Dementia comes from a Latin word "Demens" which means "Absence of mind" chronic impairment of thinking that affects a persons ability to function in a social or occupational setting. The impairment is severe enough to interfere with the patient's ability to perform routine activities.


According to WHO:


Dementia is a syndrome, usually of a chronic or progressive nature, in which there is deterioration in cognitive function beyond what might be expected from normal aging. It affects memory, thinking, orientation, comprehension, calculating, learning capacity, language, and judgment. Consciousness is not affected. The impairment in cognitive function is commonly accompanied and occasionally preceded, by deterioration in emotional control, social behavior, or motivation.


Dementia is not a specific disease. It's an overall term that describes a group of symptoms associated with a decline in memory or other thinking skills severe to reduce a person's ability to perform everyday activities. Alzheimer's disease accounts for 60 to 80% of cases. Vascular dementia, which occurs after a stroke, is the second most common dementia type. But there are many other conditions that can cause symptoms of dementia, including some that are reversible, such as thyroid problems and vitamin deficiencies. Dementia is often incorrectly referred to as senility or senile dementia which reflects the formerly widespread but incorrect belief that serious mental decline is a normal part of aging.


Dementia is not a specific disease. It is a descriptive term for a collection of symptoms that can be caused by a number of disorders that affect the brain. A progressive decline in cognitive function due to damage or disease in the brain beyond what might be expected from normal aging. Areas particularly affected include memory, attention, judgment, language, and problem solving, madness or insanity. Alzheimer's disease international estimates that are currently 30 million people with dementia in the world with 4.6 million new cases annually. The number of people affected will over 100 million by 2050.


The age group most commonly affected by this illness is 60 and over still, there is some risk group that is not age-dependent, such as people that suffer from high blood pressure, smokers high cholesterol patients and so on. Dementia is a brain disorder, beings after the age of 60 that seriously affects a person's ability to carry out daily activities. It begins slowly, involving the parts o the brain that control thought, memory & language. People with AD may have trouble remembering recent events, name of people.

Over times symptoms get worse and the patient might have trouble in speaking, reading & writing. They may forget how to brush their teeth or comb their hair, become anxious or aggressive, and wander away from home.


Causes:


Dementia is caused by damage to brain cells, this dan-mages interferes with the ability of brain cells to communicate with each other. When brain cells can not communicate normally, thinking, behavior and feeling can be affected. The brain has many distinct regions, each of which is responsible for different function (for example, memory, judgment, and movement). When cells in a particular region are damaged, that region cannot out its functions normally.



Causes divided into primary and secondary causes.







Primary Causes:


- Alzheimer's disease:

Is the most common form of dementia, and the disease most people associate with memory loss. Usually diagnosed after age 80 and is uncommon in people under the age of 65.


-Vascular dementia:

Occurs when small strokes or brain lesions impair blood flow to the brain. It is the cause of 20% of dementia cases, making it the second most common cause after Alzheimer's disease.


- Pick's Disease:

Symptoms are often hard to distinguish from Alzheimer's disease. Pick's disease damages nerve cells in the brains frontal and temporal lobes. Nerve cells affected by Pick's disease weaken and eventually die.


-Huntington's disease:

Is a genetically inherited neurological disease that can dementia. Huntington disease causes behavioral changes and chorea. The usual age of Huntington's disease onset is between forty and sixty years old.


- Parkinson's disease:

Is a progressive neurological disease that affects movement and muscle control. Symptoms of Parkinson's disease include tremors, balance problems, difficulty walking, and a rigid posture.


-Lewy- body dementia:

Related to Alzheimer's disease. The cause is the presence of abnormal substances called Lewy-body in parts of the brain such as cortex and brain stem. Lewy body dementia causes classical dementia symptoms, including memory loss. The disease can also cause hallucinations, depression, and paranoia.


Secondary causes:


Dementia like symptoms can develop as a result of an underlying condition can be treated, the symptoms will generally improve. The following are some of the common secondary causes that can lead to dementia.


-Alcohol Dementia and substance abuse:

Alcohol abuse can lead to symptoms of dementia. The long term toxic effects of alcohol on the brain are enough to cause it. Symptoms can often be improved by abstaining from alcohol.


-Infections diseases:

A number of infections that affect the central nervous system have been known to cause dementia symptoms, including HIV, meningitis, and encephalitis.


Medication:

As people age, they tend to require more medication for their health. Many of the medications include dementia symptoms as aside effect. The list of medications is incredibly long and includes such common medication as anti-diarrhea medication, anti-epileptic medications, antihistamines, cold and flu medication, sleeping pills, tricyclic antidepressants.


Pseudo Dementia:

Depression can result in dementia symptoms, including memory loss and a lack of motivation. Elderly people dealing with health problems, the loss of spouse, or loneliness are particularly susceptible to depression. Treating depression often result in the reversal of dementia symptoms.


Metabolic disorders:

Metabolic disorders can also symptoms of dementia. These disorders include cortisol hormone imbalances, diabetes, electrolyte levels, kidney failure, liver diseases, and thyroid disorders.


Wernicke- Korsakoff syndrome:

It results from a deficiency in thiamine (Vitamin B1) and is often due to chronic, severe alcoholism. It can also result from general malnutrition, eating disorders, or the effects of chemotherapy. Dementia due to Wernicke- Korsakoff syndrome involves confusion, apathy, hallucination, communication problems, and severe memory impairment.


Brain Tumors:

Brain tumors put pressure on and damage the surrounding brain tissue. A brain tumor can cause a number of symptoms, including dementia. The tumor may originate in the brain or may have spread to the brain from other organs.


