POST-PARTUM CEREBRAL VENOUS THROMBOSIS (CVT)

POST-PARTUM CVT (CLOTTING OF BLOOD IN BRAIN VEINS)

Introduction

Pregnancy and delivery are normal physiological processes, which are experienced by more than 95% of women. Delivery and arrival of a newborn is a cause of joy and celebration all across the world. However, due to the normal physiological changes (and certain other factors), mothers in the post-natal period are prone to develop certain diseases. Cerebral venous thrombosis is one such major illness.

What happens in cerebral venous thrombosis?

Brain has two kinds of blood vessels- arteries that transport blood to the brain from the heart, and veins that drain the blood out of brain towards the lungs for purification. In CVT, blood in the brain veins clot (get thrombosed), which impedes the blood flow.

What are the clinical features of CVT?

• Headache
• Vomiting
• Blurred vision, double vision, dimness of vision
• Fits or convulsions
• Weakness of hands or legs especially on one half of the body

Who are the women prone to develop cerebral venous thrombosis?

• Women with severe blood loss during delivery- such as after caesarian section, etc.
• Those who already had low hemoglobin (less than 10 gm%) before delivery
• Women who are dehydrated- such as after prolonged labor, those who can't eat or drink properly after delivery, extreme weather conditions, etc. (In India, in certain cultures, women after delivery are kept isolated in a room, and they fast, which makes them dehydrated too)
• Those with post-partum infections
• Those with deficiency of anti-clotting factors (which increases the clotting tendencies)

How can CVT be diagnosed?

If any woman in post-natal period develops features suggestive of CVT (such as headache, drowsiness, seizures, weakness, visual problems, etc), they should immediately contact the neurologist.

CT scan or MRI scan with venography can be done within a few minutes and the diagnosis of CVT can be confidently made.

Further tests (blood tests) may be done to detect the reasons for blood clotting in the brain.

How is CVT treated?

1. Patients are started on hepain injections, which are anticoagulants, as early as possible. After a period of 5-7 days, they are changed over to oral anticoagulants (warfarin, etc), which may be required for 3-6 months.
2. Anti-epileptic drugs are used for those with fits.
3. Certain medicines (steroids, mannitol) are given to reduce the brain swelling.
4. Glucose and saline infusions are given to maintain hydration.
5. Anemia is corrected (blood transfusion may be required in more severe cases)
6. Any co-existing infections are treated.

What is the outcome of CVT after treatment?

Patients do very well and recover fast. Most women recover fully, without any neurological deficits. A minority may have seizures or mild weakness or other neuro deficits.

If you require any further information, please send me an email at drsudhirkumar@yahoo.com

DR. SUDHIR KUMAR MD (Medicine), DM (Neurology)
Senior Consultant Neurologist
Apollo Hospitals, Hyderabad
Phone- 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com

VITAMIN B12 DEFICIENCY AND NEUROLOGICAL DISORDERS

Neurological Disorders due to Vitamin B12 Deficiency

Vitamin B12 is an important vitamin required for proper functioning of nervous system. Deficiency of vitamin B12 leads to anemia (low hemoglobin) causing generalised weakness, tiredness and fatigue. In addition, it is an important cause of various neurological disorders.

Common manifestations of vitamin B12 deficiency:

1. Tingling or numbness of feet and hands (due to involvement of peripheral nerves)
2. Imbalance while walking (due to spinal cord involvement)
3. Memory impairment
4. Dementia (due to brain involvement)
5. Psychiatric disturbances
6. Uncommonly, fits, tremors, parkinsonism, etc have also been reported.

Who are prone to get vitamin B12 deficiency?

1. Pure vegetarians- Vegetarian diet is a poor source of vitamin B12, hence, symptoms of vitamin B12 deficiency are more common in veg people.

2. Those with gastro-intestinal disorders such as malabsorption (where food is not properly absorbed after eating, manifested by diarrhea), after certain gastric surgeries, etc.

3. Those with other autoimmune diseases such as hypothyroidism (lack of thyroid hormone), vitiligo (white patches on skin), myasthenia gravis (manifested by muscular weakness and fatigue). This is because presence of auto-antibodies may inhibit the absorption of vitamin B12 in the gut.

