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Dr. Uday Andar  - Neurosurgeon, Mumbai

Dr. Uday Andar

Neurosurgeon, Mumbai

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Dr. Uday Andar Neurosurgeon, Mumbai
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Hello and thank you for visiting my Lybrate profile! I want to let you know that here at my office my staff and I will do our best to make you comfortable. I strongly believe in ethics; a......more
Hello and thank you for visiting my Lybrate profile! I want to let you know that here at my office my staff and I will do our best to make you comfortable. I strongly believe in ethics; as a health provider being ethical is not just a remembered value, but a strongly observed one.
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Dr. Uday Andar is an experienced Neurosurgeon in Tardeo, Mumbai. You can meet Dr. Uday Andar personally at Bhatia Hospital in Tardeo, Mumbai. Don’t wait in a queue, book an instant appointment online with Dr. Uday Andar on Lybrate.com.

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Grant Road West Station, Tardeo Road. Landmark: Near Union Bank & Near Swati Restaurant, MumbaiMumbai Get Directions
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Hi is duloxetine used to treat Parkinson disease ?Is it evident that using duloxetine confirms one has Parkinson? Please suggest.

BPTh/BPT
Physiotherapist, Delhi
Hi is duloxetine used to treat Parkinson disease ?Is it evident that using duloxetine confirms one has Parkinson? Ple...
Hello. No it's not a fact. Diagnosis of Parkinson's is not that tough. It's symptoms almost declare it. And you can opt. For MRI. Regards!
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I am 29 years old I am suffering for nerves problems last 1 year what should I do ?

MBBS, DGO (cal)
General Physician,
Consult psychiatrist and have a discussion. He might help you with counselling and some minor short term medicinal help.
1 person found this helpful
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I am suffering from migraine head ache since 5years. I am taking treatment and using ZEROGRAIN tabs. Please give me some advice to avoid this.

BAMS
Ayurveda, Ambala
To get relief from migraine- * give a balanced diet with vegetables, cereals, milk, fruits. Sit in the sun rays for atleast 8-10 minutes daily. * do bhramari pranayam twice a day. * practice sarwangasan and shirshasan under the guidance of yoga expert. * sit with the gyan mudra in hands. * take rogan badam (almond oil) and put it 1/2 tea spoon in a glass of milk and drink it in the morning. * if the headache is very severe & untolerable then you can take a tablet of paracetamol or ibuprofen. * you can take 2 teaspoon of shankhpushpi syrup in the morning. You can consult me for your doubts and detailed treatment.
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My dad suffers from epilepsy, what medications or remedies can help him get rid of or deal with this?

MBBS, MD Psychiatry, DNB Psychiatry
Psychiatrist, Nagpur
There is no absolute cure for epilepsy if there is no identifiable cause for it. Most of the epilepsy are idiopathic - i. E. Without any known cause. Anti epileptics given in a optimum dose and number can keep check on epilepsy.
1 person found this helpful
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My niece is 9 years old and suffering from fits from last 8 years. I went to meet many Doctors but her problem is still same due to this problem her mentally growth has been also affected. What should I do? Kindly suggest.

MBBS
General Physician, Cuttack
I think she is not taking proper medicine for control of fits. Consult child specialist and take medicine in proper doses regularly.
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Don't Understand Why Baby Is Crying?

M.Ch - Paediatric Surgery, MNAMS (Membership of the National Academy) (General Surgery) , DNB (General Surgery), MBBS
Pediatrician, Pune
Don't Understand Why Baby Is Crying?

All babies cry sometimes. It's perfectly normal. Most small babies cry for between one hour and three hours each day.

Your baby can't do anything for herself and relies on you to provide her with the food, warmth and comfort that she needs. Crying is your baby's way of communicating any or all of those needs and ensuring a response from you.

It's sometimes hard to work out what your baby is telling you. But in time you will learn to recognize what your baby needs. And as your baby grows she'll learn other ways of communicating with you. She'll get better at eye contact, making noises and smiling, all of which reduce her need to cry for attention.


In the meantime, if your baby is difficult to soothe, she may be trying to say:

I'm hungry

Hunger is one of the most common reasons that your newborn baby will cry. The younger your baby is, the more likely it is that she's hungry.

Your baby's small stomach can't hold very much, so if she cries, try offering her some milk. She may be hungry, even if her last feed doesn't seem very long ago. It's likely that you will be feeding often and regularly in the first day or so to help your breastmilk to come in anyway. If you are formula feeding your baby she may not be hungry if she has been fed within the last two hours.

I need my nappy changed

Your baby may protest if her clothes are too tight or if a wet or soiled nappy is bothering her. Or she may not mind if her nappy is full and may actually enjoy the warm and comfortable feeling. But if your baby's tender skin is being irritated, she will most likely cry.

I'm too cold or too hot

Your baby may hate having her nappy changed or being bathed. She may not be used to the feeling of cold air on her skin and would rather be bundled up and warm. But you will soon learn how to perform a quick nappy change if this is the case.

