J Assoc Physicians India. 2006 Apr;54:289.

Giant fourth ventricular cyst : diagnostic and therapeutic dilemmas.

Bansal KK, Gupta C, Goel D, Singhal A, Bansal R.

Department of Neurosurgery, Himalayan Institute of Medical Sciences, Swami Ram
Nagar, Dehradun (UA).

VOLUME 28 • NUMBER 4
February 28, 2006
Incidence and Natural History
Ependymomas are among the most common primary
brain tumors of children younger than 5 years of age,
accounting for 10% to 12% of all brain tumors in the pediatric
population and 2.5% of all intracranial gliomas.
Ependymomas are believed to develop from oncogenetic
events, in which ependymal lineage cells arising from the
ventricular lining of the brain and the central canal of the
spinal cord are transformed. These tumors classically show
an age-based site preference, with supratentorial and spinal
compartments more often involved in adults and the
infratentorial compartment more often involved in children.
Ninety percent of ependymomas occur intracranially,
and approximately two thirds of these arise in the posterior
fossa. The mean age at the time of diagnosis is between
3 and 6 years, with more then 25% of ependymomas found
in children under the age of 3 years. Sixty percent of supratentorial
ependymomas are found within the lateral or third
ventricles; the remaining 40% may lie in an extraventricular
cerebral parenchymal location. Ependymomas occur
with equal frequency in both sexes. Most ependymomas
are sporadic tumors, but some may be associated with neurofibromatosis
type 2 (NF2). There are no known causative
agents for ependymomas, although various viruses, such
as SV-40, have been implicated in some studies.
Treatment Modalities for Ependymomas in Children
Krishan Bansal, MD, M Ch, Paul Kongkham, MD, and James T. Rutka, MD, PhD, FRCSC
Learning Objectives: After reading this article, the participant should be able to:
1. Describe the clinical presentation of a child with an intracranial ependymoma.
2. Explain the role of surgery for patients with ependymomas.
3. Recall operative complications that can arise following surgery for posterior fossa ependymomas.
A BIWEEKLY PUBLICATION FOR CLINICAL NEUROSURGICAL
CONTINUING MEDICAL EDUCATION
Category: Neuro-oncology
Key Words: Ependymoma, Supratentorial, Infratentorial, Surgery, Radiation
therapy
Dr. Bansal is a visiting Clinical Fellow, Dr. Kongkham is a Resident
in Neurosurgery, and Dr. Rutka is Professor and Chairman, Division
of Neurosurgery, Suite 1504, Hospital for Sick Children, 555
University Avenue, Toronto, Ontario, Canada, M5G 1X8, and the
Arthur and Sonia Labatt Brain Tumor Research Centre, Toronto,
Ontario;
The authors have disclosed that they have no significant relationships
with or financial interests in any commercial organizations
pertaining to this educational activity.
Wolters Kluwer Health has identified and resolved all faculty conflicts
of interest regarding this educational activity.
Figure 1. Funduscopic image of a 6-year-old boy with supratentorial
ependymoma who presented with nausea, vomiting, and
dysphasia. Gross papilledema was present bilaterally during ocular
examination, indicating raised intracranial pressure. (The same
patient is shown in Figure 4.)
2
The prognosis for patients with ependymoma is linked
to age, with children younger than 3 years of age faring
worse than older children. Posterior fossa ependymomas
grow within the fourth ventricle, but they can extend inferiorly
through the foramen of Magendie, laterally through
the foramen of Luschka, and into the cerebellopontine angle.
These tumors may, rarely, seed along cerebrospinal fluid
(CSF) pathways along the neuraxis. The prognosis is better
for patients with supratentorial ependymomas than
those with infratentorial tumors. Five-year progression-free
survival after treatment in ependymoma ranges from 23%
to 45%, and 5-year survival ranges from 50% to 60% in various
major series. The median time to recurrence is within
2 years after diagnosis. Most recurrences are local.
Clinical Presentation
Ependymomas of the fourth ventricle often cause hydrocephalus
by blocking CSF outflow pathways, with resulting
signs and symptoms of raised intracranial pressure. Funduscopy
must be performed in children with suspected posterior
fossa or supratentorial tumors, because papilledema
is a common finding (Figure 1). Intractable paroxysmal vomiting
not related to a particular time of the day or posture,
often is the first symptom, and it is caused by the tumor’s
attachment to the area postrema of the brainstem. Pressure
on or invasion of the cerebellum or brainstem may result in
long tract signs or lower cranial nerve palsies.
Supratentorial ependymomas may cause focal neurologic
deficits, seizures, and raised intracranial pressure from
