condition in which excess cerebrospinal fluid (CSF) builds up within the ventricles (fluid-containing cavities) of the brain and may increase pressure within the head. Hydrocephalus is a chronic condition. It can be controlled, but usually not cured. With appropriate early treatment, however, many people with hydrocephalus lead normal lives with few limitations.

Hydrocephalus can occur at any age, but is most common in infants and adults age 60 and older. It affects adult males and females equally. Experts believe that normal-pressure hydrocephalus accounts for five to six percent of all dementia cases.

Normal Pressure Hydrocephalus (NPH)

Normal Pressure Hydrocephalus results from the gradual blockage of the CSF-draining pathways in the brain. The ventricles enlarge to handle the increased volume of CSF, thus compressing the brain from within and eventually damaging or destroying the brain tissue. NPH owes its name to the fact that the ventricles inside the brain become enlarged with little or no increase in pressure.

NPH can occur as the result of head injury, cranial surgery, hemorrhage, meningitis or tumor. Unfortunately, the cause of the majority of NPH cases is unknown, making it difficult to diagnose and understand. Compounding this difficulty is the fact that some of the symptoms of NPH are similar to the effects of the aging process, as well as diseases such as Alzheimer’s and Parkinson’s.

NPH can occur as the result of head injury, cranial surgery, hemorrhage, meningitis or tumor. Unfortunately, the cause of the majority of NPH cases is unknown, making it difficult to diagnose and understand. Compounding this difficulty is the fact that some of the symptoms of NPH are similar to the effects of the aging process, as well as diseases such as Alzheimer’s and Parkinson’s.

Primary symptoms include Gait disturbance,

• Headaches, Nausea, poor gait
• Unsteady walk or gait
• Leg weakness
• Sudden falls
• Irritability, drowsiness personality change,
• Seizures

 

 

Primary Symptoms of NPH are Imbalance in gait, Dementia, Urinary incontinence.

The gait in many patients with NPH is very distinctive: wide-based, short, slow and shuffling. People may have trouble picking up their feet, as if their feet are glued to the ground, they feel that, feet are attached to the ground.

Dementia and/or bladder control problems usually appear after gait disturbances as the condition progresses. Mild dementia can be described as a loss of interest in daily activities, forgetfulness, difficulty dealing with routine tasks and short-term memory loss.

Bladder control problems usually involve urinary frequency and urgency in mild cases. In severe cases, however, a complete loss of bladder control (urinary incontinence) may result. Urinary frequency is the need to urinate more than usual, often as frequently as every one to two hours.

Patients with untreated, advanced NPH may experience seizures, which can get progressively worsen.

Diagnosis

CT/MRI: It shows dilated ventricle, periventricular hypodensity

Isotopic cisternography: A test that involves injecting a radioactive isotope into the lower back through a spinal tap.

Lumbar puncture:  Removal of up to 50 cc of CSF is done to see if symptoms are temporarily relieved. This test is used to measure CSF pressure and analyze the fluid. This procedure may help determine whether a shunt will help the patient or not.

Intracranial pressure monitoring: Monitoring may be able to detect an abnormal pressure or pattern of pressure waves. Monitoring requires insertion of a catheter or small fiber-optic cable through the skull into the brain and includes a 24-hour hospital stay.

Treatment

Hydrocephalus can be treated with CSF diversion procedure. Commonly used procedure is ventriculo peritoneal shunt. Once inserted, the shunt system usually remains in place for the duration of a patient’s life, although additional operations to revise the shunt system may be needed. The shunt system continuously performs its function of diverting the CSF away from the brain, thereby keeping the intracranial pressure within normal limits.

Enlarged ventricles, with Periventricular hyperintensity.

Our Treatments

Carpal tunnel syndrome (CTS)

Carpal tunnel syndrome (CTS) is a common neurological disorder that occurs when the median nerve, which runs from your forearm into the palm of the hand, becomes pressed or squeezed at the wrist.

Compression of the median nerve in the carpal tunnel causes significant pain and numbness along the thumb, index and middle finger. Thicken tendons or other swelling narrows the tunnel and compresses the median nerve. CTS is the most common and widely known of the entrapment neuropathies.

Early symptoms include:

• Numbness, particularly at night
• A feeling the fingers being useless or swollen
• A tingling sensation or pain in the fingers

As symptoms worsen, people might feel:

• Tingling during the day, especially with certain activities such as talking on the phone, reading a book or newspaper, driving, holding broom
• Mild to severe pain, sometimes worse at night
• Weakness in the hand
• Hand weakness may make it difficult to grasp small objects or perform another manual task

 

Who is more likely to get carpal tunnel syndrome?

Carpal tunnel syndrome is often the result of a combination of factors that increase pressure on the median nerve and tendons in the carpal tunnel, rather than a problem with the nerve itself. Sometimes no single cause can be identified. Contributing factors may include:

• Trauma or injury to the wrist that cause swelling, such as sprain or fracture
• Imbalance of either the pituitary gland or the thyroid gland
• Rheumatoid arthritis or other arthritic diseases
• Mechanical problems in the wrist joint
• Repeated use of vibrating hand tools
• Fluid retention during pregnancy or menopause
• Development of a cyst or tumour in the canal
• Gender—women are three times more likely than men to develop CTS
• Having diabetes or other metabolic disorders that directly affect the body’s nerves and make them more susceptible to compression
• Repeated sleeping on a bent wrist
• Increasing age—CTS usually occurs only in adults.

People working on assembly line work—such as manufacturing, sewing, finishing, cleaning, meatpacking, data-entry personnel,

Physical exam. Your doctor will examine your hands, arms, shoulders, and neck to determine if your complaints are related to daily activities or to an underlying disorder and to rule out other conditions that mimic carpal tunnel syndrome. Your wrist will be checked for tenderness, swelling, warmth, and discoloration. Your fingers will be tested for sensation, along with muscles at the base of the hand for strength and signs of atrophy.

 

Routine laboratory tests and X-rays can reveal fractures, arthritis, hypothyroidism and nerve-damaging diseases such as diabetes.

Electrodiagnostic tests may help confirm the diagnosis of CTSs.

Nerve Conduction Study measures how quickly impulses are transmitted along a nerve. Electrodes are placed on your hand and wrist and a small electric shock is applied and the speed with which nerves transmit impulses is measured.

Electromyography, a fine needle is inserted into a muscle and electrical activity is viewed on a screen to determine the severity of damage to the median nerve.

Ultrasound imaging can show an abnormal size of the median nerve.

Magnetic resonance imaging (MRI) can show the anatomy of the wrist but to date has not been especially useful in diagnosing carpal tunnel syndrome.

Treatment

Splinting: Supporting the wrist with splint reduces the movement of the hand. Providing adequate rest to reduce the swelling and inflammation.

NSAIDS, corticosteroids: Reduces the swelling and pain

Hand exercises

Carpal tunnel release procedure: A linear incision is taken from the proximal skin crease to distal end of the base of thumb. Incision is deepened and ligaments is incised, releasing the median nerve.