Signs and symptoms:



Dementia affects each person in a different way, depending upon the impact of the disease and the person before becoming ill. The signs and symptoms linked to dementia can be understood in three stages.


Early-stage:

The early stage of dementia is often overlooked because the onset is gradual. Common symptoms include:

- Forgetfulness

- Losing track of the time

- Becoming lost in familiar places.


Middle stage:

As dementia progresses to the middle stage, the signs and symptoms become and more restricting. These include:

- Becoming forgetful of recent events and people's names

- Becoming lost at home

- Having increasing difficulty with communication

- Needing help with personal care

- Experiencing behavior changes, including wandering and repeated questioning.


Late-stage:

The late stage of dementia is one of near-total dependence and inactivity. Memory disturbances are serious and the physical signs and symptoms become more obvious. Symptoms include:

- Becoming unaware of the time and place

- Having difficulty recognizing relatives and friends

- Having an increasing need for assisted self-care

- Having difficulty walking

- Experiencing behavior changes that may escalate and including aggression.


Handling Money:

Trouble remembering simple words, often dementia sufferers will substitute inappropriate words without realizing.


Common forms of dementia:

There are many different forms of dementia. Alzheimer disease is the most common form and may contribute to 60-70% of cases. Other major forms include vascular dementia, dementia with Lewy bodies, and a group of diseases that contribute to frontotemporal dementia. The boundaries between different forms of dementia are indistinct and mixed forms often co-exist.


Rates of dementia:

Worldwide, around 50 million people have dementia, with nearly 60% living in low and middle-income countries. Every year, there are nearly 10 million new cases. The estimated proportion of the general population aged 60 and over with dementia at a given time is between 5-8%. The total number of people with dementia is projected to reach 82 million in 2030 and 152 in 2050. Much of this increase is attributable to the rising numbers of people with dementia living in low and middle-income countries.


Diagnosis:


There is no one test to determine if someone has dementia. Doctors diagnose Alzheimer's and other types of dementia based on a careful medical history, a physical examination, laboratory tests, and the characteristic changes in thinking, day-to-day function and behavior associated with each type. Doctors can determine that a person has dementia with a level of certainty. But it's harder to determine the exact type of dementia because of the symptoms and brain changes of different dementias can overlap. In some cases, a doctor may diagnosis dementia and not specify a type. If this occurs it may be necessary to see a specialist such as a neurologist or a psychologist.



Diagnosis requires a medical history, physical examination, including neurological examination and appropriate laboratory tests.

Taking a thorough medical history involves gathering information about the onset duration, and progression of symptoms, any possible risk factors for dementia, such as a family history of the disorder or other neurological diseases, history of stroke, and alcohol or other drug use.


The various laboratory investigations include:


- Thyroid hormone tests to check for an underactive thyroid.

- Vitamin B12 blood test to look for a vitamin deficiency.

- Complete blood count, or CBC, to look for infection.

- ALT or AST, blood tests that check liver function.

- Syphilis test to look for this disease.

- Chemistry screen to check the level of electrolytes in the blood and to check kidney function.

- Glucose test to check the level of sugar in the blood.

- MRI or CT to look for tumors.


Other lab tests that may be done include:


- HIV testing to look aids

- Erythrocyte sedimentation rate, a blood test that looks for signs of inflammation in the body.

- Toxicology screen, which examines blood, urine, or hair to look for drugs that could be causing problems.

- Antinuclear antibodies, a blood test used to diagnose autoimmune diseases

- Testing for heavy metals in the blood, such as a lead test.


Risk factors and prevention:


Although age is the strongest known risk factor for dementia, it is not an inevitable consequence of aging. Further, dementia does not exclusively affect older people- young-onset dementia accounts for up to 9% of cases. Studies show that people can reduce their risk of dementia by getting regular exercise, not smoking, avoiding harmful use of alcohol, controlling and blood sugar levels, Additional risk factors include depression, low educational attainment, social isolation, and cognitive inactivity.


Social and economic impact:


Dementia has significant social and economic implications in terms of direct medical and social care costs, and the costs of informal care. In 2015, the total global societal cost of dementia was estimated to be 818 billion, equivalent to 1.1% of global gross domestic product. The total cost as a proportion of GDP varied from 0.2% in low and middle-income countries to 1.4% in high-income countries.


Impact on families and carers:


Dementia can be overwhelming for the families of affected people and for their carers. Physical, emotional and financial pressure can cause great stress to families and carers, and support is required from the health, social and legal systems.


WHO response:


WHO recognizes dementia as a public health priority. On May 2017, the World Health Assembly endorsed the Global action plan on the public health response to dementia 2017- 2025. The plan provides a comprehensive blueprint for action, for policy-makers, international, regional and national partners, and WHO as in the following areas, addressing dementia as a public health priority, increasing awareness of dementia and establishing dementia-friendly initiatives, reducing the risk dementia, diagnosis, treatment and care, information systems for dementia, support for dementia carers, and research and innovation. An international surveillance platform, the global Dementia Observatory, has been established for policymakers and researchers to facilitate monitoring and sharing of information on dementia policies, service delivery, epidemiology, and research.


WHO has developed Towards a dementia plan, a WHO guide, which provides guidance to the Member States in creating and operationalizing a dementia plan. The guide is closely linked to WHO's GDO and includes associated tools such as a checklist to guide the preparation, development, and implementation of a dementia plan. It can be used for stakeholder mapping and priority setting.