Figure 2. A, T1-weighted, gadolinium-enhanced sagittal MRI scan of a 14-year-old girl who presented with a brief history of headache,
nausea, and vomiting. An enhancing, midline posterior fossa tumor is seen. B, One year after surgery and focal radiation therapy, no
residual tumor is identified.
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EDITOR: Ali F. Krisht, M.D.*
University of Arkansas for Medical Sciences
ASSISTANT EDITOR: Cargill Alleyne, Jr., M.D.*
Medical College of Georgia
PRODUCTION ASSISTANT: Ronalda Williams
EDITORIAL BOARD:
Badih Adada, M.D.
Ossama Al-Mefty, M.D.
Rick Boop, M.D.
Evandro de Oliveira, M.D.
Allan Friedman, M.D.
Gerardo Guinto, M.D.
Douglas Kondziolka, M.D.
Jacques Morcos, M.D.
Tom Origitano, M.D.
Nelson Oyesiku, M.D.
Kalmon Post, M.D.
Richard Rowe, M.D.
Martin Weiss, M.D.
M. Gazi Yas¸argil, M.D.
* Dr.Krisht has disclosed that he has no significant
relationships with or financial interests
in any commercial organizations pertaining to
this educational activity.Dr. Alleyne has
disclosed that he is a consultant for Cordis.
A B
mass effect. Headaches usually are intermittent and may
be worse in the morning. CSF dissemination is unusual,
but it can occur in patients presenting with signs of
meningismus or nerve root involvement.
Pathologic Findings
Grossly, ependymomas are grayish-red, often well-circumscribed
tumors. Histologically, they are characterized
by the presence of perivascular pseudorosettes and true
ependymal rosettes of the Homer-Wright type. The World
Health Organization divides ependymomas into three
grades as follows:
• Grade I: subependymoma and myxopapillary ependymoma;
• Grade II: four variants—cellular, papillary, clear, and
tanycytic; and
• Grade III: anaplastic ependymomas.
Microscopic examination demonstrates a predominant
glial pattern studded with islands of cells with epithelial features.
Pseudorosettes, the most common epithelial feature,
appear as eosinophilic zones surrounding blood vessels.
Molecular Biology
Losses of chromosomes 6q, 22q, and the X chromosome and
gains of chromosome 1q or 9q are common in ependymoma.
The 22q abnormality is much more common in spinal ependymomas.
Gain of 1q seen in childhood anaplastic ependymomas
appears to be associated with posterior fossa tumor.
Although both cranial and spinal ependymomas occur
in patients with NF2, the locus involved in sporadic tumors
seems to be different from the NF2 gene locus, because sporadic
tumors harboring 22q loss occur almost exclusively
in the spine. Recently, co-overexpression of certain receptor
tyrosine kinases, ERBB2 and ERBB4, has been demonstrated
to correlate with proliferative indices and worsened
patient prognosis. Although no specific tumor suppressor
gene has been identified for ependymomas, CDKN2A,
CDKN2B, and p14ARF expression often are silenced by
aberrant methylation. Taylor et al. recently have shown that
ependymomas arising in different locations of the neuraxis
may develop from radial glia progenitor cells at these sites
caused by disturbances in separate signaling pathways.
Imaging Findings
Ependymomas typically appear as isodense to heterogeneously
enhancing midline cerebellar or hemispheric
tumors on both CT and MRI scans (Figures 2–4). MR spectroscopy
can be used as an adjunct to MRI in the evaluation
of ependymomas, but its diagnostic utility is still under
investigation. In addition to cranial imaging, an MRI scan
of the spine should be obtained preoperatively to assess the
presence of possible CSF metastases. Postsurgical MRI
should be performed within 48 to 72 hours of surgery to
detect any residual tumor before postsurgical changes occur.
Treatment
Surgical Technique
Posterior fossa ependymomas are removed using modern
microsurgical techniques. Posterior fossa surgery may
be done with the patient in the prone, concord, lateral, or
sitting position. Amidline suboccipital posterior fossa craniotomy
currently is preferred. Blunt, subperiosteal dissection
of the inferior surface of the C1 lamina, progressing to
the superior surface, where the medial portion of the sulcus
arteriosus is identified, reduces the risk of injury to the
vertebral artery.
3
Figure 3. A, T1-weighted, gadolinium-enhanced midline MRI scan
of a 12-year-old boy, who presented with poor school performance
of 6 months duration. A large intraventricular tumor is seen. B,
After surgery and local radiation therapy, the tumor is under good
control 2 years postdiagnosis.
B
A
The dura is opened with a Y-shaped incision reaching to
the limits of the bony confines. At the intersection of the
arms of the Y, brisk venous bleeding from the occipital sinus
may be observed, especially in younger children. This bleeding
usually can be controlled by aggressive bipolar cautery.
Hemostatic clips should be avoided because they cause artifacts
on postoperative images and may lead to future difficulty