Median nerve block: Local anaesthetic block relives pain transiently

Botox local injection: It reduces tendon spasm and releases the nerve compression. Normal anatomy of the carpal tunnel. Transverse carpal ligament covers the median nerve

Release of the transverse carpal ligament reduces the compression over the median nerve, reducing the pain and other complains.

Our Treatments

Head injury

Annually 1 million patients suffer from head injury of which 2% of them expires.  Majority of them don’t return back to normal life and need long term rehabilitation adding to additional financial burden. Brain injuries can vary from minor brain injury to severe injuries. Some patients with head injury needs surgery, while some are managed with medications.

 

How does a head injury occur

1. Road traffic accident
2. Fall from height
3. Fall of object over head

 

Some common severe head injuries!

1. Concussion – Concussions are one of the most common severe head injuries and occur when the brain slams against the skull. They usually heal relatively well, but more severe issues can develop if someone suffers from repeated concussions.
2. Hematoma – When a blood vessel in the brain ruptures, it can lead to the collection and clotting of blood. This bleeding in the brain can lead to a bump that you may not even notice until a few days after your injury. The three types are intracerebral, epidural, and subdural hematomas.
3. Skull Fracture – When the skull becomes broken or cracked, it is known as a skull fracture. The brain can occur with skull fractures as a result of the bone cutting into the brain.
4. Edema – Edema or brain swelling can occur with any TBI, and it must be resolved quickly to avoid further damage to the brain.

 

Closed Vs. Open-Head Injuries

Some injuries can be seen, while some cannot. Those which can be seen are called open head injuries and may need to be stitched. Closed injuries cannot be seen, but can be life threatening.

 

Why to visit a doctor

Most severe head injuries, when left untreated, can prove to be life-threatening. When left untreated, a concussion can lead to poor mental health. You may develop fits, anxiety, depression, and the inability to express emotion.

 

If you have any of these, you need to see a doctor

Loss of consciousness – If you lose consciousness during your injury, you need to seek medical attention immediately.

Bleeding – Bleeding from the ears or nose can be a strong sign that you have suffered from a serious head injury.

Trouble walking – If you are feeling woozy, stumbling, or having trouble walking after a head injury, you need to seek medical attention.

Confusion – Being confused about what’s going on around you or having trouble focusing can be a sign of a serious injury.

Memory loss – If you are drawing a blank and can’t remember what happened right before or after the accident, you should seek medical attention.

Weakness – Feeling weakness in one side of the body is a strong sign of a head injury.

Headache- Continuous headache from the time of trauma, can have disastrous side effect.

Vomiting- Multiple episodes of vomiting post head injury, suggest for severe head injury and requires urgent evaluation

Uprolling of eyeballs/seizures: Paroxysmal event is a sign of internal head injury and needs to be evaluated.

 

How can you assess the head injury patient?

            It is essential to save your self prior to saving others.

Check for the safety of the surrounding prior to assessing the patient.

Remove the debris or any objects which can trouble the rescue.      

            Speak with the patient, is he able to respond? Is he answering correctly or he is confused. Ask him about his details and the event leading to head injury.

Compress any external wound with a clean cloth.

Check whether limb movements are good or not.

If unconscious, check pulse, see the pupils (if unequal, he needs an urgent medical care)

If patient develops abnormal posture, turn him/her on one side, you can place a belt or a thick cloth in the mouth to prevent tongue bite.

Check for other injuries prior to shifting patient, as long bone fractures needs to be im mobilized.

While shifting the patient, keep the spine straight, do not lift the patient without assistance.  consultation, call 402-704-4786

Position to be given to a patient having active seizures.

 

What does doctor do?

He will ask you a detail history, have a look at patient, advice a CT brain and spine to confirm the injuries. and will let you know what is to be done. In a case of critical condition, he might be firm and ask for some urgent decisions to save the patients life. Always remember TIME IS BRAIN.

Some patients, needs urgent treatment, many of them are managed conservatively. Few require ICU admission, many patients with minor injury can be managed in ward.

To manage any acutely developing complications promptly and preventing its adverse effects it is indicated to admit a patient, with minor head injury also.

A doctor can advice a patient to be kept on ventilatory support without any surgery. It is just to reduce the brain activity and reduce secondary complications.

A doctor might say, no surgery can help the patient. It is because the injury which happened at the time of accident was severe and a surgery will not benefit the outcome of the patient.

 

Post trauma, how will I recover?

The recovery process from a head injury can vary widely depending on the severity and location of the injury, as well as the age and overall health of the individual. Here are some general factors that may influence recovery:

 

1) Severity of injury: Mild head injuries (concussions) usually resolve within a few weeks to months, while severe head injuries (traumatic brain injuries, TBIs) may take several months to a year or longer to recover fully.

 

2) Location of injury: Injuries to the frontal lobes, which are involved in executive functions such as decision-making and planning, may take longer to recover than injuries to other areas of the brain.

 

3) Age: Older adults may have slower recovery rates due to age-related changes in the brain’s structure and function.

 

4) Overall health: Individuals with pre-existing medical conditions or poor overall health may have slower recovery rates due to increased vulnerability to complications or decreased ability to cope with stressors.

 

5) Rehabilitation: Rehabilitation programs that focus on cognitive, physical, and emotional recovery can greatly improve outcomes for individuals with head injuries. These programs may include speech therapy, occupational therapy, physical therapy, cognitive therapy, and counseling.

 

6) Support network: Having a strong support network of family, friends, and healthcare providers can greatly improve recovery outcomes by providing emotional support and practical assistance during the recovery process.

 

7) Lifestyle factors: Making lifestyle changes such as getting enough sleep, eating a healthy diet, exercising regularly, and managing stress can promote healing and improve overall health and well-being during recovery from head injuries.

 

How long will I be on medications?

Duration of medications depends on the severity of medications. In minor injury medication are required for few days, where as in patients with severe head injury medications can be continued for years.

 

What should I not do during the course of antiseizure medications?

Avoid all risk-taking activities like swimming, driving, riding 2 wheeler, hiking.

 

How should I take care of head injury patient?

Patients who are discharged from the hospital but still require ongoing medical care and support. Here are some benefits of head injury patient home care:

1) Comfort and familiarity: Being in their own homes can help individuals with head injuries feel more comfortable and less stressed, which can facilitate healing and recovery.

 

2) Increased independence: Home care can help individuals with head injuries regain independence and self-sufficiency by providing them with the skills and resources they need to manage their own care.

 

3) Personalized care: Home care allows for more personalized and individualized care, as the caregiver can tailor the treatment plan to the specific needs and preferences of the patient.

 

4) Family involvement: Home care allows family members to be more involved in the patient’s care, which can provide emotional support and improve overall recovery outcomes.

 

5) Improved communication: Home care allows for better communication between the patient, caregiver, and healthcare providers, as there are fewer barriers to communication in a home setting.

 

6) Flexibility: Home care allows for greater flexibility in scheduling medical appointments and therapy sessions, as the patient can receive care in their own home instead of having to travel to a hospital or rehabilitation centre.