Take care not to overdress your baby, or she may become too hot. She will generally need to wear one more layer of clothing than you to be comfortable.

Use sheets and cellular blankets as beddings in your baby's cot or moses basket. You can check whether your baby is too hot or too cold by feeling her tummy. If her tummy feels too hot, remove a blanket, and if it feels cold, add one.

Don't be guided by your baby's hands or feet, as they usually feel cool. Keep your baby's room at a temperature of between 22 and 25 degrees c depending on the weather.

If your baby is co-sleeping with you, contact with your body will elevate her skin temperature so she's likely to be warm. Is she is using a cot, place her down to sleep on her back with her feet at the end of the cot. That way she can't wriggle too far down under the blankets and become too hot.

I need to be held

Your baby will need lots of cuddling, physical contact and reassurance to comfort her. So it may be that she just wants to be held. Try a baby sling to keep her close to you, perhaps swaying and singing to her while you hold her.

You may be worried about spoiling your baby if you hold her too much. But during the first few months of her life that's not possible. Small babies need lots of physical comfort. If you hold your baby close she may be soothed by hearing your heartbeat.

I'm tired and need a rest

Often, babies find it hard to get to sleep, particularly if they are over-tired. You will soon become aware of your baby's sleep cues. Whining and crying at the slightest thing, staring blankly into space, and going quiet and still are just three examples.

If your baby has received a lot of attention and cuddles from doting visitors, she may become over-stimulated. Then, when it comes to sleeping, she'll find it hard to switch off and settle. Take your baby somewhere calm and quiet to help her to settle down. Read more on establishing good sleeping habits.

I need something to make me feel better

Be aware of changes in your baby. If she's unwell, she'll probably cry in a different tone to her usual cry. It may be weaker, more urgent, continuous, or high-pitched. And if your baby usually cries a lot but has become unusually quiet, it may be a sign that she's not well.

Nobody knows your baby as well as you do. If you feel that there may be something wrong with her, speak to your doctor and discuss your concerns. Call the doctor if your baby has difficulty breathing through the crying, or if the crying is accompanied by a fever, diarrohea, or constipation.

I need something. But I don't know what

Sometimes you might not be able to figure out what's wrong when your baby cries. Many newborns go through patches of fretfulness and are not easily comforted. The unhappiness can range from a few minutes of hard-to-console crying to several hours at a stretch, an almost constant state of crying that is sometimes called colic. Colic is defined as inconsolable crying for at least three hours a day, for at least three days a week.

Many parents find it very difficult to cope with a baby who has colic, and it can put a strain on the whole family. There is no magic cure for colic, but it rarely lasts for more than three months.

19 people found this helpful

My wife 60 years feels sometime numbness in fingertip n for last Two days in arm also. Her pathological rest are normal. Pl suggested. Can acupressure also helps.

MBBS, Diploma in Child Health (DCH), MD Internal Medicine
General Physician, Visakhapatnam
My wife 60 years feels sometime numbness in fingertip n for last Two days in arm also. Her pathological rest are norm...
Is it on left side or right side. It can be because of cervical spondylitis with compression on a nerve in the neck region. Blood tests does not detect this Try accupuncture after knowing the cause of the pain. This is what I feel.
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Now Say - GO Migraine

Bachelor of Ayurveda, Medicine and Surgery (BAMS)
Ayurveda, Gurgaon

Now say - Go Migraine

Migraine headache is usually associated with one sided throbbing headache, with nausea ( the tendency to vomit), vomiting and sensitivity to light. In a migraine there is excessive stimulation (constriction and sudden dilatation) of brain and blood vessels.

Causes-

Improper metabolism, suppression of natural urges, anger, jealousy, grief, poor elimination, intake of dry, pungent and salty food, intake of polluted food, mental and physical stress, viewing of tv for long periods, reading with insufficient light, sleeplessness etc.

Origin of a migraine headache
Due to the causative factors, pitta dosha obstructs the flow of Vata dosha in the brain, causing throbbing pain.

If you would like to consult with me privately, please click on consult now.

Management-

  • Sneha nasya - instillation of medicated oils can be carried to the nostrils. Shadbindu tailam or anu tailam yield significant benefits in this condition.
  • Apply a paste of freshly ground clay or freshly ground sandalwood to the forehead, let dry, rub off by hand and wash.
  • Sugar powder 16 parts, vamshalochana 8 parts, pippali (long pepper) 4 parts, ela (cardamom) 2 parts, cinnamon - 1 part. Make fine powder and mix it, keep in tight moisture-free container. Take half teaspoon thrice daily with honey.
  • Mix one-forth teaspoon of clove powder with 1 teaspoon of cinnamon oil. Apply this paste on the affected area for 20-30 minutes.
  • Add chamomile powder to 1 cup of boiling water. Transfer the liquid to a cup. Drink when hot. It gives fast relief from a migraine.
  • Grind 10-12 grains of black pepper and 10-12 grains of rice with water to make it a paste. Apply this paste on the affected area of the head for 15-20 minutes.
  • Take half a glass of carrot juice. Add half a glass of spinach juice. Mix well. Drink this juice to cure the migraine.
  • Practicing meditation is highly recommended.


