Successful aging and living with adversity

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                             Successful aging and living with adversity

Nitin K Sethi, MD

 

        Comprehensive Epilepsy Center, Department of Neurology, NYP-Weill Cornell Medical Center, New York, NY (U.S.A.)

Address for Correspondence:

NK Sethi, MD

Comprehensive Epilepsy Center

Department of Neurology

NYP-Weill Cornell Medical Center

525 East 68th Street, York Avenue

New York, NY 10021

Fax: 212-746-8984

Email: sethinitinmd@hotmail.com

I read a very fascinating article recently in the Journal of Neurology Neurosurgery and Psychiatry about successful aging in adversity. We all want to age successfully . Successful aging though is just not about escaping illness as the authors (Livingston et.al) point out but also of having a positive attitude towards one’s life despite poor health. In their study they interviewed patients with dementia to find out how they view their aging. To my pleasant surprise they found that many people with dementia feel that they are aging successfully and rate their quality of life as good. This may be against what their caregivers feel. I should add these were people with mild to moderate and not severe dementia.

So how can we age successfully both in health and disease? Well if you are healthy, good then the odds are with you. Your quality of life is good, you have no physical or mental impairments due to disease and if you maintain a positive attitude and avoid depression and anxiety successful aging can be readily achieved. Exercise regulary, keep your mind occupied (read books, watch television, read the newspaper), maintain good and healthy social interactions (surround yourself with family and friends, date if you are single) and hey you are on your way to aging successfully.

But what if you are sick?  Is successful aging possible in adversity. YES as the study points out. It is very much so. What is needed is good mental health and social relationships. Have a positive frame of mind. The study points out that an individual’s underlying resilience plays a big role in successful aging and even though the disease may progress as time goes by, the individual shall still continue to feel he is aging well. Again the importance of mental health is stressed. Avoiding depression and anxiety is the key to successful aging in the face of adversity. The importance of social relationships and support of family and friends cannot be stressed more.

Well there you have it, maybe a small piece to the puzzle of successful aging and at least to some of us in the face of adversity.

 

Parkinson’s disease: when to treat and how?

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Recently I was asked by someone when should we treat a patient with Parkinson’s disease, early on in the disease course or later when the clinical symptoms are more florid? As you know Parkinson’s disease is a progressive neurodegenerative condition characterized by tremor (resting tremor of the limbs, see my post on tremors http://braindiseases.info), rigidity (stiffness), bradykinesia (patients have less spontaneous movements) and a characteristic disturbance of gait and posture (patients walk stooped forward and their balance is off, making them more prone to falls).

As you can well imagine all these symptoms do not start off all at once. Infact the onset of Parkinson’s disease is quite insidious and generally asymmetrical. In its earliest stages, all the patient may have is a unilateral (one hand) tremor. Later as time goes by and the disease progresses the symptoms become more florid and the bardykinesia and disturbance of gait and posture appear.

So that brings us to the question of my post, just when do we start treating these patients? Should we treat them early or should we treat them in the later stages?

There is no good answer to this question. One concern which has been raised is that if you treat patients with Parkinson’s disease with levodopa/ syndopa (the combination is called Sinemet in The United States), early on in the disease course, the drug itself may hasten the progression of the disease (the thinking behind this is the concern that levodopa may increase the breakdown of dopamine secreting cells in the basal ganglia).

On the other hand, there is some evidence to suggest that early treatment is better because it prevents the compensatory change in hardwiring which occur in the brain in the face of decreasing dopamine (some of the neurons such as that of the subthalamic nucleus become overactive in the face of decreasing dopamine secretion and this later on leads to more problems such as the on-off phenomena).

So what is the answer? I think a patient should be treated when he devlops symptoms that start bothering him or interfere with his functioning and activities of daily living. If that occurs early in the disease course, so be it, he warrants treatment. Nowdays apart from levodopa/syndopa (Sinemet) there are many other drugs which can be used to treat the disease especially in the early phases. These drugs ( dopamine agonists like Requip (Ropinirole) and Mirapex (Pramipexole) and selegine) are less stronger than levodopa/syndopa combination but are thought to have less “neurotoxicity” and hence are preferred to be used in the early stages of the disease.