with dural repair at these sites. After the dura has
been opened, the arachnoid is opened widely and CSF liberated
to facilitate cerebellar mobilization.
For midline lesions, the cerebellar tonsils are separated
gently, after which the floor of the fourth ventricle is identified
clearly. A cottonoid pad is kept at its outlet (Figure 5).
Once the tumor is exposed, attempts are made to develop
planes laterally around the tumor before central debulking
takes place. For debulking, the ultrasonic aspirator is recommended.
Once further debulking is achieved, attention
is focused on removing the tumor margins, particularly from
the aqueduct, vermis, and hemispheres. Tumor adherent to
the floor of the fourth ventricle should be shaved off in a tangential
plane with the ependymal surface. No attempts should
be made to resect tumor that infiltrates the floor, because
attempts to do so may result in significant morbidity.
After microscopic resection is complete, hemostasis is
achieved under normotensive conditions. A duraplasty is
performed as needed, and fibrin glue is applied to the dural
repair. The bone flap is secured with sutures or miniplates
followed by a multilayered closure encompassing the fascia,
subcutaneous tissue, and skin. Postoperatively, antibiotics
are continued for 24 hours and corticosteroids are
tapered gradually over a period of 5 to 7 days. A contrastenhanced
CT or MRI scan should be obtained within 24
hours for assessment of residual tumor.
Operative Complications
In the past two decades, advances in anesthesia and
microsurgical techniques, along with a better understanding
of microsurgical anatomy, have resulted in a decrease
in postoperative morbidity and mortality. However, some
inherent morbidity in performing posterior fossa surgery
in children remains.
Hydrocephalus develops as either an early or a delayed
postoperative complication, and it must be recognized and
treated. Factors that may predict the need for postoperative
shunting include the patient’s age, the location of the
tumor, the type of tumor, the use of dural substitutes, the
development of a pseudomeningocele, and the extent of
surgical excision. Approximately one third of all patients
will require CSF diversionary procedures at some time.
Meningitis may be seen within the first 1 to 2 weeks following
surgery, prolonging the postoperative course and
adding to morbidity. Bacterial meningitis is more likely to
occur if there has been a CSF leak from the operative wound
after surgery. Occasionally, sterile or “chemical” meningitis
is seen. This may respond to corticosteroid therapy, but
those agents should be used only after bacterial meningitis
has been excluded.
Cerebellar mutism is seen following resection of posterior
fossa tumors in children. The incidence of mutism after
posterior fossa surgery is difficult to establish, but it may
occur in as many as 15% to 20% of cases. The typical presentation
is that of a child who may speak immediately after
surgery only to become mute after the first 24 hours. This
complication probably results from disruption of projection
fibers of the dentatothalamic-cortical pathway. The
mutism usually is self-limiting, with a spontaneous return
of improved speech patterns. However, mutism has been
reported to last as long as 52 months after surgery.
The Role of Surgery in Ependymoma
For ependymomas, the ultimate goal of treatment should
be total microsurgical resection. The extent of surgical resection
has been found to be the most significant determinant
of survival in almost every large pediatric ependymoma
4
Figure 4. A, Gadolinium-enhanced axial MRI scan of the 6-yearold
boy whose funduscopic image of papilledema is shown in Figure
1. A large cystic tumor is seen in the left frontal lobe. B, After
surgery and local radiation therapy, there is no evidence of recurrent
tumor 5 years after diagnosis.
B
A
5
series. Unfortunately, the ability to resect these tumors totally
differs based on their location. Overall, 35% to 50% of posterior
fossa ependymomas can be resected completely, but
only 23% to 40% of those occurring adjacent to the brainstem
in the fourth ventricle can be completely resected safely.
Complete resection is achieved more easily for supratentorial
tumors. Between 60% and 85% of supratentorial
ependymomas can be removed completely. Aggressive
attempts to remove tumors in other locations, including
those involving lower cranial nerves, are associated with
increased morbidity. Sutton et al. reported a 5-year progression-
free survival rate of 80% in patients who underwent
gross total resection of their tumor. However, Vinchon
et al. determined that this survival advantage was reduced
to 48%, 22%, and 0% for near-total resections, partial resections,
and biopsies, respectively. Pollack’s series demonstrated