Diet-

  • Apple, mango, papaya, cheeku, guava.
  • Salad 1hr before lunch, 1hr before dinner.
  • Buttermilk, boiled rice sauted with cinnamon, cumin seeds, and garlic or asafetida are good in the daytime.
  • Have warm and easily digestible foods, boiled and steamed vegetables, soups, vegetable juices, porridge, brown rice and whole-wheat flour.
  • Avoid yogurt especially at night. 
4 people found this helpful

I have been asked to do bird dog excercises for numbness & parasthesia of feet. I am 66 yrs old, wt 94 kg with a colles fracture ( optd ). Can not do this ex. Please suggest some thing else.

Dip. SICOT (Belgium), MNAMS, DNB (Orthopedics), MBBS
Orthopedist, Delhi
Hi thanks for your query and welcome to lybrate. These exercises are meant for your back and abdominal strengthening, basically you can do similar exercises lying down also, so your colle' s fracture component is taken care of. But you will need evaluation and proper management for your symptoms. Do not hesitate to contact me if you need any further assistance. Thanks & regards Dr Akshay Kumar Saxena
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Hello. I have acute pain in Neck, numbness ,huge Tingling symptoms of cervical .Though I am doing hte permanent typical exercise for this but unable to get ride it. I wanted to really get rid of it. Please guide me best.

M.Ch - Neuro Surgery
Neurosurgeon, Gandhidham
Hello. I have acute pain in Neck, numbness ,huge Tingling symptoms of cervical .Though I am doing hte permanent typic...
Hello. lybrate-user. If the pain is rradiating from neck to arm for last 6 months despite taking medications. I would advise you to undergo cervical spine MRI. Although proper and through clinical examination would help me better diagnose the issue, based on your symptoms MRI is recommended. If there is compression of nerve roots or cord exercise would not help, in fact it may worsen the problem.
9 people found this helpful
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Dear Sir, after normal walking more than half km i am getting sensation less ( i,e if blood not circulate to a hand, how we feel, like that it will happen) in 2 inch area of my right leg just below ankle,(muscle portion of leg, or Thai). can i know the reason for the same Thanking you yours faithfully K.Srinivasa Reddy

Dip. SICOT (Belgium), MNAMS, DNB (Orthopedics), MBBS
Orthopedist, Delhi
Hello, Thanks for question. I am Dr Akshay from Fortis Hospital, New Delhi. I can tell you important cause can be Spine or vascular which we have to rule out. Kindly get in touch with me on private chat. My consultation fees is Rs 400/- I will tell you what all tests you need for a diagnosis and then we can take management from there on. Thanks & Regards Dr Akshay
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My hands and my body are trembling /vibrating, when I stand somewhere for sometime the headache suddenly started.

MBBS, Basic Life Support (B.L.S), Advanced Cardiac Life Support, Fellow of Academy of General Education (FAGE)
General Physician, Bangalore
My hands and my body are trembling /vibrating, when I stand somewhere for sometime the headache suddenly started.
Trembling hands and headache could be due to multiple reasons- thyroid problem, migraine and other neurological issues. A thorough history and few tests would be needed to come to appropriate diagnosis.
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Parkinson s Disease

MBBS, DNB, Fellowship in Neurosurgery
Neurosurgeon, Kolkata
Parkinson s Disease

Deep brain stimulation in Parkinson’s disease

Abstract: Deep brain stimulation (DBS) is a widely accepted therapy for medically refractory Parkinson’s disease (PD). Both globus pallidus internus (GPi) and subthalamic nucleus (STN) stimulation are safe and effective in improving the symptoms of PD and reducing dyskinesias. STN DBS is the most commonly performed surgery for PD as compared to GPi DBS. Ventral intermediate nucleus (Vim) DBS is infrequently used as an alternative for tremor predominant PD patients.

Patient selection is critical in achieving good outcomes. Differential diagnosis should be emphasized as well as neurological and nonneurological comorbidities. Good response to a levodopa challenge is an important predictor of favorable long-term outcomes. The DBS surgery is typically performed in an awake patient and involves stereotactic frame application, CT/MRI imaging, anatomical targeting, physiological confirmation, and implantation of the DBS lead and pulse generator. Anatomical targeting consists of direct visualization of the target in MR images, formula-derived coordinates based on the anterior and posterior commissures, and reformatted anatomical stereotactic atlases. Physiological verification is achieved most commonly via microelectrode recording followed by implantation of the DBS lead and intraoperative test stimulation to assess benefits and side effects. The various aspects of DBS surgery will be discussed.

