Parasellar massive meningioma cured with therapeutic purgation (virechana) and nasal instillation (nasya): A case report

Divya Kajaria; Kundan Sushilkumar Wasnik

doi:10.4103/JIMPH.JIMPH_3_22

CASE REPORT

Year : 2022 | Volume : 1 | Issue : 2 | Page : 71-77

Parasellar massive meningioma cured with therapeutic purgation (virechana) and nasal instillation (nasya): A case report

Divya Kajaria, Kundan Sushilkumar Wasnik
Department of Kayachikitsa, All India Institute of Ayurveda, New Delhi, India

Date of Submission	19-Jun-2022
Date of Decision	19-Nov-2022
Date of Acceptance	31-Oct-2022
Date of Web Publication	20-Feb-2023

Correspondence Address:
Dr. Divya Kajaria
Department of Kayachikitsa, All India Institute of Ayurveda, New Delhi
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JIMPH.JIMPH_3_22

Abstract

Meningiomas are a benign type of intracranial tumor. Age and the site of the tumor are the two deciding factors for the prognosis. The majority of meningiomas are non-malignant, but these tumors can grow slowly and may have a progressive complicated stage, which if left untreated can be life-threatening. Presently, surgical excision is the commonest use treatment modality; radiotherapy is also used in some cases where complete surgical excision is not possible. A craniotomy is required for proper excision of the tumor and it has its own disadvantages, if not done properly can be severely disabling and may even endanger life. The cost of the surgery is also one of the limiting factors in poor and developing countries. Therefore, surgical options mostly opt for large meningiomas. This article gives detail of a case of meningioma in the left parasellar region extending medially and superiorly, displacing the pituitary stalk and indenting left orbital nerve;treated successfully with Ayurvedic treatment modalities including Virechana (~therapeutic purgation) and Nasya (~nasal instillation) therapies with a total duration of treatment was one month. CT Brain contrast imaging was the diagnostic and assessment tool used to ascertain the outcome of the treatment.

Keywords: CT Brain (contrast), Intracranial tumor, Nasal instillation, Therapeutic purgation

How to cite this article:
Kajaria D, Wasnik KS. Parasellar massive meningioma cured with therapeutic purgation (virechana) and nasal instillation (nasya): A case report. J Integr Med Public Health 2022;1:71-7

How to cite this URL:
Kajaria D, Wasnik KS. Parasellar massive meningioma cured with therapeutic purgation (virechana) and nasal instillation (nasya): A case report. J Integr Med Public Health [serial online] 2022 [cited 2023 Mar 27];1:71-7. Available from: http://www.jimph.org/text.asp?2022/1/2/71/370074

Introduction

Meningioma is a brain tumor that originated from the dura mater and is composed of neoplastic meningothelial cells.^[1] The annual incidence of meningiomas is about 5 per 100,000 individuals, and are the most frequent primary tumors in the central nervous system (30%).^[2] They tend to be more common in women and patients with neurofibromatosis type 2 (NF2). The ratio of meningioma in females as compared to males is about 4:1 often discovered at old age.^[3]Now a day‗s meningiomas are diagnosed very frequently since more people undergo neuroimaging techniques for various indications and this is again one of the major causes for meningiomas.^[4]Most commonly presented symptoms are - changes in vision such as blurred or double vision, headache, hearing loss, or ringing sound in the ears, some cases may have memory loss, loss of smell, seizures, language difficulty, and weakness in arms or legs. According to the WHO classification 2000/2007/2016 based on their histological appearance, meningiomas are given in the [Table 1].

Table 1: Current histological criteria for grading meningiomas according to the WHO- 2016 classification^[17]

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Currently for the management of meningiomas following treatment modality options are available

Observation and Symptomatic treatment – Mostly done when the tumor radius is small (<2.5 cm in size)

Surgery – meningiomas bigger in size (> 4 cm radius) surgical management is the only treatment modality.

Adjuvant therapy – Radiotherapy

In Ayurvedic literature, there is no specific description of meningioma explained but it can be correlated with Granthi or Arbuda (~a disease described in Ayurvedic texts characterized by abnormal growth or lump). The involvement of Vata(~Dosa responsible for movement and cognition), Pitta (~Dosa responsible for regulating body temperature and metabolic activities), Kapha(~phlegm), Rakta(~blood tissue), Mansa(~muscle tissue), and Meda(~fatty tissue)are involved in the manifestation of Granthi and Arbuda.^[5] For the management of Granthi and Arbuda, Apatarpana (~depletion therapy) and Virechana (~therapeutic purgation) are the treatment options as suggested by Susrutachacharya.^[6]Following Ayurvedic treatment principles, a case diagnosed with meningioma was treated successfully.