Our Treatments

 

Hemorrhagic stroke accounts upto 10-15% of all strokes and it is an important cause of neurological morbidity and mortality. Prognosis of patient with hemorrhagic stroke depends on volume of bleed, location of bleed, development of hydrocephalus and for subarachnoid hemorrhage on the development of arterial vasospasm.

Spontaneous intracranial hemorrhage may be parenchymal, intraventricular, subarachnoid, subdural, and epidural, the former being the most common location and the latter two being uncommon and usually associated with trauma.

Computed Tomography (CT) is the diagnostic test for the intracranial hemorrhage.

Causes of non traumatic ICH includes

1. Hypertensive hemorrhage:
2. Cerebral angiopathy, Dural AVF, venous thrombosis, coagulopathy, tumor
3. AVM, cavernoma, drug abuse, aneurysm, coagulopathies.
4. Hypoxic ischemic injury

Patient will present with complains of headache, inability to speak, sudden onset of limb weakness, severe bout of vomiting followed by loss of consciousness, seizures, Sudden onset of irritability, sudden onset of loss of consciousness. Cerebral hematomas are seen to a patient with long standing hypertensive vasculopathy characterized by lipohyalinosis of penetrating arteries.

 

Non-traumatic intracranial hemorrhage refers to any type of bleeding within the skull or brain that occurs spontaneously, without any external trauma. Let’s delve into the details:

• Localization of Hemorrhage:
  • Extra-axial Hemorrhage (Intracranial Extracerebral):
    • Subarachnoid Hemorrhage (SAH): This acute bleeding occurs beneath the arachnoid membrane. It is commonly seen in cases of aneurysm rupture or as a result of trauma.
  • Intra-axial Hemorrhage (Intracerebral):
    • Lobar Hematoma: Located in the periphery of a brain lobe, lobar hematomas are often associated with cerebral amyloid angiopathy (CAA). Other causes include hypertension, tumors, vascular malformations, and venous infarction.
    • Centrally Located Hemorrhage:
      • Basal Ganglia, Pons, or Cerebellum: Hypertension is the most common cause of centrally located hemorrhages. Approximately 85% of non-traumatic hemorrhages occur in patients with hypertension or CAA. In hypertension, the hemorrhages tend to be central (in the basal ganglia, pons, thalamus, and cerebellum), while in CAA, they are more peripheral (deep within the frontal, parietal, or temporal lobes, also known as lobar hemorrhages).
    • Differential Diagnosis: In patients with intracerebral hemorrhage, consider other conditions such as vascular malformations (e.g., arteriovenous malformation, dural arteriovenous fistulas), aneurysms, cavernomas, and infarction with hemorrhagic transformation.
    • Other Causes:

1. • • • Hemorrhagic Venous Infarction (seen in sinus thrombosis)
       • Hemorrhagic Primary Brain Tumors or Metastases

• Drug Abuse

1. • • • Reversible Cerebral Vasoconstriction Syndrome¹.
2. Cerebral Amyloid Angiopathy (CAA):
   • CAA is characterized by amyloid deposits in cerebral blood vessels. It often leads to lobar hemorrhages and is a significant cause of non-traumatic intracranial bleeding.

Remember that any intracranial hemorrhage is a medical emergency, and prompt evaluation and management are crucial. If you experience sudden symptoms like severe headache, confusion, or numbness on one side of your body, seek immediate medical attention

 

Intracranial hemorrhage can present with various symptoms, depending on the location and severity of the bleeding. Here are some common signs to watch out for:

1. Sudden Severe Headache: A sharp, intense headache that comes on suddenly can be a warning sign of intracranial bleeding.
2. Nausea and Vomiting: Nausea, sometimes accompanied by vomiting, may occur due to increased intracranial pressure.
3. Altered Mental Status:
   • Confusion: Patients may become disoriented or have difficulty concentrating.
   • Drowsiness or Unresponsiveness: Severe bleeding can lead to unconsciousness.
4. Focal Neurological Deficits:
   • Hemiparesis: Weakness or paralysis on one side of the body.
   • Hemisensory Loss: Numbness or loss of sensation on one side.
   • Visual Disturbances: Blurred vision, double vision, or visual field defects.
   • Speech Difficulties: Slurred speech or inability to speak.
5. Seizures: Intracranial hemorrhage can trigger seizures.
6. Vital Sign Changes:
   • Increased Blood Pressure: Hypertension may be present.
   • Bradycardia: Slow heart rate.
7. Other Symptoms:
   • Neck Stiffness: Especially if there’s associated subarachnoid hemorrhage.
   • Loss of Consciousness: In severe cases.
   • Focal Motor Abnormalities: Weakness or abnormal movements.
   • Pupillary Changes: Unequal pupil size (anisocoria).

Remember that any sudden, severe headache or neurological symptoms warrant immediate medical attention. If you or someone else experiences these symptoms, seek urgent evaluation to rule out intracranial hemorrhage .

 

 

Intracranial hemorrhage, also known as a brain bleed, occurs when there is bleeding within the skull or brain. Let’s explore the causes of this serious condition:

1. Head Trauma:
   • A common cause of intracranial hemorrhage is head injury resulting from falls, car accidents, sports injuries, or other traumatic events.
2. High Blood Pressure (Hypertension):
   • Uncontrolled high blood pressure weakens blood vessels, making them prone to rupture.
3. Blood-Thinning Medications:
   • Taking blood-thinning medications (such as aspirin or anticoagulants) increases the risk of bleeding.
4. Cerebral Aneurysms:
   • Weak spots in blood vessel walls (cerebral aneurysms) can burst, causing bleeding.
5. Arteriovenous Malformations (AVMs):
   • Abnormal connections between arteries and veins in the brain may lead to bleeding.
6. Brain Tumors:
   • Bleeding can occur within a brain tumor.
7. Other Factors:
   • Cocaine or amphetamine use (uppers).
   • Being born with abnormal blood vessels in the brain.
   • Severe migraines.

Remember, intracranial hemorrhage is a life-threatening emergency. Seek immediate medical attention if you experience symptoms like severe headache, vomiting, weakness, or confusion after a head injury or if you have uncontrolled hypertension¹²³⁴.

Intracranial hemorrhage (ICH), which refers to acute bleeding inside the skull or brain, can have serious consequences. Let’s explore the risk factors associated with ICH:

1. Head Injury:
   • Most ICH cases are due to head trauma. Activities or lifestyle choices that increase the risk of head injury can lead to ICH.
2. Family History:
   • A family history of ICH may predispose individuals to this condition.
3. Heavy Alcohol Use:
   • Excessive alcohol consumption is a risk factor for ICH.
4. Hypertension (High Blood Pressure):
   • Uncontrolled high blood pressure weakens blood vessels, making them susceptible to rupture.
5. Cigarette Smoking:
   • Smoking increases the risk of ICH.
6. Drug Use:
   • Certain drugs, including amphetamines, cocaine, and MDMA (often called “ecstasy”), are associated with ICH.
7. Extreme Physical Exertion:
   • Intense physical activity can contribute to ICH.