Your doctor shall help you navigate these questions. Have a good weekend everyone. It is Saturday morning here in NYC as I pen this, I think I shall go for a run.

Personal Regards,

Nitin Sethi, MD

Diabetic neuropathy: how to deal with it

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In this post lets discuss about diabetic neuropathy. Diabetes is one of the most common causes of neuropathy. Neuropathy is a general term which refers to any condition which involves the nerves of the body. Diabetes involves the peripheral nerves of the body and can also involve the cranial nerves. The damage to the peripheral nerves is thought to be mediated by the increased levels of glucose and other metabolic factors in diabetic patients.

As I have stated in my earlier posts (see by my website http://braindiseases.info) neuropathies can be of different types. One may have a motor neuropathy in which only the motor nerves of the body are involved (hence patients present with weakness), one may have a predominantly sensory neuropathy in which the sensory nerves of the body are involved ( patients present with sensory complaints of numbness, tingling, pins and needles sensation) or one have a mixed sensory motor neuropathy (patients have a combination of motor and sensory findings in varying proportion).

Diabetes usually causes a mixed sensory motor neuropathy.

Clinical presentation: So how do patients with diabetic neuropathy present clinically? Well most patients seek medical help when they are bothered by dysesthesias (dysesthesias refers to uncomfortable sensations like feeling a part of the body usually the feet and hands are numb or “dead”, patients may also complain of feeling pins and needles sensation, tingling, burning etc). Patients with diabetic neuropathy have allodynia ( a condition in which a non-painful stimulus feels painful. Let me explain with an example. Suppose I touch your feet with a feather, you are not going to feel that as a painful stimulus. Now if I do the same to a patient with diabetic neuropathy, he may perceive that as a painful stimulus). They also have hyperpathia ( a condition in which the patient experiences a greatly exaggerated pain sensation to painful stimuli. Let me explain this with an  example. I touch the same diabetic patient’s leg with a sharp pin. Now any healthy person shall perceive this as a painful stimuli but to a patient with diabetic neuropathy, the pain may be so intense that it might be unbearable).

We sometimes divide these sensations experienced by patients with neuropathy into positive and negative symptoms.

Postitive symptoms include sensations of burning, pins and needles, pain etc while negative symptoms include sensations of feeling a part is numb or “dead”. It is easier to treat and control the positive symptoms while negative symptoms are more hard to treat.

The neuropathy in diabetes is length dependent (by that I mean, the longest nerves are the first to get involved). Hence symptoms first start in the feet (numbness in the toes etc and then proceed upwards. As the neuropathy progresses patients complain of numbness in the feet, then ankles, then shin, finger tips and so on).

Diagnosis of diabetic neuropathy: so now we come to the question of how do we diagnose diabetic neuropathy. The diagnosis of neuropathy is mostly clinical. If you are a diabetic patient presenting to a neurologist with compliants of numbness and tingling in the hands and feet, the diagnosis is readily apparent. Your doctor may test with with a tuning fork (to dtermine how well you perceive vibration), a disposable pin (pain sensation) and shall be able to determine if you clinically have an evidence of neuropathy or not. If the diagnosis is not apparent, he may order other tests like a Nerve Conduction Velocity test (we call this a NCV). During a NCV study, we check for the conduction of a nerve and whether it is delayed or not (this is done by giving a short electrical stimulus and then recording the response as it travels down the length of the nerve. As we are applying a short electrical current as stimulus, patients at times are not very comfortable during the test. The NCV study also helps in grading the severity of the neuropathy and helps in following the response to treatment.