a sudden drop in 5-year progression-free survivals
from 80% to 8.9% with total and subtotal tumor removal,
respectively. Perilongo et al. retrospectively analyzed 92
children with ependymoma who were enrolled in the Italian
Pediatric Neuro-oncology Group study. For patients
who underwent gross total resection, the 10-year survival
rate was 70%, and the progression-free survival rate was
57%; for patients who had subtotal resection, the 10-year
survival rate was 32%, and the 10-year progression-free survival
rate was only 11%. Robertson et al. prospectively
treated 32 patients and reported a 5-year progression-free
survival rate of 66% for patients with residual tumor measuring
1.5 cm2 or less and 11% for patients with residual
tumor measuring greater than 1.5 cm2. All of their patients
received postoperative radiation therapy.
Vinchon et al. recently reported the results of reoperation
in ependymoma. They achieved total resection in recurrent
cases, describing a survival rate greater than 50% at
74.7 months of follow-up after reoperation. Because maximal
surgical extirpation is critical to long-term outcome, it
is now advocated that a postoperative enhanced MRI scan
be obtained within 48 hours of surgery, with the intention
being to perform a second operation if accessible tumor is
found on the imaging study.
Radiation Therapy for Ependymoma
Mork et al. were the first authors to document that postoperative
radiation therapy improves the outcome in ependymoma.
They reported a 17% survival rate for patients who
underwent resection alone versus 40% for those who received
cranial radiation after surgery. Since then, postoperative
radiation therapy has been considered vital in the treatment
of patients who have undergone surgery for ependymoma.
Radiation therapy can now be given as craniospinal radiation
with a posterior fossa boost, conformal radiation therapy
(CRT), or stereotactic radiotherapy (SRT) and stereotactic
radiosurgery (SRS) as provided with the gamma knife.
Craniospinal radiation with a posterior fossa boost has
been used in the past because of the known tendency for
some ependymomas to metastasize. However, craniospinal
irradiation has serious long-term side effects, the most serious
of which is neurocognitive decline. Therefore, efforts
are being made to eliminate craniospinal irradiation as standard
treatment and instead to deliver fractionated radiotherapy
to the tumor and tumor margins.
CRT initially was developed for the treatment of adults
with prostate and head and neck cancers. This technique
requires three-dimensional imaging (CT and MRI) as part
of the planning process. The successful application of CRT
to ependymoma in children may improve outcomes by
reducing radiation-related treatment effects and as a treatment
option for very young children. Nonetheless, guidelines
for the use of CRT are needed to ensure that the
appropriate volume of the brain receives the prescription
dose and that disease control is not compromised.
SRT typically requires a linear accelerator, with doses of 54
Gy in daily fractions of 1.8 Gy over 6 weeks given via precise
delivery of the radiation dose. SRT usually is administered
with the patient in a stereotactic, relocalizable head frame.
Gamma knife SRS is a noninvasive procedure that delivers
radiation with high precision while sparing normal tissue.
Therapy is given in a single sitting. Astereotactic head
frame first is placed on the patient, and the tumor then is
localized in the three-dimensional stereotactic system by use
of MRI. Dose planning is performed with the GammaPlan
Figure 5. Intraoperative photograph of the patient whose imaging
sequences are shown in Figure 2. The cerebellar tonsils are shown
splayed apart by a vascular midline ependymoma that descends
below the foramen magnum and rests on the dorsal aspect of the
high cervical spinal cord. The tumor was removed through a minimal
split of the cerebellar vermis.
(Elekta Instruments) sophisticated software system. The total
dose ranges from 26 to 42 Gy, depending on the size of the
tumor, including tumor bed and marginal tumor dose. The
drawback of the gamma knife is that it cannot be used for
tumors larger than 3 cm.
The Role of Radiation Therapy in Ependymoma
Duffner et al. found that children with completely
resected ependymoma in whom radiation therapy was
delayed for 2 years experienced a worse outcome than those
in whom therapy was given at 1 year (5-year survival rate,
38% versus 88%, respectively). Hyperfractionated radiation
therapy does not appear to be beneficial for ependymoma.
In a phase II trial of CRT, Merchant et al. documented a
3-year progression-free survival rate of 75% after a median
follow-up of 38.2 months.
Various studies have shown a dose-dependent response
for ependymoma, with a dose threshold of 45 to 50 Gy.
