“Merely me” is a mother, a writer and a staunch MS patient advocate. I have had the good fortune of getting to know her recently. She has an amazing drive and feels strongly about issues related to multiple sclerosis. She recently interviewed me.
Here is the link to her site and the interview. I hope you find the information presented there helpful.
http://www.healthcentral.com/multiple-sclerosis/c/73302/54272/doctor
Personal Regards,
Nitin Sethi, MD
Sudden Unexpected Death In Epilepsy
Nitin K Sethi, MD
Assistant Professor of Neurology
New York-Presbyterian Hospital
Weill Cornell Medical Center
New York, NY 10021
I recently read about the tragic death of John Travolta’s son from a reported seizure while on a family vacation. The news got extensive coverage on prime time television networks but unfortunately none of the news segments provided any credible information about death from a seizure or epilepsy in general. While I respect medical journalists and the work they do, I feel they owe a bigger moral obligation not just in getting news across to the public but also going a step forward in researching the topic and utilizing the news story to spread awareness about a disease. The tragic death of Mr. Travolta’s son limelights epilepsy and its at times unexpected tragic consequences.
When people think of a seizure or epilepsy, death as a possible consequence does not come to mind as conjured by other illnesses like cancer. Seizures usually are discreet episodes, guaranteed they are frightening to witness (if you happen to be a family member or a bystander). The patient falls down (if standing at the time of seizure onset), shakes and jerks violently, eyes roll up, drools and may bite his or her tongue. After a minute or two (which for the caregiver or bystander may seem like an eternity), the person stops shaking and may infact appear to fall asleep and breathe loudly. Emergency medical staff are there by then and take the person to the hospital.
ALL’S WELL THAT ENDS WELL YOU MAY SAY!!!
Well yes and no. As I tell most of my patients and their concerned family members, most seizures end on their own and do not need any “active intervention” (meaning giving them some drug to stop the seizure). By the time EMS arrive, the seizure is already over and the patient is confused and disoriented (we call this the post-ictal stage meaning the stage after the ictus/seizure is over). There are a few patients in whom the seizure may not stop or in whom one seizure is followed in rapid succession by another seizure without regaining consciousness in between. These patients are said to be in “status epilepticus” and need urgent medical attention to abort the onoing seizures. These are the patients who the EMS give intravenous medications to stop the seizure (you can read about this more on my website http://braindiseases.info), once these patients reach the ER, intravenous medications to abort the seizure are administered.
But coming back to where I started most seizures do abort on their own. That is what I tell my patients and their caregivers. As a physician the seizure itself does not worry me so much, it is the circumstances surrounding the seizure which can prove to be fatal. When a person is having a seizure, his or her brain is malfunctioning (think of it as a massive short circuit in the neural pathways), he is thus unable to fend for himself. Seizures are usually associated with a loss of body tone, a standing patient thus may fall and injure himself. A hard fall on the head may result in a fatal head injury due to intracranial hemorrhage. A person standing next to a subway line in New York City may fall onto the tracks after a seizure episode and get hit by an oncoming train, he or she may suffer a fatal car crash if the seizure happens to occur while they are driving (this of course poses a risk to other motorists and pedestrians who share the road. There are rules with respect to driving with epilepsy and these vary from state to state). Deaths have occurred due to submersion and drowning if the patient has a seizure while swimming or while taking a bath in a tub.
So what I tell my patients is this
“YOU DO NOT WANT TO GET CAUGHT WITH A SEIZURE AT THE WRONG PLACE AND AT THE WRONG TIME”.
There is a further entity called “Sudden Unexplained Death in Epilepsy” also called SUDEP. SUDEP refers to patients with epilepsy/ seizure disorder who are found dead due to no “apparent reason”. These usually are epilepsy patients who on the surface seem to be fine and one day are found dead. At times they may go to bed okay but are found in bed dead the next morning. A lot of research and studies have looked into SUDEP to try to determine its etiology and thus help in better identification of those epilepsy patients who are more prone to SUDEP. While we still do not know what causes SUDEP, we now do know certain facts.
There is neural control of heart rate (meaning parts in the brain control our heart rate). Hence seizures which arise from certain areas in the brain such as the insular cortex may at times be accompanied with bradycardia (that is the heart slows down and in extreme cases may even stop for a few seconds to minutes). Thus ictal bradycardia or ictal asystole may be one of the mechanism underlying SUDEP. In other documented cases of SUDEP, patient was found to have severe laryngeal muscle spasm thus impairing respiratory effort.