Management of diabetic neuropathy: the management of diabetic neuropathy is twofold. One is the treatment of the underlying disease process (in this case the diabetes which is the cause of the neuropathy in the first case) and the other is the treatment of the neuropathy itself (how to control its symptoms so patients are not bothered by the sensations of numbness, tingling etc).

First and foremost in the managment of diabetic neuropathy, one should ensure good control of the blood sugar. Studies have shown that neuropathy develops in those diabetics who have uncontrolled or poorly controlled blood sugars. Hence aiming for euglycemia is essential (euglycemia means normal or near normal blood sugars). There are oral medications as well as insulin which can be used to achieve euglycemia and your doctor shall guide you in this. It is also essential to follow the blood sugars on a periodic basis so that one is sure that the blood sugar is well controlled.

There are many medications available to treat neuropathic symptoms. Some anti-depressants and anti-convulsants group of drugs are used for this purpose. The role of complimentary therapies like acupuncture, acupressure is not clearly determined as there are not many scientific studies to determine whether these are truly beneficial.

Patients should be advised about the importance of skin and foot care. Patients with diabetic neuropathy are prone to ulcers and infections in the foot, hence the feet should be kept clean and dry, avoid wearing ill fitting shoes and always always do wear clean pair of socks.

I hope this is useful to some of you.

Personal Regards,

Nitin Sethi, MD

Infantile spasms and hypsarrhythmia: what do we know?

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One of my readers emailed me and asked me to talk a little about infantile spasms and hypsarrhythmia as he has a niece who has been diagnosed with this condition. So in this post we shall talk about the same.

First and foremost the term hypsarrhythmia does not refer to a disease, it actually refers to a characteristic EEG pattern seen in some infants who have infantile spasms (their EEG shows some special features and is characteristic for their disorder). So what do we mean by infantile spasms. Infantile spasms as the name suggests are spasms which occur in infants (by infants I mean less than one year of age). These are special kind of seizures in which the infant is noted to have spasm like movements. It is hard to describe what spasms look like clinically but they can be of 2 types: extensor spasms and flexor spasms (the infant is noted to have sudden abduction of the arms and legs, a good example would be to imagine what you would do if some one suddenly frightens you: you shall suddenly jerk and abduct your arms and legs).

In infantile spasms, infants have flexor and extensor spasms. They usually occur in clusters and sometimes an infant may have as many as 15-20 spasms in 5 mins. These spasms represent seizures and when you do an EEG on these infants you do find characteristic EEG findings suggestive of seizures. This now brings us to the term hypsarrhythmia. As I stated earlier this refers to the EEG of a child with infantile spasms (the EEG is disorganized, of very high amplitude and shows multi-focal epileptiform activity. By multi-focal I mean, that there are many spots/ areas in the brain which shows signs of epileptogenicity). Infants who have infantile spasms may also have other types of seizures as they grow up. They may have seizures characterized by sudden jerks (we call these myoclonic jerks) and other more typical seizures where-in they have jerks of the arms and legs.

Etiology/ causes of infantile spasms: an infant may have infantile spasms and no cause may be determined even after a good work up. In that case the condition is referred to as idiopathic infantile spasms (idiopathic meaning for which no cause is determined). Usually though in most infants a cause for infantile spasms can be determined after a thorough work up. Work-up for infantile spasms usually should be carried out in a big center where the doctors have sufficient experience in dealing with these complicated cases. The doctor shall order many tests. Some of them include an EEG (at times the doctor might admit the infant and do a more prolonged EEG test. This is called a video-EEG monitoring test). Other tests which may be carried out include imaging studies of the brain such as an MRI (children and babies usually have to be sedated prior to the MRI test), tests of the blood to rule out any metabolic and storage diseases etc.

Once the diagnosis is secured and the etiology determined, then the question of management arises. Management involves 2 issues, one is the management of the underlying condition which is the cause of the infantile spasms (if the spasms are idiopathic we do not have to deal with this issue), the other is the management of the spasms/ seizures itself.