Remember that recognizing symptoms promptly and seeking medical attention are crucial. Signs of ICH include sudden severe headaches, confusion, vomiting, and neurological deficits. If you experience any of these symptoms, seek urgent evaluation to rule out intracranial hemorrhage¹².

Intracranial hemorrhage, also known as a brain bleed, is a serious condition that requires prompt medical attention. Treatment strategies depend on the type, location, and severity of the hemorrhage. Here are the key approaches:

1. Emergency Care and Observation:
   • Immediate medical evaluation is crucial.
   • Intensive care unit (ICU) monitoring is often necessary.
   • Neurological changes are closely watched for.
   • Repeated head CT scans may be performed to assess progression.
2. Blood Pressure Management:
   • Medications are used to control blood pressure.
   • Surgery may be considered in severe cases.
3. Reversing Blood Thinners:
   • If the patient is on blood-thinning medication (e.g., warfarin), therapy to reverse its effects is administered to reduce the risk of further bleeding.
   • Options include vitamin K and fresh frozen plasma.
4. Surgical Interventions:
   • Surgical drainage:
     • For liquid hematomas that have changed from a solid clot to a liquid.
     • A small hole is created in the skull, and suction is used to remove the liquid.
   • Craniotomy:
     • For large hematomas.
     • A section of the skull is temporarily opened to remove the blood.
5. Recovery and Rehabilitation:
   • Recovery after intracranial hemorrhage can take time.
   • The greatest improvement occurs within the first three months after the injury.
   • Occupational and physical therapy may be needed for neurological problems.

Remember, early intervention is critical for better outcomes. If you experience sudden symptoms like severe headache, confusion, or numbness, seek immediate medical help¹².

Hypertensive gangliocapsular bleed

Our Treatments

 

Pediatric brain tumor is the second most common neoplasm after leukemia. Primary brain tumors are responsible for 20% of all cancer in children and for 20% of childhood cancer death. Surgical treatment in patients with brain tumor is to preserve neurological function and good quality of post surgical life.

Brain tumors are classified as per WHO classification

Classification of tumors

1. Supratentorial tumors
   1. Sellar
   2. Supra sellar
   3. Hemispheric tumor (intraventricular/parenchymal
2. Infratentorial tumors

Presenting complains of patients depends upon the location of the tumor.

Tumors may be more insidious because of the non-specific nature of clinical features that arise from a variety of causes, including vomiting, irritability, listlessness, macrocephaly, failure to thrive, and stagnation of development or loss of developmental milestones. Common signs and symptoms of brain tumors in children include Irritability, Listlessness Vomiting, Headache, Failure to thrive, macrocephaly, seizures, focal neurologic deficits/ hemiparesis, Visual field loss/ deficit, Neuroendocrine dysfunction.

Low grade glioma

Low grade glioma are heterogeneous entities represents approximately 30% of all primary CNS tumor in childhood. They are classified into WHO grade I and II. Cortical tumors present with hydrocephalus, headache, fatigue, ataxia, visual changes, facial weakness, and gagging. Low grade tumors tend to progress slowly.

Management of low-grade gliomas is usually related to surgical resection; complete resection is the most favorable predictor of patient outcome. In the past, complete surgical resection, histological diagnosis, and age were used to determine prognosis. Currently, the molecular data of low-grade gliomas supplement the stratification of these tumors and their prognosis.

Various pediatric low grade glial tumors includes pilocytic astrocytoma, pilomyxoid astrocytoma, diffuse astrocytoma, pleomorphic xanthoastrocytoma, angiocentric glioma, astroblastoma.

 

High grade glioma

8 to 10% of all primary CNS tumors in children have high grade gliomas. High grade tumors are characterised by molecular, genetic and biological data. These tumors are classified by WHO grade III/IV or termed as IDH wild type, IDH mutant. They tend to progress rapidly. Even with maximum safe resection and further adjuvant therapy they tend to recur. It includes Diffuse midline glioma, High grade glioma.

Neuronal and mixed neuronal glial tumors

Neuronal and mixed neuronal glial tumors are uncommon CNS tumors more frequently categorized as WHO grade 1. Commonly presents with epilepsy. Commonly located in the floor of 3^rd ventricle, temporal lobe, cerebellum, parieto occipital region and frontal lobe. MRI shows cortical dysplasia. It includes ganglioglioma, dysplastic cerebellar gangliocytoma, diffuse leptomeningeal glioneuronal tumor, desmoplastic infantile tumor, DNET, Rosette forming glioneuronal tumor.

 

Embryonal tumors

Embryonal tumors are aggressive, malignant, undifferentiated or poorly differentiated neoplasm’s of neuroepithelial origin that demonstrate an increased tendency t recur and propagate throughout CNS vis cerebrospinal fluid. These are WHO grade IV tumors. It includes medulloblastoma, ATRT (atypical teratoid/rhabdoid tumor). Other embryonal tumors includes PNET.

 

Ependymal tumors

Ependymoma is a neuroepithelial neoplasm accounting for 10% of pediatric brain tumors. These tumors typically occur in the posterior fossa, following supratentorial compartment and, less frequently in the spine. Prognosis of the patient depends on the molecular study.

 

Choroid plexus tumor

Choroid plexus tumor are rare intraventricular tumors of neuroectodermal origin accounting for 2-4% of brain tumors in children. Complete resection is the curative treatment for choroid plexus papillomas. It is a grade I tumor with good prognosis. Choroid plexus carcinoma represents WHO grade III tumor with median age of occurrence of 1 year. It has a poor prognosis.

 

GCTs and differential diagnosis in the sellar region and pineal gland

Intracranial GCT are uncommon and biologically diversified CNS tumor. It represents 2-3% of all pediatric brain tumors. Mostly originates in the suprasellar and pineal region. Patients with GCT have poor prognosis.

 

 

Midline suprasellar germ cell tumor

 

Signs and Symptoms

Signs and symptoms depend on the location of the tumor

Most of the patients present with early morning headaches or headache that goes away after vomiting, seizures, visual, hearing or speech problems, loss of appetite, frequent nausea, vomiting, personality changes, loss of balance, limb weakness, unusual sleepiness or change in activity level.

 

Tests

After preliminary history, physician may perform

1. Neurological examination: It includes questions to assess the orientation, memory, language, attention, calculation. He may also check power of the limbs, the tone, reflexes, sensations. Visual assessment, hearing examination, swallow assessment.
2. Visual field examination: It is performed to assess the diminution of the vision.
3. MRI/CT scan: It help to confirm the diagnosis, provide localization of the tumor if any.

Treatment

For brain tumor patients it is essential to have a tissue diagnosis prior to any adjuvant treatment.