Case Description

A 65-year-old female having complains of headache, swelling over the left lateral side of the face and left frontal region (the left eyebrows lining was significantly lower than the right eyebrow lining), right knee joint swelling associated with pain, andabdominal pain for 5 months, visited the OPD, for consultation and further management. She visited the allopathic doctor in her village and for time being her complaints were relieved but in a short period her complaintsaggravatedand she revisited her physician, who then advised for a head CT scan and finally diagnosed her as a case of meningioma of the brain. As the symptoms were aggravating, she was advised for craniotomy. Her attendant considering her age was not willing for brain surgery and therefore bring her to the hospital for Ayurvedic management.

Physical Examination of the Patient

The patient‗s general condition was good on arrival having BP-140/90 mm of Hg, pulse rate- 76 per min, and temperature- 97.1° F with no signs of anemia, cyanosis, and lymphadenopathy. She didn‗t have any history of diabetes, hypothyroidism, hypertension, or any particular allergy. Her height was 4.5 feet and her weight was about 51 kg witha BMI of 27.0. Her menopause occurred at the age of 48. The Ashtavidha Pariksha (eight parameters scale for physical examination) is given in [Table 2].

Table 2: Ashtavidha Pariksha (eight parameters scale for physical examination)

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On local examination, mild tenderness was found in the right hypochondria region without any organomegaly. There was the presence of crepitus in both knee joint movements along with periarticular tenderness and swelling without any sign of joint effusion. The range of knee joint movement was restricted (extension-160⁰and flexion -20⁰). B/L air entry was normal with no added sound. Heart sounds were normal with no additional/ abnormal sounds.

Timeline

– A detailed timeline is given in [Table 3].

Table 3: Timeline

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Diagnostic assessment

– As there is no specific information regarding meningioma in Ayurveda it is confirmed with the help of a CT scan of the brain technique and the detailed information is given in [Table 4].

Table 4: Diagnostic investigations

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Therapeutic Intervention

On detailed examination of the patient and considering the disease condition there is significant involvement of Bahudosha Avastha Lakshana (multiple humor symptoms) identified thus,Shodhana Chikitsa (~cleansing therapy) decided for the management with knowing this therapy can enhance the quality of life as well as longevity of the patient as explained in the Phalashruti (~outcome) of Shodhana Chikitsa.^[7]Standard Virechana Karma and Nasya Karma followed and after that Rasayana (~rejuvenation) therapy was also given to maintain the procedural effect for the longer duration of time. The detailed information of treatment course is given in [Table 5]. Before Virechana Karma patient was given Deepana (~enhancing metabolic fire) and Pachana (~enhancing digestion) and then Snehapana (~internal oleation) with Panchatikta Guggulu Ghrita for the 7 days was done. During the time of Snehapana the patient was advised to consume only Khichadiand Daliyafor the food when she felt extreme hunger and daytime sleep contraindicated. After achieving the Samyak Snigdha Lakshana (~proper oleation), Sarvanga Abhyanga (~oil massage), and Bashpa Swedana (~steam) were done for 3 days, and then Virechana was given and a total 18 Vegas observed and considered as Madhyama (~medium) Shuddhi (~purification) according to this the Sansarjana Krama (~graduated diet) followed and then Anu Taila Nasya treatment followed along with the Rasayana Chikitsawith Amalaki (Emblica officinalis Gaertn.)and Haritaki (Terminalia chebula Retz.) Churna.

Table 5: Treatment course and findings

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Follow up and Outcome

After completion of the Rasayana Treatment patient visited the OPD and all the vitals were stable the complaint of headache and heaviness in the head was completely relieved and very much lightness in the head was felt by the patient and the report of CT brain also suggested that there was no abnormal brain parenchymal or meningeal enhancement.

