Had tumours in his spine twice: Surgical Navigation saved him

By Dr.Ravindra Patil

Chief Neurosurgeon of Samarth Neuro and Multispeciality Hospital [Miraj, South Maharashtra] Dr Ravindra Patil writes about how he could operate a difficult case with the help of surgical navigation.

Mr Mahantesh Shellikeri is from Belgaum. He had a rare disease called Neurofibromatosis. He had two tumours pressing on the spinal cord in his back and as a result he had lost the ability to walk in the past two months.

Table of Contents

Neurofibromatosis

Neurofibromatosis (NF) is a conditions in which tumours grow in the nervous system. There are three types of neurofibromatosis, type I (NF1), type II (NF2) and Schwannomatosis. The tumours in NF are generally non-cancerous.

Non-cancerous tumours are of course good as compared to cancerous tumours, of course, because they don’t grow rapidly and spread to other parts of the body. But Mahantesh’s bad luck was that he had NF tumours in in spinal cord. He had been previously operated in the lumbar spine for the removal of an NF tumour 13 years ago. The surgeon had removed the tumour at the level of the second lumbar vertebra [L2]. But sadly for Mahantesh, the neurofibromatosis tumours recurred! This time it was at the 12^th thoracic vertebra [T12] and first lumbar vertebra [L1].

Due to the regrowth of the tumour, Mahantesh developed weakness in both lower limbs. As the tumours grew, gradually he could not walk. His MRI scan showed multiple spinal tumours at the level of the T12, L1 and L2 vertebrae. So he was referred to a neurosurgeon. The neurosurgeon explained that the surgery was very risky as the tumours were small and would be difficult to locate exactly and during their removal Mahantesh was likely to suffer permanent weakness or paralysis of his lower limbs and partial or complete loss of bladder and bowel control.

And if Mahantesh was not operated soon, then too he was likely to suffer permanent weakness or paralysis of his lower limbs and partial or complete loss of bladder and bowel control!

There was another complication. Mahantesh’s wife has poliomyelitis. She is a differently abled and challenged person. She needs a stick to support herself when she walks. So if Mahantesh suffered paraplegia, she would not be able to help him survive.

Besides, the cost of surgery, if it were attempted, would be high.

Thus Mahantesh Shellikeri and his wife were indeed in a desperate situation. Their extended family helped them a lot during their helpless condition.

Many neurosurgeons were consulted for Mahantesh’s treatment. All explained to them that surgery is a risky step because there was a high chance of Mahantesh developing complete paraplegia and bladder plus bowel incontinence.

Chance referral

One of Mahantesh’s relatives is a doctor. He met Dr Somnath Kheradkar, who suggested my name for another opinion.

When Mahantesh and family they came to me, they were very apprehensive and did not have much hope. I reassured them, explained about the disease, although they knew so much.

It was clear to me that if Mahantesh was not operated soon, he would loose control over his lower limbs, bladder and bowel. The surgery was risky.

Advantage factor

But we had one advantage. At Samarth Neuro and Superspeciality Hospital where I work, we have surgical navigation system which is very useful in fine brain and spine surgeries. Mahantesh’s tumours were small and would require accurate removal. The surgical navigation equipment would help me pinpoint his tumours and remove only the tumours without damaging his surrounding spinal cord tissue. I would remove the least amount of vertebral bones and leave his spine intact.

I explained Mahantesh and family about the one almost magical and extremely tool that Samarth Hospital has, namely Surgical Navigation and how it would help me pinpoint the tumours and remove them accurately.

Mahantesh and his wife had many. I answered them all and cleared all their doubts. Then they became were hopeful. They were willing for surgery. But they had reservations about the cost.

But it was a special case. Nearly all neurosurgeons had refused to operate and almost all had advised that the risk of the surgery was far more than the benefits.

I was willing to take the risk of surgery only because of surgical navigation guidance system in Samarth Neuro and Super-speciality hospital where I work. That system would give me the almost magical advantage of doing accurate surgery without and permanent aftereffects.