So who are the patients who are at high risk for SUDEP? These are usually patients who have poorly controlled epilepsy (seizure control is inadequate on current therapy). Patients who have seizures associated with ictal bradycardia and/or laryngeal spasm remain at exceptionally high risk.
Epilepsy is a relatively common neurological disorder. It imposes a high price in terms of socio-economic costs and quality of life issues. Every attempt should be made to attain good seizure control (thankfully we now have many options both medical therapy ( anti-seizure medications) as well as surgical, you can read about them on my website http://braindiseases.info).
The battle is still to be won but together we can!!!
I recently read an editorial in the Journal of Neurology Neurosurgery and Psychiatryby Dr. Larry Sparks about statins and cognitive function. Multiple studies have hinted at reduced risk of incident Alzheimer’s disease with elective statin use. I thought this would be worthwhile to share with the readers of my blog and website (http://braindiseases.info).
As I stated above, multiple studies have linked a high fat/ high cholesteroldiet with increased risk of Alzhemier’s dementia. Hence many studies have been carried out to determine if lowering cholesterol levels with the use of statin group of medications (these are popular cholesterol lowering medications with names like atorvastatin (Lipitor), simvastatin (Zocor) among others) reduces the risk of Alzhemier’s dementia. While some studies have indicated a benefit others have provided contradictory results indicating little to no benefit on cognitive functioning.
As Dr. Larry Sparks states in his editorial there is likely a small subset of patients who will benefit from statin therapy. The trick lies in identifying these patients early on in their disease course from others in whom there is little or no benefit from statin therapy. Also it seems that some statins may be more beneficial than others when it comes to reducing the risk of Alzheimer’s dementia. This difference is likely due to their individual differences in blood brain barrier permeability (meaning to what extent they are able to penetrate the brain).
Till we are better able to identify this subgroup of individuals, there are certain things which we can implement in our own lives to tilt the scales in our favor. A low fat, low cholesterol diet should be encouraged. The cardiovascular (lowering the risk of myocardial infarction)and possible neurological benefits (with respect to possibly reducing the risk of incident Alzheimer’s dementia and stroke) makes this a very attractive proposition. Moreover this is a relatively cheap intervention. It though needs a comprehensive strategy to educate the public about the benefits of a low fat/ low cholesterol diet ( about the benefits of eating right {more vegetables, less of red meat and saturated fats} and incorporating a regular exercise schedule. People who already have cardiovascular risk factors like hypertension, diabetes mellitus and high cholesterol (dyslipidemia) should talk to their doctors about possible statin therapy.
I want to add that statins just like any other medication do have their own risk of side-effects. They thus should only be taken under the supervision of a physician.
The adage ” Eat right, live long and happy” still holds good!!! To that I would add ” EAT RIGHT, SAVE A BRAIN!!!”
Nitin Sethi, MD
Not quite dementia? red flags to watch out for
Nitin K Sethi, MD
Assistant Professor of Neurology
New York-Presbyterian Hospital
Weill Cornell Medical Center
New York, NY 10065
I get many patients who tell me during their office visit that they are worried they may be getting dementia. The thought of Alzheimer’s disease with its progressive neurocognitive decline and memory loss is a frightening thought indeed and patients are justifiably worried.
SO LETS GET DOWN TO THE BASICS. What are the red flags/ warning sings that you indeed do have Alzheimer’s dementia starting off?
Patients who have Alzheimer’s dementia are usually not aware that they have a memory problem. In the initial stages of the disease, social graces are maintained. These early patients may be able to hold down a job, socialize with friends and no one is aware that they have a memory problem. Small problems may be starting off though. Losing keys, misplacing things, having problems with numbers, having problems balancing the cheque books and in counting change, forgetting names etc. As you can imagine these are not “major issues” and may not be noticed by the patient or family initially.
So usually when a patient hinself comes to me and tells me, he feels he may be getting demented, I approach it with a healthy dose of skepticism. Most of the times these patients do not have dementia, rather they may be depressed. Depression at times can lead to dementia like symptoms with loss of energy and drive and feelings of self-doubt. It is hence sometimes referred to as pseudo-dementia. You treat their depression and the patient feels much better and the memory problems resolve.
But when the patient is brought to my attention by a family member with complaints of memory problems, getting lost in the neighbourhood, change in personality, becoming indifferent to his personal appearance and grooming, apathy and lost of interest in activities previously enjoyed, in such patients the possibility of dementia crosses my mind.
