I really feel that this post a bit late, but better late than never. Ok, so, here we go..
Epileptic seizures are produced by abnormal electrical activity in the brain. Surgical removal of seizure-producing areas of the brain has been an accepted form of treatment for over 50 years.
Brain surgery is one of the scariest operations a person can endure. While the thought itself is terrifying, brain surgery is necessary to combat certain cancers, aid victims of strokes and help head trauma victims lead a normal life. People who have to undergo brain surgery and their loved ones want to know if brain surgery is painful. The short answer is not as much as you might think.
The brain is the epicenter for emotion, conscious and unconscious function, thinking and memory. Your brain is the reason you recognize and feel pain, but oddly enough, your brain doesn’t have any pain receptors of its own.
Surgery can be performed on both children and adults. However, it is not a suitable treatment for everyone who has epilepsy, or for everyone with poor seizure control.
Brain surgery is a way of treating certain kinds of epilepsy that cannot be controlled with medication. Risks and benefits of surgery should be carefully discussed in advance with the doctors who are going to perform the operation. Certain testing is necessary before the operation. In some cases, surgery for epilepsy requires two operations.
Ask your doctor and the neurosurgeon that will be performing the operation how much pain you can expect. Brain surgery is performed with patients while they are awake and asleep. During the operation you will have anesthesia, either local or general. Either way, you will feel nothing during the brain surgery.
Learn about the post-operational pain. Once again, it is less than you might think. You will have a headache for a few days, and it will be a very strong one. Fortunately, you will be able to take pain medication to manage the pain. Nothing too strong, though. The doctors want you to be alert.
If you know someone who has undergone brain surgery you could ask them about the pain, or you could join a support group. Not all patients are good candidates for surgery.
Having brain surgery does not guarantee that a person will be free of seizures or won't have to take medicine anymore. However, chances are good that most people will have fewer seizures after surgery and many will become seizure-free.
Not all epilepsy-related surgery is performed on the brain. Therapy which delivers pulses of energy to the brain through a large nerve in the neck (VNS therapy) requires a different type of surgical procedure to set the system in place.
Brain surgery and VNS implants are accepted treatments for relief of seizures and are covered by most health insurance plans.
Brain Surgery : Introduction
Cranial Ultrasound
Cranial ultrasound uses reflected sound waves to produce pictures of the brain and the inner fluid chambers (ventricles) through which cerebrospinal fluid (CSF) flows. This test is most commonly done on babies to evaluate complications of premature birth. In adults, cranial ultrasound may be done to visualize brain masses during brain surgery.
Ultrasound waves cannot pass through bones; therefore, an ultrasound to evaluate the brain cannot be done once the bones of the skull (cranium) have grown together. Cranial ultrasound can be done on babies before the bones of the skull have grown together or on adults after the skull has been surgically opened. It may be used to evaluate problems in the brain and ventricles in babies up to 18 months old.
Cranial ultrasound for babies
If an older baby is having the test, it may help to have the baby be a little hungry. The baby can be fed during the test, which will help the baby be comforted and hold still during the test.
Because ultrasound cannot penetrate bone, cranial ultrasound can be performed only on babies whose skull (cranial) bones have not yet grown together. However, duplex Doppler ultrasound can be done to evaluate blood flow and vessel spasms in the brain in children and adults.
Complications of premature birth include bleeding in the brain (intraventricular hemorrhage, or IVH) and periventricular leukomalacia (PVL). PVL is a condition in which the brain tissue around the ventricles is damaged, possibly from decreased oxygen or blood flow to the brain that may have occurred before, during, or after delivery. Both IVH and PVL increase a baby's risk of developing disabilities that may range from mild learning or gross motor delays to cerebral palsy or mental retardation.
IVH is more common in premature babies than in full-term babies. When it occurs, it most commonly develops in the first 3 to 4 days after birth. Most cases of IVH can be detected by cranial ultrasound by the first week after delivery. By contrast, PVL can take several weeks to detect. For this reason, cranial ultrasound may be repeated between 4 and 8 weeks after delivery if PVL is suspected. Several cranial ultrasound tests may be done to evaluate areas in the brain.
Cranial ultrasound may also be done to evaluate a baby's large or increasing head size, detect infection in or around the brain (such as from encephalitis or meningitis), or screen for brain problems that are present from birth (such as congenital hydrocephalus).
Magnetic resonance imaging (MRI) scanning may be done instead of cranial ultrasound to evaluate PVL or IVH in babies born prematurely.
Cranial ultrasound for adults
Cranial ultrasound may be done on an adult to help locate a brain mass. Because cranial ultrasound cannot be done once the skull bones have fused, it is only done once the skull has been surgically opened during brain surgery.
Why is it called a Gamma Knife?
The Swedish inventor, Professor Lars Leksell, coined this term because the machine utilizes Gamma radiation from a cobalt source to destroy tumors or treat other brain pathologies. It acts like a surgeon’s scalpel, thus “the Knife” in its ability to precisely conform the radiation to a tumor shape. The Gamma Knife was invented in 1968 in Sweden where the first clinical treatment was delivered. The first U.S. unit was installed in 1988 at the University of Pittsburgh. Dr. Duma has been performing gamma knife procedures for more than 10 years, on more than 1,800 patients.