1. Stereotactic biopsy: In patients with deep seated tumors which cannot be excised, stereotactic biopsy is essential.
2. Open biopsy: A part of the skull is removed in an operation called a craniotomy. A sample of brain tissue is removed and viewed under a microscope. If cancer cells are found, some or all of the tumor may be removed during the same surgery.
3. SRS: Stereotactic radiation surgery, it is used for the treatment of small size tumors or the tumors which cannot be resected.
4. Proton therapy: It uses radiation of high intensity to treat inaccessible tumors.
5. Chemotherapy/Radiation: Post surgery, if the tumor is a high grade than the physician may advice for further chemotherapy along with radiation to treat the tumor. Even with complete treatment grade IV tumors tends to recur after short duration of time.

Immunohistochemistry, cytogenetic analysis are performed to assess the grading of the tumor.

 

The prognosis and treatment

• The type and grade of the tumor
• Where the tumor is in the brain and spinal cord
• Whether the tumor can be removed by surgery
• Whether cancer cells remain after surgery
• Whether there are certain changes in the chromosomes
• Whether the cancer has just been diagnosed or her recurred
• The patient’s general health

 

The prognosis and treatment options for metastatic brain and spinal cord tumors depend on the following:

• Whether there are more than two tumors in the brain or spinal cord.
• Where the tumor is in the brain or spinal cord.
• How well the tumor responds to treatment.
• Whether the primary tumor continues to grow or spread.

It is essential to evaluate oneself in case of any of the symptoms persists. As early treatment has a better outcome.

Our Treatments

 

MRI of the brain of a child with Congenital hydrocephalus

Hydrocephalus

Hydrocephalus comes from the Greek: “hydro” means water, “Cephalus” means head. Hydrocephalus is an abnormal accumulation of cerebrospinal fluid (CSF) within cavities called ventricles inside the brain. CSF is produced in the ventricles, circulates through the ventricular system and is absorbed into the bloodstream.

CSF is in constant flow, providing cusion, neutrition to the brain tissue and also extracts waste from the brain. Blockage in the CSF flow, causes ventricles to enlarge and the pressure inside the head to increase.

CSF pathway

The Choroid plexus is the mainsource of CSF. The CSF formed in the lateral ventricles gains access to thethird ventricle through the paired foramina of Munro. From there through theAqueduct of Sylvius it enters the fourth ventricle from which is exits throughthe foramina of Luschka and Magendie. Part of it flows down into the spinal subarachnoid space. The bulk flows over the hemispheres and the subarachnoid pathway to be absorbed by the arachnoid villi in the superior sagittal sinus. 

 Causes

Hydrocephalus results from

1. Over production of Cerebrospinal Fluid
2. Inadequate drainage of Cerebrospinal Fluid

Over production is due to Choroid Plexus tumour.

Inadequate drainage of CSF due to blockage in the CSF pathway or defective absorptive mechanism.

Clinical Features

Infants: Increase in Head circumference, bulging anterior fontanelle, Sutural separation, sunset sign, poor feeding, irritability, vomiting and dilated scalp veins. Hydrocephalus that is congenital (present at birth) is caused by a complex interaction of environmental and perhaps genetic factors. Aqueductal stenosis and spinal bifida are two examples. Acquired hydrocephalus may result from intraventricular hemorrhage, meningitis, head trauma.

Children: In children with closed fontanelle, patients present with headache, recurrent vomiting, memory loss, imbalance while walking, urinary incontinence, blurring of vision, Sleepiness, tightness in limbs, restricted eye ball movements.

Diagnosis

CT, MRI USG brain is the diagnostic modality. Congenital hydrocephalus can be diagnosed with prenatal ultrasound or fetal MRI.

Treatment

In patients with congenital hydrocephalus, spinal screening for dysraphism has to be ruled out. Assessment for congenital TORCH infection, intracerebral bleed needs to be evaluated and treated accordingly. Congenital Hydrocephalus needs to be treated post delivery. In case of its association with spinal dysraphism, spinal surgery is also essential.

There is no known way to prevent or cure hydrocephalus.

Medical management

There is no known medical or non-operative management of hydrocephalus. Commonly used medicine is acetazolamide. It reduces the CSF production.

Surgical

CSF diversion procedure: Endoscopic 3^rd Ventriculostomy an effective treatment as an alternative for insertion of a shunt.

Measures to divert CSF: The CSF has been diverted commonly to the peritoneum, pleura and right atrium have proved useful.

Commonest site for CSF diversion is peritoneum.

 

Different types of shunts are used of various companies

Commonly used shunts are

1. Chabbra
2. Medronic
3. Codman hakin

 

What should I do?

If an obstetric USG shows hydrocephalus, then a fetal MRI is indicated to rule out other abnormalities. Further evaluation and treatment have to be done after delivery.

 

 

 

Various types of shunts

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Our Treatments

 

Spina Bifida

The term “Spina Bifida” applies to a failure of the spinal cord and spinal column to form properly before birth. This failure can occur anywhere from the head to the tailbone, but is more common in the lumbar spine. It can occur with a wide range of severity.

Tethered Spinal cord is caused by abnormal tissue attachments that restrict the movement and ascend of the spinal cord within the spinal column. With the spinal column growing spinal cord stretches beyond its tolerance which can then result in lower spinal cord dysfunction due to the damage of nerve cells and nerve fibre. Tethered spinal cord may go undiagnosed until late childhood, when sensory and motor problems and loss of bowel and bladder control emerge.

Disorders which can lead to tethered cord include:
Myelomeningocele
Spinal cord lipoma
Dermal Sinus Tracts
Split cord malformation

Almost all spinal dysraphism have Neurocutaneous marker viz midline dimples, sinuses or tracts leading the skin toward the spinal cord, birthmarks, hairy patches, skin discoloration, skin tags or fatty lumps.

The most common signs of tethered cord syndrome include loss of bladder or bowel control and/or loss of function in the legs. The symptoms and signs of a tethered cord are not always obvious and may result in a delayed diagnosis. The neurological defect that results from abnormal stretching of the spinal cord may not be reversed by surgery, so it is important to diagnose this condition as soon as possible. Some signs and symptoms include: Bowel or bladder incontinence, decrease in strength of legs or feet, Deformity of the legs or hips, Loss of reflexes and sensation in the legs, Stumbling or walking changes, Leg or back pain
Curvature of the spine, Skin abnormalities.

 

Evaluation

MRI spine, Bladder function evaluation, Nerve conduction studies.

 

 

Treatment

The main purpose of the surgery is to stop any further deterioration of neurological function. The surgery (Detether) the spinal cord also may restore some function or alleviate other symptoms.

 

Myelomeningocele/ Spina Bifida

Spina bifida or myelomeningocele is a condition that occurs when the spinal cord to fully form early in development. Myelomeningocele is once of the most common birth defects of the nervous system. It is a neural tube defect in which the skin, muscle and bones of the spine do not completely formed. This allows the spinal cord and meninges (the membranes covering the spinal cord) to protrude out of the child’s back. The spinal cord is exposed through the opening in the spine, resulting in partial or complete paralysis of the parts of the body below the spinal opening. The affected individual may be unable to walk and may have bowel and urinary dysfunction.