WHO Guidelines on risk reduction of cognitive decline and dementia provide evidence-based recommendations on interventions for reducing modifiable risk factors for dementia, such as physical inactivity and unhealthy diets, as well as controlling medical conditions linked to dementia, including hypertension and diabetes. Dementia is also one of the priority conditions in the WHO mental health gap action program, which is a resource for generalists, particularly in low- and middle-income countries, to help them provide first-line care for mental, neurological and substance use disorders.

Ayurvedic Perspective of Migraine and its management
Migraine is one of the worst headaches a person can experience. It is described as a throbbing or pulsating pain that can be on one side of the head.It can begin in a specific area and then spread while it builds in intensity. A migraine is associated with nausea and vomiting. The person will also be
sensitive to light, sounds and even certain smells. Sleeping can be difficult and many people become depressed. They can last for a couple of hours or for several days. The symptoms of Migraine almost simulates with the condition “Ardhaavabhedaka “ which is one among the 11 types of Shiro rogas explained
in Ayurvedic classics .Lets discuss about the causative factors, pathology and management of Migraine in Ayurveda.
General Pathology
Vagbhata in the Ashtanga Hridaya explains the causative factors of Shiro ruja (Different types of head aches) as Air pollution, too much exposure of sun, cold, over use of water activities, too much sleeping or less sleep, sweating of head,
stress and related conditions, holding of tear, too much water intake, alcohol over use, infections, blocking natural urges, not being tidy and clean- both internally and externally, reduced oil application on body, use of computer or similar activities where the person has to look downwards for a longer period of time, digestive disturbances, talking on loud voice for longer time etc. Because of these factors, the Doshas are vitiated with the dominance of Vata, reaches head to create the pathological process. There is a migraine "pain centre" or generator in the brain. A migraine begins when hyperactive nerve cells send out impulses to the blood vessels, causing them to clamp down or constrict, followed by dilation (expanding) and the release of
prostaglandins, serotonin, and other inflammatory substances that cause the pulsation to be painful. The hyper action of the nerve cells and expansion and dilation of blood vessels are caused because of the Vata vitiation due to the above factors. This further vitiates Pitta and Kapha Doshas in our body, which
causes the inflammatory process. Charaka also mentioned that if this condition left untreated, it can lead to blindness or deafness.
Management in Ayurveda
Ayurveda has a variety of efficacious procedures and medications with no drawbacks and incidence of recurrence in the treatment of Migraine. Internal preparations, external treatments and Panchakarma (purification) treatments
are adopted for the management. This is done after a detailed diagnosis according to Ayurvedic methods. History of the disease with duration, previous disease history, mental state, pattern of sleep, appetite, food habits, activities, analysing the sense organs, analysing the pulse, character of stool and urine,
menstrual history, etc are examined in detail. This helps to get knowledge regarding the involvement of Dosha and the intensity of the disease. Treatment is done according to these two factors. First phase in the management of Migraine (Ardhavabhedaka) is Nidana Parivarjana (avoiding Triggering factors). Ayurveda enlists various nidanas (Reasons) which includes aharaja (diet born), vihaaraja (lifestyle related), manasika (mind and emotions related) factors. Most of the nidanas mentioned in Ayurveda go in similarity with migraine triggers, which has an active part in the diagnosis as well as in planning the treatment modalities.
Therapies Generally Used.---
External treatments along with the internal preparations are very effective in chronic conditions. Panchakarma helps to remove the accumulated toxins and help to strengthen the nerve system. Involvement of other systemic disorders is also taken into account before deciding the treatment protocols.
1. Thala pothichil : Various kinds of paste (grinded mixture of selected herbs in suitable liquid media ) over the forehead / entire head help for the sudden relief from the ache. The preparations help to normalize the hyper action of the nerve cells and regulates the blood circulation towards the brain
2. Thalam : Special herbal powders suitable to reduce the Dosha vitiation, are selected and mixed with suitable liquid media(oils/ghee) and this medicated herbal paste is applied lukewarm over the crown of head (Anatomically over the Bregma point on skull). (Dur 25-45min).
3. Shiro abhyanga : Head Massaging with Oils suitable for the Dosha vitiation, helps to increase the blood circulation towards brain and also helps to relax the spastic muscles on head. Special care is taken to massage the Marmas or the Vital points on head which have marvelous results.
4. Nasya : Nasya (application of herbal preparations through nostrils) is one of the treatments which directly acts on the nerves and removes the toxins accumulated in the sinuses. Mucus lining inside the nostrils are one of the areas where numerous nerve endings are exposed. The medicated oils applied through Nasya directly acts on these nerve endings and help to pacify Vata Dosha in disturbed nerves and control the abnormal impulses gernerated by these nerves. The special preparations used for Nasya drains the mucus deposited in the sinuses there by the pressure in this area is relieved. The
medicinal contents of the oils administered, stimulate the higher centers of brain which have actions on regulation of endocrine, nervous system and circulatory functions.
5. Shiro dhara : Shiro dhara with Takram (medicated butter milk) is also another important therapy which is used to control the vitiated vata kapha doshas localized head.(Dur 25-75min) Other Panchakarma treatments like Vasti (a course of medicated oil and decoction enemas), Virechana (purgation) also helps to put the toxins out from the body.
After the Panchakarma therapies, special preparations called Rasayana (immuno regulatory) is administered. Rasayana preparations improve the immune system further improving the perception of sense organs. Migraine due to other systemic involvement like psychological problems, digestive problems,
blood pressure, ophthalmic problems, immune problem, improper menstruation, etc will be relieved when treated according to the specific treatment told for these diseases.