Surgical navigation would help me find the tumour inside the spinal canal. Also, I could reduce the size of the incision. Besides knowing exactly where to cut and what to remove, the time of the surgery would be much reduced. This would result in less post operative pain and faster healing. The possibility of infection would also be somewhat reduced.

Without Navigation…

The surgery would have been very risky. Had I operated without navigation, I would have been forced to remove one or more levels of his vertebrae which in turn would cause complications during and after the surgery.

Day of surgery

Then we posted him for surgery at the earliest. We did the surgery at reduced charges as Mahantesh Shellikeri’s financial condition is weak. We had CT scan and MRI scan images of his neurofibromas. We started the surgical navigation system after feeding the CT and MRI images into its computer system. We fitted the trackers of the navigations system at exact locations.

Now we knew exactly where to cut and how to cut. Some of our surgical instruments have markers. Thus the markers fixed on the patients and some of our surgical instruments showed up clearly on the 3D screen of the surgical navigation system. With the help of these images and our skills we operated.

We localized the level of the tumour exactly. Then we removed the exact amount of the bone to excise the tumour. We opened the duramater [a stiff covering of the brain and the spinal cord] and I dissected that tumour carefully away from the spinal cord. Afterwards I removed both the tumours located between the T-12 and L-1 levels as also the tumour below the L-2 level.

We were able to remove both the tumours in a single surgery most important of all, the surgery was successful.

Then came the post-operative care. Apart from nursing care and doctors’ rounds came in a very important care giver, the physiotherapist. She motivated and guided Mahantesh to move his limbs as the pressure of the tumours on the nerves was relieved. Mahantesh was surprised that he could move his legs. Remember, he had lost the ability to move his lower limbs when he came to me.

From merely moving his lower limbs to being able to walk was a gradual journey for Mahantesh. But he accomplished it and was able to walk with the support of a walker. But we are moving ahead too fast.

First came Mahantesh’s discharge from Samarth Hospital. We discharge him on the seventh day after surgery.

Many months have passed since Mahantesh was discharged. His would was very small, thanks to navigation assisted surgery. So he did not require much wound dressing. His surgical wounds healed fast.

The Shellikeri couple lives in Belgaum and hence it is too far away for them to come for follow up visits. Local doctors in Belgaon take care of Mahantesh’s routine problems.

But Mahantesh’s wife Mrs Shellikeri called me once after many months to tell me that Mahantesh is progressing well.

With our efforts we were able help Mahantesh walk again. I hope to god that he does not get more episodes of Neurofibromatosis either on his spine or anywhere else.

The Shellikeri family is happy about the results.

Spine Fusion Surgery Cost in India

By Dr.Ravindra Patil

Any type of spine surgery is thought to be a very expensive surgery. It is true to some extent as spinal fusion surgery cost is high because it needs very highly skilled surgeons, state of the art operation theatres and above all, surgical navigation for accuracy. But all these give fairly good results in patients who could not be operated at all a decade ago, because the skillset and surgical navigation were not available then. So now although back surgery cost is high, results are better.

Table of Contents

Cost of Spinal Fusion Surgery

The average Spinal Fusion Surgery cost is very high in western countries.

India is known worldwide for its advanced medical facilities and promising technology for Low Cost of Spinal Fusion Surgery. Many of the best hospitals for Spinal Fusion Surgery can be found in India.

Spinal Fusion Surgery cost in India is much less when compared to any other countries. Also the cost of Spinal Fusion Surgery in India is substantially lower than other developed countries of the world.

Private back surgery cost is higher because Private back surgery cost means treatment in a private hospital

Various deciding factors could determine the price of Spinal Fusion Surgery in India. These can be broadly classified as Hospital, Medical Team or Patient Dependent factors.

Hospital Factors

Type of the hospital (Government/Trust/Private).

Use of insurance, type of insurance or self paid.

Accreditation of the facility

Reputation and brand value of the hospital.

Medical Team Factors

Technology / Approach Used

Surgery Type

Type of Anesthesia or Sedation

Qualification / Expertise of the specialist

Extent of the surgery needed

Patient Factors

Patient’s diagnosis

Patient’s general health

Room Category selected by the patient

Other treatment required by the patient in conjunction

What is the definition of spinal fusion?