Causes

Causes of myelomeningocele is unknown. However, folic acid deficiency is through to play a part in neural tube defect. Other factors like genetics, radiation exposure. With the use of folate supplementation in maternal vitamins, the incidence of spina bifida has decreased dramatically.

Symptoms

Symptoms include partial or complete paralysis of the legs, with partial or complete lack of sensation, and may include loss of bladder or bowel control.  Weakness of the hips, legs, or feet of a newborn. Myelomeningocele is a visible defect after the child is born. Neurologic examination may indicate loss of neurologic functions below the defect.

Treatment

The goal of initial treatment are to reduce the amount of neurological damage caused by the defect, to minimize complications such as infection, and to aid the family in coping with disorder. Before surgery, the infant must be handled carefully to reduce damage to the exposed spinal cord. This may include positioning, protective devices, and modifications in the methods of handling, feeding, bathing and caring for the infant.

 

Lipomyelomeningoceles
Spinal cord lipomas are a fatty mass or tumour within the spinal cord and are usually associated with spina bifida but will, in rare circumstances occur among adult men and women who do not have spina bifida. Lipomyelomeningoceles, congenital lesions due to the failure of closure of spinal bones associated with spina bifida.

Symptoms
A gradual stretching of the spinal cord causes numbness or tingling for the patient. In extreme cases, there is weakness, difficulty in urination or bowel movements, incontinence and stiffness of the extremities. Patient can lose neurologically function over a broad range of time.

Diagnosis

MRI gives exceptional anatomical details and can help in surgical planning.

Surgical treatment is indicated at 6 months of age or at the time of diagnosis if the patient is older. The goals of surgery are to release the attachment of the fat to the spinal cord and reduce the bulk of the fatty tumor through a laminectomy.

 

Dermal sinus tract

The tract may end just below the skin surface or may extend to the conus medullaris (part of the spinal cord) or the central canal of the spinal cord from the back, the fourth ventricle from the occipital region, or the crista galli from the nasal bridge.

Symptoms
A Spinal Dermal Sinus may appear as a dimple or a sinus (open tract), with or without hairs, usually very close to the midline,

Diagnosis
If the tract is seen initially following birth, a MRI should be obtained. MRI also shows masses within the canal.

Treatment
Sinuses above the lumbosacral region should be surgically removed. Although approximately 25% of presumed sacral sinuses seen at birth will regress to a deep dimple on follow-up, it is recommended that all dermal sinuses should be surgically explored and fully excised prior to the development of neurologic deficit or signs of infection.

 

Split Cord Malformation
Split cord malformation (Diastematomyelia) is a complex congenital condition where the spinal cord is split into two halves, each half usually functioning normally. The presence of the tissue splitting the spinal cord causes tethering. The surgical procedure is to remove any tissue that is between the two split cords, thus releasing any tethering that is present.

symptoms?
The signs and symptoms of Diastematomyelia may appear at any time of life, although females are affected much more commonly than males. Pain is the number one reason patients will visit their doctor for this problem. Other common symptoms include a decrease in strength of the legs; loss of bowel and bladder control; sexual dysfunction; deformity of the legs, feet or hips; back or leg pain; loss of reflexes and sensation in the legs; and curvature of the spine.

prognosis
The presence of Diastematomyelia has no influence on the prognosis when spina bifida is present. When diastematomyelia presents as a closed neural tube defect, the prognosis for neurological function may be enhanced by early surgical removal of the septum, dural reconstruction into a single tube, excision of associated developmental masses and division of the tethering filum.

 

What should I do?

Visit a pediatric neurosurgery, he will guide you what has to be done ahead.

• Nuclear magnetic

Our Treatments

Spinal Disc

Multilevel cervical disc herniation with compression over the thecal sac

Lumbar intervertebral disc prolapse causing nerve root compression

 

Cervical intravertebral disc bulge

Vertebral disc is a soft sponge like structure between vertebral body.

It acts as a shock absorber in the spine, supporting structures holding vertebrae together, promotes mobility.

Disc degeneration

Over time, spinal discs dehydrate and become stiffer, causing the disc to be less able to be adjust to adjust to compression.

Disc herniation

Abnormal protrusion of disc causes compression of the nerves, causing pain, weakness, urinary complains.

Disc at cervical level causes pain and weakness in upper limb along with tightness in lower limbs and urinary complains.

Disc at Thoracic level causes band like sensation in chest along with tightness in the lower limbs and urinary complains.

Disc at Lumbar level causes pain and weakness in lower limb.

Causes:

Degenerated Disc

Sudden heavy weight lifting, twisting the upper body too quickly

 

Symptoms includes

Difficulty in holding pen, comb, making food bolus

Falling of objects from hand

Difficulty in combing hairs

Difficulty in standing from sitting position

Difficulty in climbing stairs

Back pain, electric shock like pain in legs or along the back

Foot, knee weakness

 

Back pain

Injury to the spinal joint, swelling of the joint, muscle spasm causes pain and restricted movements.

Signs

Pain going from back to knee or ankle, or thumb or elbow

Pain in back on coughing, sneezing

Pain on prolong sitting

Chronic back pain

Stress can also lead to muscle weakness and back pain.

Exercises strengthens the back muscles, provides the necessary tone, prevents disc herniation and stress related muscle and vertebral degeneration.

Symptoms of disc prolapse

Diagnosis

X ray spine: Abnormal reduction in disc space

MRI spine: Degenerated disc, abnormal protrusion of disc, bony compression

Nerve conduction study: Provides knowledge about the damaged nerve

Treatment

Bed Rest

Analgesic

Exercises

Local Injection

Surgery

Disc removal: Surgery to remove the prolapsed disc only

Bone fusion: To place screws and rod to stabilize the joint in case of spinal weakness.

 

 

 

Our  Treatments

 

Spinal trauma

 Spinal trauma refers to injuries that affect the spine, which is made up of a series of bones (vertebrae) that are connected by intervertebral discs and ligaments to provide support and flexibility to the body’s upper and lower segments (neck and back). Spinal injury can occur due to various reasons such as accidents, sports injuries, falls, and acts of violence. Here are some ways in which spinal injury can happen:

1) Falls: Falls are a common cause of spinal injury, especially in older adults. Falls can result in spinal fractures, dislocations, or compression fractures, depending on the force and direction of the fall.

2) Motor vehicle accidents (MVAs): MVAs are a leading cause of spinal injury due to high-impact forces that can cause fractures, dislocations, or spinal cord injury depending on factors such as speed, direction, and seatbelt use at impact time during MVA accidents. MVAs can also cause whiplash injuries that can result in neck pain and stiffness without any fracture or dislocation but can cause nerve root compression.

3) Sports injuries: Sports such as football, rugby, and gymnastics can result in spinal injuries due to high-impact forces, twisting motions, or falls. Common sports injuries include spinal fractures, dislocations, and spinal cord injury.

4) Acts of violence: Acts of violence such as assaults, stabbings, and shootings can result in spinal injuries due to high-impact forces, penetrating injuries, or blunt force trauma.