Preconditions
• Diagnosis compatible with brain stem death
• Presence of irreversible structural brain damage
• Presence of apnoeic coma
Exclusions
• Therapeutic drug effects (sedatives, hypnotics, muscle relaxants)
• Hypothermia (Temp >35°C)
• Metabolic abnormalities
• Endocrine abnormalities
• Intoxication
Clinical tests
• Confirmation of absent brain stem reflexes
• Confirmation of persistent apnoea
• Clinical tests should be performed by two experienced practitioners
• At least one should be a consultant
• Neither should be part of the transplant team
• Should be performed on two separate occasions
• There is no necessary prescribed time interval between the tests
Clinical tests for absent brain stem reflexes
• No pupillary response to light
• Absent corneal reflex
• No motor response within cranial nerve distribution
• Absent gag reflex
• Absent cough reflex
• Absent vestibulo-ocular reflex
Test for confirmation of persistent apnoea
• Preoxygenation with 100% oxygen for 10 minutes
• Allow PaCO2 to rise above 5.0 kPa before test
• Disconnect from ventilator
• Maintain adequate oxygenation during test
• Allow PaCO2 to climb above 6.65 kPa
• Confirm no spontaneous respiration
• Reconnect ventilator

Hydrocephalus is a build-up of fluid on the brain. The excess fluid puts pressure on the brain, which can cause it to be damaged.
The damage to the brain can result in a wide range of symptoms, including:
Headache
Being sick
Blurred vision
Difficulty walking
Hydrocephalus can usually be treated using a piece of equipment known as a shunt. A shunt is a thin tube that's surgically implanted in the brain and used to drain away the excess fluid.
Cerebrospinal fluid
In the past, hydrocephalus was often referred to as ‘water on the brain’. However, this term is incorrect because the brain is not surrounded by water but by a special fluid called cerebrospinal fluid (CSF).
Cerebrospinal fluid has three important functions:
It protects the brain from damage
It removes waste products from the brain
It provides the brain with the nutrients it needs to function properly
The brain constantly produces new cerebrospinal fluid (about a pint a day), while old fluid is released from the brain and absorbed into the blood vessels. However, if this process is interrupted, the level of CSF can quickly build-up, placing pressure on the brain.
Types of hydrocephalus
There are three main types of hydrocephalus:
Hydrocephalus that's present at birth (congenital hydrocephalus)
Hydrocephalus that develops after birth (acquired hydrocephalus)
Hydrocephalus that usually only develops in older people (normal pressure hydrocephalus or NPH)
These are briefly described below.
Congenital hydrocephalus
Congenital hydrocephalus is present in babies when they're born and can be caused by birth defects, such as spina bifida, or as a result of an infection that the mother develops during pregnancy, such as mumps or rubella (German measles).
Congenital hydrocephalus carries the risk of long-term mental and physical disabilities as a result of permanent brain damage.
Acquired hydrocephalus
Acquired hydrocephalus can affect children or adults. It usually develops after an injury or illness. For example, it may occur after a serious head injury or as a complication of a medical condition, such as a brain tumour.
Normal pressure hydrocephalus
Normal pressure hydrocephalus (NPH) is a poorly understood condition that usually only affects people over 50 years old.
It can sometimes develop after an injury or a stroke, but in most cases the cause is unknown.
The average age of people with NPH is 75, although it's a rare condition.
Symptoms of hydrocephalus
Hydrocephalus (fluid on the brain) causes slightly different symptoms depending on the type of hydrocephalus and the age of the person affected.
Congenital hydrocephalus
Babies with hydrocephalus at birth (congenital hydrocephalus) often have distinctive physical characteristics. Physical signs include:
Your baby’s head may appear unusually large
Your baby’s scalp may be thin and shiny with easily visible veins
Your baby may have a bulging or tense fontanelle (the soft spot on the top of their head)
Your baby's eyes appear to be looking down; this is known as the ‘setting-sun sign’ because the eyes resemble the sun setting below the horizon
The muscles in your baby’s lower limbs may appear stiff and be prone to muscle spasms (contractions)
As well as these physical signs, congenital hydrocephalus can also cause symptoms such as:
Poor feeding
Irritability
Being sick
Drowsiness
Acquired hydrocephalus
Hydrocephalus that develops in adults or children (acquired hydrocephalus) can cause headaches. The headache may be worse in the morning after waking up, as the fluid in your brain doesn't drain so well while you're lying down and may have built up overnight. Sitting up for a while may improve your headache. However, as the condition progresses, the headaches may become continuous. If hydrocephalus is not treated, it can be life-threatening.
Other symptoms of acquired hydrocephalus include:
Neck pain
Feeling sick
Being sick – which may be worse in the morning
Drowsiness, which can progress to a coma
Changes in your mental state, such as confusion
Blurred vision or double vision
Difficulty walking
Not being able to control your bladder (urinary incontinence) and, in some cases, your bowel (bowel incontinence)
Normal pressure hydrocephalus
Unlike the other two types of hydrocephalus, the symptoms of hydrocephalus that develop in older people (normal pressure hydrocephalus or NPH) usually develop slowly, over the course of many months or years.
There are three sets of distinctive symptoms. They affect:
How you walk
Your urinary system
Your mental abilities
These are discussed below.
How you walk
Usually, the first noticeable symptom of normal pressure hydrocephalus (NPH) is a change in how you walk (your gait). You may find it increasingly difficult to take the first step when you want to start walking. Some people have described it as feeling as though they're frozen to the spot. You may also shuffle rather than take proper steps.
As the condition progresses, you may become increasingly unsteady on your feet. You may be more likely to fall, particularly when turning.
Urinary symptoms
The change in the way that you walk is often followed by bouts of urinary incontinence, which may include symptoms such as:
A frequent need to urinate
An urgent need to urinate
Loss of bladder control
Mental abilities
The normal thinking process also starts to slow down. This can take the form of:
Being slow to respond to questions
Reacting slowly to situations
Being slow to process information
These may be confused with the symptoms of dementia. You may actually have mild dementia, which will improve when the normal pressure hydrocephalus (NPH) is treated.
Causes of hydrocephalus
To understand the causes of hydrocephalus (fluid on the brain), it is first useful to understand how cerebrospinal fluid (CSF) circulates through the brain.
Cerebrospinal fluid and the brain
Cerebrospinal fluid (CSF) is created in the brain. It flows through the brain through a series of chambers called ventricles.
Excess cerebrospinal fluid moves out of the brain, where it's absorbed back into the bloodstream by a specialised tissue called the arachnoid villi. The arachnoid villi act like a one-way valve. They allow excess cerebrospinal fluid to leave the brain and filter into blood vessels while preventing the blood from leaking into the brain and damaging it.
Hydrocephalus can develop if:
There's a blockage in one of the ventricles so that excess fluid can't move out of the brain
