Basic facts about Epilepsy or Fits or Seizures or Convulsions.

Epilepsy is a symptom which indicates that there is some problem in the physiology of brain.
So, if a person presents with seizures a detailed work up should be done. It begins with detailed history.
Broadly epilepsy is classified as:

GTCS: Generalized Tonic Clonic Seizures
CPS: Complex Partial sezures ( Usually due to temporal lobe involvement,  may be associated with hallucinations or other complex symptoms)
Focal seizures
Focal seizures with secondary generalization

In infants and children of less than five year of age, if single episode of seizure occurs during high grade fever, it is most likely a Febrile convulsion for which long term antileptic medication is not required.
In majority of cases , the cause of the seizure is not known. When neuroradiology does not reveal any abnormality and other causes are ruled out after detailed work up , it is labeled as idiopathic epilepsy.

The common causes are infections, neoplasm , trauma, vascular lesions, development, etc. The infective granulomas ( Tubercular, Neurocysticercus, Toxoplasma) , Abscess, Meningitis, encephalitis are the common infective etiologies.
Head injury ( Extradural hematoma, Subdural hematoma, Diffuse axonal injury,etc) may present as Post traumatic Epilepsy, immediately following trauma or at later stage, known as Post Traumatic Late onset Epilepsy.
Brain tumors can present as seizures. All the tumors which involve or compress the cerebral hemispheres may present with seizures. Supratentorial Gliomas and Meningiomas have very high incidence of seizures. Although, Meningioma is an extra axial lesion as it arises from dura ( originates  from Arachnoidal Cap Cells), it is associated with brain edema, and so presents with seizures.
Brain metastasis is also associated with brain edema and presents with seizures.
Arterivenous malformation in the cerebral hemispheres usullay presents with seizures in children. Subarachnoid hemorrhage due to rupture of the intracranial aneurysm may present with seizures.
Other brain abnormalities like Schizencephaly, arachnoid cyst, epidermoid may present with seizures.
Mesial Temporal Sclerosis usually presents with Complex partial seizures.
How to investigate a case of Epilepsy?
History, Physical Examination may reveal a clue to the diagnosis, like Tuberculosis, Primary cancers elsewhere in the body.
CT scan or MRI of the brain with contrast with MR spectroscopy
EEG
How to treat Epilepsy?
Sodium Valproate or Phenyton should be used as primary antiepileptic medication, because these two antiepiletics had been in clinical  use since very long time, their complications are well known and very much predictable. In case of status epilepticus , their injectable forms are available so a loading dose can easily be delivered. Because of injectable, neurosurgeons can also use them during perioperative period.
Carbamazepine can aso be used as primary antiepileptic medication.
It is very easy to remember the doses of these three very commonly used drugs.
Phenyton,  5 mg/ kg body weight ( so, in an adult of about 50 kg weight  give Phenytoin 100 mg TthreeTimes a Day)
Carbamazepine, 10mg/ kg body weight ( so, in an adult of about 50 kg weight give CBZ 200 mg TDS)
Valproate, 15 mg/ kg body weight ( so, in an adult of about 50 kg weight  give Valproate 300 mg TDS).Valproate is a very common conditions, like Migraine, Mood disorders, so it may help in comorbid conditions,as well)
Seizures are usually controlled with single antiepileptic drug if prescribed in proper dosage. If it is not controlled increase the dose.
For Long term Antiepileptic medication :Another add on therapy should only be given when the maximum dose of the first drug is already in use and seizures are still uncontrolled.
The first drug to be added is usually Clobazam.
For example,  If in an adult operated patient of glioma , seizures were controlled earlier with Tab Phenytoin 100mg TDS, if Seizures occur, add 100 mg : So it will be 100 mg 4 times a day, and seizures are not controlled , an addition of Tablet Clobazam 10 mg can control the epilepsy.
Now, another epileptic is vigorously marketed as primary antiepileptic and also as add-on therapy, i.e., Levetiracetam. This drug has also been use in clinical practice with good safety profile. Moreover, the availability of injectable forms are added advantage, for treating status epilepticus.
Many other antiepileptics are used depending upon condition of the patient. Topiramate is used in cases of migraine and seizure patients with obesity.




