Case Notes

PART I:


1. The nervous system is made up of cells called neurons. Neurons communicate with each other by generating electrical impulses known as action potentials. The action potential runs down the length of the cell body and ends at the axon terminal. Here, the electrical activity induces the release of chemicals known as neurotransmitters. These neurotransmitters are released into the intercellular space right outside the axon terminal, known as the synaptic cleft, where they bind to receptor proteins on the dendrites of another neuron. This is called a synapse and is the point of communication between neurons.

2. Seizures occur when there is abnormal electrical activity within the brain. This can be caused by an imbalance of excitory and inhibitory neurons in the brain. As a result, individuals can lose voluntary control of certain muscle groups or lose consciousness.

3. Epilepsy is a chronic disease that involves recurring, unprovoked seizures. Diagnosing epilepsy is difficult, as it can be caused by a number of different things (e.g. brain tumors, Alzheimer’s, strokes). Specialists usually recommend that the patient and/or their family gather as much information about the seizures as possible. This includes circumstances surrounding the seizure, behavior or sensations during the seizure itself and condition following the seizure. Doctors may also look into a patient’s medical history to see if there are any risk factors for epilepsy (e.g. family history, head injury, meningitis).

4. MRI (magnetic resonance imaging) scans provide detailed pictures of the brain’s surface. These are useful in identifying areas of abnormal brain structure and/or development. It can show abnormalities in the size of brain regions, the presence of a tumor, or a lesion on the surface on the brain. This is very important in determining the immediate cause of a seizure and what kind of action would be required to rectify the problem. For example, MRI scans can show whether or not invasive surgery would be effective in preventing future seizures.

The MRI itself involves the use of a magnetic field contained in an MRI machine. Patients lie in an MRI machine for around half an hour. During this time, they are asked to minimize movement so as to provide as clear an image as possible. This allows the magnetic field to penetrate and produce images based on the structure of the brain.

EEG (electroencephalography) is used to provide information on brain activity. This is done by attaching many electrodes to the patient’s scalp, and recording electrical activity in the brain. The electrical activity of the brain can show evidence of epilepsy risk factors like tumors or brain trauma. There are also EEG patterns that are specific indicators of epilepsy called ‘epileptiform abnormalities’.

The recording of the EEG can last between 20-30 minutes. An EEG technician usually exfoliates the scalp a bit to remove residue or substances that might interfere with the recording. The technician then attaches the electrodes to the patient’s head using an adhesive paste that can be washed off later. During the recording itself, the patient is asked to relax, fall asleep or shown mild stimuli.

5. Non-epileptic seizures have causes other than epilepsy. They mainly differ in that they are not caused by malfunctions in the brain’s electrical activity. They could be caused by metabolic disorders (like diabetes), extreme stress or emotional problems.

6. I believe Jerrod appears to be having partial epileptic seizures.

7. When witnessing a seizure one should remain calm and try to make sure the patient is not in environment in which they could get injured. One should gently try and make the patient lie or sit down to prevent injury, but avoid forcing the patient to do anything. Furthermore, one must pay close attention to the patient’s breathing and the length of the seizure. If the seizure lasts longer than 5 minutes, one should call an ambulance.

8. There are a variety of treatments for epilepsy, but they depend on the root cause of the condition. Some epilepsies can be cured using surgical techniques, others may require medication. In some cases, patients are implant with a vagus nerve stimulation (VNS) device that works as a sort of pacemaker to regulate electrical impulses in the brain.

Sources:
“About Epilepsy.” Epilepsy Society. National Society for Epilepsy. Web. 04 Aug. 2014.
Epilepsy Therapy Project. Ed. Patricia O. Schafer. Epilepsy Foundation. Web. 04 Aug. 2014.

PART II:


1. Rasmussen’s syndrome is a disease that is usually manifested in early childhood. The exact cause is still unknown, but scientists suspect it may be triggered by a particular virus. In Rasmussen’s syndrome, one hemisphere of the brain becomes inflamed and deteriorates. The damage that is done to the brain is irreparable. One of the first signs of the syndrome are frequent partial seizures; the seizures can sometimes be continuous. Rasmussen’s commonly affects the frontal lobe, which is where the motor cortex is located. This is why the seizures tend to involve twitching and rhythmic jerking. The syndrome is progressive and can cause weakness on one side of the body in the long run, called hemiparesis. It can also result in developmental and intellectual difficulties and behavioral problems.