Spinal fusion is a surgical procedure wherein one or more vertebrae are united to eliminate any motion between them. The approach is similar to welding. Spinal Fusion Surgery, only does not weld the vertebrae immediately during surgery. The bone grafts are placed around the spine during surgery. The body then heals the grafts over several months.

When are the indications of spinal fusion surgery?

There are several potential reasons to consider spinal fusion. These include treatment of a fractured vertebra, rectifying deformity, elimination of pain caused during motion, treatment of instability, and treatment of cervical disc herniations.

Not all spinal fractures need surgery, some fractures, particularly those associated with spinal cord or nerve injury, generally require fusion as part of the surgical treatment.

Another condition treated is instability, i.e. the abnormal or excessive motion between two or more vertebrae. It is commonly believed that instability can be a source of back or neck pain or cause potential irritation or damage to close by nerves.

Cervical disc herniations that require surgery usually need fusion as well. In this technique, the disc is removed by an incision in the front of the neck and a small piece of bone is inserted in its place.

How is the Spinal Fusion Surgery performed?

There are many surgical methods available to fuse the spine that involve placement of a bone graft between the vertebrae. The spine may be treated from the back (posterior), from the front (anterior) or by a combination of both. The anterior approach is more common. The ultimate objective of fusion is to obtain a solid union between two or more vertebrae.

A fusion may or may not involve use of supplemental tools like plates, screws and cages. Instrumentation is sometimes used to rectify a deformity, but is usually used to hold the vertebrae together to while the bone grafts heal. Whether the hardware is used or not, it is important that bone or bone substitutes be used to get the vertebrae to fuse together.

The bone may be taken either from another bone in the patient or from a bone bank. Fusion using bone from the patient has a long history of use and results in predictable healing. Smoking, medications you are taking for other conditions and your overall health can affect the rate of healing and fusion, too.

How long does it take to recover from spinal fusion surgery?

Immediate discomfort following a spinal fusion is generally greater than with other types of surgeries. Fortunately, there are excellent methods of postoperative pain control available, including pain medications and intravenous injections.

Another option is a patient-controlled postoperative pain control pump. Here the patient presses a button that delivers a predetermined amount of narcotic pain medication through an intravenous line.

Patients generally stay in the hospital for three to four days, but a longer stay after more extensive surgery is also possible. A short stay in a rehabilitation centre after discharge from the hospital is recommended for patients who underwent extensive surgery, or for elderly or debilitated patients.

The fusion process varies in each patient. The healing process after fusion surgery is similar to that after a skeletal fracture. During this time, the patient’s activity is generally restricted. Substantial bone healing does not usually take place until three or four months after surgery.

Many a times spinal decompression surgery cost and healing time is compared with spinal fusion surgery cost. It must be understood that both are far different. Spinal decompression surgery does not need bone fusion and healing like spinal fusion surgery.

How many patients underwent Spinal Fusion Surgery in India in the last 5 years?

Private back surgery prices will vary from place to place. Scoliosis surgery cost is also of interest to many patients who have suffered kyphosis or scoliosis. Cost of spinal decompression surgery is also queried.

In recent years, India has emerged as a medical hub for patients looking for affordable, accessible and efficient low cost Spinal Fusion Surgery Treatment. Some of the best Spinal Fusion Surgery hospitals in the world are found in India. The country is known for offering advanced medical facilities at the most reasonable cost. An average increase of 15 to 20 percent annually has been observed in the number of patients in the last 5 years. The Indian Spinal Fusion Surgery hospitals deliver advanced health care and highest quality services backed by elaborate infrastructure and lower treatment cost

Here are the approximate figures of the patients underwent Spinal Fusion Surgery in the last 5 years in India

Year	2013	2014	2015	2016	2017
Surgeries	4800	6000	7500	9600	10800

What are our special services offered to international patients?

At Samarth Neuro and Super Speciality Hospital we help arranging your treatment in a way that will suit you and be affordable for you. Chief neurosurgeon at Samarth Neuro and Super Speciality Hospital Dr Ravindra Patil is vastly experienced in all types of spine and brain surgeries. Spine fusion surgeries are done there as required.