Gamma Knife Radiosurgery at the moment not on experimental stages at all. It was approved by the FDA in 1988 and has been used to successfully treat more than 250,000 patients worldwide at state-of-the-art treatment cancer centers.
The Gamma Knife is used to treat brain metastases (tumors that started in the body and spread to the brain) such as lung cancer, breast cancer, melanoma, etc. It is used to treat benign tumors such as meningiomas and acoustic neuromas. It is also used for treatment of Arteriovenous Malformations (AVMs). The pain syndrome of trigeminal neuralgia, and the tremor of Parkinson’s disease may also be treated with Gamma Knife. Finally, the most malignant tumors of the brain, the glioblastoma multiforme, or anaplastic astrocytomas, as well as a number of other primary tumors of the brain, can be treated. For tumors, the very intense dose of radiation directed precisely to the tumor, causes the DNA and proteins in the cell to render themselves unable to divide. The tumor cells can then no longer live, and slowly die over time. The waste is then removed by circulating white blood cells. For AVMs, the radiation causes the blood vessels to thicken and scar until flow ceases. For trigeminal neuralgia, the protective covering or insulation around the pain nerves is destroyed, thus making the nerve unable to conduct an impulse of pain.
And although can treat certain head and neck tumors, the Gamma Knife cannot treat any pathology below the neck. The Gamma Knife treatment starts early in the morning (usually 6:30 a.m.) and is over by noon. After the procedure, the patient eats lunch and is then able to be discharged home or admitted overnight for observation, depending upon the clinical condition being treated. The actual time inside the Gamma Knife varies from about 10 minutes to 90 minutes. And because of the need for extreme accuracy in treating anything in the brain, a special frame is attached to the skull using four pins. The area of the pins is injected with local anesthetic (Lidocaine) and the pins are placed with the patient under sedative anesthesia. Therefore, most patients have no recollection of the frame being placed and have no pain at all. The frame is removed painlessly at the end of the procedure. These all depend upon the area of the brain of a patient’s pathology. In general, we have a 6% risk of temporary neurologic deficit, and a 3% risk of permanent neurologic deficit. This means that 97% of the treatments using Gamma Knife have no permanent side effects at all. These statistics are far superior to those of open craniotomy (brain surgery) for similar pathologies. And because of the superior results and short hospital stays using Gamma Knife technique instead of craniotomy, essentially all insurance companies including Medicare and MediCal cover the procedure. Check with your insurance provider regarding your specific coverage.
Epilepsy does not stand forever
Epilepsy can last a few months, years, or be life-long. It varies among individuals. And approximately six people out of 1,000 have epilepsy. Epilepsy can begin at any age. It most commonly begins in children and in older adults. Most commonly we use medicine to treat epilepsy. If medicines fail, and epilepsy surgery is not an option, some patients opt for the vagus nerve stimulator, an electrical device implanted under the skin like a pacemaker.
The gamma knife has primarily been used to treat irreparable vascular malformations and tumors, and if the seizures are being caused by those things then the gamma knife may help treat the seizures also. Research is being done on treating other forms of epilepsy with the gamma knife, but this is experimental at the present time. Resection surgery (removing the area where seizures come from) is still the most common surgical treatment of epilepsy.
The tests are done to see where the seizures are coming from and if that area can be safely removed. Most centers perform an EEG recording of seizures (called video EEG) and MRI scan, and a test of brain function known as neuropsychological testing. Other tests include PET and SPECT scans, magnetoencephalography (MEG) and functional MRI (fMRI). These are tests that measure the brain's function.
Infantile spasms are a type of seizure that occur in young children (6-12 months old). Most often they are treated with a medicine called ACTH, but they are often difficult to control and may evolve into other severe forms of epilepsy.
If absence seizures go undiagnosed these could happen:
The possibilities include 1) affecting school performance such as learning, 2) absence seizures are occasionally associated with other seizure types, such as convlusive seizures, and 3) absence seizures can go away on their own.
About 2% of children with febrile seizures will eventually develop epileptic seizures. The odds are slightly higher if the child has a long febrile seizure, the seizure primarily affects one side of the body or multiple seizures occur with a single febrile illness. Most children with febrile convulsions do not develop epilepsy. There is a diet known as the ketogenic diet that can treat certain types of epilepsy, mostly occurring in children. There has been some recent evidence from a small study that a modified version of the Atkins diet may help treat seizures, but this needs to be confirmed with a larger study. In general, I advise healthy diet and not skip meals.
If a person has inherited epilepsy, a sibling who has not yet had a seizure then by definition they do not have epilepsy. And as additional info, please don't EEG on a family member that does not have seizures.