5) Medical procedures: Medical procedures such as surgeries, injections, or biopsies can sometimes result in spinal injury due to complications such as bleeding, infection, or nerve damage.

6) Degenerative diseases: Degenerative diseases such as osteoporosis, arthritis, or spinal stenosis can result in spinal injury due to weakened bones, joints, or spinal cord compression.

Spinal injury can have serious and long-lasting consequences, including paralysis, loss of sensation, and reduced mobility. It’s important for individuals to take precautions to prevent spinal injury, such as wearing protective gear during sports, using seatbelts while driving, and avoiding risky behaviors that can result in falls or acts of violence. If an individual experiences a spinal injury, it’s important to seek prompt medical care and follow their healthcare provider’s recommendations for treatment and follow-up care.

Types of spinal trauma and their potential consequences:

1) Fractures: Fractures are breaks or cracks in the bones of the spine that can result from spinal trauma such as MVAs or falls. Fractures can range from simple cracks to complete breaks, and can sometimes result in spinal instability or deformity.

2) Dislocations: Dislocations occur when the vertebrae are forced out of their normal position, which can result in nerve damage, spinal cord injury, or paralysis.

3) Compression fractures: Compression fractures occur when the vertebrae collapse, which can result in pain, deformity, and loss of height.

4) Spinal cord injury: Spinal cord injury (SCI) occurs when the spinal cord is damaged, which can result in paralysis, loss of sensation, or other neurological deficits depending on the location and severity of the injury.

5) Spinal instability: Spinal instability occurs when the spine is unstable due to injury or degeneration, which can result in pain, deformity, and the potential for further injury.

6) Spinal deformity: Spinal deformity occurs when the spine is misaligned or curved, which can result in pain, discomfort, and reduced mobility.

Reduce your risk of spinal injury:

1) Practice safe habits: Always wear seatbelts while driving or riding in a car, use stairs and ladders safely, and avoid risky behaviors that can result in falls or acts of violence.

2) Maintain a healthy weight: Being overweight or obese can put additional strain on your spine, increasing your risk of spinal injury. Maintaining a healthy weight through a balanced diet and regular exercise can help reduce this risk.

3) Exercise regularly: Regular exercise can help strengthen the muscles that support your spine, reducing your risk of injury. Low-impact exercises such as swimming, cycling, or yoga can be particularly beneficial for spinal health.

4) Lift properly: When lifting heavy objects, always bend at the knees and lift with your legs, rather than your back. This can help prevent spinal injuries such as herniated discs or strains.

5) Quit smoking: Smoking can weaken the bones in your spine, increasing your risk of spinal fractures and other injuries. Quitting smoking can help improve spinal health and reduce your risk of injury.

6) Manage chronic conditions: Chronic conditions such as arthritis or osteoporosis can weaken the bones in your spine and increase your risk of injury. Managing these conditions through medication and lifestyle changes can help reduce your risk of injury.

7) Wear protective gear: When participating in sports or other activities that involve a risk of injury to the spine or neck (such as football or gymnastics), always wear appropriate protective gear such as helmets or padding to help reduce the risk of injury.

By following these steps and taking precautions to prevent spinal injury whenever possible, you can help protect your spine and reduce your risk of serious and long-lasting consequences such as paralysis or loss of sensation.

Here are some steps for the care of spine trauma patients:

Stabilization: The first priority in the care of spine trauma patients is to stabilize the patient’s spine to prevent further injury. This may involve the use of immobilization devices such as backboards, cervical collars, or spinal splints to keep the spine in alignment during transport and initial evaluation.

Stabilization of cervical spine

Get help to lift the patient with spinal injury

2) Imaging studies: Imaging studies such as X-rays, CT scans, or MRI scans can help identify the extent and location of any spinal injuries, as well as any associated injuries such as fractures, dislocations, or spinal cord injury.

3) Neurological evaluation: A neurological evaluation should be performed to assess the patient’s level of consciousness, sensory and motor function, and reflexes. This can help determine the severity of any spinal cord injury and guide treatment decisions.

4) Pain management: Spine trauma patients may experience significant pain due to injuries such as fractures or dislocations. Pain management strategies such as medication, nerve blocks, or epidural anesthesia can help alleviate pain and discomfort.

5) Rehabilitation: Spine trauma patients may require rehabilitation to help regain strength, mobility, and function following their injury. Rehabilitation may involve physical therapy, occupational therapy, or speech therapy, depending on the nature and severity of the injury.

6) Follow-up care: Spine trauma patients may require ongoing follow-up care to monitor their recovery and manage any ongoing symptoms or complications. This may involve regular check-ups with a healthcare provider, as well as ongoing physical therapy or other rehabilitation services.

7) Prevention of complications: Spine trauma patients are at risk of developing complications such as pneumonia, urinary tract infections, or pressure ulcers due to immobilization and other factors. Preventative measures such as frequent turning and positioning, deep breathing exercises, and catheterization can help reduce the risk of these complications.

8) Collaborative care: Spine trauma patients may require input from a multidisciplinary team of healthcare providers, including physicians, surgeons, physical therapists, occupational therapists, and speech therapists, to ensure the best possible outcomes. Collaborative care can help ensure that all aspects of the patient’s care are addressed and that the patient receives the most appropriate and effective treatment possible.

Our Treatments

 

Spinal Tumors

A spinal tumor is an abnormal mass of tissue within or surrounding the spinal cord and/or spinal column. These cells grow and multiply uncontrollably, seemingly unchecked by the mechanisms that control normal cells. Spinal tumors can be benign (non-cancerous) or malignant (cancerous). Primary tumors originate in the spine or spinal cord, and metastatic or secondary tumors result from cancer spreading from another site to the spine.

They are referred in 2 ways

1. Depending on level on spinal column: Cervical, Thoracic, Lumbar, Sacral
2. Depending on the location in the spine
   1. Intradural extramedullary: The tumor is located inside the thin covering of the spinal cord (the dura), but outside the actual spinal cord. Frequency of occurrence in this location is 40%. The most common of these types of tumors develop in the spinal cords arachnoid membrane(meningiomas), in the nerve roots that extend out from the spinal cord (schwannomas and neurofibromas), or at the spinal cord base (filum terminale ependymomas).
   2. Intramedullary– These tumors grow inside the spinal cord. They typically derive from glial or ependymal cells (a type of glial cell) that are found throughout the interstitium of the spinal cord. Frequency of occurrence in this location is approximately 5%. Astrocytomas and ependymomas are the two most common types.
   3. Extradural– The tumor is located outside the dura, which is the thin covering surrounding the spinal cord. Frequency of occurrence in this location vs the ones above is approximately 55%. These lesions are typically attributed to metastatic cancer or less commonly schwannomas derived from the cells covering the nerve roots.

 

The bony spinal column is the most common site for bone metastasis. Estimates indicate that at least 30% and as high as 70% of patients with cancer will experience spread of cancer to their spine.

 

Common primary cancers that spread to the spine are lung, breast and prostate. Lung cancer is the most common cancer to metastasize to the bone in men, and breast cancer is the most common in women. Other cancers that spread to the spine include multiple myeloma, lymphoma, melanoma and sarcoma, as well as cancers of the gastrointestinal tract, kidney and thyroid.