Congenital Brain and Spine Anomalies

By Dr. Ravindra Patil

Table of Contents

What are congenital brain and spine malformations?

Congenital means present at birth.

These conditions may be mild and without symptoms or may be serious, requiring treatment. In some cases, surgery may be recommended to:

1. Address the child’s or the patient’s symptoms.
2. Correct the form and function of the brain and spine structures.
3. Maximize cognitive and motor
4. Prevent development of neurological deficits.

Congenital abnormalities, called malformations, are conditions affecting the form and function of the nervous system. There are numerous variations of congenital malformations of the bone and soft tissue of the head and spine, including neural tube defects, such as spina bifida, encephaloceles, Chiari malformations and arachnoid cysts.

Some congenital malformations are mild, and some are severe but correctable with surgery by a pediatric neurosurgeon.

Types of some of the Congenital Brain and Spine Malformations are as follows:

Chiari Malformations

This is a condition in which portions of the brain, called the cerebellar tonsils, protrude through the bottom opening of the skull into the upper spine, which can put pressure on the brain or spinal cord. Chiari malformations may block the flow of cerebrospinal fluid, leading to hydrocephalus.

Treatments often focus on removing portions of the bone and soft tissue to relieve pressure on the spinal cord and brain, as well as providing new pathways to drain cerebrospinal fluid. Surgeons use different methods for treating these malformations, including decompression, with or without cutting open a small part of the dura mater [thick membrane covering the brain].

Encephaloceles

Encephaloceles are a type of neural tube defect characterized by the brain being exposed to the outside instead of being covered by the skull and skin. It can lead to infections and hydrocephalus.

Surgical treatment of this condition involves removing bone and soft tissue, draining cerebrospinal fluid, and surgically repairing or closing the encephalocele.

Children who have developed hydrocephalus as a result of an encephalocele will require treatment for that condition, often with a cerebrospinal fluid shunt. Shunting is the placement of a tube into the open area (ventricle) of the brain that allows cerebrospinal fluid to drain to the child’s abdomen or other location where it can be safely reabsorbed into the body.

Arachnoid Cysts

Arachnoid cysts are the most common type of brain cyst. They are congenital (present at birth) lesions that occur as a result of the splitting of the arachnoid membrane. The cysts are fluid-filled sacs, not tumors, appearing in one of the three layers of tissue covering the central nervous system.

Surgical treatment of this condition involves draining the cyst by drilling a small hole or by opening the skull and making small openings in the cyst to open the natural fluid pathways in the brain. This process is called fenestrating.

What are Spinal Deformities?

A spine deformity occurs when your spine varies by more than 10 degrees from ‘healthy’ curvature. But, what does this mean exactly?

Contrary to popular belief, your spine isn’t 100% straight and vertical. The spinal shape has curvatures, but the end result is that it is vertical! Our spine consists of a series of gentle arcs. Our lumbar spine, or lower back, swoops slightly to the back, and our thoracic spine, or upper back, bends subtly forward. The backward curve of your lower back is known as lordosis and the forward stoop that runs between our shoulder blades is known as kyphosis. Lordosis and kyphosis are spinal curvature deformities. Both are abnormal curvatures of the spine.

But, when viewed head-on, our backbone should look like a straight pillar. Hence, it is also called the ‘vertebral column’.

Moreover, the curves and straight stretches of your spine make symmetry possible. Your head sits directly over your pelvis because the lordosis of your lower back and the kyphosis of your upper spine balance each other out. If one of these curves becomes greater or lesser than the other, then problems can occur. We refer to this as sagittal imbalance, because the head and pelvis no longer fall within the same, or sagittal, plane.

Too much swaying backwards can be thought of as ‘lordosis’, and too much forward stooping in the upper back is ‘kyphosis’.

Likewise, when the spine tilts away from the midline of the body, doctors refer to this problem as coronal imbalance or scoliosis. Unevenness in the ‘coronal’ plane (the view from head-on) causes asymmetry in the trunk of the body. This can include uneven hips and shoulders or one-sided bulging of the ribs.

Diagnosis of Congenital Brain and Spine Malformations

If a child is born with any of the above malformations, a thorough evaluation by a paediatrician or neurologist is needed to diagnose the problem and recommend a plan for addressing it.

