Featured Case

MODERN DIAGNOSIS: Bilateral Papilledema- Idiopathic intracranial hypertension

ABOUT THE DISEASE:

Papilledema is when pressure in your brain makes your optic nerve swell. A mild papilledema with minimal symptoms is usually nothing to worry about. More severe symptoms may indicate a serious underlying condition. However, papilledema can be a sign of an underlying condition or injury that needs to be treated as soon as possible. This is especially true if you notice the symptoms after major trauma to your head.

Causes: The fluid bathing your brain and spinal cord is known as cerebrospinal fluid, or CSF. Optic nerve swelling can happen when CSF builds up where your optic nerve and the central retinal vein travel between your brain and your eye nerve. This area is known as the subarachnoid space. When pressure pushes on the nerve and vein, blood and fluid can’t leave the eye at a normal rate, causing papilledema. Brain swelling can be caused by a number of injuries and conditions, including: 

traumatic injury to your head

not having enough red blood cells or hemoglobin (anemia)

CSF buildup in your brain (hydrocephalus)

brain bleeding (hemorrhage)

brain inflammation (encephalitis)

brain tissue inflammation (meningitis)

high blood pressure (hypertension)

collection of infected pus in the brain (abscess)

brain tumor

Sometimes, brain pressure builds up for no apparent reason. This is known as idiopathic intracranial hypertension, which is more likely to happen if you’re obese. In this case report, a 38 years female patient presented with recurrent episodes of headaches since 3 months which were triggered by loud noise and the honking of vehicles. She also had persistent heaviness on the right side of her head. She was diagnosed with B/L Papilledema (Rt.>Lt.) along with idiopathic intracranial hypertension. In spite of taking allopathic medication and lumbar puncture, the condition persisted, for which she was suggested to undergo brain shunt surgery (in patient's words). The patient refused surgery and opted for Ayurvedic management. The condition was diagnosed as shirashoola/ shiroroga in Ayurveda and  managed with shamana yogas along with Jalaukavacarana. 

Symptoms:The most common early symptoms of papilledema are brief changes to your vision. These changes may barely be noticeable at first, with blurring, double vision, seeing flashes, or vision loss lasting a few seconds. If brain pressure continues, these changes may last for minutes at a time or longer. In some cases, they may become permanent. The brain swelling that causes papilledema triggers other symptoms that distinguish it from other eye conditions, including: 

feeling nauseous

throwing up

having abnormal headaches

hearing ringing or other noises in your ears (tinnitus)

Diagnosis: A full physical examination to check the overall health and clinical evaluation is the primary diagnostic tool. The field of vision will be checked by moving their hands back and forth past the eyes to see where your blind spots are. The ophthalmoscope is used to have a glance at the optic nerve. Additional tests like MRI test or a CT scan of your head to check for tumors or other abnormalities in the brain and skull may be resorted to. Tissue sample (biopsy) of the tumor is removed to test for cancerous cells or drain some of the CSF to test it for any abnormalities.

Image 1. Baseline MRI report dated 1.2.2023

Treatment: This depends on the cause of the condition. The doctor will prescribe medications to reduce swelling. Corticosteroids, such as prednisone (Deltasone), dexamethasone (Ozurdex), and hydrocortisone (Cortef), can all be used to keep swelling down in your brain. These medications may be injected or taken by mouth. If high blood pressure is causing papilledema, the doctor may prescribe medications to keep the blood pressure under control. Common medications for high blood pressure include:

• Diuretics: bumetanide (Bumex) and chlorothiazide (Diuril)
• Beta blockers: atenolol (Tenormin) and esmilol (Brevibloc)
• ACE inhibitors: captopril and moexipril

If there is a tumor, then brain surgery is done to remove the tumor. If there is an infection, then antibiotics are prescribed. If there is an abscess, a combination of antibiotics and drainage to treat a possible infection as well as to remove the infected pus or fluid from your brain will be adopted.If there is a major head injury, then the target is to reduce pressure and swelling in the head. This may involve draining CSF from head and removing a small piece of the skull to relieve the pressure.

Prognosis: Papilledema isn’t usually an issue on its own. It can typically be treated by draining extra CSF fluid, which reduces swelling. Symptoms then disappear in a few weeks. Swelling or injury to your brain can be serious and life-threatening. If papilledema is caused by an underlying condition, get treated right away to prevent any long-term complications.