And below some first aid if you see someone having a bystander:
1) Helping the person lie down and taking them away from any dangerous objects like stoves;
2) Rolling them onto their side so they do not choke if they vomit;
3) Loosening any tight clothing such as neck ties;
4) Reassuring them as they are coming out of the seizure as they may be confused; and
5) Calling an ambulance if it is the person's first seizure or if it is significantly longer than their usual seizure.
There are many different types of seizures. The two main types include
1) generalized seizures that affect the entire brain, and
2) partial seizures, that come from a part or region of the brain. There are many sub-types of generalized and partial seizures.
The most important factor in diagnosis is a description of the seizures, not only from the person, but also from a witness to the seizures. A neurological examination is performed to look for any signs of brain dysfunction. Then we often use tests like the EEG or MRI to help us with the diagnosis. Also, there are a dozen medicines that are now used to control seizures. None of them, however, have been shown to cure epilepsy.
Cavernous Malformations of the Brain (Cavernomas)
A cavernoma or cavernous malformation is a vascular abnormality of the central nervous system. It consists of a cluster of abnormal, dilated vessels. Pathologically, it is red to purple in colour, appearing as a raspberry. Cavernomas contain blood products at various stages of evolution and are usually less than 3 centimetres in size.
Some individuals are born with a tendency to develop cavernous malformations. They are not a cancer, which means they cannot spread to other parts of the body. Occasionally, people can have multiple cavernomas.
Cavernous malformations occur in people of all races and sexes. The male-female ratio is about equal. Family history may be positive especially in patients of Hispanic descent. Recent work has linked the predisposition to cavernous malformation to the seventh human chromosome. Cavernomas can be found in any region of the brain, be of varying size, and present with varying clinical disorders. In a general population of 1,000,000 - .5% or 5000 people may be found to have a cavernous malformation, although many are not symptomatic.
* Seizures
* Progessive or transient neurologic deficits
* Bleeding
* Headache
It is important to know that a cavernous malformation can be present and not produce any symptoms. In fact, approximately 12% of patients at our clinic are asymptomatic.
Headaches accompany a cavernous malformation in many patients and may have even precipitated the diagnostic evaluation uncovering the lesion. 6-10% of patients with a cavernoma will report headaches as an accompanying symptom.
Patients may present with double vision, unsteadiness, sensory disturbances, and weakness or paralysis on one side of the body. These complaints are closely related to where the lesion is located. 20% of patients will complain of these when they present to the physician.
Sometimes patients present to emergency with a seizure and upon investigation of the seizure a cavernous malformation is found. 36% of patients with a cavernous malformation will present with seizures.
Up to 25% of patients will present with a hemorrhage. This is the most serious complication of a cavernoma. If the cavernoma does bleed, it usually, but not always, starts with a headache. The headache starts suddenly and may be followed by nausea, neurological problems or a decreasing level of consciousness. Sometimes a bleed may be very small and produce very mild or no symptoms at all.
The risk of Cavernous Malformation will Bleed depends on where the malformation is located. Deep lesions in the brainstem bleed and cause problems at a rate of 10% per year, whereas symptomatic hemorrhage from a superficial lesion is very uncommon. The risk with a superficial lesion is much lower (less than 1% year).
Here are two main tests that are used to diagnose cavernomas. These are:
* Computerized Axial Tomography (CAT Scan)
* Magnetic Resonance Imaging (MRI)
MRI has provided the ability to image and localize otherwise hidden lesions of the brain and provide accuracy of diagnosis preoperatively. Both the MRI and CAT scans produce images of slices through the brain. These tests help the doctors to see exactly where the cavernoma is located. Cavernomas cannot be seen on a cerebral angiogram.
The following are indications to consider treatment of a cavernous malformation:
* Neurological dysfunction
* An episode of bleeding
* Intolerable symptoms
* Uncontrolled seizures
There are two possible options available for patients who are found to have a cavernous malformation:
* Surgery
* No treatment
NOTE: Alternatives may exist to these two options, that your doctor will be happy to discuss with you.
* The statistics for the above information were based on data obtained by the University of Toronto Brain Vascular Malformation Study Group and published in the paper Cerebral Cavernous Malformations: Natural History and Prognosis After Clinical Determination With or Without Hemorrhage by Philip J. Porter, MD, Robert A. Willinsky, MD, FRCSC, William Harper, MD and M. Christopher Wallace, MD, FRCSC. Accepted for publication, J. Neurosurgery, 1997.
Brain Tumors in Children
craniopharyngiomaMost brain tumors in children are primary. They start in the brain and are not the result of malignant cells spreading to the brain from another location in the body. A primary tumor in the brain rarely spreads beyond the brain and spinal cord. But any brain tumor can be life threatening if it becomes too big and presses against tissues that control vital body functions such as breathing or blood circulation.
There are many different types of brain tumors and a wide variation in how they grow and affect the brain. Treatment and chance of recovery (prognosis) depend on the type of tumor, its location within the brain, how much it has spread, and the child's age and general health.