Key words: deep brain stimulation (DBS); Parkinson’s disease(PD),  stereotaxis

Introduction

Parkinson's disease is a slowly progressive, neurodegenerative disease characterized by tremor, rigidity, bradykinesia and postural instability. It is the most common movement disorder in middle or late life with a prevalence of about 0.3% of the general population, rising to 1% in people over 60 years of age. Approximately 130 000 people suffer from it in the UK and it presents an increasing burden in our ageing population. Pathological findings in Parkinson's disease demonstrate greatly diminished neuromelanin pigmented neurons in the substantia nigra of the basal ganglia with associated gliosis, and Lewy bodies present in many remaining neurons.

James Parkinson, in his original 1817 Essay on The Shaking Palsy, gave an account of six patients in which he noted signs of tremor, festinating gait and flexed posture.  Nearly two centuries from Parkinson's observations, and almost four decades after Cotzias' dramatic demonstration of levodopa's efficacy, the limitations and complications of levodopa treatment for Parkinson's disease have become well documented Five years after initiation of therapy, a majority of patients develop medication related motor complications, namely levodopa induced dyskinesias (LID) and motor fluctuations. Deep brain stimulation (DBS) has been developed primarily to address these treatment related motor complications and therapeutic failures.

Pathophysiology of PD

The loss of dopaminergic neurons in the substantia nigra, the main functional characteristic of PD, affects the circuit described above and leads to the cardinal motor symptoms of PD. While the exact mechanism of this process is unknown, animal research as well as human recordings have provided functional and biochemical evidence that bradykinesia in PD results from excessive activity in the STN and the GPi. This leads to an exaggerated beta (10-30 Hz) synchronization within and between structures in the basal ganglia circuitry  that could also contribute to rigidity and akinesia.

The pathophysiology of rest tremor in PD is less clear and probably more complicated. This symptom most likely results from a dysfunction of both the striato-pallidal-thalamocortical and the cerebellodentato-thalamocortical circuits, with hyperactivity and hypersynchronization between central oscillators.

Possible mechanism of action of DBS

DBS acts through delivering an electrical current in a specific target area of the brain. This current can be modulated through modification of voltage, frequency and duration of each electrical pulse delivered. The delivered energy creates an electrical field of variable size and shape according to the parameters used for stimulation. Although initially believed to stimulate the target, thus the name of the whole process, it seems that

DBS actually excites the neuronal fibers, but inhibits the neural cells. In fact, GPi DBS decreases the GPi mean firing rate back to a normal range in animal models as well as PD patients, and high frequency DBS has a similar effect as dopamine replacement therapies, and promotes faster (about 70 Hz) nonhypersynchronous activity in the basal ganglia, correlated with clinical improvement. This might be achieved through stimulation of bypassing inhibitory pathways, synaptic inhibition, depolarizing blockade, synaptic depression, and simulation-induced disruption of pathological network activity. Overall, this leads to modifications of the firing rate and pattern of neurons in the basal ganglia, as well as local release of neurotransmitters such as glutamate and adenosine. In addition, it seems that DBS also increases blood flow and stimulates neurogenesis. Over the last few years, functional imaging, specifically functional magnetic resonance imaging (fMRI), positron emission tomography (PET) and single-photon emission computed tomography (SPECT), has been used in an attempt to clarify the mechanism of action of DBS. In fMRI, blood-oxygen-level-dependent (BOLD) signals are acquired, and oxygenated blood marks areas of neural stimulation or inhibition. On the other hand, PET and SPECT allow for imaging of multiple activity markers, such as blood flow, glucose and oxygen metabolism. While fMRI is less powerful than nuclear medicine techniques, it provides a much better spatial and temporal resolution. Because of the suspected inhibitory DBS effects in electrophysiological studies, reduced STN blood flow or glucose metabolism would have been expected on functional imaging. However, the opposite has been found to be true in an overwhelming majority of imaging studies to date. In addition, BOLD activation in the area surrounding the electrode has been reported, despite the electrode imaging artifact preventing direct observation of the STN around the electrode. This discrepancy between apparent STN inhibition in single-cell studies and activation in imaging studies might be explained by a few hypotheses. First, electrophysiological recordings identify short neuronal modulation (in the order of milliseconds) while neuroimaging methods may reflect the summed activity changes over seconds to minutes. Second, non-neuronal contributions to the change in blood flow and/or glucose metabolism cannot be excluded, and could confound the results of neuroimaging.

Finally, it is possible that PET and fMRI actually detect the increased activity in the axons, rather than in the cell bodies. Complicating matters further, some imaging studies after STN DBS have showed increased

activity in the GPi while others reported decreased activity in that nucleus. In summary, it is still unclear how exactly DBS affects the firing rate and pattern of neurons and how these changes actually modify the symptoms of Parkinson’s disease. DBS is presently more of an empirically proven treatment in search of physiological explanation.