How to prevent vitamin B12 deficiency?

1. Eating diet rich in vitamin B12 can prevent vitamin B12 deficiency. All animal sources are excellent sources of vitamin B12, such as meat, chicken, fish, shrimps, eggs, etc. Since, vitamin B12 can be stored in the body for long, 1-2 servings per week may suffice in normal people. No plant source is a good and reliable source of vitamin B12.

2. Regular check ups- If you notice any of the symptoms of vitamin B12 deficiency (as listed above), consult your family physician/neurologist so that it can be diagnosed and treated early.

How to diagnose vitamin B12 deficiency?

1. Vitamin B12 level can be estimated in blood. It is a simple investigation available in most labs.

2. Further tests may be required to see the effects of vitamin B12 deficiency on nervous system or to ascertain the cause of vitamin B 12 deficiency.

How is vitamin B12 deficiency treated?

Once vitamin B12 deficiency is establilshed (after clinical exam and blood tests), patients are started on vitamin B12 supplements. Initially, injections are given, so as to prevent the problem of less absorption. Then, maintenance treatment is given with oral tablets of vitamin B12.

What is the outcome of treatment?

Most patients who are diagnosed and treated early show a good recovery, which, however, may be prolonged over weeks to months.


Dr Sudhir Kumar MD (Medicine) DM (Neurology)
Consultant Neurologist
Apollo Hospitals, Hyderabad
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com

SHARING NEGATIVE MEDICAL NEWS WITH CHILDREN

SHOULD WE DISCUSS "BAD NEWS" WITH CHILDREN-
a real life experience

We often come across younger patients especially children who are diagnosed to have illnesses with relatively poor outcomes. These may include a child diagnosed to have cancer of blood (leukemia) or cancerous tumor of brain (glioma), etc, which could prove fatal in some cases. In our normal medical practice, we discuss in detail about the disease with the patients and immediate family members. Areas of discussion involve the nature and likely progression of disease, the likely causes of the disease, the different modes of treatment (including cost of medicines or surgery, as the case may be) and the expected outcomes of disease & treatment.

In case of children, parents often tell us not to share any medical details with the child, fearing the child would get depressed or anxious or they won't be able to handle the "bad news" and many other excuses. Sometimes, we are asked to tell a lie to the child- for example, in stage IV glioma of brain, the expected survival could be 6 months to 12 months. In this scenario, parents usually ask us to tell the child that "he does not have tumor" and that "there is no risk to his life because of the illness".

Are we justified in not sharing medical details (bad news) or distorting the facts to child patients?

I want to share an experience that I recently had.

An 8-year-old child Arjun was referred to me by the oncologist for control of convulsions (fits). Arjun was diagnosed to have grade IV (late stage cancer) glioma of brain and was receiving chemotherapy after having undergone a brain operation. In my OPD, Arjun's parents met me first and requested me not to disclose anything about the illness to him, including the diagnosis and likely outcome, and lie to him that "he will be well soon". They told me that Arjun does not know anything about his illness or its outcome. I told them I would do what they expected of me.

When parents brought the child in, he looked very calm and composed. He was on a wheel-chair as he could not walk due to weakness of legs (nerves in brain that send signals to legs were damaged by the brain tumor). He had a beautiful smile on his face. While interacting with him, I found him to be very intelligent and smart. I asked his parents if I could privately talk to Arjun and they agreed. As soon as his parents left the room, Arjun told me he knows everything about the illness. He had read the doctors' medical notes and then browsed the internet to find out more about his illness. He told me that he has grade IV glioma and that at the best, he would survive for six months. He told me not to disclose to his parents that he already knows everything about his illness; otherwise they would feel "hurt".

Next I sent Arjun out and told his parents about the interaction I had with the child. They stood speechless and expressionless. They were shocked! Here, we had a family living in denial....that the other party does not know anything!.

Today, obtaining information is easy to get. One can get all desired information about a disease with a few clicks on the internet. So, hiding information from a child is not so easy. On the other hand, I feel sharing all details over 2-3 meetings is more appropriate. It is more important in situations where the child has a terminal illness. The child can be allowed to spend a quality time with family and friends and be allowed to fulfil any of his wishes during that period. In my clinical practice, I prefer to tell everything about the illness to my patients- old or young, men or women....unless, of course, they don't want to know (which is very rare).