Diagnosis
Diagnosing a brain tumor usually involves several steps. The child's physician may perform a neurological exam, which includes checking vision, hearing, balance, coordination and reflexes, among other things. Depending on the results of that exam, the physician may request one or more additional tests.
After getting the patient's medical history, physicians usually conduct a neurologic exam to help determine whether a patient has a craniopharyngioma. During this procedure a physician tests the patient's vision, hearing, balance, coordination, and reflexes. Patients may also be tested for any changes in hormone levels. Physicians may then order one or more of the following imaging studies.
- Computed tomography (CT) scan. A CT scan uses a sophisticated X-ray machine linked to a computer to produce detailed, two-dimensional images of the brain. Patients lie on a movable table that technicians guide into an enormous tube where images are taken. In some cases a special dye may be injected into the bloodstream to make tumors more visible on the images.
- Magnetic resonance imaging (MRI) scan. This technology uses magnetic fields and radio waves to generate images of the brain. MRI scans show the contour of soft tissues as well as bone. Occasionally radiologists use a special dye injected into the bloodstream to help distinguish tumors from healthy tissue.
- Angiogram. A special dye injected into the bloodstream helps locate blood vessels in and around the craniopharyngioma on an X-ray.
- Other brain scans. Other tests help doctors gauge brain activity by studying brain metabolism and chemistry and blood flow within the brain. Some tests include magnetic resonance spectroscopy (MRS), single-photon emission computerized tomography (SPECT), and positron emission tomography (PET) scanning. These scans can be combined with MRIs to help doctors understand the effects of the tumor on brain activity and function.
Physicians recommend surgery for many craniopharyngiomas. Surgery is performed by an otorhinolaryngologist and a neurosurgeon. Surgeons will take a sample of the tumor and send it to the laboratory for examination (biopsy). A pathologist determines whether the tumor is malignant or benign. Most craniopharyngiomas are benign. Surgery may be the only treatment necessary for a benign craniopharyngioma.
For complex craniopharyngioma cases, surgeons and radiation oncologists may recommend stereotactic radiosurgery, fractionated stereotactic radiotherapy, or another surgical procedure.
During a procedure, a surgeon may determine that none or only a small part of a tumor can be safely removed. In that situation, the doctor may recommend radiation therapy following surgery. Malignant tumors may require radiation and/or chemotherapy after surgery.
Radiation Therapy
Radiation therapy uses high-energy X-rays, electron beams, or radioactive isotopes to kill cancer cells. Radiation oncologists then tailor each treatment to protect nearby normal tissue. Patients must have access to the technologies for treatment planning and delivery including intensity-modulated radiation therapy (IMRT). These advanced systems help radiation oncologists and neurosurgeons treat the cancer effectively while limiting radiation to critical normal tissues, such as the eyes, optic nerves, brain, brain stem, and spinal cord. This is important for cancers located in the head and neck.
Chemotherapy
When a biopsy reveals that a craniopharyngioma is malignant, medical oncologists use drugs to destroy cancer cells. The chemotherapy may be given by mouth or infused into the patient's veins.
Never ever let the children alone during the whole process.
Medication used for Epilepsy
Anticonvulsants indicated for use in partial seizures are the medical treatment of choice. Patients generally require many years of treatment, so consideration of side effects is important. While most of the anticonvulsants are in pregnancy category C or D, the risk of medication to the fetus must be weighed against the risk of maternal seizures to the fetus. Because of the risk of level fluctuations, patients should not switch between brand and generic anticonvulsants, and if a generic is used, patients should receive the same generic formulation consistently. Drug Name Carbamazepine (Tegretol, Tegretol XR, Carbatrol) -- First-line agent for partial seizures with or without secondary generalization; particularly effective in treatment of nocturnal motor/dystonic frontal lobe seizures; potential hematologic and other adverse effects; blood monitoring recommended. Adult Dose 200 mg PO qd or bid initially; increase by 200 mg weekly as needed; maximal recommended dose 1200 mg/d in divided doses, although higher doses may be required in patients on other enzyme-inducing drugs Pediatric Dose Small children frequently require suspension Contraindications Documented hypersensitivity; history of bone marrow depression; MAOIs within last 14 d Interactions Danazol may increase serum levels significantly within 30 d (avoid whenever possible); do not coadminister with MAOIs; cimetidine may increase toxicity, especially if taken in first 4 wk of therapy; may decrease primidone and phenobarbital levels (their coadministration may increase carbamazepine levels) Pregnancy D - Unsafe in pregnancy Precautions Do not use to relieve minor aches or pains; caution with increased intraocular pressure; obtain CBCs and serum iron