The effect of DBS on the cardinal symptoms of PD have been established in three randomized controlled clinical trials --- 

TABLE 1

Author, year

 

No of patients

Follow up

Target

Results

Deuschl et al., 2006

156

6 months

BL STN

QOL better with DBS, motor symptom better with DBS

 

Weaver et al., 2009

255

6 months

BL STN or GPi

Dyskinesia free ON time better with DBS

 

Williams et al., 2010

366

12 months

BL STN  or GPi

QOL better with DBS

 

 

PATIENT SELECTION for DBS in PD

Patient selection is a critical first step as poorly chosen candidates may not have optimal benefits and have increased morbidity. Several factors must be considered before determining if a patient is an appropriate candidate for DBS surgery. A multidisciplinary approach involving the neurosurgeon, neurologist, and neuropsychologist is important to determine the appropriate surgical candidate. It is also important that the diagnosis of idiopathic PD be confirmed prior to proceeding with DBS surgery. Key to this assessment is evaluating the surgical candidate in both the on and off medication states with a corroborating levodopa challenge. Perhaps the best prognostic indicator of a patient’s suitability for DBS surgery is their response to levodopa.In general, a levodopa challenge following a 12-hour medication withdrawal should provide at least a 33% improvement in the motor section of the Unified Parkinson’s Disease Rating Scale (UPDRS).

                     In our institute, we follow a simple chart(below) for screening of patients for DBS in PD.

 

 

  1.  

Age<75 years

 

  •  

No

  1.  

Idiopathic PD ( No PSP/MSA/NSD etc)

 

  •  

No

  1.  

Levodopa responsive  

                      

  •  

No

  1.  

Poor/adverse response to drug          

 

  1.  Increased off period                                                              

 

  1. Disabling dyskinesia                                                              

 

 

  1. Disabling motor fluctuations                 

 

 

Yes

 

Yes

 

 

Yes

 

 

No

 

No

 

 

No

  1.  

Degree of disability(UPDRS part III score)>25

 

  •  

No

  1.  

Neuropsychology, MMSE>24

 

  •  

No

  1.  

LEVODOPA CHALLENGE RESPONSE POSITIVE                                                   

 

(30% improvement in UPDRS after 12-hours off medication)

 

  •  

No

  1.  

Advanced  co-morbidity

 

Yes

  •  
  1.  

long term anticoagulation

 

Yes

  •  
  1.  

Willing for surgery and programming

 

  •  

No

 

 

PREOPERATIVE MANAGEMENT

A full medical assessment is a necessary part of the preoperative evaluation, as advanced PD patients tend to be elderly with significant comorbidities. Major issues are---

 

Anticoagulation/antiplatelets--- The risk of discontinuing medications that affect anticoagulation and

platelet aggregation should be weighed against the potential benefits in the quality of life offered by DBS surgery. However, timely discontinuation of these latter medications is mandatory for stereotactic surgery since intracerebral hematomas are the most serious of all potential complications from DBS. Any anticlotting medications, including aspirin, ticlopidine, clopidogrel, and all nonsteroidal anti-inflammatory drugs should be discontinued at least 7 to 10 days preoperatively to ensure the return of normal blood clotting function.

Arterial hypertension can also increase the risk of intracranial bleeding during stereotactic procedures and must be controlled in the weeks prior to surgery.

A prolonged discussion on the short- and long-term effects of DBS on Parkinson’s disease should be carried out with the patient, family, and caregivers.

The night prior to DBS surgery, the antiparkinsonian medications are typically held to pronounce the Parkinson’s symptoms at the time of surgery to see the clinical effects on symptoms during surgery and the families must be counselled regarding their role in facilitating the patient.

Target selection

The two main targets considered for DBS in PD are the STN and the GPi. current tendency is to prefer targeting the STN because of a greater improvement in the OFF phase motor symptoms as well as a higher chance to decrease the medication dosage and a lower battery consumption linked to the use of lower voltage in the STN compared to the GPi DBS. GPi can be the preferred target if LID is the main complaint. GPi DBS might be preferred for patients with mild cognitive impairment and psychiatric symptoms. Because STN DBS might have a higher rate of cognitive decline and/or depression and worsening of verbal fluency in some studies.

Surgical technique

The basic components of DBS implantation surgery involve frame placement, anatomical targeting, physiological mapping, evaluation of macrostimulation thresholds for improvement in motor symptoms or induction of side effects, implantation of the DBS electrode and implantable pulse generator (IPG).

Head-frame placement

The CRW frame is the most commonly used followed by the Leksell frame. Placement of the frame is done under local anesthesia unless anxiety or uncontrollable movements necessitate the use of sedation or general anesthesia.

Leksell stereotactic frame  placed over the head of a patient showing the correct method for placement of the Leksell head-frame. The frame should be placed parallel to orbito-meatal line in order to approximate the AC-PC plane. It is attached to the patient’s head using four pins under local anesthesia.

Imaging and anatomic targeting

Computerized Tomography (CT) scans and MRI are the two main imaging modalities used for targeting when performing DBS implantations. A thin cut stereotactic CT (_2 mm slices with no gap and no gantry tilt) is obtained after frame placement and is then fused with the stereotactic MRI on a planning station (Stealth station). The advantage of fusing the CT with MRI is the ability to avoid image-distortions inherent to MR imaging adding to the stereotactic accuracy. To better define the STN, T2-weighted images (TR 2800, TE 90, flip angle 90˚, slice thickness 2.0 mm) were obtained.