One must remember that in dementias like Alzheimer’s disease (there are many different types of dementia), the problem is not just with memory. Dementias like Alzheimer’s disease affect a range of neuro-cognitive abilities. Thes patients have problems with language (we call this aphasia–there are many different kinds of aphasia), calculation, ability to sustain attention, ability of abstract thinking, of planning for the future (what I shall do next week) and in executitive functioning. They also suffer from what we call apraxias. Let me explain what apraxia is. Lets assume I can button and unbutton my shirt. Now this is a learned act, which I learned as a small child. Now suppose I get demented. Even though I am not weak (meaning the strength in my arms is intact), I forget how to button and unbutton my shirt. This loss of ability to carry out learned tasks despite intact motor/ muscle strength is called apraxia. Patients who have Alzheimer’s dementia forget how to tie their shoes laces, how to drive a car, how to eat with a spoon and so on. Hence in a way they become totally dependent on care-givers for all activities of daily living. Memory loss is just a component of a much bigger problem. Even when it comes to memory, they have problems in short term memory (what they ate for breakfast, who is the current President elect, whom did he defeat in the elections etc), long term memory (what is your name, your wife’s name, your child’s name, where you were born, what date) may remain intact in the initial stages of the disease.
So watch out for the red flags, not everything is dementia!!!
Pearls and perils of cyberchondria
Nitin K Sethi, MD
Assistant Professor of Neurology
New York-Presbyterian Hospital
Weill Cornell Medical Center
New York, NY 10065
Cyberchondria is a relatively new term used at times to describe the behavior of some individuals who use the Internet to gather information about health or a disease which they feel they may have based on their signs and symptoms. The Internet search results leads to an unfounded concern, preoccupation and worry about their health status.
The term is derived from the more commonly used term hypochondria. Hypochondriasis is excessive preoccupation or concern about having a serious often incurable illness.
Nowadays more and more people are turning to the Internet for health and disease related information. In my practice I frequently come across patients who have already “Googled” their diagnosis even before they come to see me. Some even “Google” their MRI results.
Cyberchondria can have its pearls as well as its perils. Let us start with the pearls first. No one doubts the power of the Internet. It has and continues to revolutionize the way medicine is practiced. There is an abundance of information on the Internet about common and even esoteric neurological conditions. All one has to do is type the relevant key words into a popular search engine like Google and low and behold, Dr. Google starts churning out answers-pages and pages of it. The Internet houses many blogs and sites exclusively devoted to a particular condition. Some of these sites are run by reputable organizations like American Academy of Neurology (www.aan.com) and Centers for Disease Control and Prevention (www.cdc.gov). Thus sitting in the comfort of one’s home, useful and credible information can be readily accessed. Is there any new treatment for multiple sclerosis or ALS? If yes, where is it been offered? Where are the best doctors in NYC? Which is the nearest hospital for acute stroke care? Are there any caregiver organizations for neurodegenerative conditions like Alzheimer’s disease? Pretty much whatever you type in, Dr. Google shall have an answer.
But in this pearl itself, are the perils of the Internet. There are ample sites where in the information content is not standardized. These include blogs run by patients themselves, some by care-givers and yet others by pharmaceutical companies or companies which manufacture medical equipment. The abundance of information leads to many falling prey to cyberchondria. Let us take an example. Your doctor gets a MRI scan done because you have headaches. The MRI report reads “non-specific white matter hyperintensities are seen. These have been noted in ischemic, inflammatory and demyelinating conditions like multiple sclerosis. Clinical correlation is advised.” Now you get this report in front of you and of course what do you do? You go to the Internet and page Dr. Google for help. In you type “white matter lesions, headache and multiple sclerosis” Dr. Google hums for a nanosecond and churns out pages and pages which talk about multiple sclerosis, white matter lesions on MRI and at times headache.
THERE THE GROUND HAS BEEN SET FOR CYBERCHONDRIA!!! You are now convinced you have multiple sclerosis and spend another couple of hours in cyberspace getting worried, confused and finally panicky.
It is indeed easy to get cyberchondria. The Internet is a powerful tool. By all means use it to get health and disease related information. It is way easier than going to a library and searching for it there. BUT THE CATCH IS TO USE IT WISELY!!! If rightly used it is a slave working tirelessly on our behalf. Random searches with random key words about signs and symptoms of a disease you feel you have, risk leading to cyberchondria giving you many sleepless nights and needless worry.
This blog is my own endeavor and project. Though I work in New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, the blog is in no way connected to the hospital.
The information provided in this blog should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 if you have a medical emergency.
Links to other sites are provided for information only — they do not constitute my endorsements of those sites.