at baseline prior to treatment, during first 2 months, and yearly or every other year thereafter; can cause drowsiness, dizziness, and blurred vision; caution while driving or performing other tasks requiring alertness Drug Name Phenytoin (Dilantin Kapseals, Dilantin Infatabs) -- Available as tab, cap, infatab, and susp. First-line agent for partial seizures; advantages include quickly achieving therapeutic level and possibility of once daily dosing (Dilantin Kapseals), which increases compliance. Adult Dose Some patients require oral loading to attain therapeutic level quickly; phenytoin can be loaded as 1 g divided in 3 doses (400 mg-300 mg-300 mg) at 2-h intervals; maintenance dose of 300 mg/d should be started 24 h after loading; if patients are not to be loaded, initiate dosing at 300 mg/d, as tid, bid, or qd; further dosage increase should be based on response to treatment; because of zero order kinetics, increase by 30 mg or 50 mg Pediatric Dose <6 st="on">PO in 2-3 divided doses; maintenance dose is 4-8 mg/kg Contraindications Documented hypersensitivity; sinoatrial block; second- and third-degree AV block; sinus bradycardia; Adams-Stokes syndrome Interactions Amiodarone, benzodiazepines, chloramphenicol, cimetidine, fluconazole, isoniazid, metronidazole, miconazole, phenylbutazone, succinimides, sulfonamides, omeprazole, phenacemide, disulfiram, ethanol (acute ingestion), trimethoprim, and valproic acid may increase toxicity Pregnancy D - Unsafe in pregnancy Precautions Rapid IV infusion may result in death from cardiac arrest, marked by QRS widening Drug Name Valproic acid, divalproex sodium (Depakote, Depakene, Depacon) -- Available as tablets, capsules, syrup, sprinkles, injection. Although considered first-line agent for treatment of primary generalized epilepsy, indicated for partial seizures as well, particularly for patients with secondary generalization. Must be used cautiously in women of childbearing age; has limited use in young children because of risk of hepatic failure, which may be fatal. Adult Dose 10-15 mg/kg/d Pediatric Dose <2>>2 years: Administer as in adults Contraindications Documented hypersensitivity; hepatic disease/dysfunction Interactions Cimetidine, salicylates, felbamate, and erythromycin may increase toxicity; rifampin may reduce levels significantly; in children, salicylates decrease protein binding and metabolism of valproate; may result in variable changes of carbamazepine concentrations with possible loss of seizure control; may increase diazepam and ethosuximide toxicity (monitor closely); may increase phenobarbital and phenytoin levels while either may decrease valproate levels; may displace warfarin from protein-binding sites (monitor coagulation tests); may increase zidovudine levels in HIV-seropositive patients Pregnancy D - Unsafe in pregnancy Precautions Thrombocytopenia and abnormal coagulation parameters have occurred; risk of thrombocytopenia increases significantly at total trough plasma concentrations >110 mcg/mL in females and >135 mcg/mL in males; determine platelet counts and bleeding time before initiating therapy, at periodic intervals, and prior to surgery; reduce dose or discontinue therapy if hemorrhage, bruising, or hemostasis/coagulation disorder occurs; hyperammonemia may occur, resulting in hepatotoxicity; monitor patients closely for appearance of malaise, weakness, facial edema, anorexia, jaundice, and vomiting; may cause drowsiness Drug Name Gabapentin (Neurontin) -- Indicated for use in partial seizures with and without secondary generalization; has relatively few drug interactions and adverse effects. Adult Dose 300 mg PO bid or tid; may be increased weekly up to 1800-2400 mg/d in divided doses; some patients require doses as high as 3600 mg/d or higher; renally excreted, dosage adjustment necessary for patients with renal dysfunction Pediatric Dose <12>>12 years: Administer as in adults Contraindications Documented hypersensitivity Interactions Antacids may significantly reduce bioavailability (administer at least 2 h following antacids); may increase norethindrone levels significantly Pregnancy C - Safety for use during pregnancy has not been established. Precautions Caution in severe renal disease Drug Name Lamotrigine (Lamictal) -- Newer agent, effective for partial seizures with or without secondary generalization. Main side effect of concern is rash, which may be severe. Adult Dose Dosing depends on coadministration of other anticonvulsants, specifically valproate; see dosing instructions for specific guidelines; slow titration recommended to prevent rash Pediatric Dose Not established Contraindications Documented hypersensitivity Interactions Acetaminophen increases renal clearance, decreasing effects; similarly, phenobarbital and phenytoin increase lamotrigine metabolism, causing decrease in lamotrigine levels; valproic acid increases half-life Pregnancy C - Safety for use during pregnancy has not been established. Precautions Serious or life-threatening rash, more likely children and patients on valproate; while many other adverse effects reported, all are infrequent or rare Drug Name Levetiracetam (Keppra) -- Newer agent, effective for partial seizures with or without secondary generalization. Few adverse effects, no drug-drug interactions. Does not require blood monitoring, although slight decreases in RBC and WBC counts have been reported. Adult Dose 500 mg PO