Rasmussen’s syndrome is usually diagnosed by evidence of deterioration in one hemisphere provided by MRI scans. Medicines tend to be ineffective in treating the disease as a whole, though they may offer a means to better manage the epilepsy in the long run. If left untreated, the inflammatory process appears to decrease after a few years and eventually stop. However, the damaged neurons still malfunction and the epilepsy itself may still exist. The most effective ‘cure’ for Rasmussen’s syndrome is a hemispherectomy, but the surgery will most likely result in permanent hemiparesis or even hemiplegia

2. Jerrod’s EEG showed the doctors that the seizures were partial. This is because the abnormal electrical activity was localized to one part of the brain (in this case, the left hemisphere). The MRI scan later helped the doctors to diagnose Jerrod’s condition as Rasmussen’s because the left hemisphere was damaged whereas the right hemisphere was not.

3. The left temporal lobe is associated memory, emotion and hearing. It is particularly functional in speech and the understanding of language. The frontal lobe deals with cognitive functions such as planning and decision making, and also contains the part of the motor cortex that controls the right side of the body. Both the parietal and occipital lobes deal with receiving and interpreting sensory information.

4. Typically, a functional hemispherectomy results in some degree of hemiparesis, with patient’s typically losing the function of the hand on the opposite side of the hemisphere that is removed. In addition, patients tend to lose vision in the eye on that side as well. There is also the possibility of disabilities in speech, language and memory.

5. Jerrod should not experience weakness on the left side of his body, and his sensory input from that side of the body should also not be impaired. Scientists have found that, due to the plasticity of the brain (especially at a young age) the ability to speak and understand language, intellectual development and coordinated movement like walking may not be affected by functional hemispherectomies. In fact, because of the lack of seizures and medication, many children’s intellectual abilities increase following a hemispherectomy.

6. After the surgery, Jerrod will need to undergo occupational, physical and speech therapy to prevent long term disability from the surgery. His family will need to facilitate that, as well as try and help Jerrod to develop intellectually as much as possible throughout his childhood. There is the possibility of changes in Jerrod’s temperament and behavior, which they would need to anticipate and accommodate.

7. Seeing as Jerrod showed no signs of hemiplegia prior to the surgery, it is likely that his motor skills on the right side of his body will get worse afterwards. However, his cognitive abilities have the potential to develop much more due to the absence of seizure medication. Overall, Jerrod’s quality of life should increase as the epilepsy would be cured, and Jerrod could function as a normal child.

8.  Will the functional hemispherectomy work for sure?
Usually, functional hemispherectomies are successful in curing epilepsy. However, there are cases when the inflammation can return. Only anatomical hemispherectomies (where the entire hemisphere is removed) have been shown to be 100% successful.

9. I would recommend that Jerrod’s family go ahead with the surgery. The potential benefits far outweigh the risks, and there are many examples of children recovering from hemispherectomies and living healthy, fulfilling lives. This is especially true seeing as there is no other cure for Rasmussen’s syndrome: the loss of function associated with hemispherectomies are also associated with progressive Rasmussen’s. Hence, Jerrod’s family have nothing to lose by going ahead with the surgery.

Sources:

Appleton, Richard, Rachel Kneen, and Stewart Mcleod. “Rasmussen Syndrome.” Epilepsy Action. British Epilepsy Association, n.d. Web. 05 Aug. 2014.
Choi, Charles. “Strange but True: When Half a Brain Is Better than a Whole One.” Scientific American. Scientific American, Inc., 24 May 2007. Web.
“Epilepsy and Functional Hemispherectomy.” WebMD. WebMD, LLC., n.d. Web. 05 Aug. 2014.
Suzuki, Kelli. “Hemispherectomy.” Childrens Hemiplegia Stroke Association. CHASA, n.d. Web. 05 Aug. 2014.

2 responses to “Case Notes”

  1. Brianna Margaret Cathey says:

    Why do you think Jerrod is having partial seizures? I concluded that he was having absence seizures but I would like to hear your opinion on why you think otherwise.

    • Madiha Shafquat says:

      I personally felt that his symptoms were localized to a particular area of the brain (in this case, the motor cortex) which is a characteristic of partial seizures. His lack of response during the seizure as well is typical of a partial seizure. However, according to The Epilepsy Foundation website, absence and partial seizures are often confused and are usually differentiated using an EEG.

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