(Arjun is the changed name to hide identity of the patient)

Dr Sudhir Kumar MD (Medicine) DM (Neurology)
Consultant Neurologist
Apollo Hospitals, Hyderabad, India
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com

Importance of timely treatment in brain stroke (paralysis)

STROKE TREATMENT: Benefits the most within the FIRST 4.5 HOURS

Brain stroke, commonly causing paralysis of one half of the body (called as "lakwa" in Hindi) is among the top 3 causes of death and disability in the world (the other two being heart attack and cancer). Stroke brings about a sudden transformation in the sufferer's life. A completely independent person may become paralysed, making him/her dependent on others for even their basic needs such as bathing, toileting and feeding needs.

Moreover, stroke is a major cause of financial burden for the sufferer. The patient is unable to attend to his job due to disability leading to the loss of income. In addition, the treatment of stroke and caring for the stroke patient adds to the financial burden.

Therefore, it is important to recognize and treat stroke at the earliest. There is only a single approved treatment for brain stroke- thrombolysis (or clot-buster therapy) using a drug called as tissue plasminogen activator (tPA). The point to note is that this medicine should be started within 4 hours and 30 minutes of onset of brain stroke to achieve maximum efficacy and to avoid any complications.

Success of the treatment being linked to time after symptom onset, makes it mandatory to identify the stroke symptoms and transportation to a recognized stroke center at the earliest a priority. In Hyderabad, Apollo Hospital at Jubilee Hills is accredited by Joint Commission International (JCI, USA) for the management of acute stroke since April 2006.

In the best centers for stroke treatment, there is a stroke team comprising of an emergency physician, neurologist, radiologist, physiotherapist, intensivist, dietician, etc. There is a standard protocol for taking care of patients with stroke. The ER is notified beforehand about the expected stroke patient, which in turn alerts the stroke team. As soon as the patient reaches ER, a clinical examination is carried out to ascertain the stroke. CT scan is immediately done (within 20 minutes of arrival to ER). Blood tests are done to ascertain the patients' eligibility for thrombolytic therapy. These reports are obtained and treatment started within 45 minutes of patients' arrival to ER (i. e. door to needle time is less than 45 minutes). Stroke unit and treatment at Apollo Hospitals, Jubilee Hills, Hyderabad, adheres to all the above.

Dr Sudhir Kumar MD (Medicine) DM (Neurology)
Consultant Neurologist
Apollo Hospitals, Hyderabad
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com

EPILEPSY- Is it treatable?

What is epilepsy?

Epilepsy is a neurological disease characterized by repeated abnormal electrical discharges from the brain, resulting in fits or convulsions. Either a part of the body can be involved called as partial or focal epilepsy; or the whole body is affected called as generalized epilepsy. During a generalized epileptic attack, the person can lose complete consciousness resulting in falls or injuries.

 How is epilepsy diagnosed?

Epilepsy is diagnosed on the basis of clinical description of the seizure episode. So, it is important for the eye witness to accurately describe it to the neurologist. Doctor may get brain scans and EEG to confirm the cause and type of seizure.

Is epilepsy treatable?

Epilepsy is very well treatable with medications (anti-epileptic drugs). Neurologist would be able to select the best medication depending on the type of epilepsy and also age & sex of the patient. The medicines are required to be taken for long-term without any discontinuation.

Can women with epilepsy get married?

Women with epilepsy can get married and have normal married lives. They can get pregnant and have babies just like other women. Neurologist would advise on the safe anti-epileptic drugs in pregnancy and some vitamins (folic acid) are also required. Please discuss regarding any concerns with your neurologist.

Can people with epilepsy do normal jobs?

Most jobs are safe for people with epilepsy. However, they should avoid driving, swimming and other hazardous activities, as occurrence of seizures during these activities can be dangerous.

Is epilepsy a result of bad evils/demons?

No, they are only misconceptions.

What are the first aid measures to be adopted when someone has an epileptic attack?