There's a problem with the arachnoid villi so that fluid is unable to filter into the blood vessels
The brain starts to produce too much cerebrospinal fluid (this is very rare)
Congenital hydrocephalus
Congenital hydrocephalus, where a baby is born with the condition, may be the result of a brain defect that restricts the flow of cerebrospinal fluid. For example, the passages that connect the ventricles in the brain become blocked or narrowed.
These defects in the development of the brain can be caused by health conditions known to cause birth defects. For example, most children born with the most serious type of spina bifida will develop hydrocephalus.
Congenital hydrocephalus can also occur in babies born prematurely (before week 37 of the pregnancy). Some premature babies experience bleeding in their brain, which can block the flow of cerebrospinal fluid and cause hydrocephalus.
Other possible causes of congenital hydrocephalus include:
X-linked hydrocephalus – where the condition occurs as a result of a mutation (change in the genetic material) of the X chromosome
Rare genetic disorders, such as Dandy Walker malformation
Rrachnoid cysts – fluid filled sacs located between the brain or spinal cord and the arachnoid membrane, which is one of the three membranes surrounding the brain and spinal cord
In many cases of congenital hydrocephalus, the cause is unknown. This is medically referred to as idiopathic.
Acquired hydrocephalus
Hydrocephalus that develops in adults or children (acquired hydrocephalus) is usually the result of an injury or illness that causes a blockage between the ventricles of the brain.
Possible causes of acquired hydrocephalus include:
Bleeding inside the brain – for example, if blood leaks out of blood vessels over the surface of the brain (subarachnoid haemorrhage)
Blood clots inside the blood vessels in the brain (venous thrombosis)
Meningitis – an infection of the protective membranes that surround the brain and spinal cord
Brain tumours
Head injury
It's also possible for someone to be born with narrowed passageways in their brain that restrict the flow of cerebrospinal fluid, but don't cause any symptoms until years later.
Normal pressure hydrocephalus
Hydrocephalus that develops in older people (normal pressure hydrocephalus or NPH) can occur after a brain injury, bleeding in the brain or infection. However, in most cases, there's no clear reason why the condition occurs.
There are several theories to explain what happens to the brain in cases of NPH. Some are outlined below.
Problems with the arachnoid villi
One idea is that NPH occurs when something goes wrong with the arachnoid villi, which is the layer of tissue that allows cerebrospinal fluid to filter into the blood vessels. This means that the blood vessels don't reabsorb the fluid. This creates a gradual increase in pressure, which can cause progressive brain damage.
Underlying health conditions
NPH may be caused by underlying health conditions that affect the normal flow of blood. For example, diabetes, heart disease or having a high level of cholesterol in the blood.
The exact cause is unknown, but conditions that affect blood vessels within the brain or that supply blood to the brain (cerebrovascular disease) may be linked to NPH
Diagnosing hydrocephalus
The different types of hydrocephalus (fluid on the brain) can be diagnosed with brain scans.
Congenital hydrocephalus
In some cases, an ultrasound scan can detect congenital hydrocephalus before your baby is born. An ultrasound scan uses high-frequency sound waves to create an image of your womb and the baby inside.
If your baby has some of the physical characteristics associated with congenital hydrocephalus after they're born, such as an enlarged head, they may be referred for an ultrasound scan. If the results of the ultrasound are inconclusive, further testing can be carried out using:
A computerised tomography (CT) scan – this takes a series of X-rays at slightly different angles and uses a computer to put the images together
A magnetic resonance imaging (MRI) scan – this uses a strong magnetic field and radio waves to produce detailed images of the brain
These scans can examine the brain in greater detail. As well as showing the build-up of fluid on the brain and the increased pressure, the scans can also highlight any defects in the structure of the brain that may be causing the hydrocephalus.
Acquired hydrocephalus
Hydrocephalus that develops in adults or children (acquired hydrocephalus) can be diagnosed using a combination of CT and MRI scans. The scans can also reveal any possible causes of your symptoms, such as a brain tumour.
Normal pressure hydrocephalus
Hydrocephalus that usually develops in older people (normal pressure hydrocephalus or NPH) can be difficult to diagnose for the following reasons:
The symptoms come on very gradually
The symptoms are more common to conditions, such as Alzheimer's disease, which may frequently occur with NPH
It's important to make a correct diagnosis because, unlike Alzheimer’s disease, it's possible to relieve the symptoms of NPH using appropriate treatment.
Healthcare professionals have therefore devised a diagnostic checklist. There are four main factors that the checklist examines:
How you walk (your gait)
Your mental ability
Symptoms that affect your bladder control such as urinary incontinence
The appearance of your brain during CT, MRI and ultrasound scans
You may be diagnosed with NPH if you have the combination of an impaired gait, slowing of the normal mental processes and urinary incontinence, and scans have shown that your cerebrospinal fluid (CSF) is at a higher level than usual. CSF is the fluid that surrounds your brain and spinal cord.
However, you may not have all of the symptoms in the checklist.
Further tests may also be carried out to decide whether you would benefit from having surgery, such as:
A lumbar puncture
A lumbar drainage test
A lumbar infusion test
These procedures are briefly described below.
Lumbar puncture
A lumbar puncture, also known as a spinal tap, is a procedure that's used to take a sample of CSF from your lower back.
A hollow needle is inserted between your back bones (vertebrae), and a small amount of the fluid is removed. The pressure of the CSF sample can then be checked.
Removing some CSF during a lumbar puncture may help to improve your symptoms. If this is the case, it's a good indication that you may benefit from treatment with surgery.
Lumbar drain
If having a lumbar puncture doesn't improve your symptoms, this doesn't mean that you do not have NPH. If the lumbar puncture test is negative, you may have a lumbar drain.
A lumbar drain involves inserting a tube between your back bones to drain a large amount of CSF. This is done over a few days to see if this improves your symptoms, such as your ability to walk around. This is usually done under local anaesthetic to numb the area, or sedation to relax you.
Lumbar infusion test
A lumbar infusion test can also be used to help diagnose NPH and decide whether you need surgery. The procedure should be carried out under local anaesthetic so it shouldn't be painful.
The test involves slowly injecting fluid into your lower back while measuring the pressure. The additional fluid should be absorbed by your body so that the pressure stays low. However, if your body can't absorb the extra fluid, the pressure will rise. This could indicate that you have NPH and that surgery will be beneficial. l be beneficial.
Treating hydrocephalus
Hydrocephalus (fluid on the brain) is treated with surgery.