Recent studies have proven that dose escalation in subtotally
resected posterior fossa ependymoma provides favorable
results. Kovner et al. observed a 50% 4-year event-free
survival rate with 69.6 Gy, compared with a 24% 4-year survival
rate after lower-dose radiation. Other studies also
have demonstrated that an increase in radiation dose to the
primary site appears to improve local control. SRS is being
used increasingly in patients with residual, unresectable,
or recurrent ependymoma.
Adjuvant Chemotherapy
Although the role of chemotherapy for ependymoma is
not yet established, it commonly is used in children younger
than 3 years when radiation therapy cannot be given. Various
retrospective and prospective trials have been published
showing minimal benefit in terms of improving
long-term disease-free survival. The main chemotherapeutic
agents used are vincristine, ifosfamide, etoposide, and carboplatin,
in a variety of schedules. Myelosuppression is the
major toxicity noticed during combination chemotherapy.
The development of a multidrug chemotherapy regimen
for primary malignant brain tumors was based on the cellular
heterogeneity within individual tumors.
Most researchers consider ependymoma a chemoresistant
tumor. Overexpression of the multidrug-resistance-1
gene and the 06-methylguanine-DNA methyl transferase
gene has been blamed as possible mechanisms for this phenomenon.
Cisplatin is the only agent that has demonstrated
some value in ependymoma, with a cumulative response
rate of 34%. The Children’s Cancer Study Group protocol
942 was the only randomized trial to compare survival after
radiation alone versus the combination of radiotherapy and
chemotherapy. Outcome was not improved despite combination
therapy.
Current Postoperative Treatment Protocols
Various institutions have approved protocols using different
approaches to the child with intracranial ependymoma.
Some investigators are exploring the efficacy of
pre-irradiation chemotherapy, second-look surgery for residual
tumor, and multiagent chemotherapy followed by craniospinal
radiotherapy.
Conclusion
Local tumor control is single most important prognostic
factor for ependymoma. This is best achieved through gross
total tumor resection whenever possible. If aggressive, total
resection is not possible, long-term control may be achieved
through adherence to state-of-the-art radiation therapy practices.
Chemotherapy with current agents does not appear
to hold much promise. However, it may be useful in the
context of providing the surgeon with an opportunity to
perform further surgery on a tumor that is less vascularized.
It remains important to continue to enroll patients in
current clinical trials.
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Shuman RM, Alvord EC, Leech RW. The biology of childhood ependymomas.
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Sieb JP, Pulst SM, Buch A. Familial CNS tumors. J Neurol 239:343, 1992
Sutton LN, Goldwein J, Perilongo G, et al. Prognostic factors in childhood
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Taylor MD, Poppleton H, Fuller C, et al. Radial glia cells are candidate stem
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From the Editor:
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8
1. Ependymomas in children are situated more commonly in the
supratentorial than the infratentorial compartment.
True or False?
2. Ependymomas are found more commonly in patients with
neurofibromatosis type 2 than in patients with neurofibromatosis
type 1.
True or False?
3. Patients with infratentorial ependymomas have a better prognosis
for survival than those with supratentorial ependymomas.
True or False?
4. Vomiting due to irritation of the area postrema of the brainstem
can be one of the first presenting symptoms of posterior
fossa ependymomas.
True or False?
5. Cerebellar mutism is caused by interruption of the spinocerebellar
tracts.
True or False?
6. The most significant factor that predicts survival in patients
with intracranial ependymoma is extent of resection.
True or False?
7. Craniospinal irradiation should be used in all patients with
intracranial ependymoma.
True or False?
8. Ependymoma is a chemosensitive tumor.
True or False?
9. Stereotactic radiosurgery may be used for locally recurrent
ependymomas.
True or False?
10. Homer-Wright rosettes are a histopathologic feature of ependymoma.
True or False?
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Menopause is not a disease. It is a natural process in a woman's life. It is a unique experience for every woman. It is the ending of a woman's monthly Menstrual Periods and Ovulation. It also signals other changes to the body and mind, brought on in part because the body begins producing lesser amounts of the hormones Estrogen and Progesterone.