The AC and the PC were marked and the centre of the AC–PC line determined. The next step is planning the entry point and trajectory. The strategy here is to avoid surface and sub-cortical vessels. After trajectory planning, the patient is placed supine on the operating table and the frame attached to the table using an adaptor. Prophylactic antibiotics are given at least 30 min prior to incision. The head is prepped and draped in a sterile fashion. Under local anesthesia, a burr-hole is placed on the calculated entry point marked on the skull. The entry point is determined by the calculated arc and ring angles. Hemostasis is achieved with bone wax and bipolar cautery.

A Medronic Stim-Loc anchoring device (Medtronic, Minneapolis, MN) burr-hole base ring is then placed on the burr-hole and secured with two screws which are used at the end of the procedure to anchor the DBS electrode.

The dura is then cauterized and opened exposing the underlying surface of the brain. The microdrive is then assembled and cannulae inserted 10 mm above the target to avoid lenticulostriate vessels found deeper. Gel- foam and fibrin glue is applied on dural hole to minimize cerebrospinal fluid (CSF) loss and air entry into the skull. Subsequently, microelectrode recording and stimulation is undertaken.

Microelectrode recording/ Mapping

Microelectrode mapping is used to precisely define the target STN and its boundaries as well as nearby critical structures. We believe microelectrode mapping is crucial in order to give one the best chance for optimal placement of the DBS lead given anatomical inaccuracies due to image distortion and intraoperative brain shifts secondary to CSF loss, and pneumocephalus that can lead to inaccuracies in defining the initial target coordinates and shifts in the target itself once the skull is opened. Microelectrode mapping is performed using platinum-iridium glass coated microelectrodes dipped in platinum black with an impedance of around 0.3–0.5 Mo. These platinum-iridium microelectrodes are capable of recording single unit activity and can also be used for micro-stimulation up to 100 mAwithout significant breakdown in their recording qualities.

As the recording electrode was advanced, entry into the STN was identified by a sudden increase in the density of cellular discharge, with the characteristic irregular pattern of discharge—spikes of different sizes, occurring at random intervals. On coming out of the STN a quiet period (background noise) was seen followed by recording from the substantia nigra if the recording was continued far enough, described as high frequency (50–60 spikes/s) discharge pattern.11 Characteristic STN recordings (visual and audio) were identified and the depth of the STN activity was noted. Identification of STN activity was only based on the visual identification. The centre of the point of best electrical activity was selected as the final target. The microelectrode was replaced with a permanent quadripolar macroelectrode (Medtronic electrode no. 3389) to target the centre of the STN electrical activity. The proximal part of this electrode consists of four nickel conductor wires insulated with a polytetrafluoroethylene jacket tubing. The distal part has four metallic noninsulated contacts of 1.5 mm spaced at 0.5 mm intervals. The diameter of the distal electrode is 1.27 mm. Based on the clinical response any of the four contacts can be used for stimulation. Macrostimulation using the DBS electrode itself is then used to determine benefits and side effects. In most cases lateral skull x rays were obtained at this point with image intensifier carefully positioned to locate the target point in the centre of the Leksell-G frame rings.

Initial programming is always refined by using intra-operative macrostimulation data and a mono-polar review to identify the thresholds of stimulation for improvement in parkinsonian motor signs as well as the thresholds for inducing side effects at the level of each contact. The four variables that are used in programming are choice of contacts (0, 1, 2 or 3 used either as the cathode or anode), frequency of stimulation (hertz), pulse-width (ms) and amplitude (voltage).

POSTOPERATIVE MANAGEMENT

In the immediate hours after surgery, it is important to keep arterial blood pressure in the normal range. In addition, the patient’s preoperative drug regimen should be restarted immediately after surgery to avoid problems with dopaminergic withdrawal. Patients should undergo postoperative CT scans and/or MRI scans to assess the electrode location and intracranial status. In addition, plain X-rays are obtained to assess the location and geometry of the leads and hardware. Parkinson’s medications may need to be adjusted depending on the patient’s status. Cognitive and behavioral changes may occur in the postoperative period, particularly in older patients. Patients can be discharged as early as 24 hours after surgery, depending on their neurological and cognitive status.

Conclusion

For the last 50 years, levodopa has been the cornerstone of PD management. However, a majority of patients develop motor fluctuations and/or LID about 5 years after the initiation of therapy. DBS of the STN or the GPI grant to patients with PD improved quality of life and decreased motor complications, and has been approved as such by the Food and Drug Administration in the US in 2002. We reviewed the experience and available literature on DBS for Parkinson’s disease over the last decade and arrive at the following understandings.

The success of DBS surgery depends on the accurate placement of the leads and meticulous programming of the stimulation. Therefore, it is best accomplished by an experienced team of neurosurgeon, neurologist, and support staff dedicated to the treatment.