Congenital and acquired hydrocephalus
Babies who are born with hydrocephalus (congenital hydrocephalus) and adults or children who develop hydrocephalus (acquired hydrocephalus) usually require prompt treatment to reduce the pressure on their brain. If the hydrocephalus is not treated, the rise in pressure will damage the brain.
Both congenital and acquired hydrocephalus will be treated with either shunt surgery or neuroendoscopy (see below).
Normal pressure hydrocephalus
Hydrocephalus that usually develops in older people (normal pressure hydrocephalus or NPH) can also be treated with a shunt. However, experience has shown that not everyone with NPH will benefit from shunt surgery.
Due to the risks of complications occurring as a result of surgery, you will need tests to assess whether the potential benefits of surgery outweigh the risks. A lumbar drainage test or lumbar infusion test, or both, can be used to find out whether shunt surgery will benefit you. See Hydrocephalus – diagnosis for more information about these tests.
Shunt surgery will be recommended if testing reveals that it would be beneficial.
Shunt surgery
Shunt surgery involves implanting a thin tube, called a shunt, in the brain. The excess cerebrospinal fluid (CSF) in the brain runs through the shunt to another part of the body, usually the abdomen. From here the fluid is absorbed into your blood stream. The shunt has a valve inside it to control the flow of CSF and to ensure it does not drain too quickly. You can feel the valve as a lump under the skin of your scalp.
The operation
Shunt surgery is carried out by a neurosurgeon (a specialist in surgery of the brain and nervous system). You will be given a general anaesthetic before the operation so that you will be asleep throughout the procedure, which usually takes one to two hours.
After the operation, you may need to spend a few days in hospital to recover. If you have stitches in the wound in your head, they may dissolve on their own, or you may be advised about when these will be removed. Some surgeons use skin staples to close the wound. Like stitches, these will need to be removed after a few days.
Once the shunt has been installed, further treatment for hydrocephalus may be required if the shunt becomes blocked or infected. Shunt repair surgery will then be necessary.
Endoscopic third ventriculostomy (ETV)
An alternative procedure toshunt surgery is an endoscopic third ventriculostomy (ETV). This procedure involves making a hole in the floor of the brain, allowing the trapped CSF to escape to the surface of the brain where it can be absorbed, instead of inserting a shunt.
An ETV is not suitable for everyone. However, it could be a possible treatment option if the build-up of CSF in your brain is the result of a blockage (obstructive hydrocephalus). The CSF will be able to drain through the hole, avoiding the blockage.
During an ETV, a small hole is made in your skull and your neurosurgeon will use an endoscope to look inside the chambers of your brain. An endoscope is a thin, long tube that has a light and a video camera at one end. A small hole will be made inside your brain with the help of the endoscope. After the endoscope has been removed, the wound will be closed using stitches. The procedure takes around one hour.
There is less risk of an infection developing after an ETV than with shunt surgery. However, as with all surgical procedures, there are some risks associated with ventriculostomy.
The long-term results for treatment with ETV are very similar to those for a shunt operation. As with shunts, ETVs may block months or years after surgery, resulting in your symptoms reocurring.
Complications of hydrocephalus
Hydrocephalus (fluid on the brain) can cause some complications, or complications may develop as a result of the surgery used to treat it.
Shunt malfunction
A shunt is a delicate piece of equipment that's prone to malfunction, usually through blockage or infection. It's estimated that up to 4 out of 10 shunts will malfunction in the first year after surgery. Sometimes a scan carried out after the operation shows that the shunt isn't in the best position, and that further surgery may be needed to reposition it.
If a baby or child has a shunt fitted, the shunt may become too small as your child grows, and it will need to be replaced. As most people need to have a shunt for the rest of their life, more than one replacement may be needed.
It's estimated that most children with hydrocephalus may have an average of two procedures for shunt problems before they're 10 years old.
Occasionally, when shunt tubes are positioned, bleeding can occur. This can result in nerve problems, such as weakness down one side. There's also a small risk of seizures (fits) following any surgery on the brain.
In younger children, particularly babies, cerebrospinal fluid (CSF) can run alongside the shunt rather than down it, and it can leak through the skin wound. If this occurs, further stitches will be needed to stop the leak.
Shunt blockage
A shunt blockage can be very serious because it can lead to an excess build-up of fluid on the brain, which can cause brain damage. This will cause the same symptoms of hydrocephalus, such as:
Headaches
Feeling sick
Being sick
Confusion
Drowsiness or coma
In babies, you may notice their head growing larger or they may have a bulging or tense fontanelle (the soft spot on the top of their head).
Contact Dr. B C Shah immediately if you or your child have these symptoms. Emergency surgery will be required to replace the malfunctioning shunt.
Shunt infection
Shunt infection is also a relatively common complication. The risk of infection can be around 3-15% and is more likely to occur during the first few months after surgery.
The symptoms of a shunt infection may include:
Redness and tenderness along the line of the shunt
A high temperature (fever) of 38ºC (100.4ºF) or over
Headache
Being sick
Neck stiffness
Tummy pain (if the shunt drains into your tummy)
Irritability or drowsiness in babies
Contact Dr. B C Shah immediately if you or your child has these symptoms. You may need to have a course of antibiotics to treat the infection and, in some cases, surgery may be required to replace the shunt.
Complications of endoscopic third ventriculostomy (ETV)
An endoscopic third ventriculostomy (ETV) is a surgical procedure where a small hole is made in the floor of your brain. Complications can occur after this type of surgery, such as:
The hole can close
Your brain may not be able to absorb the cerebrospinal fluid that's now draining through it
You may develop an infection, although this is less likely than after shunt surgery
You may have bleeding inside your brain (this is usually minor)
If there's a problem with the hole, it may be possible to repeat the procedure, or you may need to have a shunt fitted.
Other risks of ETV include nerve problems, such as weakness down one side of the body, double vision or hormone imbalances. Most nerve problems will get better, but there's a small risk of permanent problems. There's also a small risk of epilepsy, and a very small risk of an injury to one of the blood vessels in the brain, which may be fatal.
Long-term complications of congenital hydrocephalus
Many babies born with hydrocephalus (congenital hydrocephalus) have permanent brain damage. This can cause a number of long-term complications, such as:
Learning disabilities
Impaired speech
Memory problems
Short attention span
Problems with organisational skills
Vision problems, such as a squint and visual impairment
Problems with physical co-ordination
Epilepsy

