Case Notes

August 4, 2014

 Part 1:
There is constantly some form of electrical activity in the brain as this is how neurons are able to communicate with each other. As electrical impulses are conducted down the axon away from the cell body of the neuron (the soma), the axon generates an action potential (causing the release of a particular neurotransmitter across the synapse). During in a seizure, the brain becomes “hyperactive”, meaning that the action potentials fired by the axons of the nerve cells are disproportionately higher in magnitude than what would be considered a normal level of activity. These sudden bursts of electrical activity results in a loss of control of all voluntary behaviours or movements. Epilepsy is classified a neurological disorder in which the individual experiences recurrent episodes of these kind of unpredicted seizures, or convulsions. Epilepsy can develop at any time during your life, at any age. Despite this, the disorder is most commonly seen in young children and in older people.

Epilepsy is a very difficult disorder to diagnose quickly, since signs of the disorder greatly overlap with the symptoms of many other neurological disorders, making it difficult for doctors to distinguish between them. The nature of the seizures, frequency, sensation before the seizure, whether or not the individual experienced any warning signs etc. are all vital pieces of information to the doctor in making a diagnosis. In most cases however, it is likely that further tests (such as an EEG or an MRI) will be necessary. An EEG uses electrodes placed on the scalp to record your brain’s electrical activity, and is able to detect abnormality in neural activity, or “epilepsy waves”. Since abnormality of the brain’s activity can be a sign of a number of other disorders, Epilepsy is categorised by the electrical “waves” spreading over both sides of the brain. Alternatively, an MRI scan produces an image of the brain’s structure, rather than directly measuring the brain’s signals. The procedure lasts anywhere between 15- 90 minutes, and requires the individual to lay on a motorised bed within an open-ended cylinder, while the magnetic field produces a detailed image of your brain. Use of the magnetic field means it is vital to remove all metal objects from your body, including watches/jewellery.

Non- Epileptic seizures have a range of different causes, from low blood sugar, to psychological distress (causing the function of the heart to become irregular).Based on the given information, I believe Jerrod appears to be affected by Epileptic seizures, since they are so unpredicted, and the normality of his lifestyle would rule out seizures induced by psychological distress. His young age would also indicate the likelihood of Epilepsy.

 Unfortunately the only way of helping Jerrod during a seizure would be to reduce the  risk of possible injury by putting something soft and supportive under the head, and making sure he is in a clear space. It is also important to wait for the seizure to pass before attending to the child. The type of treatment given for Epilepsy is typically tailored to the frequency and severity of the experienced seizures, as well as by the age of the individual. However, anticonvulsant drugs is the most common form of treatment for this disorder. Classic examples of medication used include Valium and Zarontin. Such medication can successfully control seizures in about 70% of patients. In more severe cases,  brain surgery may be required. Some diets and vitamin supplements  (in large doses) have been found to help those suffering from Epilepsy.


Part 2:

 Rasmussen syndrome is a rare, inflammatory neurological disorder most common between 14 months, to 14 years of age, and is associated with the rapid deterioration of one hemisphere of the brain (causing irreversible damage). The associated symptoms of Rasmussen syndrome include frequent, severe seizures (caused by the irregular function of the brain cells), which can in turn lead to the weakness of the side of the body affected by the seizures. There is no consistent prognosis for this disorder, with a great deal of variation from child to child. Unfortunately, most children affected by the disorder are left with partial paralysis, and suffer from problems with their speech. However, it has been known in some cases that only mild impairments have been experienced. Using an EEG, doctors were able to identify the seizure activity of Jerrod’s brain, noted by the particular pattern of “spikes” obtained from the results. From this the doctors were able to determine that only part of Jerrod’s brain was affected by the seizures (which is characteristic of Rasmussen syndrome). By using an MRI scan,  it  was possible to locate the precise area of the brain affected by the seizures, as well enabled doctors to identify the extent of the damage to the left hemisphere of Jerrod’s brain. Combined, this allowed for an accurate diagnosis.

During a hemispherectomy, structures of the left hemisphere that would be removed from Jerrod’s brain include the left temporal lobe, part of his left frontal lobe, as well as some areas in his parietal and occipital lobes if necessary. This radical surgery could possibly affect Jerrod’s short term memory, speech and hearing, as well as his judgement and decision making. If his parietal and occipital lobes are disturbed during the surgery, he could possibly experience some visual problems. Jerrod’s adaptive skills may be one significant area of change to his behaviour, which could potentially impact his social interactions with friends. However, since the thalamus, hippocampus and amygdala will remain intact, it is likely that Jerrod would not experience paralysis, while retaining sensations and spatial sense. In addition, his long term memory is likely to remain intact. Following this radical surgery, roughly 85% of patients report significant improvement to their seizures, and in about 60% of cases, their seizures will be completely eliminated.

To enable the best outcome of this surgery, Jerrod’s family could help him by taking him to rehabilitation/ speech therapy, to limit the effects of the hemispherectomy on his speech (following his discharge from hospital). If Jerrod had this surgery, I believe that his functioning would get better, and would not be so debilitated by his seizures (thus affecting his overall quality of life, not just the frequency of his seizures). One question to bare in mind about this surgery is the likelihood that the child will remain dependent on their medication, which has been  investigated by a study at John Hopkins Children’s Center. Their study showed that almost all children no longer required their medication, and were able to lead a close to normal life.