Infantile spasms usually respond to ACTH (adrenocorticotrophic hormone), a type of steroid preparation. It has been seen that when infants are started on ACTH, their spasms may completely stop and their EEG may also normalize (that is the hypsarrhythmia pattern goes away). There are other drugs which can be used too and your doctor shall help you in deciding the best option. It has been noticed that in some infants as the ACTH is stopped the spasms come back.

It is important that infantile spasms be detected and treated in time because ongoing spasms effect the cognitive development of the child and may lead to developmental arrest.

I hope this shall be helpful to some of you. If you seek more information, please do let me know.

Personal Regards,

Nitin Sethi, MD

Tip of the tongue and “senior moments”: the truths behind dementia

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Tip of the tongue and “senior moments”: the truths behind dementia

Nitin K Sethi, MD

 

        Comprehensive Epilepsy Center, Department of Neurology, NYP-Weill Cornell Medical Center, New York, NY (U.S.A.)

 

Address for Correspondence:

NK Sethi, MD

Comprehensive Epilepsy Center

Department of Neurology

NYP-Weill Cornell Medical Center

525 East 68th Street, York Avenue

New York, NY 10021

Fax: 212-746-8984

Email: sethinitinmd@hotmail.com

I read an interesting article in the Wall Street Journal by Melinda Beck titled ” The science behind senior moments”. In it she talks about “senior moments”-episodes where-in you are temporarily unable to recall a name, forget a number (like the telephone number of a close friend or a relative) or enter a room and forget what you were supposed to do. Just what do these “senior moments” represent-are they just signs of normal aging process or are they a warning sign of impending dementia?

Let me give you an example. Let us assume you are watching a movie starring Cary Grant. You see Cary Grant on the screen, you know who he is but for the life of you, you cannot recall his name. we call this the “tip of the tongue” syndrome. You have the name on the tip of your tongue but are unable to get it out. We all have older family members and friends. We notice that at times they are more forgetful. They forget their keys, forget names: are these “senior moments” or are they signs of dementia? Is there anything called senile dementia? (that is dementia occuring due to old age itself, not due to a neurodegenerative condition like Alzheimer’s disease).

Before we discuss this further, we should try to understand how memories are formed and stored in the brain. In simple terms we first register and encode memory, then this is stored and finally it is retrieved. What do i mean by this? Well the first thing which occurs is registration and encoding. For one to retain memory, one must first register what one is trying to remember. Let me explain this with an example. Lets assume you are reading a book. At the same time you are watching the TV and talking to your friend on the phone (that is you are multi-tasking). Now if I ask you to recall what you just read, it is possible that you shall not be able to do so well. Why? This is because your attention was divided and hence you never really registered what you were reading in the first place. If you did not register, you did not commit it to your memory and hence you cannot recall it. So first lession is that when you are trying to memorize something, make sure you pay attention.

Then comes consolidation and storage of memory, the process by which the brain stores the memory. Memory is usually stored in the temporal lobes and the hippocampus. This is a complex process and a lot is still not known how exactly are these memory programs laid down in the brain. Consolidation and storage of memory ensures that the memories become more permanent. There is some data to suggest that consolidation and storage of memory occurs at night while we are asleep. Maybe there is some truth to grandma’s saying of getting a good night sleep before a big examination.

Finally is the process of retrieval. This is the process by which we are able to recall an old memory. One can have a problem at any step of this memory process. Patient’s with Alzheimer’s dementia usually have a problem with both consolidation and retreival. Someone who is intoxicated but does not have Alzhemier’s dementia like an alcoholic shall have problems with encoding as he is delirious.

Now that we know how memory is formed, I want to stress that the tip of the tongue syndrome occurs in many healthy people. Why does it occur? Why is there a temporary memory block which then clears by itself and we are able to remember everything? No one quite knows the answers to these questions.