Reports of surgical complication rates and long-term side-effects of DBS are very variable, so benefits and potential adverse results should not be under- or over-emphasized.

While essentially equal in improving the motor symptoms of PD, STN and GPi might have their own benefits and risks, and the choice of the target should be individualized and adapted to the patient’s situation.

Knowledge to further improve DBS treatment for Parkinson’s disease, such as a more scientific and reliable protocol on programming, strategies to minimize cognitive and psychiatric complications, and the better

long-term maintenance of the implanted device, are still lacking.

Data on the impact of DBS on non-motor symptoms affecting the quality of life of PD patients, such as pain, speech or gastro-intestinal complaints, are still scarce. Further research in these areas will help make this useful treatment even more beneficial.

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My aunt aged 36 years got her ct scan report and doc says she hasbrain tumour. Would like to know if brain tumor is curable or at which stage. How can sure. About this?

FRHS, Ph.D Neuro , MPT - Neurology Physiotherapy, D.Sp.Med, DPHM (Health Management ), BPTh/BPT
Physiotherapist, Chennai
At an early intervention or of acute stage and depends on lesion definitely it can be managed well and treated.
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My grandfather is 70 and he's got 3 seizures in last 1 year. Last one was one week ago and while going to hospital he had 2 fractures in his vertebrae and his shoulder too had a fracture. What should be done to cure him. And how much time to cure him?

Hand Surgery, M.S. (Orthopaedics
Orthopedist, Ahmedabad
Dear lybrate-user you grand pa needs detailed evaluation by a neurophysician and has to be treated on long term basis with regular check up.
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Can cerebral palsy be cured by surgery? Age 25 years and the disease continue from childhood?

MS - General Surgery, Mch Neurosurgery
Neurosurgeon, Guwahati
Can cerebral palsy be cured by surgery? Age 25 years and the disease continue from childhood?
For cerebral palsy no Surgical treatment as such. Sometimes surgeries are done for intractable seizure in cases of cerebral palsy.
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Epilepsy - How Seizures Affect It?

DM - Neurology
Neurologist, Rajkot
Epilepsy - How Seizures Affect It?

Epilepsy is a disorder of the central nervous system, thus it is basically a neurological disorder. In this the nerve cell activity of the brain is disrupted and causes seizures along with episodes of unusual behavior along with the loss of consciousness. The symptoms of the seizure can vary and some people with epilepsy just stare blankly for few seconds when a seizure takes place, while some twitch their arms and legs repeatedly.

Symptoms of Epilepsy:
As epilepsy is caused by the abnormal activities in the brain cells, seizures affect the processes with which the brain coordinates. Some signs and symptoms are:

  1. Staring blankly
  2. Confusion which is temporary
  3. Uncontrolled jerking movements of the legs and arms
  4. Loss of awareness and consciousness
  5. Psychic symptoms

Mostly the symptoms vary depending on the type of the seizure. The seizures are further classified into focal and generalized depending on which part of the brain shows abnormal activity.

Focal seizures
When seizures are due to the abnormal activity of the cells in just one area then it is known as focal seizures. These seizures are of two types:

  1. Simple partial seizures or the focal seizures without loss of consciousness. These seizures basically alter the emotions and the things like change in smell, look, sound and taste. These also result in the involuntary jerking of the body like the legs and arms, with spontaneous sensory symptoms like the tingling and flashing of the lights.
  2. Complex partial seizures or the focal dyscognitive seizures. These seizures have a loss of awareness and consciousness. One might just stare blankly into space in this seizure and performs repetitive activities like swallowing, chewing, walking in circles and chewing.

Generalized seizures
There are six types of generalized seizures. These are:

  1. Absence seizures, also known as petit mal seizures, are commonly seen in children and are characterized by subtle body movements like lip smacking and eye blinking and staring blankly into space. These also cause loss of consciousness.
  2. Tonic seizures lead to stiffening of the muscles. These affect the muscles of the legs and arms and also cause to fall to the ground.
  3. Atonic seizures are also called as drop seizures. These cause loss of control in the muscles, thereby leading to collapse or fall.
  4. Clonic seizures are the rhythmic and jerking muscle movements. These affect the arms, face and neck.
  5. Myoclonic seizures appear as twitches in the arms and legs.
  6. Tonic-clonic seizures also known as grand mal seizures are very dramatic and lead to body stiffening, abrupt loss of consciousness, shaking and loss of bladder control and tongue biting. If you wish to discuss about any specific problem, you can consult a neurologist.
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I am on medication for more than 15 years for Epilepsy. (Juvenile Myoclonic Epilepsy). Dosage: Encorate Chrono 500 MG. (Sodium Valporate. Valporate Acid)

MBBS, cc USG
General Physician, Gurgaon
Hello, Is CT scan/ EEG was done? can cause of seizure was detected ? I want to tell you that medicine as advised by your Doctor need to be taken regularly and must not missed dose even for single day You can Consult Good Neurologist for second opinion, i can guide you further
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I have uric acid count up to 6.6 ml . And my left leg thigh numbness has increased and acute back pain and leg pain . I'm on few medications , but is there anything I still can do ?