Based on these outcomes, I think that proceeding with Jerrod’s surgery would be the best option for both Jerrod, and his family, by eliminating the distress of their day to day lives. Without surgery, it is inevitable that his condition will deteriorate, and is extremely likely that his brain would be damaged further by his seizures.

 


Case Notes

August 3, 2014

Electrical activity in the brain is propagated through the axon. These axons use action potentials (little bursts of electricity) in order to communicate with other neurons.

During a seizure, the electrical signals become too excessive for the brain to handle, and the brain goes into a brief period of unconsciousness where a person loses voluntary motion. Epilepsy is a set of neurological disorders which are characterized by a certain type of seizure: epileptic seizures. Epileptic seizures can appear to a viewer as uncontrolled jerking or a brief lapse in consciousness. Epilepsy is usually diagnosed after ruling out other syndromes with similar symptoms. Afterwards, the use of EEGs and MRIs are necessary in order to diagnose epilepsy.

EEGs are brief (20-40 minutes) and are useful in measuring brain waves, in a gross manner. Patients must wash their hair without using product to expedite the EEG procedure. Electrodes are placed on the skull (EEGs are completely noninvasive), and EEG technologist will ask for some activities to be carried out; these include, but are not limited to, blinking eyes, breathing rapidly, or look at flashing lights. EEGs show patterns of electrical activity in the brain. EEGs are useful in the determination of whether the electrical activity is normal or abnormal. MRIs are extremely helpful in obtaining a detailed picture of the brain itself in order to view any abnormalities or aberrations. The procedure is slightly more complicated than an EEG due to the dangerous machine that is the MRI machine. This machine has a huge magnetic field, and resultantly, one cannot wear any metal objects around the machine. This includes zippers – clothing for an MRI must be stringently chosen and must adhere to the necessities of the MRI. In an MRI, one must lay down in a cylindrical hole for an extended period of time (around half an hour). Patients who are unable to lay still for this period of time will be given sedation or other forms of anesthesia. During the MRI, there will be quite a bit of noise which will negated through the use of earplugs or soothing music. MRIs, if one follows all the rules, is quite safe, and like an EEG, noninvasive.

Seizures can come in all levels of severities, from slight shaking of the hand to violent shaking of the entire body. Seizures – when not a result of epilepsy – can be attributed to low blood sugar, meningitis/encephalitis, withdrawal, or concussions.

Jerrod appears to be having partial seizures that may or may not be complex.

During a seizure, the best thing to do is remove all possibly hazardous objects from the vicinity of the person, and refrain from holding or restraining the person who is suffering from a seizure.

There are a variety of treatments available for epilepsy including at the most extreme brain surgery, to simply a change in diet or antiepileptic medication.

 

Part Two:

Rasmussen syndrome is a serious neurological disorder which can worsen with time. Symptoms include partial seizures, weakness, and possible mental retardation. The forecast for a patient with Rasmussen syndrome is not very auspicious; although not a fatal disease, Rasmussen syndrome can lead to mental retardation, paralysis on one side of the body, while continuing epileptic seizures occur.

The doctors used the EEG to detect the abnormal electrical impulses being generated by the brain while using the MRI to show the abnormalities on the left hemisphere of Jerrod’s brain.

The left hemisphere is very important to a human (although to be fair, the entire brain is very important). Specifically, the left hemisphere controls language and logical reasoning.  With the hemispherectomy, Jerrod could potentially lose some of his speech ability.

With the removal of the left side of the brain, severe effects will be extremely noticeable. These include partial paralysis (if not full) of the right side of the body, loss of speech, inability to reason, severe drop in mathematical abilities, and a disturbance in the comprehension of language. However, fortunately, the right brain can learn many of the tasks the left brain carries out, but there will be noticeable cognitive difficulties. Further, with physical therapy, Jerrod could regain movement of the right side of his body.

The right side of the brain will remain unaffected. Consequently, Jerrod will continue to show emotions, recognize faces, listen to music, and of course use the left side of his body.

The family should attempt to take Jerrod to physical therapy every day and exercise his lost cognitive abilities (i.e. language and logic). Using the lost abilities may aid Jerrod in regaining some of his previous cognitive function.

Subsequent to Jerrod’s surgery, with the onset of rehabilitation and physical therapy, his function and cognitive abilities will only improve. The fortunate thing is, Jerrod is young and has a high brain plasticity and will be able to recover faster than any adult would.

How would Jerrod suffer in school? Would he be a subject of bullying?

I think the best way to answer these questions would be to consult the support group of parents that made a similar decision for their children. Using this information, the parents could potentially move Jerrod to a more friendly school or keep him at home until he has recovered, at least a little.

I would recommend the family to go through with the surgery. Jerrod will continue to have epileptic seizures (ipso facto have continued brain damage) if the surgery is not done. He could potentially become mentally retarded without surgery. With the surgery, there are many costs, but much of it can be regained through physical therapy and exercising mental faculties. The best course of action is to go through with the surgery, and be supportive of Jerrod.