How a woman views this time of her life can have a lot to do with how frequent and severe her symptoms are. If menopause is viewed as the end of youth and sexuality, this time will be much more difficult than if it is viewed as the next, natural phase of life, a time of greater freedom, liberation from the restrictions of youth. .

Although Menopause is one of the important physical milestones in a woman's life, with a proper diet, nutritional supplements, and exercise and simple lifestyle changes, most of the unpleasant side effects of menopause can be minimized to a great extent and with this knowledge and preparation you can step forward with grace and embrace Menopause.

Ayurveda links Menopause with Aging. Aging is a ‘Vata’ predominant stage of life. Thus, the symptoms of menopause experienced by some women are similar to the symptoms seen when the Vata dosha rises and upsets the normal balance of the body. Vata-type menopausal symptoms tend to include depression, anxiety, and insomnia. Menopause may also manifest itself as a rise in the other two humors also. Women with Pitta-type symptoms are often angry and suffer hot flashes. Kapha type symptoms include listlessness, weight gain, and feelings of mental and physical heaviness. The type of treatment depends upon the dosha in which the woman's menopausal symptoms are manifesting.

Here it is important to note that health problems at menopause represent imbalances in the body that were already growing in the body and are unmasked by the stress of shifting hormones. Menopause symptoms are Nature's wake-up call to let you know you need to start paying more attention to your health. Taking proper steps in the direction of balancing the imbalance doshas, paying attention to your diet and making lifestyle changes now is critical to ensuring that you age gracefully without the burden of chronic health problems.

Key factors in achieving Graceful Menopause –

A smooth Menopause Transition and Great Health in the years to come can be achieved with the help of –

1. Balancing Doshas - Ascertain the imbalance dosha according to your symptoms and follow the advice by an Ayurvedic Specialist to balance that dosha.

2. Balancing Diet - Diet plays a key role in balancing hormones during and after menopause. It is well known that Japanese women rarely experience hot flashes, probably because their diet contains large amounts of Soy/Soya, a food rich in certain plant estrogens called "Isoflavones." Soya products are not the only source of plant estrogens, however. Another equally healthful source of phytoestrogens are "Lignans," compounds found in a variety of whole foods including grains and cereals, dried beans and lentils, flaxseed, sunflower seeds and peanuts, vegetables such as asparagus, sweet potatoes, carrots, garlic and broccoli and fruits such as pears, plums and strawberries. Common herbs and spices such as nutmeg, turmeric and licorice also have estrogenic properties.

Eat a varied diet high in fruits, vegetables and whole grains. It’s a rich source of phytoestrogen. Variety and moderation are important because just as too much estrogen is unhealthy after menopause, too much phytoestrogen may also be dangerous.

Apana Vata, which governs the genito-urinary tract, elimination, and menstruation, is a key area to attend to when preparing for menopause. Drink plenty of warm water throughout the day. Eat plenty of cooked, leafy greens, as this helps elimination and is also a good source of calcium.

3. Panchakarma - More serious symptoms, such as frequent hot flashes, continual sleep disturbance, and moderate to severe mood swings, are signs of deeper imbalances.
Ayurveda describes that these stubborn symptoms are usually due to the buildup of wastes and toxins, referred to as "ama," in the body's tissues.

In this case, a traditional Ayurvedic Detoxification program "Panchakarma," may be needed to clear the body's channels and gain relief. This internal cleansing approach is also the treatment of choice for more serious problems such as osteoporosis and high cholesterol.

4. Rejuvenation Procedures: Speciality Rasayana Chikitsa or Rejuvenation Procedures are told in Ayurveda to rejuvenate the systems of the body and thus live a healthy, Peaceful and long life.