Senior moments though (especially if they are occuring in the senior population above the age of 65) deserve a more closer look. Is the problem episodic (comes and goes) or is it constant (always present)? Is is static and stable or is it progressive? Does it involve just one domain of memory (like names) or is it more widespread involving multiple domains (not just names but things like forgetting how to drive a car, problems with calculations and abstract thinking etc).

If the above are present, then it is not senior moments and is more likely to be dementia. Some neurologists doubt if something like senile dementia actually exists. We all have met some elderly people with razor sharp memory.

That in essence is the truth behind senior moments and the tip of the tongue syndrome.

Radiation therapy: some facts

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Hello everyone, it is Memorial day as I sit down to pen this. Thought since we were on the topic of management of brain tumors, I should give you all some information about radiation therapy. As I stated earlier, radiation therapy is one of the modalities we use in the treatment of brain tumors apart from surgery (debulking the tumor) and chemotherapy (anti-cancer drugs).

So how does radiation therapy work? Well put in a simple form, radiation is given to the tumor to kill the tumor cells. Either you can irradiate the whole brain or just the tumor site. Radiation of the whole brain is done when there are multiple metastasis or when you are worried that microscopic spread of cancer might have already occurred.

Advantages of radiation therapy: one of the biggest advantages of radiation therapy is the ease of administration. Usually you go to a radiation oncology center and it is an outpatient procedure. But we are jumping ahead of ourself. Before radiation is administered, the radiation oncologist in consultation with your neurologist and neurosurgeon shall look at your MRI scans and then determine which shall be the best protocol for you. How much radiation to give over how much time and sittings. Should the whole brain be radiated and then a boost of radiation given to the tumor itself? As you can imagine it is very technical and involved expertise. How to give the radiation without affecting any neighbouring cells (remember radiation by itself cannot differentiate between healthy and tumor cells. It shall kill all cells in its path). If the tumor is near the visual pathways (the optic nerve), then you have to be careful that you do not irradiate the optic nerve as it shall lead to blindness. All such issues are looked at and considered before the protocol is decided.

By studies on animals we now know approximately how much radiation we can safely give to the brain and spinal cord over how much time.

Points to remember: when radiation is started, it leads to death of tumor cells. This increases the edema and swelling in the brain initially. Your doctor may prescribe you steroids or additional steroids if you are already on them to make the swelling go down. Also as the brain swells after radiation, some patients can have seizures and it may make sense to be on an anti-epileptic drug at the time of radiation.

What are the long term side-effects of radiation: Radiation does have some side-effects. In adults and especially in children it can lead to cognitive deficits and affect memory. That is why we try to avoid radiating a developing brain of a child. Also radiation itself at times can lead to a secondary tumor ( we try to avoid this by using the lowest radiation dose as possible). There is an entity called post radiation necrosis which at times can cause some diagnostic problems. About 12-18 months after radiation, necrosis of brain tissue occurs. This at times can present with seizures and be confused with recurrence of brain tumor.

I hope I have been able to shed some light on radiation therapy with respect to brain tumors. It is a lovely Memorial day here in NYC. Plan to head to Central Park and read with the sun on my back. Life is beautiful, I try to remind myself everyday. I wish you all a restful and enjoyable day.

Personal Regards,

Nitin Sethi, MD

 

Stroke and nirvana: what is the connection

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Stroke and nirvana: what is the connection

 

Nitin K Sethi, MD

 

        Comprehensive Epilepsy Center, Department of Neurology, NYP-Weill Cornell Medical Center, New York, NY (U.S.A.)

 

Address for Correspondence:

NK Sethi, MD

Comprehensive Epilepsy Center

Department of Neurology

NYP-Weill Cornell Medical Center

525 East 68th Street, York Avenue

New York, NY 10021

Fax: 212-746-8984

Email: sethinitinmd@hotmail.com

I just read this article in the New York times today titled ” A superhighway to Bliss” by Leslie Kaufman which talks about Dr. Jill Taylor a neuroscientist working at Harvard’s brain research center who experiences nirvana while she is suffering a stroke. She suffers a left parietal bleed and at the time when she is hemorrhaging into the brain, she experiences this amazing peace. The constant chatter that normally fills her brain stops, her perceptions change and she feels disconnected.