After a thorough physical and detailed family and patient history, your doctor may order imaging of the brain and/or spine through an MRI scan. If the MRI scan shows any evidence of these malformations, a neurosurgical consultation is a must to plan the best treatment.

Congenital Brain and Spine Malformations Treatment

A multidisciplinary approach is often beneficial for addressing children with congenital brain and spine malformations. Neurosurgeons, craniofacial plastic specialists and geneticists, among others, may be called upon to develop your child’s treatment plan and determine what kind of surgery may be appropriate.

If a congenital brain or spine malformation is mild and not causing any signs or symptoms in your child, the neurosurgeon may recommend observation, which means regular visits and testing to monitor your child’s condition.

If your child does undergo surgery, follow-up care is extremely important in tracking the progress of your child’s recovery. Your paediatric neurosurgeon will schedule follow-up appointments to ensure your child is making the best recovery possible.

Spinal treatments are focused on both correcting the functional shortcomings as well as the structural defects of the spine.

Congenital brain and spine defects treatment in Miraj, Maharashtra

Samarth Neuro and Super Speciality hospital has facilities to surgically treat some of the above brain and spine deformities present since birth. Abnormal curvature of the spine can be corrected to some extent.

Chief Neurosurgeon at Samarth Hospital Dr Ravindra Patil has considerable experience in treating such defects. Besides, as his hospital is located in a tier two city, the cost of treatment is considerably less than in major cities of India. Patients from foreign countries may find going to Miraj for treatment of brain and spine diseases from Dr Ravindra Patil considerably cost effective.

Pituitary Gland Disorders

By Dr. Ravindra Patil

What is the pituitary gland and where is it located?

The pituitary gland is a tiny pea-sized organ located at the base of the brain. Barely a cubic centimetre in volume, it produces and stores so many hormones of our body that it is known as the ‘master gland’. These pituitary hormones control the activity of other hormones in the body.

The pituitary gland has 2 parts: the anterior (front) and the posterior (back) parts, each producing a different set of hormones. Each of these hormones acts on different parts of the body and controls their proper functioning. The pituitary hormones are:

• Prolactin
• Growth hormone
• Adrenocorticotrophic hormone [ACTH]
• Thyroid stimulating hormone [TSH]
• Luteinizing hormone
• Follicle stimulating hormone
• Melanocyte stimulating hormone
• Antidiuretic hormone [ADH]
• Oxytocin

Function of pituitary hormones are vital for human survival. The deficiency or overproduction of each and every of the above hormones results in major medical disorders. For example, a shortage of growth hormone during childhood leads to reduced growth. The child does not grow like a normal adult but remains a dwarf. Conversely, excess of growth hormone leads to gigantism, a condition where the person keeps on growing abnormally.

Table of Contents

Hormones and Hormone Diseases

Hormones are the body’s chemical messengers, sending signals into the bloodstream and tissues. Hormones work slowly, over time, and affect many different processes, including growth and development, blood sugar, sexual functions, reproduction, urine output, managing stress and mood. Hormone diseases occur when the level of any hormone is reduced or increased because of any reason. The Pituitary Gland produces many hormones and any pituitary gland problems lead to major illnesses.

What are common pituitary disorders?

Apart from a deficiency or excess production of the above hormones, disorders of pituitary gland are as follows:

• Tumours
• Pituitary damage because of Head injury
• Birth defects
• Inherited genetic defects
• Low blood supply to the pituitary gland
• Previous history of pituitary disorders
• Iron overload
• Medication
• Radiation therapy in the head and neck region

What are the different types of anterior pituitary disorders?

Anterior pituitary disorders occur as a result of overproduction or underproduction of hormones secreted by the anterior lobes.

     Disorders caused by over-production of anterior pituitary hormones

• Acromegaly & gigantism
• Prolactemia
• Cushing’s disease

     

      Disorders caused by under-secretion of anterior pituitary hormones

• Dwarfism
• Central adrenal insufficiency
• Gonadotropin deficiency
• Hypothyroidism

  

What are the different types of posterior pituitary disorders?