Ayurveda has excellent solutions for a safe and happy Menopause. There are several single drugs and preparations that can be taken by women who are nearing the age of menopause to remain symptom-free.

Published in THE HINDU News paper on Tuesday, 3rd Aug, 2004. Written by Dr. R. Kranthi Vardhan, Chief Physician & Managing Director, Dr Kranthi’s Institute of Ayurvedic Sciences & Research, THE KERALA AYURVEDIC CARE, Speciality Panchakarma Centre, Basheerbagh, Hyderabad-500029. Andhra Pradesh. India. Ph: 092461 66636, 98666 66055.

Fast paced Life, Skipping Breakfast/Lunch/ Dinners, Chinese/ fast foods/ Junk Food Cultures, Busy Schedules, Sleepless Nights, Competition & Complexity of Today’s World- in this process of hectic growth we subject ourselves to all kinds of unlimited Physical & Mental Stresses.

Besides Stress & Fatigue, an accumulation of Toxins can interfere with the normal functions of the body. After 25 or 30 high levels of Toxins also accelerate the rate of degeneration of the body. The human body is no different to a vehicle, which needs constant Care & Servicing.

Ayurveda brings about the balance between our Physical & Mental aspects and helps us to remain naturally beautiful. Herbs of tremendous medicinal values are found abundantly in nature. Ayurveda uses these herbs individually and in special blends to treat every kind of Physical & Psychological Problems.

As the Stress builds up, we move towards the Lack of Confidence and a feeling of Inferiority becomes a part of our Life. Lest the Thorn / The Cause/ The Toxins/ Stress is removed only then the normal healing mechanism of the body is initiated or else it effects the other organs of the body & thus Uncurable Diseases are produced.

Skin, the Largest Organ in our body directly reveals the energetic level of the entire Psychophysical unit, it is a transparent mirror where the movement of the doshas bring about changes also of a radical nature in its biochemical balance. Skin is the expression of our overall State of Health; this Stress invariably affects it. The diseases of the skin like Psoriasis, Eczema, Dandruff, Lichen Planus etc occur due to this Stress.

For Males as young as 25, Multiple Late Nights and Unlimited Stress can lead to a diminished Sexual Desire, Premature Ejaculation, Erectile Dysfunction, Impotency, Low Sperm Count, Semen Discharge with urine and the damaging feeling of Inferiority accompany with all these Sexual Problems. The same Stress factor in Females will lead to Low Sexual Desire, Infertility and Loosening of Breasts etc.

5000 years old ancient wisdom of Ayurveda has a lot to offer for millions of people to combat Stress, the effects of which are often associated with Skin, Sexual Health of the individuals. Since Times immemorable, Ayurveda has been advocating many Rejuvenating Recopies for Improving & Maintaining Good Health, which leads to a Normal and Happy Life thus improving the deficiencies without any side effects.

Treatment procedures mainly involve the changing of Nutritional Protocol & Life Style by which we can greatly influence our Physical, Mental & Emotional health. While each patient should follow a regimen Tailored to his/ her individual needs, the Five Classical Procedures are meant to Detoxify the human body- THE PANCHAKARMA CHIKITSA-are particularly beneficial. They are:

1) VAMANA: a Medicated Emesis Therapy cleanses Kapha collected in the body & decongests the Respiratory Tract.

2) VIRECHANA: a Medicated Purgation Therapy, removes Toxins from the body that are accumulated in the Gastro Intestinal Tract.

3) VASTHI: cleanses the accumulated Toxins from all over the body. It is also highly beneficial in Rejuvenation Therapies.

4) NASYAM: Nasal administration of Medicated Oils to cleanse accumulated Kapha dosha from the Head & Neck regions.

5) RAKTHA MOKSHANAM: Blood lLetting using Leeches etc effective in Haemopathological Conditions.

Once the Toxins are removed and the body is purified from doshas responsible for causing the diseases then Rejuvenation Procedures & Therapeutic Massages are beneficial. Judicious combinations of Scientifically Standardized Drugs having Rejuvenating Correcting Imbalances are administered for the promotion of a Healthy Normaliving of the person.