1. Make the person lie down on one side (either left or right)
2. Do not give water or anything else by mouth, as it can get aspirated into lungs (causing pneumonia) in an unconscous person.
3. Try to prevent any injury because of fall or tongue bites.
4. Intra-nasal midazolam may be safely given at that time.
5. There is no point giving any keys or any other metals in person's hands, or making him smell handkerchief or socks.
6. Take him to the nearest clinic/hospital at the earliest.

Dr Sudhir Kumar MD (Medicine), DM (Neurology)
Senior Consultant Neurologist
Apollo Hospitals, Hyderabad
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com

Homocysteine in heart and brain disease

IMPORTANCE OF HOMOCYSTEINE

Myocardial infarction (heart attacks) and brain strokes (paralysis) are the two most common causes of death and disability in the world. They occur in all regions of the world, and the prevalence increases with advancing age.

There are a number of known risk factors for causing heart attacks and brain strokes, which include high BP, diabetes, high cholesterol, smoking, positive family history and so on.

Role of homocysteine in heart attacks and brain strokes

• Homocysteine is a normal amino acid in our blood.
• However, elevated levels of homocysteine in the blood is an additional risk factor for causing atherosclerosis (narrowing of blood vessels for heart and brain).
• Elevated levels of homocysteine causes injury to the inside of blood vessel.

Though there are no definite reasons for elevated homocysteine levels, they tend to occur more in smokers and pure vegetarians.

It is easy to identify high homocysteine, by doing a simple blood test in fasting state.

Treatment of elevated homocysteine is also easy. One needs to use certain vitamins (folic acid, and other B group vitamins).
Please consult your neurologist for any further information.

Dr Sudhir Kumar MD (Internal Medicine) DM (Neurology)
Senior Consultant Neurologist
Apollo Health City, Hyderabad
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com

How to diagnose migraine?

How is MIGRAINE DIAGNOSED?

Introduction

Migraine is the commonest cause of headache in the world, affecting about 15% of all women and 5% of all men. It affects younger people, affecting their education or employment. It is important to make an early and accurate diagnosis of migraine so that the best treatment can be started early.

Diagnosis of migraine is based on clinical signs and symptoms and usually no investigations are necessary.

Following features are suggestive of a migraine:

1. Headache- classically on one side of the head, but it may occur on both sides, it is described as pulsatile or throbbing type. Headache episodes last for more than 4 hours, and upto 72 hours.
2. Nausea (a feeling of vomiting) or vomiting
3. Photophobia or phonophobia- headache gets worse on exposure to bright light or noise.

Following features may not be suggestive of migraine and in these cases, one should consult a neurologist (a brain scan may be necessary):

1. Most severe headache of the lifetime,
2. Early morning headaches,
3. Drowsiness along with headache,
4. Weakness of one side of body,
5. Occurrence of fits or convulsions.

If you notice any of the above symptoms, please contact your neurologist or family doctor.

Dr Sudhir Kumar MD (Internal Medicine) DM (Neurology)
Senior Consultant Neurologist
Apollo Hospitals, Hyderabad, India
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com

What are the risk factors for brain stroke?

RISK FACTORS FOR BRAIN STROKE

Brain stroke is a medical emergency, which is characterized by sudden onset weakness or paralysis of one half of the body. Other disabilities may include inability to speak, impaired vision, severe headache or imbalance while walking.

Risk factors for brain stroke include modifiable and non-modifiable factors:

Modifiable factors:

• Obesity,
• Smoking,
• High blood pressure,
• Diabetes mellitus,
• Elevated cholesterol
• Elevated homocysteine levels
• Cardiac diseases
• Stress

Non-modifiable risk factors for stroke include:

• Older age
• Family history of brain stroke
• Male sex

It is important to get regular check-ups done to identify any risk factors for stroke. If any of the above conditions are identified, proper treatment would ensure a stroke-free life. In case of any stroke-like symptoms, you should immediately contact your neurologist/family doctor.

Dr Sudhir Kumar MD (Internal Medicine) DM (Neurology)
Senior Consultant Neurologist
Apollo Hospitals, Hyderabad, India
Phone- 0091-4023607777/60601066
Email: drsudhirkumar@yahoo.com