Posterior pituitary disorders are caused by either under-production or overproduction of the ADH hormone. ADH helps the kidneys to prevent excess water loss through urine. Imbalance in ADH production can lead to the following disorders:

• Disorders of ADH secretion
• Diabetes insipidus

Pituitary disorders symptoms: Hypopituitarism

Hypopituitarism is a condition that results in a partial or complete loss of the anterior pituitary gland functions. Panhypopituitarism is a condition, characterized by damage to the entire pituitary gland. In such cases, the production of all pituitary hormones stops. 

Causes of hypopituitarism

• Growth of a pituitary tumour
• Head injuries
• Brain surgery
• Medication
• Radiation therapy

Signs and symptoms of hypopituitarism

• Tumours may cause eyesight problems.
• The symptoms of hypopituitarism depend upon which hormones are no longer being produced.
• Symptoms vary depending upon the age of the patients.

Diagnosis

• Blood tests and stimulation or dynamic testing to identify low levels of pituitary hormones
• Brain imaging using an MRI or CT scan to detect tumour or other pituitary gland problems
• Vision tests to determine if the pituitary gland is affecting eyesight

Pituitary gland disorders treatment

• Hormone replacement therapy: Patients need to take life-long medications to control the symptoms. The doctor monitors and adjusts the medication dose periodically based on the patient condition
• Surgery or radiation treatment may be required in some patients suffering from pituitary tumours

What are pituitary tumours?

Pituitary tumours are abnormal growths in the pituitary glands. They may cause overproduction or low levels of pituitary hormones.  Most pituitary tumours are noncancerous growth and remain confined within the pituitary gland. These are known as an adenomas.

When the tumour size is less than one cm, it is called a Microadenoma. Most pituitary adenomas are microadenomas. When the tumour is greater than one cm in size, it is called a Macroadenoma.

Malignant Pituitary tumours (cancers) are rare and mostly affects old aged persons. Pituitary carcinomas can spread to the brain, spinal cord or the bone surrounding the pituitary glands. In some patients, the pituitary adenoma can turn cancerous and spread to other parts of the body.

 

What is the prevalence of pituitary tumours?

A pituitary adenoma is the third largest cause of brain tumours, accounting for 10% of all cases. The global prevalence of pituitary adenomas is approximately 17%. Studies have reported the risk of pituitary tumours to increase with age, with maximum cases being diagnosed between 30 and 60 years.

What causes pituitary tumours? Are there any risk factors?

The cause of pituitary adenoma remains unknown. Genetic alteration is thought to play an important role in adenoma development. Studies have shown that people with certain genetic factors such as multiple endocrine neoplasia, type 1 (MEN 1) are at increased risk of pituitary tumours.

What are the signs and symptoms of pituitary adenomas?

• Tumours can put pressure on the pituitary gland and the nearby structures. This can cause headaches and loss of side-visions
• As the tumour grows in size, it can damage the normal functioning of the gland and interfere with hormone production. Overproduction or hormonal deficiencies can cause specific signs and symptoms or sometimes a combination of them.
• For example, ACTH tumours exhibit signs and symptoms of Cushing’s syndrome.

Are pituitary tumours life-threatening?

If diagnosed early, pituitary tumours can be managed well. However, if left undiagnosed and untreated for a long period, such tumours can become large and affect the functioning of several organs of the body, causing blindness, hypertension, diabetes, osteoporosis, heart disease and death.

Evidence suggests the 5-year survival rate of pituitary gland tumours be about 82%. 

Survival rate also depends upon factors like:

• Type of tumour
• Person’s age
• How far the tumour has spread in the brain or to other parts of the body

Complications of pituitary tumours

• Blindness
• Permanent hormone deficiency
• Pituitary apoplexy is a rare and serious complication

How are pituitary tumours diagnosed?

• Blood and urine tests help to determine whether there is an overproduction of deficiency of hormones
• Biopsy: This involves removing a small number of cells and examining them under a microscope to check for abnormal growth
• Brain imaging: A CT scan or brain MRI scan can help the doctor to determine the size and location of the tumour
• Vision testing to understand if the tumour has caused eyesight problem
• Neurological exam: A set of questions and answers to check a person’s mental status and appropriate brain functioning controlling movement and coordination.