Reference

1. https://www.healthline.com/health/papilledema#outlook

AYURVEDA DIAGNOSIS: Shiroroga- Shirashoola

ABOUT THE DISEASE:

 In this case report, a 38 years female patient presented with recurrent episodes of headaches since 3 months which were triggered by loud noise and the honking of vehicles. She also had persistent heaviness on the right side of her head. She was diagnosed with B/L Papilledema (Rt.>Lt.) along with idiopathic intracranial hypertension. In spite of taking allopathic medication and lumbar puncture, the condition persisted, for which she was suggested to undergo brain shunt surgery (in patient's words). The patient refused surgery and opted for Ayurvedic management. The condition was diagnosed as shirashoola/ shiroroga in Ayurveda and  managed with shamana yogas along with Jalaukavacarana. 

The word ‘Shira’ stands for head and ‘Roga’ means disease. The disease pertaining to shira has been specified as ‘Shira shoola’ which means ‘headache’. This is also called as Shiroruk, Shiropida  or Shirovedana. It may occur as a symptom of some underlying disease or as a problem in itself. Shirashoola is classified into eight types based upon the cause and the dosha involved. 

Causes: 

Ahara- Excessive eating, preferring  ruksha ahara, liquids - alcohol in excess, food which aggravates dosha altogether and individually are causative factors.

Vihara- Exposure to smoke, frost, breeze, dew, vishamashana, adyashana, ratri jagarana, diva swapna, atapa dhuma sevan, asatmya gandha sevana, exposure to bright and high intensity light, light stimuli, placing pillows in wrong height, aversion to abyanga, indulging in water sport, chinta, krodha, shoka, lamenting, weeping, bhaya, Vega dharana of mutra, mala, kshavatu and nidra,  weight lifting, talking too much and too loudly. 

Environmental factors 

Ayogya upchara - genetic, hereditary, or other diseases 

Abhighataja

Types of Shirashoola and their lakshanas: 

Ayurveda classifies a headache into the following types: 

Vataja: This type of headache occurs due to an imbalance in the vata dosha. It usually causes loss of balance while walking. 

Pittaja: It originates in pitta dosha and leads to a burning sensation along with headache. 

Kaphaja: It is caused due to kapha and occurs with cold and cough. 

Sannipatika: The vitiation of tridoshas causes a sannipatika headache, and it could show symptoms from any or all of the types of headaches mentioned above. 

Ananta vata: In this type of headache, pain is felt all over the head with accompanying nausea and giddiness.

Ardhavabhedaka: It involves pain in half of the head.

Samkhaka: In this type of headache, pain is confined to the left and right sides of the head, which swells and become red.

Suryavarta: This type of headache follows the path of the sun – it starts in the morning, increases till midday, and decreases as the sun goes down. 

But in this case report, the treating physician has not specified the type of headache. 

Treatment & rationale of treatment as specified by the treating physician:

In general the treatments given for Shirashoola are as follows: 

Basti karma 

Nasya karma 

Lepa 

Virechana (purgation) karma 

Seka 

Snehana 

Shirodhara 

The treating physician explains that the line of treatment adopted is Raktamokshana with Jalauka as it is Pitta vyadhi and Rakta vyadhi hara. 

Sadhyasadhyata: The cause of the shirashoola plays an important role in determining the sadhyasadhyata. If the cause can be addressed, then there is curability. But if the cause persists, then the condition is not curable. 

Reference:

1. Caraka Samhita. Su. 17
2. Sushruta Samhita. Utt.25

 In this case report, a 38 years female patient presented with recurrent episodes of headaches since 3 months which were triggered by loud noise and the honking of vehicles. She also had persistent heaviness on the right side of her head. She was diagnosed with B/L Papilledema (Rt.>Lt.) along with idiopathic intracranial hypertension. In spite of taking allopathic medication and lumbar puncture, the condition persisted, for which she was suggested to undergo brain shunt surgery (in patient's words). The patient refused surgery and opted for Ayurvedic management. The condition was diagnosed as shirashoola/ shiroroga in Ayurveda and  managed with shamana yogas along with Jalaukavacarana. 

Assessment: Only Subjective and objective parameters were assessed to analyse the outcome of the treatment.

Subjective parameters: The symptoms were documented after each Jalaukavacarana and tabulated.

Image 1.Daily/weekly/monthly progress tabulated date wise  

Objective parameters: VAS was documented as 8 before treatment, became 1 after treatment

Image 2. Photographs of Jalaukavacarana taken during treatment

Eye check up was done during follow ups to assess the outcome.

Image 3. Eye check up report during treatment dated 6.3.2023

Image 4.  Eye check up report during treatment dated 10.4.2023

Image 5. Eye tests done 3.7.2023