Case Notes

Part I:

The brain is filled with billions of cells called neurons that communicate with one another by sending electrical signals called action potentials. The action potential travels down the axon, the output end, of one neuron and reaches the dendrites, the input end, of the next neuron at a connection called the synapse.

During a seizure, the brain experiences sudden abnormal electrical activity. A seizure can happen in only one part of the brain, called a focal or partial seizure, or in both sides of the brain, called a generalized seizure. It is possible to experience loss of consciousness due to the overwhelming electrical activity in the brain.

Epilepsy is a neurological disorder that causes reoccurring, unpredictable seizures. Generally, two unprovoked seizures are required for diagnosis. An electroencephalogram (EEG) will show abnormal electrical activity in the brain that is indicative of epilepsy. CT scans and MRIs are also often done to find the cause and location of the problem.

To perform an EEG test, electrodes connected to a recording machine are placed on the scalp. The recording machine measures the electrical activity of the brain, often showing abnormal patterns in patients with epilepsy. The EEG may show the area in the brain where a seizure starts. An MRI scan uses magnets and radio waves to generate pictures of the body. An MRI scan of the brain can show abnormalities in size or shape, or other abnormalities like a tumor.

There are many possible causes of seizures other than epilepsy. One type of non epileptic seizure is a psychogenic seizure, like a panic attack, caused by subconscious thoughts or emotions interfering with normal brain activity. Organic seizures have a physical cause,  like abnormal levels of sodium or glucose in the blood, or a heart problem.

It seems that Jerrod is experiencing absence seizures. Absence seizures are characterized by staring and subtle body movement, and cause loss of awareness. It was noted that Jerrod stares blankly during his seizures, some muscles twitched, and he moved his head slightly back and forth. Also, he was nonresponsive and had no memory of the seizures.

The main goal during one of Jerrod’s seizures is to prevent him from being injured. There should be nothing around him that could hurt him if he were to hit it. He should not be held down or moved, as this could be dangerous as well.

Treatments for epilepsy vary from person to person, but can include medications, lifestyle changes, and sometimes surgery. During surgery, a vagus nerve stimulator (VNS), similar to a pacemaker, may be placed to reduce the number of seizures.

Sources:
http://www.nlm.nih.gov/medlineplus/ency/article/003200.htm
http://www.nlm.nih.gov/medlineplus/ency/article/000694.htm
http://www.nlm.nih.gov/medlineplus/ency/article/003931.htm
http://www.nlm.nih.gov/medlineplus/ency/article/003335.htm
http://www.mayoclinic.org/diseases-conditions/epilepsy/basics/definition/con-20033721
http://www.epilepsysociety.org.uk/non-epileptic-seizures#.U-E-6FYxMhc


Part II:

Rasmussen Syndrome is a neurological disease, most often found in children under the age of 10, that usually effects only one hemisphere of the brain. It causes frequent and severe seizures that cause damage to the brain, which could include loss of motor skills and speech, hemiparesis, inflammation of the brain, and mental deterioration. This disease can cause irreversible damage, but for some children, surgery can decrease seizures and improve cognitive abilities.

An EEG will show abnormal patterns that indicate seizures and epilepsy, and can also tell us where in the brain these abnormalities are coming from. Ultimately, an MRI helps diagnose the disorder by showing a loss of brain substance (atrophy).

In Jerrod’s case, the left temporal lobe, part of the left frontal lobe, and possibly parts of the parietal and occipital lobes will be removed in the hemispherectomy. The corpus collosum, which allows the two hemispheres of the brain to communicate, will be severed.

Removal of the left temporal lobe may affect Jerrod’s memory, emotions, or communication. Removal of part of the left frontal lobe may affect his decision making, problem solving, and planning skills. Removal of the parietal lobe may affect his processing of sensory information, and removal of the occipital lobe may affect his vision. He will also be partially paralyzed on the side opposite of the removed hemisphere.

Jerrod’s deep brain structures would remain intact, including the thalamus, amygdala, and hippocampus. Though the left temporal lobe is removed, Jerrod will likely retain some control over his emotions because his amygdala is left intact, and some control over memory because his hippocampus is left intact. He will still have full control over the side of his body of the removed hemisphere.

After the surgery, Jerrod’s family should make sure he receives proper physical, occupational, and speech therapy. They should also talk with his school to discuss what options for support he would have there.

Jerrod’s level of functioning would likely get better over time, as he would not be having the seizures that cause damage to his brain nor would he be taking as many medications as before the surgery. Since he is young, the remaining hemisphere of his brain will adapt and will be able to take over the function of the lost side. However, he would experience some weakness or paralysis on the side opposite of the removed hemisphere.

One question I had was about the rate of success of this surgery. I found that recently, 86% of children who had a hemispherectomy were either seizure-free or have non-disabling seizures that do not require medication. However, for patient’s with Rasmussen Syndrome, only 65% are seizure-free after the surgery.

I would recommend that the family goes ahead with this surgery for Jerrod. He is still young, so he is likely to recover successfully. The surgery would prevent further damage to his brain as he will be having seizures less frequently and they will be less severe. The effects of not receiving the surgery will be more harmful than the consequences of receiving it.

Sources:
http://www.aans.org/en/Media/General%20Press%20Releases/2000/September/Hemispherectomy%20shown%20on%20ABC%20show%20%20Dr%20Ben%20Carson%20says%20most%20young%20people%20who%20have%20half%20their%20brains%20surgically%20removed%20do%20great.aspx?sc_database=web
http://www.ninds.nih.gov/disorders/rasmussen/rasmussen.htm
http://www.epilepsy.com/learn/types-epilepsy-syndromes/rasmussens-syndrome
http://my.clevelandclinic.org/neurological_institute/epilepsy/treatments-services/hemispherectomy.aspx
http://www.hopkinsmedicine.org/press/2003/October/031014.htm

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