Pituitary gland diseases treatment

Not all pituitary tumours require treatment. Treatment depends upon the following:

• Type and size of the tumour
• If the tumour is making hormones
• If the tumour is obstructing vision or associated with other signs or symptoms
• If the tumour is localized or has spread to other parts of the body
• If the tumour has occurred for the first time or has recurred
• The patient’s overall healt

  The treatment is usually given by a brain surgeon (neurosurgeon), endocrine system specialist (endocrinologist) and a radiation oncologist. Doctors use a combination of surgery, radiation therapy and medications to normalize hormone levels.

Surgery for pituitary

Surgery is needed when the tumour presses on the optic nerve or leads to the overproduction of hormones. The Endoscopic transnasal transsphenoidal approach involves removing the tumour through the nose without making an incision. This is usually done when the tumour is small in size and no other part of the brain is affected by it. The Transcranial approach (craniotomy) is used for removing large tumours by making an incision in the scalp.

Radiation therapy

This technique uses high-energy radiation to destroy tumour cells. It can be used alone or in combination with surgery.

Medicines

They help to limit excess hormone production and shrink certain types of pituitary tumours.

Hormone replacement therapy is done in patients with reduced hormone production after surgery.

Watchful waiting: Many patients do not exhibit any symptoms and function normally without any treatment. In such cases, patients are advised only regular tests to keep a check on the tumour growth.

To summarise, a disease of pituitary gland can be very harmful. It must be diagnosed and treated as soon as possible. Such complex disease treatment is available in Samarth Neuro and Superspeciality Hospital in Miraj, Maharashtra. Dr. Ravindra Patil, the chief neurosurgeon there, is an expert in performing such operations.

Ventricles of the Human Brain

By Dr. Ravindra Patil

A ventricle is a hollow part or cavity in an organ. The word ventricle originates from Latin, the language which has given most of the words used in anatomy and medicine. Ventricles of brain are cavities within the brain. Ventricles of the brain have distinctive functions, which we will see in this article.

Two major organs of the major organs of the human body which have ventricles are the heart and the brain. The ventricles of the heart pump blood through our body, while the ventricles of the brain are cavities within the brain that produce and store a liquid called cerebrospinal fluid (CSF). This liquid surrounds our brain and spinal cord, cushions them and protects them from injury. The CSF is also responsible for removing waste and delivering nutrients to our brain.

Table of Contents

Where in the brain are the ventricles?

There are four ventricles in the brain. They are interconnected cavities. They extend throughout the brain. As has been mentioned, they produce, store and circulate the cerebrospinal fluid (CSF).

The two lateral ventricles of brain are C-shaped chambers found in the cerebral hemispheres, which is one in each hemisphere.

Lateral ventricles are connected to the third ventricle by an opening called the inter-ventricular foramen. The third ventricle is a very narrow cavity that runs along the midline of the diencephalon.

What structure connects the third and fourth ventricles? The third ventricle communicates with the fourth ventricle via the cerebral aqueduct. The fourth ventricle is wedged between the cerebellum on one side and the brainstem on the other; it extends to the central canal of the spinal cord. Which means in effect, the four ventricles extend from the brain to the end of the spinal cord. The CSF surrounds the brain and is also within the ventricles. The CSF is a liquid cushion in which the brain literally floats. The brain ventricles essentially supply, store and circulate the CSF around the brain.

The CSF is a thick viscous fluid which serves to cushion the brain, regulate its temperature and supply the brain with nutrients.

More about the brain ventricles

When looking at the interior of the brain, the four hollow ventricular cavities stand out in contrast to the rest of the organ, which is mostly composed of brain tissue, which in turn is made of grey matter and white matter. The main ventricle function is of course, producing CSF.

As the ventricles contained nothing except fluid, in ancient times it was thought that the ventricles contained ‘animal spirits’, a mysterious substance that allowed the immortal soul to exert control over the physical body. Later it was thought that the ventricles were credited with functions like the generation of imagination and memory. However, it was in 1764 that it was discovered that the ventricles were filled with CSF, fluid, and not animal spirits. And the CSF flowed around and inside the brain through the connections between ventricles. The ventricles gave the CSF a route to flow throughout the brain. Gradually it was discovered that it is the production, storage and circulation of CSF which is the main role of the ventricles.