Discussion and Conclusion

The cause of meningiomas is still not well understood. Radiation, family history, and neurofibromatosis type2 are generally attributed as risk factors but none of these were found to have a definite etiological contribution. Uncontrolled growth of arachnoid cells produces tumors but what stimulates the neural cell to differentiate exponentially is undefined. As most meningiomas are found near the vicinity of venous sinuses, we got a clue that it may be due to hypoxia-induced oxidative stress that stimulates oncogenes of the nerve cells by modulating signaling pathways. Oxidative stress (ROS) contributes to tumor promotion and progression by modulating signaling pathways and inducing DNA mutation. However, ROS are also able to trigger programmed cell death (PCD).^[8] The biochemical integrity of the brain is vital for the normal functioning of the central nervous system (CNS). One of the factors contributing to cerebral biochemical impairment is a chemical process called oxidative stress. Oxidative stress occurs upon excessive free radical production resulting from an insufficiency of the counteracting antioxidant response system. The brain, with its high oxygen consumption and lipid-rich content, is highly susceptible to oxidative stress.^[9] Therefore, oxidative stress-induced damage to the brain has a strong potential to negatively impact normal CNS functions. This pathological hallmark was very obvious in the given case. The patient was having cholelithiasis and cholecystitis in association with meningioma, supporting the hypothesis of lipid metabolism derangement and thereby depletion of essential lipids to the brain. She was having chronic constipation (incomplete evacuation of bowel in this particular context) suggesting dysbiosis was a probable cause of oxidative stress. It is well documented that a peculiar microbiota type might increase brain inflammation and reactive oxygen species levels and might favour abnormal aggregation of proteins.^[10] Overall pathogenesis supports long standing dysbiosis causing array of consequences starting from dyslipidemia to meningioma. According to Ayurveda, the patient was diagnosed as case of Margavrodhajaya Vata-vyadhi (obstructive pathogenesis). As there is obstruction in the natural path of the Vata (referring to the one of three humor), treatment aims to retain its natural path of movement termed as Vataanuloma in Ayurveda. Opting Virechana solves both the purpose of disrupting pathogenesis, firstly it helps in Vataanuloma and secondary it helps in rectifying the disturb gut micro biome, it is basically a cleansing procedure. Before Virechana, preparatory procedure deepana-pachana was done to stimulate enzymatic reactions. Acharya Susruta (Father of Surgery) has also mentioned the use of Virechana for the management of Kaphaja Granthi.^[11]

Knowing the obstructive pathology and the complaint of pain to relieve this and achieve the proper Rukshana effect before SnehapanaChitrakadi Vati^[12] along with Hingvastaka Churna^[13] was planned. The use of Lavana (~salt) and Kshara (~alkali) along with Hinga (Ferula northex), Ajamoda (Apium graveolens Linn),and Chavya (Piper retrofractum Vahl) in Chitrakadi vati helps remove the obstruction in Srotas (~structural or functional channels) and enhances the digestive fire and thus achieve Vatanulomana (~proper functioning of Vayu). Hingvastak Churna also contains the Ushna (~hot)drugs which enhance the metabolism and pacify the Vata Dosha, thus subsiding the pain and achieving the DeepanaPachana aim prerequisite for the Snehapana.

The patient having cholelithiasis and cholecystitis in association with meningioma Panchatiktaguggulu Ghrita^[14]was selected for the Snehapana as it has anti-tumor, anti-cancerous, anti-mutagenic, anti-proliferative, anti-inflammatory, neuroprotective and analgesic properties owing to this broad spectrum this has been chosen. The patient was having Krura kostha for that strong Virechana given Trivrit leha, Kutaki (Picrorhiza kurroa Royle ex Benth.)churna and Phalatrikadi kwatha given and Samyaka (~proper) Virechana target has been achieved.

With the above treatment,Vatanulomana was done and for the pacification ofVatain the head Nasya with Anu Taila^[15]is planned since the nose is the gateway to the brain.^[16]The nasal drug delivery seems to be a favorable way to bypass the obstacles to the blood-brain barrier (BBB) allowing the direct drug delivery in the biophase of the central nervous system(CNS) active compounds. Pooling of blood from nasal veins to venous sinuses of the brain is more likely to occur in head lowering position due to gravity and thus the absorption of the drug into the meninges and related intracranial organs occur and helps to relieve the pressure in the meninges and with the properties of Anu Taila helps to eliminate the vitiated dosha and thus managed the disease condition.

Annulment of meningioma in CT brain (contrast) that Virechana is helpful in improving the microcirculation and modulation of gut microbiome has definite role in reducing oxidative stress and most significantly it helps in regressing the cellular damage.^[17]

Conclusion

Complete cure of parasellar massive meningioma by Virechana (therapeutic purgation) and Nasya (nasal instillation) signifies that uncontrolled cellular growth can be controlled and regress by improving micro-circulation and modulating micro-biome. It clinically demonstrates that Virechana as indicated in Ayurveda improves micro-circulation at cellular level (detoxifying). This also strengthen the concept of nose- to brain transport of medicine and compel to develop this non-invasive and safe technique to be use for the management of brain disorders.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.

Ethical statement

Not applicable.

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