What would you ask all this has to do with nirvana. Nirvana by the way is the state where you attain the supreme bliss. In Hindu mythology we talk about nirvana and mosha. Mosha as in when you are free from the troubles of this world and one with God.  Well basically as the article goes on to mention that the right and left hemispheres of the brain have different functions. The dominant left hemisphere (in people who are right handed) houses ego, context and time logic. The right hemisphere on the other hand gives creativity and empathy. So in a way when your left hemisphere is shut down (as in Dr. Taylor’s) case by a hemorrhagic stroke, she experiences this peace and calmness because her ego is gone. The article later goes on to mention, that she has written a book about the same and now lives a more peaceful and spirtual life because she has learnt how to sidestep her left brain.

Hmmmmm I am not sure what to make of this and where I stand on this topic. Sensory disintregation may occur at the time of a stroke and patients have reported some very vivid experiences during the time of the stroke such as out of body experiences. Did Dr. Taylor suffer something like that during the time of the stroke. The fact she is a neuroscientist may have given the ability to better recognize her stroke as it was occuring.

In any case, parietal strokes especially when large can be devastating and not everyone has such a nice outcome as Dr. Taylor. The two hemispheres in the brain are closely interconnected and it is not possible to voluntary shut down one part of the brain. We can do it in the lab, by injecting a drug which shuts down one side of the brain such as amobarbital. This test is called WADA test and it would be interesting to note if anyone else has described reaching nirvana at the time of WADA testing.

The human brain is indeed like the wind and difficult to control. Thoughts are always racing through the brain some useful and others at time meaningless. Why you may ask are we always having thoughts in our head? Is there a way to make the brain empty of thoughts maybe for just a short time so that we can be totally in peace. Can the practice of yoga and meditation do that.

This brings me to the question I asked in my post on yoga and meditation: Does a meditative mind lead to a meditative brain?  Can by intense meditation, yoga or spirituality we slow down and stop these thoughts in our head?

I would appreciated all my readers thoughts about this.

MRI white matter abnormalities

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This is to Nancy

Dear Nancy, thank you for your comment to the post on white matter abnormalities on MRI does it represent MS? While it is hard for me to comment on your case specifically, the MRI report reads suspicious for MS. The reason is the lesions are periventricular (around the ventricles of the brain) and such lesions are at times more specific for MS.

I would though correlate this information with your age, your symptoms and importantly your history and clinical examination findings. If there is suspicion for MS from your history or clinical findings, then I would recommend doing further tests to either rule in or rule out the diagnosis of MS. Tests like spinal fluid examination, visual evoked potential and somatosensory evoked potential. As I stated earlier one can see these white matter lesions in patients who have vascular risk factors like hypertension and diabetes mellitus. I am not sure whether the drug you mentioned for RA has been implicated in causing them. You should follow up with your doctor, who would guide you in how to interpret these MRI findings.

Please refer to the MS articles on my website http://braindiseases.info for further information. Feel free to drop me an email if you have any further questions. I wish you my very best.

Personal Regards,

Nitin Sethi, MD

Brain tumors: malignant gliomas

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Thank you for sharing your brother’s history with me Franciso, I understand how difficult it must be for you and the entire family. I wish him my very best and please feel free to contact me here if you have any particular questions related to him.

Let me continue a little about the management of brain tumors. Well like I said once we discover a glioma in the brain, we first try to determine its extent in the brain. Tests like CT scan and MRI brain  with contrast (dye) are carried out to determine its boundries. Then the question of staging the tumor arises. At times from the MRI itself one can be reasonably sure that this is a malignant glioma or GBM. GBM is one of the few brain tumors, that can spread to the underside of the brain via the corpus callosum and hence gives rise to what we call a butterfly lesion on the MRI (imagine a butterfly with her wings spread out). GBM usually have a lot of surrounding edema which we can see on the MRI again hinting that is a malignant tumor we are dealing with.