 

Functional Neurosurgery, Stereotaxy, Stereotactic Radiotherapy, Gamma Knife and X-knife or Cyberknife

Lot of people are not aware about the stereotaxy and gamma knife and to a certain extent some medical professionals find it difficult understand these terms. There is ample of literature and academic material on these subjects but I would like to explain in brief and in a very simple manner.
Gamma knife or Gamma surgery or cyber knife is a misnomer and it is nothing to do with surgery or scalpel. These are the non invasive method of intervention. Gamma knife and cyberknife are the procedures in which radiation is used to treat a lesion in brain. 

Now there are variety of lesions which can be treated with Gamma knife or Cyber Knife including vascular malformations like arterivenous malformations ( AVM), small tumors  and even malignant metastasis to the brain.

Brain Metastasis is the commonest intracranial malignancy and constitutes 20% to 40% of patients with neoplastic lesion. The most frequent primary cancers which metastasize to brain are lung, breast , renal cancers and melanoma.

Surgical Resection with adjuvant WBRT (whole brain radiation therapy) is considered the standard of treatment. However, in metastatic lesion localized in deep structures or in eloquent brain areas not amenable to surgery, patients may benefit  from stereotactic radiotherapy ( SRS) treatment.

SRS is based on focusing multiple , high dose, ionizing radiation beams using stereotactic guidance on an intracranial target.

Although both these procedures involve Photon Radiation Technology, there is some difference between Gamma knife and Cyber knife. Gamma Knife uses Cobalt-60 sources and a stereotactic system but Cyberknife uses LINAC ( Linear Accelerator) without need for head fixation.

Stereotactic Radiotherapy( SRT) is a non invasive external beam Radiation therapy for the malignat lesions of the brain where the targeting of the lesion is done using a stereotactic apparatus. One of the important indication for SRT is the brain metastasis and upto three metstatic lesions of about 3.5 cm size or less in the brain can be treated without invasive surgery.
Stereotactic procedures became famous with the pioneering work of Leksell.
At present various types of Stereotactic apparatus available which are compatible with CT scan or MRI. The aim of this apparatus is to to localize a lesion very precisely ( sub millimeter) and three dimentionally. Therefore to localize sub  thalamus or a small AVM of a very small deep seated lesion in brain a stereotactic frame is fixed to the head of the patient without giving general anesthesia and patient remains conscious.
This stereotactic apparatus can be used to localize a lesion for stereotactic biopsy or putting an electrode in Deep brain stimulation in DBS surgery for Parkinson disease.
The procedures like vagal stimulation for epilepsy,  Deep brain stimulation (DBS )for Parkinson disease and dystonia come under a broad term called Functional Neurosurgery.

References-

Dr. Daniele Rigamonti, Schmidek & Sweet operative Neurosurgical techniques Indication, Methods, and Results, Sixth Edition, section V.

Brain & Mind A to Z- Ask anything pertaining to brain & mind

Study of the brain is very simple and interesting. Some of the topics include:
Anatomy of the brain includes Brain, brainstem, Cerebrospinal fluid ( CSF), Carotid artery, arterial and venous supply of the brain, cranial nerves. Neuro-Physiology, Neurochemistry, Neuropathogy and neuroradiology.
Vascular diseases of the brain and spinal cord like Arteriovenonous malformation, Intracranial Aneurysms, Cavernous malformations, Surgical and Endovascular treatment ( Coiling, Embolization).
Infectios of the CNS Meningitis, Encephalitis, Abscess in the brain,
Degenerative disease like Alzheimer's disease, Memory deficits.
Brain tumors : Glioma, Meningiomas, Craniopharyngioma, Acoustic Neuroma, Pituitary tumors, Prolactinoma,, acromegaly,Chordoma, Medulloblastoma
Deep Brain Stimulatin ( DBS), Functional Neurosurgery.
             Sometimes, few terms appear albeit complicated, you are welcome to ask me to explain that particular terminology.

If you have any question related to brain, spinal cord or diseases affecting these structures, you may ask me. Questions and feedback are welcome. It will make my blog more interactive and may benefit many other people who might be having similar querries.