How is CSF produced?

The production of CSF is done by a specialized membrane called the choroid plexus, which is made up of ependymal cells. This choroid plexus lines the ventricles in brain. Ependymal cells are glial cells tailored to produce CSF, and they secrete the fluid into the ventricles at a relatively constant rate; about a half a litre of CSF is produced by ependymal cells every day. CSF passes through the ventricular system and circulates around the brain and spinal cord in a small area between the meninges called the subarachnoid space.

Functions of the CSF

CSF is thought to play many important roles in the brain. The CSF and the brain ventricular system together keep the brain buoyant, reducing its weight and hence the physical stress it would otherwise experience from the forces of gravity and movement. The brain is a very delicate and soft organ. If the  brain would not have been suspended in the CSF, it would have been distorted with its own weight! While organs like the kidney and liver and heart are much sturdier, the brain is very soft. Without being suspended in a fluid the delicate tissue of the brain can tear.

There is about 125–150 mL of CSF at any one time. The actual mass of the human brain is about 1400–1500 grams; however, the net weight of the brain suspended in CSF is equivalent to a mass of 25-50 grams. The brain therefore exists in neutral buoyancy, which allows the brain to maintain its density without being impaired by its own weight. Had the brain been suspended in the skull without floating in the CSF, its blood supply would have been cut off and its neurons would be killed in the lower sections of the brain!

The layer of CSF surrounding the brain also acts as a buffer against potential injuries that can be caused by mechanical pressure or force (e.g. being hit hard in the head). Additionally, as the CSF circulates over the brain it carries away toxins and other waste matter and empties these into the bloodstream where they can eventually be removed by mechanisms like kidney filtration.

Ventricles and the CSF

The rate of CSF production in the ventricles is fairly constant regardless of changes in pressure within the ventricles (i.e. inter-ventricular pressure). This can be problematic if the passage of CSF is blocked somewhere within the ventricular system. In the ventricular system of brain, CSF will continue to be produced, but it will have no means of exiting the system. This will cause pressure within the ventricles to increase, and the rising pressure may eventually force the ventricles to expand. The expanding ventricles can then put pressure upon other brain structures, and cause a variety of complications depending on where exactly the blockage has occurred and which structures are most affected by the blockage.

When such a blockage of the brain ventricles occurs in children whose skull has not completely become bony [generally under age of 2 years], it results in the enlargement of the head. It is known as hydrocephalus. Hydrocephalus can be cause by blockage in the passage of CSF as well as by excess CSF production. In lay language, hydrocephalus is referred as ‘Water in the Brain’.

There can be a number of causes of a blockage that leads to hydrocephalus, such as a tumour, infection, or congenital malformation, which impedes the function of ventricles. Hydrocephalus can often be treated by surgically implanting a shunt that drains the ventricles of excess CSF and empties it into the abdominal cavity. This approach can be successful, but if the reason for the blockage isn’t resolved additional surgeries may be required in the future (e.g. to replace an outgrown shunt, treat an infected shunt, etc…).

How is blockage in ventricles diagnosed?

A contrast CT Scan can show the size and shape of the ventricles in brain. Either a radiopaque dye is injected in the patient’s veins or the CSF is replaced with air and then CT Scan of brain ventricles is done. In either case, a good contrast will be seen and the ventricles can be visualised. While the radio opaque dyes shows up as white colour, air shows up as black colour in CT scans and that helps doctors view the ventricular shape and size and reach a diagnosis about tumours, raised CSF pressure or blockage in the brain ventricular system.

Samarth Neuro and Superspeciality Hospital in Miraj has all the infrastructure and staff to treat hydrocephalus in children and other reasons of CSF blockage. The chief neurosurgeon Dr Ravindra Patil has operated upon many children suffering from hydrocephalus who needed shunts. These children are now grown up. Dr Ravindra Patil has also successfully operated on many adult patients with brain tumours.