August 1, 2012 · by deemagclinic · in Uncategorized · Edit

What is a seizure?

A seizure is a symptom, not a disease. It happens when nerve cells in the brain don’t work right and there is a sudden abnormal electrical signal in the brain. The seizure can cause strange sensations and behavior. Sometimes it causes muscle spasms and a change in or loss of consciousness.

The 2 most common types of seizures are:
focal or partial seizures, which begin in just a part of the brain but sometimes may spread to involve all of the brain
generalized seizures , which seem to involve all areas of the brain from the start of the seizure.

A common feature of partial seizures is the sensing of something that others are not aware of. For example, you may see flashing lights, have a particular taste in your mouth, or hear noises not seen or heard by others. Sometimes partial seizures also cause some numbness or jerking of the limbs. You may be awake and remember what happened, or you may lose consciousness for a short time.

There are 2 types of generalized seizures based on the pattern of the attack:
A grand mal seizure is a seizure that starts with a loss of consciousness and falling down, followed by a brief period of rigid muscles and a 1- to 2-minute period of violent, rhythmic jerking. The seizure ends with a few minutes of deep sleep before you are conscious again. You will probably not remember the seizure. You may be drowsy for hours after the seizure.
An absence or petit mal seizure is a short period of staring, fluttering eyelids, or twitching of muscles in your face. You do not lose consciousness. You are awake, but you are not able to understand what is going on around you. It’s not possible to pay attention at work or school when you are having petit mal seizures. You will probably not remember the seizure. Petit mal seizures usually begin when you are a child. Each seizure may last only 10 to 30 seconds, but hundreds may happen each day.

One seizure right after another or one very long seizure is called status epilepticus. The symptoms are usually those of a grand mal seizure. This can be life threatening because it can keep you from getting enough oxygen. It is a medical emergency.

If you have had several seizures and no cause can be found that can be corrected with treatment, your healthcare provider may diagnose seizure disorder, which is also called epilepsy.
How does it occur?

Seizures can happen for many different reasons, but most seizures have no known cause.

Seizures can be a symptom of many diseases and conditions, including:
head injury
brain injury at birth
brain infections such as meningitis or encephalitis
brain tumor
stroke
drug and alcohol abuse
withdrawal from alcohol and drugs such as narcotics, cocaine, tranquilizers, and sleeping pills
metabolic imbalances, such as low blood sugar or low blood sodium.
What are the symptoms?