Any duplication or distribution of the information contained herein is strictly prohibited.
Nitin Sethi, MD
One of the readers of my blog emailed me this query. A very good question and I wanted to reproduce it here, my answer follows.
on November 28, 2008 said: 
I am very confused about whether I have diabetic neuropathy or not. I have been a diabetic for 21 years. A podiatrist confiremd recently that I have VERY good sensation in the feet & there is no evidence of neuropathy. I do not experience any numbness, pins & needles as such but I do have signficant pain at times in the my feet. The pain is largely due to a heightenend sensitivity at skin level. For example having things brush against my skin is unbearable, or putting on my shoes is also uncomfortable or walking on rough surfaces. But applying direct pressure on my feet – as in reflexology – is not painful. The podiatrist could not explain what this heightened sensitivity is due to.
I am however prone to occasional bouts of deep aching pain the feet & legs – which seems to always be the case now when I am a bit rundown & tired.
I also do have electrical type of stabbing pains that come & go – they can be quite painful stabs. Again they seem to be apparent only when rundown & tired.
Can you please offer any comments on the above? It would be greatly appreciated.
Bree
Dear Bree,
Thank you for writing in. You ask a very good question and that is what I shall attempt to answer. First at the onset let me tell you that most diabetics (especially those who have had long standing diabetes, in your case for over 21 years) shall have clinical evidence of diabetic neuropathy if one subjects them to a thorough clinical examination and electrodiagnostic testing (we use tests like nerve conduction velocities (NCV) and electromyogram (EMG) to unearth evidence of nerve damage/ neuropathy).
Diabetes can cause different kinds of neuropathies depending upon what kind of nerves are preferentially involved:
(large nerves that carry sensations like joint sense and vibration versus smaller nerves that carry sensations of crude touch, pain and temperature)
(motor nerves that help in moving muscles and joints versus sensory nerves which carry sensation)
THE MOST COMMON NEUROPATHY THOUGH IN DIABETES IS A MIXED MOTOR SENSORY POLYNEUROPATHY WHICH USUALLY INVOLVES THE SMALL NERVES WHICH CARRY SENSATIONS LIKE PAIN, CRUDE TOUCH AND TEMPERATURE. MEANING THAT AT LEAST INITIALLY IN THE DISEASE COURSE THE MOTOR NERVES AND THE LARGE SENSORY NERVES (CARRY SENSATIONS OF VIBATION, JOINT SENSE AND POSITION SENSE) MAY BE SPARED OR AT LEAST WE DO NOT SEE EVIDENCE OF THEIR DEGENERATION ON NERVE CONDUCTION TESTING.
Patients who have small nerve fiber involvement commonly have what we refer to as allodynia and hyperpathia. What is allodynia you may ask?
Well allodynia is when a normally non-painful stimulus becomes painful. Let me explain with the aid of an example. You are lying in the bed, settling down to sleep. You pull the sheets over your bare legs. The sheets touch your legs, now they are silk sheets that is not a painful stimulus. But a patient with diabetic neuropathy may find it excruciatingly painful. THERE THAT IS ALLODYNIA.
They also have hyperpathia. What is hyperpathia? Well lets take another example. I take a pin and stab you with it. Now that is a painful stimulus and everyone shall find it so. A normal person may say “ouch”, a patient with diabetic neuropathy though may jump out of his seat. SO HYPERPATHIA IS WHEN YOU FEEL A GREATLY EXAGGERATED PAIN SENSATION TO A PAINFUL STIMULI.
So in conclusion, it is more that likely that you have diabetic neuropathy. My advise to you would be to see a neurologist. If you do indeed have diabetic neuropathy, there are many good medicines out there that can treat the pain and more over prevent the progression of this painful and disabling condition.
Personal Regards,
Nitin Sethi, MD
Just a quick post about Ginkgo biloba. Some of my patients use Ginkgo biloba extract as a supplement to enhance memory and prevent neurodegenerative conditions like Alzhemier’s dementia. The data that it is indeed effective has always been inconclusive. I always feel that if a drug is truly effective for a condition then we seldom need studies to prove it. It is only when the evidence is insufficient to suport a recommendation that studies are needed. Many of these are funded by the drug manufacturer (large pharmaceutical companies).
Recently results were made available from a big study looking at whether Ginkgo biloba extract actually aided in preventing Alzheimer’s dementia. The study found that Ginkgo biloba did not prevent or delay dementia or Alzhemier’s disease. In simple words, the study showed that it does not work. Further there is some data to show that it may actually be dangerous to take this extract as it increases the risk of hemorrhagic strokes (bleeding in the brain).