bid, increase additional 1000 mg/d in divided dosing every 2 wk to maximum recommended daily dosage of 3000 mg; slower titration may be better tolerated by some patients; no IV form available; requires adjustment for impaired renal function Pediatric Dose Not established Contraindications Documented hypersensitivity Interactions None reported Pregnancy C - Safety for use during pregnancy has not been established. Precautions Somnolence, coordination abnormalities, and behavioral abnormalities may occur; requires adjustment for impaired renal function Drug Name Oxcarbazepine (Trileptal) -- Indicated as monotherapy or adjunctive therapy in treatment of partial seizures with or without secondary generalization. Mechanism of action similar to that of carbamazepine, without metabolism to epoxide. Active metabolite MHD (monohydroxy derivative). Adult Dose Monotherapy: 150 mg or 300 mg Pediatric Dose Approved for use as adjunctive therapy in children aged 4-16 years Contraindications Documented hypersensitivity Interactions Increases phenytoin level; may interact with oral contraceptives, calcium channel blockers Pregnancy C - Safety for use during pregnancy has not been established. Precautions Hyponatremia may be clinically significant with sodium <125;> Drug Name Topiramate (Topamax) -- Indicated for adjunctive treatment of partial seizures with or without secondary generalization, and for tonic-clonic seizures. Approved for adults and for children aged 2-16. Has multiple mechanisms of action. Adult Dose 25-50 mg/d Pediatric Dose 1-3 mg/kg/d PO for 1 wk, then increase by 1-3 mg/kg/d Contraindications Documented hypersensitivity Interactions Phenytoin, carbamazepine, and valproic acid can decrease levels significantly; reduces digoxin and norethindrone levels; carbonic anhydrase inhibitors may increase risk of renal stone formation and should be avoided; use with extreme caution concurrently with CNS depressants since may have an additive effect in CNS depression, as well as other cognitive or neuropsychiatric adverse events Pregnancy C - Safety for use during pregnancy has not been established. Precautions Risk of developing kidney stone increased 2-4 times that of untreated population; risk may be reduced by increasing fluid intake; caution in renal or hepatic impairment Drug Name Zonisamide (Zonegran) -- Indicated for adjunctive treatment of partial seizures with or without secondary generalization. Evidence that is effective in myoclonic and other generalized seizure types as well. Adult Dose 100 mg/d Pediatric Dose Not established Contraindications Documented hypersensitivity Interactions May increase serum carbamazepine levels; carbamazepine may increase concentrations; phenobarbital may decrease levels Pregnancy C - Safety for use during pregnancy has not been established. Precautions May cause drowsiness, weight loss, ataxia, nausea, and slowing of mental activity Drug Name Tiagabine (Gabitril) -- Indicated for adjunctive treatment of partial seizures with or without secondary generalization. Adult Dose Begin at 4 mg/d Pediatric Dose Not established Contraindications Documented hypersensitivity Interactions Cleared more rapidly in patients treated with carbamazepine, phenytoin, primidone, or phenobarbital than in patients who have not received these drugs Pregnancy C - Safety for use during pregnancy has not been established. Precautions Patients receiving valproate monotherapy may require lower doses or slower dose titration for clinical response; moderately severe to incapacitating generalized weakness has been reported following administration of tiagabine in as many as 1% of patients with epilepsy; weakness may resolve after reduction in dose or discontinuation of tiagabine; tiagabine should be withdrawn slowly to reduce potential for increased seizure frequency Drug Name Pregabalin (Lyrica) -- Structural derivative of GABA. Mechanism of action unknown. Binds with high affinity to alpha2-delta site (a calcium channel subunit). In vitro, reduces calcium-dependent release of several neurotransmitters, possibly by modulating calcium channel function. FDA approved for neuropathic pain associated with diabetic peripheral neuropathy or postherpetic neuralgia and as adjunctive therapy in partial-onset seizures. Adult Dose 75 mg PO bid or 50 mg Pediatric Dose Not established Contraindications Documented hypersensitivity Interactions May cause additive effects on cognitive and gross motor functioning when coadministered with drugs that cause dizziness or somnolence Pregnancy C - Safety for use during pregnancy has not been established. Precautions Discontinue gradually (over a minimum of 1 wk) to minimize increased seizure frequency in patients with seizure disorders; may cause insomnia, nausea, headache, or diarrhea with abrupt withdrawal; common adverse effects include dizziness, somnolence, blurred vision, weight gain, and peripheral edema; may elevate creatinine kinase level, decrease platelet count, and increase PR interval; doses >300 mg/d associated with higher rate of adverse effects and treatment discontinuation; decrease dose with renal impairment (ie, CrCl <60> Further Outpatient Care: In/Out Patient Meds: Deterrence/Prevention: Medical/Legal Pitfalls:
Drug Category: Anticonvulsants -- These agents prevent seizure recurrence and terminate clinical and electrical seizure activity.
29-39 kg: 1200 mg/d
>39 kg: 1800 mg/d
What Is Epilepsy?
