Epilepsy Surgery: A Pediatric Neurologist's Perspective

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  • Sadly the patient is no more...RIP... No convincing reason was given by the doctor.
    We felt that we should have taken her to a good hospital instead of Care hospital, Hyderabad. Also, we felt that Dr JMK Murthy was not that prompt/serious in treating her...he used to spend days out of station for seminars leaving the patient to his students/juniors... he had a limited time 10-15 mins everyday to ask questions that too to a single member, would not respond to our queries other than that time slot...the patient should have got a better treatment from Dr JMK Murthy which was not the case. WHATS THE USE OF SUCH A DOCTOR WHO CONSIDERS HIMSELF A TERROR...CANNOT CONNECT WITH PEOPLE...DOES NOT EMPATHISE WITH FAMILY MEMBERS....we regret to admit her to Care Hospital under Dr JMK. ...RIP ... SDS...
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  • Dear Doctor,

    Following are the details of a person suffering from continuous seizures from the midnight
    of 31st Jan 2011. We'd appreciate if you can share your views on the outcome and other
    complications, if any.

    From 20th Jan 2011 to 31st Jan 2011 the chief complains were vomitting, headache,
    intolerance to light and fever on day 1. Medication for the above was prescribed by the local
    doctor. She was admitted in hospital on sudden onset of seizures, lumbar puncture showed
    no infection in CSF, CT SCAN done twice but showed no significant findings. She is getting
    seizures on left side. EEG showed siezure activities. Patient did not respond to first line of
    treatmen, so the doctors started on second line of treatment which she responded for intial
    time but seizures persisted on lower doses and dose had to be increased. Post onset on 8th
    day condition is same, patient is still in ICU on ventilatory support.

    Patient details-28 yrs
    Gender-Female
    Previous medical history-no significant illness
    Medicines given - Anti epileptic drugs, Acyclovir, Anti bacterial, Blood Pressure regulator,
    Sedatives
    Treated by Dr. JMK Murthy, Head of Department Neurology, Care Hospital, Hyderabad, India.

    Please suggest for prognosis of the same, suggested line of treatment and expected
    outcome/complications. Please let us know if you need any further information about the
    patients.
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Epilepsy Surgery: A Pediatric Neurologist's Perspective

  1. 1. Epilepsy Surgery: A Pediatric Neurologist’s Perspective Juliann M. Paolicchi, MD, MA Associate Professor of Neurology and Pediatrics Director, Pediatric Neurology Director, Pediatric Epilepsy and EEG Vanderbilt University
  2. 2. Where does it all start?
  3. 3. Where does it all start?
  4. 4. Where does it all start?
  5. 5. Why do we ask SO MANY questions?
  6. 6. Why do we ask SO MANY questions? • The answers to the questions inform us: – How did the epilepsy start? – Is it genetic or related to a lesion? – Is the epilepsy “medically intractable?” – Is there a medical or dietary option that would be more effective? – Where in the brain do the seizures come from? – How do the seizures impact this person’s lifestyle: their talents and goals?
  7. 7. How did the epilepsy start? • Trauma • Injury • Infection • A prolonged epilepsy • Difficulties at birth • No clear reason “idiopathic”
  8. 8. Is it genetic or related to a lesion? • Childhood absence epilepsy • Juvenile Absence epilepsy • Benign Rolandic Epilepsy • Juvenile Myoclonic Epilepsy • Doose syndrome • Dravet Syndrome • Otahara Syndrome • Angelman’s syndrome • Cornelia De Lange syndrome • Aicardi’s syndrome
  9. 9. Is the epilepsy “medically intractable?” • Failure of 3 appropriate anti-epileptic medications – Failure – Three medications – Appropriate
  10. 10. Where in the brain do the seizures come from? • Frontal Parietal • Temporal Occipital
  11. 11. The Presurgical Evaluation • Detailed history and physical by a pediatric epileptologist • Routine EEG
  12. 12. Routine EEG
  13. 13. The Presurgical Evaluation • Detailed history and physical by a pediatric epileptologist • Routine EEG • MRI
  14. 14. The Presurgical Evaluation • Detailed history and physical by a pediatric epileptologist • Routine EEG • Head MRI • Admission to the Pediatric EMU “PEMU” for identification of the seizure focus
  15. 15. The Presurgical Evaluation • Detailed history and physical by a pediatric epileptologist • Routine EEG • Head MRI • Admission to the Pediatric EMU “PEMU” for identification of the seizure focus • PET: neuroanatomic localization of seizure focus
  16. 16. The Presurgical Evaluation • Detailed history and physical by a pediatric epileptologist • Routine EEG • Head MRI • Admission to the Pediatric EMU “PEMU” for identification of the seizure focus • PET: neuroanatomic localization of seizure focus • Neuropsychological/developmental evaluation
  17. 17. The Presurgical Evaluation
  18. 18. The Presurgical Evaluation • Detailed history and physical by a pediatric epileptologist • Routine EEG • Head MRI • Admission to the Pediatric EMU “PEMU” for identification of the seizure focus • PET: neuroanatomic localization of seizure focus • Neuropsychological/developmental evaluation • Language localization
  19. 19. The Presurgical Evalutation • The most important aspect, and the most unique to Vanderbilt • The Epilepsy Surgery Case Conference
  20. 20. The Presurgical Evalutation • Additional testing may be recommended: • Additional EMU monitoring • Interictal and ictal SPECT test
  21. 21. The Surgical Evaluation • History and physical by a trained, pediatric neurosurgeon, specializing in epilepsy surgery • Decision by conference: – 1 stage vs. 2 stage surgery
  22. 22. The Surgical Evaluation
  23. 23. The Surgical Evaluation • Special circumstances: – Infantile spasms – Hemimegalencephaly – Rasmussen’s encephalopathy
  24. 24. Outcome: Epilepsy • In a large study of children undergoing surgery over a 10 year period: • Overall: 78% good outcome (SF or >90% reduction), 60% SF (seizure-free) • Lesional cases vs Non-lesional cases : – 80% good outcome, 65% SF – 74% good outcome, 51% SF (no statistical difference) • Site of seizures: – Temporal 80% good, 70% SF, – Non-temporal 78% good outcome, 61% SF (no statistical difference) • Most significant feature: – Completeness of the resection: 92% good outcome, 76% SF (p<0.0001) – Paolicchi et al, Neurology 2000; 54 (3): 642-647
  25. 25. Outcome: Development • Factors that improve developmental outcome: – Younger age at the time of surgery – Short duration of epilepsy – Seizure freedom/outcome – Improved developmental, dependent on the study is estimated at 59-70% » Paolicchi, Nature Clinical Practice Neurology, 2007; 3, 662-663.
  26. 26. What if my child doesn’t qualify? • New medications • Dietary therapy • Vagus Nerve Stimulator Implantation
  27. 27. Epilepsy Surgery: A Pediatric Neurologist’s Perspective

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