 

Causes

The cause of most primary spinal tumors is unknown. Some of them may be attributed to exposure to cancer-causing agents. Spinal cord lymphomas, which are cancers that affect lymphocytes (a type of immune cell), are more common in people with compromised immune systems. There appears to be a higher incidence of spinal tumors in particular families, so there is most likely a genetic component.

In a small number of cases, primary tumors may result from presence of these two genetic diseases:

Neurofibromatosis 2: In this hereditary (genetic) disorder, benign tumors may develop in the arachnoid layer of the spinal cord or in the supporting glial cells. However, the more common tumors associated with this disorder affect the nerves related to hearing and can inevitably lead to loss of hearing in one or both ears.

Von Hippel-Lindau disease: This rare, multi-system disorder is associated with benign blood vessel tumors (hemangioblastomas) in the brain, retina and spinal cord, and with other types of tumors in the kidneys or adrenal glands.

Symptoms

Back pain, especially in the middle or lower back, is the most frequent symptom of both benign and malignant spinal tumors. This back pain is not specifically attributed to injury, stress or physical activity. Depending on the location and type of tumor, other signs and symptoms can develop, especially as a tumor grows and compresses on the spinal cord, the nerve roots, blood vessels or bones of the spine.

Additional symptoms can include the following:

• Loss of sensation or muscle weakness in the legs, arms or chest
• Stiff neck or back
• Pain and/or neurologic symptoms (such as tingling) increase with Valsalva manoeuvre
• Difficulty walking, which may cause falls
• Decreased sensitivity to pain, heat and cold
• Loss of bowel or bladder function
• Paralysis that may occur in varying degrees and in different parts of the body, depending on which nerves are compressed
• Scoliosis or other spinal deformity resulting from a large and/or destructive tumor

Testing & Diagnosis

A thorough medical examination with emphasis on back pain and neurological deficits is the first step to diagnosing a spinal tumor. Radiological tests are required for an accurate and positive diagnosis.

• X-ray: Application of radiation to produce a film or picture of a part of the body can show the structure of the vertebrae and the outline of the joints. X-rays of the spine are obtained to search for other potential causes of pain, i.e. tumors, infections, fractures, etc. X-rays, however, are not very reliable in diagnosing tumors.
• Computed tomography scan (CT or CAT scan): A diagnostic image created after a computer reads X-rays, a CT/CAT scan can show the shape and size of the spinal canal, its contents and the structures around it. It also is very good at visualizing bony structures.
• Magnetic resonance imaging (MRI): A diagnostic test that produces three-dimensional images of body structures using powerful magnets and computer technology. An MRI can show the spinal cord, nerve roots and surrounding areas, as well as enlargement, degeneration and tumors.
• Bone Scan: A diagnostic test using Technectium-99. Helpful as an adjunct for identification of bone tumors (such as primary bone tumors of the spine), infection, and diseases involving abnormal bone metabolism.

Radiology studies noted above provide imaging findings that suggest the most likely tumor type. In some cases, however, a biopsy may be needed if diagnosis is unclear or if concern for malignancy vs benign tumor type.

Treatment

Treatment decision-making is often multidisciplinary, incorporating the expertise of spinal surgeons, medical oncologists, radiation oncologists and other medical specialists. The selection of treatments including both surgical and non-surgical is therefore made keeping in mind the various aspects of the patient’s overall health and goals of care.

Non-Surgical Treatments

Nonsurgical treatment options include observation, chemotherapy and radiation therapy. Tumors that are asymptomatic or mildly symptomatic and do not appear to be changing or progressing may be observed and monitored with regular MRIs. Some tumors respond well to chemotherapy and others to radiation therapy. However, there are specific types of metastatic tumors that are inherently radioresistant (i.e. gastrointestinal tract and kidney): in those cases, surgery may be the only viable treatment option.

Surgery

Indications for surgery vary depending on the type of tumor. Primary (non-metastatic) spinal tumors may be removed through complete en bloc resection for a possible cure. In patients with metastatic tumors, treatment is primarily palliative, with the goal of restoring or preserving neurological function, stabilizing the spine and alleviating pain. Generally, surgery is only considered as an option for patients with metastases when they are expected to live 3 – 4 months or longer, and the tumor is resistant to radiation or chemotherapy. Indications for surgery include intractable pain, spinal-cord compression and the need for stabilization of pathological fractures.

Lesion at C7 level arising from the dural covering causing compression over the cord

Our Treatments

 

Trigeminal neuralgia

Trigeminal neuralgia (TN) is a chronic neurological disorder that affects the trigeminal nerve, which is responsible for carrying sensations from the face to the brain. TN is characterized by sudden, severe, and recurrent episodes of pain in the face, typically in the areas that correspond to one or more branches of the trigeminal nerve (hence its name).

Trigeminal branches

The ophthalmic, or upper, branch supplies sensation to most of the scalp, forehead, and front of your head.

The maxillary, or middle, branch stimulates your cheek, upper jaw, top lip, teeth and gums, and to the side of the nose.

The mandibular, or lower, branch supplies nerves to your lower jaw, teeth and gums, and bottom lip.

 

1) Aging: TN is more common in older adults, as the nerves in the face can become more sensitive and prone to irritation as we age.

2) Multiple sclerosis: Individuals with multiple sclerosis (MS) are at increased risk for developing TN due to the damage that MS can cause to the nervous system, including the trigeminal nerve.

3) Dental procedures: Dental procedures, such as extractions or fillings, can sometimes trigger or exacerbate TN due to the close proximity of the trigeminal nerve to the teeth and gums.

4) Trauma: Trauma to the face, such as a blow to the jaw or a fall, can sometimes cause TN due to the damage that the trauma can cause to the trigeminal nerve.

5) Tumors: Tumors that grow near the trigeminal nerve can sometimes cause TN due to the pressure that the tumors put on the nerve.

6) Medications: Certain medications, such as antidepressants or antiseizure medications, can sometimes cause TN as a side effect.

7) Vascular compression: In some cases, the blood vessels in the brain can compress the trigeminal nerve, causing TN.

Diagnosis

MRI brain with CISS/ FIESTA sequence showing compression of the trigeminal nerve by a vessel.

 

 

 

Treatment

Treatment for TN typically involves a combination of medication, surgery, and lifestyle changes. Medications such as anticonvulsants, antidepressants, and opioids can help to manage the pain, while surgery to decompress the trigeminal nerve or destroy the nerve can sometimes provide long-term relief from symptoms. Lifestyle changes such as avoiding triggering factors (e.g., cold temperatures, touching the face, or brushing teeth), practicing relaxation techniques (e.g., meditation or yoga), and maintaining a healthy diet and exercise routine can also help to manage.

 

 

 

 

 

 

 

 

 

 

 

Imaging showing neurovascular conflict. (black arrow) shows trigeminal nerve over the basilar artery causing thining of the nerve