To understand how epilepsy arises, we must briefly outline how the brain functions normally. The brain consists of millions of nerve cells, or neurones, and their supporting structure. Each neurone maintains itself in an electrically charged state. It receives electrical signals from other neurones, and passes them on to others. What actually happens is that a tiny quantity of a special neurotransmitter substance is released from the terminals of one neurone. This chemical excites an electrical response in the nuerone next in the chain, and so the signal moves onward. All the functions of the brain, including feeling, seeing, thinking and moving muscles depend on electrical signals being passed from one neurone to the next, the message being modified as required. The normal brain is constantly generating electrical rhythms in an orderly way. In epilepsy this order is disrupted by some neurone discharging signals inappropriately. There may be a kind of brief electrical "storm" arising from nuerones that are inherently unstable because of a genetic defect (as in the various types of inherited epilepsy), or from neurones made unstable by metabolic abnormalities such as low blood glucose, or alcohol. Alternatively, the abnormal discharge may come from a localised area of the brain (this is the situation in patients with epilepsy caused by head injury, or brain tumour). Virtually everyone can have a seizure under the right circumstances. Each of us has a brain seizure threshold which makes us more or less resistant to seizures. Seizures can have many causes, including brain injury, poisoning, head trauma, or stroke; and these factors are not restricted to any age group, sex, or race and neither is Epilepsy. Varieties of Epilepsy What is a seizure?
Epilepsy is a general term used for a group of disorders that cause disturbances in electrical signaling in the brain. Like an office building or a computer, the brain is a highly complex electrical system, powered by roughly 80 pulses of energy per second. These pulses move back and forth between nerve cells to produce thoughts, feelings, and memories.Can anyone have Epilepsy?
There are several forms of epilepsy. Most people will have seen someone suffer a major epileptic seizure, suddenly losing consciousness, jerking the arms and legs, etc. But there are other types of epilepsy - for example, one common form of epilepsy in children merely consists of staring blankly and losing contact with the surroundings for a few seconds.
The best available classification of seizures is that proposed by the International League Against Epilepsy ("seizure" is an alternative term for "epileptic attack").
It starts by dividing seizures into partial seizures, where the abnormal electrical discharge originates from one specific area of the brain, and generalised seizures, where the whole brain is involved. What makes it a little confusing is that a partial seizure may occasionally go on to become generalized, if the epileptic discharge originating in one area of the brain is strong enough to then spread to the whole brain. However, even if the situation of a partial seizure progressing to become generalized, with complete loss of consciousness, convulsions, etc., the initial symptoms will be prominent, and will distinguish it from other forms of generalised epilepsy, where the whole brain is involved from the outset.
How long does a seizures last?
Depending on the type of seizure, they can last anywhere from a few seconds to several minutes. In rare cases, seizures can last many hours. For example, a tonic-clonic seizure typically lasts 1-7 minutes. Absence seizures may only last a few seconds, while complex partial seizures range from 30 seconds to 2-3 minutes. "Status Epilepticus" refers to prolonged seizures that can last for many hours, and this can be a serious medical condition. In most cases, however, seizures are fairly short and little first aid is required.
Partial Seizures
Simple partial seizures are those in which the epileptic activity in one area of the brain does not interfere with consciousness. Thus, a person whose epilepsy has been caused by injury to the area of the brain which controls movements of one leg may experience a series of involuntary jerking movements of that leg as the only symptom.
Complex partial seizures do involve some alteration of awareness. The commonest example is where the discharge originates from one of the temporal lobes of the brain. Here the attack may consist of a feeling of intense familiarity with the surroundings ("deja vu") but being unable to respond. Automatic chomping movements of the jaw may occur.
As mentioned, it is possible that each form of partial seizure may, if the epileptic disturbance is strong enough, occasionally lead to a generalized tonic-clonic seizure.
Generalised Seizures
Absence seizures are not dramatic - in fact, they may not even be noticed at first. This form of epilepsy was previously known as "petit mal", (from French, meaning "little sickness"), and begins in childhood, between the ages of 5 and 10. It may cease at puberty, or continue throughout adult life. Typically, the child may be seen to stare vacantly for a few seconds, often fluttering the eyelids briefly, and seeming to be out of contact with surroundings. The child does not fall to the ground, and recovery is prompt, although the attacks may recur repeatedly, up to many times in the same day. The school work then suffers, and the child may be accused wrongly of "daydreaming".
Tonic-clonic seizures were previously called "grand mal" attacks (from French, meaning "big sickness"). The episodes are dramatic. There may be a brief warning consisting of a feeling of sinking or rising in the pit of the stomach, or the person may cry out or groan before losing consciousness completely. The limbs become stiff and rigid, and breathing stops, causing the lips to go blue. The eyes are rolled upward, and the jaws are clenched - if the tongue or lips are in the way, they will be bitten. This "tonic phase" is followed, within 30 to 60 seconds by the "clonic phase", in which the body is a shaken by a series of violent, rhythmic jerkings of the limbs. These usually cease after a couple of minutes. The person then recovers consciousness, but may be confused for several minutes, and wishes to sleep for an hour or two afterward. Headache and soreness of the muscles which have contracted so violently are commonly experienced for a day or more after the attack.
Other varieties of generalized epilepsy are uncommon. They include:
Myoclonic seizures where there may be sudden, symmetrical, shock-like contractions of the limbs, which may or may not be followed by loss of consciousness.