BHMS
Homeopath, Chennai
I have uric acid count up to 6.6 ml . And my left leg thigh numbness has increased and acute back pain and leg pain ....
Your body produces uric acid when it breaks down purines — substances that are found naturally in your body, as well as in certain foods, such as steak, organ meats and seafood. Other foods also promote higher levels of uric acid, such as alcoholic beverages, especially beer, and drinks sweetened with fruit sugar (fructose). Normally, uric acid dissolves in your blood and passes through your kidneys into your urine. But sometimes your body either produces too much uric acid or your kidneys excrete too little uric acid. When this happens, uric acid can build up, forming sharp, needle-like urate crystals in a joint or surrounding tissue that cause pain, inflammation and swelling, called Gout. Homoeopathy offers permanent cure for such tendency since it is the susceptibility which makes one more prone for high uric acid while under same circumstances other people are normal . Normal Uric acid levels are 2.4-6.0 mg/dL (female) and 3.4-7.0 mg/dL (male). Normal values will vary from laboratory to laboratory. Also important to blood uric acid levels are purines.
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I am 18 years old and I have been suffering from migraine since last 9 years. I had taken number of medical treatments for this but doesn't get relief. Please suggest me something that would help me to get rid of this severe pain.

Bachelor of Ayurveda, Medicine and Surgery (BAMS)
Ayurveda, Gurgaon
A. Causes-: Improper metabolism, Suppression of natural urges, anger, jealousy, grief, poor elimination, intake of dry, pungent and salty food, intake of polluted food, mental and physical stress, viewing of TV for long periods, reading with insufficient light, sleeplessness etc. B. Origin of migraine headache-: Due to the causative factors, Pitta Dosha obstructs the flow of Vata dosha in brain, causing throbbing pain. C. Pain Management-: 1. Avoiding the cause and trigger factors. 2. Keeping a diary record of specific foods eaten, environmental exposure, sleep patterns may help to identify personal trigger factors. 3. Sneha nasya therapy at home-: Sneha nasya, instillation of medicated oils to the nostrils by Shadbindu tailam or Anu tailam yield significant benefits. 4. Apply a paste of freshly ground clay or freshly ground sandalwood to the forehead, let dry, rub off by hand and wash. 5. Mix ¼ teaspoon of clove powder with 1 teaspoon of cinnamon oil. Apply this paste on the affected area for 20-30 minutes. 6. Add chamomile powder to 1 cup of boiling water. Transfer the liquid to a cup. Drink when hot. It gives fast relief from migraine. 7. Take ½ glass of carrot juice. Add ½ glass of spinach juice. Mix well. Drink this juice twice daily. 8. Grind 10-12 grains of black pepper and 10-12 grains of rice with water to make it a paste. Apply this paste on affected area of the head for 15-20 minutes. 9. Sugar powder 16 parts, Vamshalochana 8 parts, Pippali (long pepper) 4 parts, Ela (Cardamom) 2 parts, Cinnamon – 1 part. Make fine powder and mix it, keep in tight moisture free container. Take half teaspoon thrice daily with honey. 10. Aromatherapy- Pitta calming aromas typically flower fragnances like Lily, Cloves, Lotus, Lavender, Peppermint, Rose, Sandalwood are beneficial. 11. According to ayurveda Virechan (Laxative therapy) is an effective way to reduce excess pitta. Castor oil or warm milk with ghee or triphla at bedtime is helpful. 12. Practicing meditation is highly recommended. 13. Morning and Evening walk followed by brisk exercise is recommended. 14. Avoid hard physical exertional exercises and aggresive sports competitions. 15. Avoid working for long hours continuously; take short breaks. Have a good night’s sleep (8hrs) in a dark room. D. Diet: ~~Apple, mango, papaya, cheeku, guava. ~~Salad 1hr before lunch, 1hr before dinner. ~~Buttermilk, boiled rice sauted with cinnamon, cumin seeds and garlic or asfoetida are good in the daytime. ~~Have warm and easily digestible foods, boiled and steamed vegetables, soups, vegetable juices, porridge, brown rice and whole-wheat flour. ~~Avoid yogurt, especially at night. ~~Avoid refined, oily, spicy, cold, sour foods (fermented, pickled) and stale food, aerated drinks. ~~Avoid coffee, tea, alcohol, smoking. ~~Avoid cheese, chocolate and wine. E. Yogasanas and Pranayama: Hastapadasana, Setu Bandhasana, Marjariasana, Paschimottanasana, Bhastrika and Anulom-Vilom Pranayama. NOTE: When suffering from a migraine attack: ~Lie down in a dark, quiet place & get some sleep. ~~Avoid eating. ~~Drink only water. ~~Apply hot or cold compresses. ~~ Consult doctor.
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