My advise to my readers would be to avoid taking this supplement till we have more conclusive data on its effectiveness. Especially avoid taking supratherapeutic doses (large doses).
Nitin Sethi, MD
Non epileptic seizures or pseudoseizures-what are they and what is to be done about them?
Nitin K Sethi, MD
Assistant Professor of Neurology
New York-Presbyterian Hospital
Weill Cornell Medical Center
New York, NY
I thought in this post of mine, I shall discuss pseudoseizures. As the name suggests pseudoseizures means “not true seizures”. We nowdays prefer to refer to them as non-epileptic events (NEE).
So what do we mean when we say someone has pseudoseizures? Let me illustrate with the aid of an example. A patient lets say Ms.XYZ comes to me for initial consultation for her seizure disorder. History is as follows. She has had 2 episodes where-in she was witnessed to have violent jerking movements of her arms and legs. First episode occurred in school after she got into a heated verbal argument with her best friend while the second occurred after a similar confrontation at home with her mother. None of these events were preceded by any aura. As per history she did not bite her tongue or have loss of bladder control though she says she felt tired after the events.
Hmm sounds suspicious for seizures you might rightly say. I tell her I would like to bring her into the hospital to do a video-EEG study to better characterize her seizure type (see my posts on seizure types at http://braindiseases.info). She agrees to the study.
EEG recording is initiated and is read as normal after 24 hours. The next day in the hospital, I tell her and her mother about the results of the normal EEG. A few hours after my discussion with the family, she is noted by the nursing staff to have a violent “seizure”. I review her EEG. On the camera I notice her to suddenly stiffen and then have violent out of phase (uncoordinated) flinging movements of the arms and legs. Her head moves from side to side and I overhear her yelling “too much, too much, let me go!!! let me go!!!). The event occurs while her mother and her best friend are by her bedside.
I look at the time locked EEG (EEG synchronized with the video in real time). While she is clinically having a “seizure”, her brain waves are normal (the brain is not having a seizure). A correct diagnosis of pseudoseizures (non-epileptic event) is made and she is discharged home with advise to follow up with a psychiatrist.
So what is a pseudoseizure?
1. It is not a true seizure but rather an episode or episodes which clinically look like seizures but are not accompanied by any EEG changes.
2. It usually has a psychological basis. In my experience I commonly see them in people who are passing through tremendous stress be it interpersonal relationships or at the job.
3. A person may have pseudoseizures to achieve a secondary gain (in the case of our patient, attention and love from her mother and best friend).
4. Pseudoseizures are not treated like seizures. These patients do not need anti-seizure medications. They rather at times need a psychiatrist to explore the underlying reasons for the NEE (conflicts in family etc).
5. Some patients who have true seizures (epilepsy) may also have pseudoseizures.
Read another fascinating article by Melinda Beck in the Wall Street Journal titled ” You must remember this: forgetting has its benefits”. Her articles in the Wall Street Journal always tweak the neurologist in me. Ms. Beck in her piece talks about the importance of forgetting and how it is important in formulation and consolidation of memories.
Let us take a simple example, how many of us remember what we were doing at noon last Monday or what we ate for dinner a week ago (now some of you may very well remember what you ate for dinner a week ago if you eat the same thing every night or lead a very regimented life). The rest of us do not remember this information. Why you may ask does out brain not remember all these details? Well the answer is simple. This information is trivial and the brain does not consolidate these memories and hence these memoried are easily erased.
To continue with the above example, you may very well remember what you ate or did the night Senator Obama became President Elect Obama and you might be able to recall that information even many years from now. Why? Well the brain has linked the “trivial information” of what you were eating or wearing that night to more important information “the night when history was made with the election of Senator Obama as President elect”. This linking of information leads to long term potentiation and hence consolidation of memories. Memories like these are not easily erased or lost.
The brain is always purging trivial memories, this keeps the hippocampi and other memory pathways always available and free to make new memories. Put in a different way, it prevents memory overload. If we remembered each and everything we did in our lives we shall be inundated with memories and not know what is important and what is not.
So is there anything practical which you can take away from what I said above? Well for one thing if you want to remember something and never forget, associate that memory to something important to you (eg associate something to your birthday). Memory becomes more and more resilient when you associate it with other memories (eg a scent to a pretty lady, you smell the perfume, her picture comes up in your mind!!!). Secondly forgetting is not always bad, it “frees up” space in the brain so that when something important comes along your brain has space to store that memory trace.
Nitin Sethi, MD
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