Low grade tumors usually are walled off (encapsulated) and do not much surrounding edema. So the next step is trying to stage the tumor and trying to determine its grade. For this reason at times a brain biopsy is done. At the time of the brain biopsy, a frozen specimen is sent to the lab and if the lab gives its initial impression as a tumor, the surgeon might try to debulk the tumor right then and there (that means at the time of biopsy, try to debulk the tumor. This makes sense because the skull is already open and it avoids a second operation).

There is one issue here which is unique for brain tumors like gliomas. The tumor may have one grade on one side and another grade in a different part of the tumor (meaning one part of the tumor may show grade II and the other grade III. To overcome this problem multiple biopsies are taken from different parts of the tumor. The highest grade found is the final grade given to the tumor).

Like I said earlier depending upon the stage of the tumor and its location, the surgeon may or may not be able to remove the entire tumor.

After the biopsy/ surgery patients undergo rehablitation and are then referred to either radiation oncology for radiation or to an oncologist for consideration of chemotherapy. Most of the times all these facilities are available under one roof in a big hospital.

I shall touch on the finer aspects of radiation and chemotherapy in my next post. Its 7.00 pm sat evening NYC, do not have any major plans but do want to get to the gym at some point. Hope all is well in the big world around me.

Personal Regards,

Nitin

Brain tumors: malignant glioma

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Since the diagnosis of Ted Kennedy with a malignant glioma, the focus has again turned to brain tumors. Let me discuss in this post a little about malignant gliomas. Glioma are one of the most common primary brain tumors. They are called gliomas because the tumor arises from the glial cells (the tumor does not arise from neuronal cells, rather from glial cells which form the structural supporting cells in the brain).

The WHO (world health organization) grades gliomas into 4 classes:

1) Grade I and II gliomas: are also what are called low grade gliomas. These are slow growing tumors, usually seen in the younger age groups. As they are slow growing, they are less malignant and compatible with a longer survival. They ususally present clinically with a seizure (when they irritate the underlying brain) or when they grow in size and become large, they present with mass effect (the mass and bulk of the tumor presses on surrounding structures and patients may present with weakness on one side). How are low grade gliomas treated?

Treatment of low grade gliomas; as these tumors are slow growing, they are at times amenable to surgical resection. This is because these tumors are usually well encapsulated and its margins are well defined. So in children or adults, if we catch these tumors in time and if the tumor does not involve the eloquent cortex (parts of the brain which subserve speech, or control the hand and leg movements), one may be able to resect the entire tumor out enbloc. In some patients, that is all what may be needed and we usually like to avoid radiation in children ( since radiation has its own problems and may cause cognitive deficits in the young child later on). You doctor may also put you on an anti-seizure medication for a short while to prevent you from having seizures.

Grade III and IV gliomas: or high grade gliomas. This includes glioblastoma multiforme or GBM. Since these tumors are high grade, they are usually fast growing and invade the surrounding brain tissue. Hence it is impossible to resect the entire tumor out usually. Even if you resect the entire tumor you see macroscopically (that is with the naked eyes), the tumor has already caused microscopic metastasis and spread in the brain. Here in lies the fact why these tumors are so hard to treat and patients usually have a poor prognosis. In the best centers in the world, we treat these tumors with a combination of surgery ( try to debulk the tumor and remove some of it and decrease the pressure in the brain), radiation (you may either radiate just the tumor or irradiate the entire brain to prevent metastatic spread) and chemotherapy. Radiation and chemotherapy may either be used concurrently  to supplement each other or one after the other. Again usually these tumor present at first with seizures and your doctor may start you on an anti-epileptic drug to prevent it.

I shall build on this discussion in my next post. Enjoy the weekend everyone, it is a beautiful day here in NYC.

Personal Regards,

Nitin Sethi, MD