Symptoms of a seizure can include:
aura, a peculiar sensation that occurs just before a seizure and may give you warning that a seizure is about to happen (for example, you may see flashing lights or hear noises)
rapid eye blinking or staring
twitching of the face
smacking of the lips
shaking or jerking of the arms and legs
stiffening of the body
crying or moaning
hallucinations, which may be visual or involve other senses such as hearing, touch, or taste
intense feelings of fear or déjà vu (the feeling that what you are experiencing has happened before even though you know it hasn’t)
loss of consciousness
loss of control of your bladder muscles so that you wet yourself
loss of bowel control
falling suddenly for no clear reason
not responding to noise or words for brief periods
appearing confused or in a haze
nodding the head
breathing problems from choking on food or saliva
vomiting.

You may be drowsy for several minutes after the seizure.
How is it diagnosed?

Your healthcare provider will examine you and take your medical history. You may have blood tests and one or more of the following safe and painless tests or scans to look for possible causes of your seizures:
EEG, which measures electrical activity in the brain
MRI (magnetic resonance imaging) scan, which uses magnetism, radio waves, and a computer to produce a picture of the inside of your head
CT (computed tomography) scan, in which X-rays are taken of your brain at different angles and then combined by a computer.
How is it treated?

The treatment for seizures depends on the cause. If you have a medical problem that is causing the seizures, such as diabetes, you will be treated for that problem.

Your healthcare provider may prescribe an anticonvulsant drug. This medicine will help prevent seizures. Your healthcare provider will adjust the dosage to minimize any side effects from the drug. If you keep having seizures while you are taking medicine, your healthcare provider will:
Check the level of the medicine in your blood.
Make sure you are taking your medicine as prescribed.
Make sure you aren’t drinking alcohol or using illegal street drugs.
Check to see if you are taking other medicines that may interfere with the anticonvulsant.

Medicine is the main treatment for seizures, but several new treatments are being evaluated. These include:
surgery on the area of the brain where the seizures occur
stimulation of a nerve in the neck by a device placed under the skin.
How long will the effects last?

It is not possible to know how long seizures will be a problem for any one person. Absence seizures often stop by the time you are an adult. You may keep having other types of seizures. Depending on the type of seizures you have and how often you have them, after a time your healthcare provider may recommend that you try to slowly decrease your medicines. You usually need to have not had any seizures while on medicine for at least 3 years before this is even considered. During this time it is very important to avoid driving a car or other activities where your life or the lives of others might be in danger if you had a seizure. Never stop taking your medicine without first checking with your provider.
How can I take care of myself?

Your friends and family should know first aid for seizures and CPR. When you have a seizure, they should:
Help you lie down on a bed or the floor.
Loosen clothing around your neck and remove eyeglasses.
Not try to hold you down. If possible, they should roll you onto your left side and gently hold you there. This position will help keep you from choking on vomit if you start vomiting. Objects should be moved away from you to avoid injury.
Check to make sure you are breathing.
Not put anything in your mouth. (The risk of biting your tongue is less than the danger of inhaling or being injured by anything put in your mouth. You will not swallow your tongue.)
Not move you during a seizure unless there is danger of injury.
After the seizure is over, let you rest while you wake up.

Someone should call 911 for emergency help if you are having a seizure and:
It is the first time you have had a seizure.
You have stopped breathing.
The seizure lasts 5 minutes or longer.
You have another seizure soon after the first one stopped.
You are not fully awake within a few minutes after the seizure.
Your lips or face look blue.
You fall and hit your head during a seizure.
A seizure happens after a head injury.

If you are having a seizure and not breathing, someone should start giving you CPR and keep giving it until the ambulance arrives.

If you keep having seizures one right after another or have one seizure for a long time, it is dangerous because you may not be getting enough oxygen. It is a medical emergency and you will need help.

Ways to care for yourself include:
Follow the treatment prescribed by your healthcare provider. Take medicine exactly as prescribed. Do not increase how much you take or how often you take it.
Eat a healthy diet and create a balance of work, rest, recreation, and exercise in your life.
Wear a medical ID bracelet or necklace so others will know about your condition.
Tell family, friends, and co-workers what to do if you have a seizure.
If your seizures are not well controlled, you should avoid high-risk activities that would be unsafe if you had a seizure. Some examples of risky activities might include swimming alone, cycling on a highway, scuba diving, or skiing. Ask your healthcare provider which activities are safe for you.
Avoid high-risk jobs that involve heavy or fast-moving equipment, heights, bodies of water, or other situations where you or others might be injured if you have a seizure.
Ask your provider when you may safely drive a car again. Check with your state’s Department of Motor Vehicles for rules about reporting a history of seizures.
Keep a positive attitude and develop ways to lessen stress.
Keep all of your follow-up appointments with your provider.
Call your healthcare provider if:
You have side effects from your medicine.
You keep having seizures and you are taking your medicine correctly.
The seizures change–for example, they happen more often or last longer.
You are a woman who takes medicines to prevent seizures and you want to get pregnant or you are pregnant.
You have any symptoms that worry you.

For more information, call or write:

Epilepsy Foundation of America
Phone: 800-332-1000
Web site: http://www.epilepsyfoundation.org
How can I help prevent seizures?

To help prevent further seizures:
Take your medicine as directed. Never skip a dose or stop taking your medicine without first checking with your provider.
Make sure you get enough sleep every night. Getting too little sleep can be a major cause of seizures if you have a seizure disorder.
Avoid alcohol.
Avoid mood-altering drugs, including stimulants and sedatives.
If you start having a fever, lower it right away with aspirin or acetaminophen. (Check with your healthcare provider before you give any medicine that contains aspirin or salicylates to a child or teen. This includes medicines like baby aspirin, some cold medicines, and Pepto-Bismol. Children and teens who take aspirin are at risk for a serious illness called Reye’s syndrome.)