Rejuvenation Procedures include:

A Simple ABHYANGA revives Body, Mind, Senses and the Soul, increasing energy levels and thus promotes the feeling of well being.
SIRODHARA in which Medicated Oils are streamed on to the Fore Head, relaxes the Central Nervous System, melting away all the Stresses & Strains.
PIZHICHIL(Medicated Oil Bath) Sarvanga Dhara/ Kaya Seka provides the ultimate Rejuvenation and Increases the Circulation around the body
ELAKIZHI (Herbal Leaf Bundle Massage) is a highly Rejuvenating Treatment used to Treat Chronic Back Pain, Sciatica etc.
NAVARAKIZHI ( Shali Shastika Pinda Swedam) is very effective in Emaciation, Debility, Strengthens Tissues and is Anti Ageing.

We at “THE KERALA AYURVEDIC CARE”, Speciality Panchakarma centre, Basheerbagh, Hyderabad offer Genuine, Shastrokta, Value based & High Quality Treatments for all the Chronic Ailments through AYURVEDA & PANCHAKARMA Since 1999. We are open on all days. Intrested persons can Contact 92461 66636/ 9866666055/ 66101140.

Premature Ejaculation (PE) is persistent or recurrent ejaculation with minimal sexual stimulation before, upon or shortly after penetration and before the person wishes it and is associated with marked distress or interpersonal difficulty. PE is one of the most common Sexual Problems for which couples seek advice.

In most cases, the partners may not climax together, they are not satisfied and the ejaculation is termed “Premature”. However, Premature Ejaculation may be caused by a variety of Psychological and Social reasons. It is seen that it occurs frequently when the man is under Mental Stress or Anxiety. Anxiety may be due to the Fear of Non-performance, The Fear of being discovered (as during premarital or extramarital sex in our society) or Anxiety related to contraction of Sexually Transmitted Diseases or an Unwanted Pregnancy.

Though men of all ages may experience the condition, it is more common in Adolescents, Young Adults and Inexperienced men. However, it is also true that almost all men experience it at some point in their lives. It is diagnosed by a Physical Examination, in addition to interviews with the couple regarding their relationship.

In Ayurveda, the clinical condition is described under Shukraghata Vata, which restrains and impels different mental activities, is responsible for the functional state of mind. Shukra, the finest tissue element in the body has the functions of Dhairya (Courage), Cyavana (Ejaculation) and Preeti (Pleasure). The activities of components of Vata can be analyzed in Physiological and Pathological states of Psychosexual behaviour.
Based on the Detailed Diagnosis an Individual Specific Treatment Schedule is chalked out to include the following: Cleansing, Purification and Detoxification of the Dhatus; a Schedule of Panchakarma Therapies to Dislodge, Liquefy, Mobilize and Evacuate the accumulated Dhoshas, with an Aim to Cleanse and Purify the Countless Body Channels is carried out.
Abhyangam (Oil application on entire body), Swedam (Medicated Steam), Elakizhi (Leaf Bundle Massage), Pizhichil (Sarvanga Dhara or Oil bath), Shali Shastika Pinda Swedam (Navarakizhi), Shiro Dhara (Pouring of Oil on the head), Uttara Vasthi etc are carried out. Among Panchakarmas Vasthi is an ideal choice as it controls Vata at its own site. Rejuvenation Procedures, Diet Management, Life Style Corrections, Stress relieving Procedures, breathing Exercises like Pranayama etc are followed for the Best results in treating PE.

Specially prepared & Researched Internal medicines which have Vrishya (Spermiotropic), Balya (Strengthening), Vatahara (Alleviates Vata), Medhya (Psychotropic) and Shukra Stambhaka (Effective control of Ejaculation) Properties are given to improve and rejuvenate the Vascular and Neuro Muscular Activity.

In some cases, the problem can be solved simply by Educating an individual about the condition and reassuring him. Counseling helps to deal with one’s Fears and Anxieties and, thus, Eliminate the Psychological causes of the condition. The Squeeze Technique, Stop & Start Methods may be beneficial in Delaying Ejaculation.

We give the Best Treatments for “Premature Ejaculation” with High Success Rates at
Dr. Kranthi’s Institute of Ayurvedic Sciences & Research, The Kerala Ayurvedic Care, Speciality Panchakarma Centre, 3-6-101/1, St No: 19, Basheerbagh, Hyd-29. Contact Dr Kranthi R Vardhan on 9246166636 for Appointments, Evaluation and Treatments.