Atonic seizures, in which there is momentary loss of tone in the muscles of the limbs, leading to sudden falling to the ground or dropping of the head. The pattern is most often seen in children who have suffered injury to the brain, through lack of oxygen at birth, meningitis in infancy, etc.
Tonic seizures, where stiffening of the abody (arching the back) is the predominant feature. This type of attack may or may not be followed by loss of consciousness. It too is most commonly seen in children who have suffered some form of major insult to the brain.
The Causes of Epilepsy
What is it that makes neurones of the brain discharge abnormally?
An inherited instability in the functioning of neurones seems to be responsible for the common forms of generalized epilepsy, especially absence attacks, and tonic-clonic seizures where there is a family history of similar disorder. How this genetic defect operates has yet to be established - perhaps the abnormality lies in the structure of the neurone's outer membrane, leading to electrical instability.
Injury to the brain may certainly cause epilepsy. This includes deprivation of oxygen at birth, trauma to the head at any time of life, and stroke (injury to part of the brain caused by blockage or haemorrhage of one of its blood vessels).
Metabolic disturbance can produce generalized seizures through disturbing the normal functioning of neurones. This may occur when there is severe lowering of blood glucose levels, and when there is severe malfunctioning of the liver or kidneys.
Alcohol and drug abuse may cause seizures during intoxication, or when the offending substance is being withdrawn. Withdrawal of certain medications, such as barbiturates and other sedatives, can cause epileptic seizures in those who have taken them for long periods.
Brain tumor is, fortunately, a relatively uncommon cause of epilepsy, but it must be excluded in all patients who develop epilepsy for the first time during adult life. Tumour should also be excluded in children and adolescents in whom the appearances of the EEG test are not typical of genetic epilepsy, or where these does not seem to be an adequate alternative explanation (such as birth injury).
Recovering from brain surgery
After brain surgery, it is not uncommon to have dizzy spells or to get confused about where you are and what is happening to you from time to time. These episodes can come and go. They can be upsetting for your relatives and also for you. Your nurse and doctor will explain that this is normal and part of the recovery period.
The operation itself can often make your symptoms worse at first. Or you may notice symptoms that you didn’t have before. The swelling can cause
This time can be particularly difficult for your loved ones. They may worry that your operation has not worked. But the symptoms will usually lessen and disappear as you recover. This may take only days. But it can take weeks or sometimes months.
Your surgeon will have given you some idea of what to expect in the way of recovery. For some people, recovery will be complete. You may be able to get back to the same fitness level you had before your tumor. And may be able to return to all your usual activities before long, including your job if you have one.If you have long term problems
Because of the position of their tumour, some people have long-term problems with speech or with weakness of an arm or leg. This can take a long time to recover from. It may be hard for you to keep your spirits up through this time. But with effort and help from physiotherapists, speech therapists and other rehabilitation specialists, you will get a lot better.
Your rehabilitation will start as soon as you can get out of bed. You will gradually be able to do more and more for yourself. You may never quite recover to the same level of fitness as before your treatment. But your condition can and will improve to some extent. Your confidence will increase as you learn to manage with whatever level of disability you have to cope with. There is more about recovering after a brain tumor in the Living with a brain tumor section.
What is the brain?
The brain is the most complex organ in the body, the most complicated computer network known to man. It is not only responsible for the workings of the human body, but also those features that define us as human, our ability to think, emote and feel. The following article is only a brief summary of the information that is available regarding the brain, and even though there has been extensive research into the brain, it still remains the most mysterious organ in the body.
Purpose of the Brain
The brain can be considered the most complicated computer in the world. Saying this though, doesn't quite do justice to just how complicated and amazing the brain is. In one sense the brain does act as a computer - it receives information from inputs such as the eyes and ears, and interprets this information. It also uses this information as well as other, more mysterious processes, to control the movement of the various parts of the body.
The way in which it does this is as fascinating as it is complicated, with the brain being clearly divided into different areas, each having a slightly different function. As each part of the brain has a slightly different function, the loss of these areas through traumatic damage or a stroke can lead to a wide variety of outcomes.
Functions such as vision, movement, hearing and the other senses are actually understood in a bit of detail, however there is another side to the brain that is far more unknown, and people have still not been able to work out the intricacies of it. Emotions, thoughts, memories and what drives someone to do something, things which some people may say are the very essence of what it is to be human, are still complete mysteries. Parts of the brain seem to be associated with this, but how it works is still unknown.
The brain is made up of two types of 'matter', the grey matter and white matter. The grey matter is the thinking part of the brain - the brain cells. In the brain they lie over they surface as well as in several 'islands' called nuclei that are deeper. The surface coating of brain cells is known as the cortex.
The other type of matter is white matter, which is composed of all the nerves of the brain - the connectors that allow the brain cells to communicate with each other. It is white because all of these nerves are coated with a substance called myelin that is quite fatty. So the brain is a coating of 'grey' cells around the outside that send their signalling 'white' nerves towards the centre. It should be noted that in life, the brain is actually pinkish.