Seizures in children: febrile convulsions

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In this post I would like to talk about seizures in children. Seizures are among the most common conditions for which pediatric neurologists are consulted. Seizures in children differ from seizures in adults. Also the etiology of seizures in children differs from that in adults. There are many epilepsy syndromes which have been described in the pediatric age group, each has its own natural history and prognosis.

Typical febrile convulsion: as the name suggests this is a seizure (convulsion) associated with fever. Febrile seizures/ convulsions are mostly seen in the age group of 6 months to 6 years of age. Classically the child has high fever (may be on account of a sore throat or any other condition), as the fever is rising, the child is noted to have a brief seizure/ convulsion. I used the word brief because in its typical form a febrile seizure is brief lasting for a few seconds to minutes. Also in a typical febrile seizure, the seizure is a generalized tonic clonic seizure (the child stiffens up and then shakes). Typical febrile seizure has a good prognosis and does not lead to epilepsy later on in life. As a result these children need not be treated with anti-epileptic drugs. Children outgrow the seizures after the age of 6 years or so. All we advise parents is to keep the fever down. At times the neurologist might prescribe rectal diazepam. This is marketed under the name Diastat. Rectal diazepam is a benzodiazepine drug which can be given by the rectal route. Parents can give it by themselves, the drug is rapidly absorbed across the rectal mucosa and may abort a prolonged febrile convulsion. Usually febrile seizures run in the family and if a careful history is taken, one finds that one of the child’s parents too had febrile seizures as a child.

Atypical febrile convulsion: a febrile seizure is said to be atypical when either it is very prolonged (remember I said febrile seizures are usually brief) or when it is not generalized but rather focal (one arm or limb shakes not the whole body).  Sometime the seizure may occur without fever or even with temperature less than 100 F. Atypical febrile seizures may lead to epilepsy later in life and hence these children have to be closely followed. If a child has multiple febrile seizures or has a seizure everytime he or she has fever, your doctor may recommend an anti-epileptic drug for a short time. The drug most commonly used in this age group is phenobarbital. Phenobarbital is a safe drug which has been around for awhile now. Its most common side-effect is sedation.

Dr. Sethi

ALS pathophysiology

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ALS pathophysiology

As a lot of you have shown interest in ALS, I thought this would be a good time to dwell into its pathophysiology. I shall try to explain what happens in ALS in simple terms. ALS as has been pointed out is a motor neuron disease. What does one mean by motor neuron disease (MND)?

In the human body we have motor neurons and sensory neurons. Motor neurons refer to nerve cells and their bodies which control motor movements for example a motor neuron helps you to move your fingers or move your toes. We have sensory neurons too, these help us to perceive sensations like temperature (when you touch a hot cup of coffee), pain (you step on a nail—ouuuchhh) and touch (you touch a soft coat made of fur).

Each neuron whether motor or sensory has a cell body and then has a process called the axon (think of it as a body and its tail). The motor neurons which control the movements of the arms and legs are located in the spinal cord (we refer to them as the anterior horn cells becuase they lie anterioly in the spinal cord). We also have motor neurons which control other movements like that of swallowing, speech etc. These neurons lie in the brain stem (the lower part of the brain). MND’s like ALS cause the death of these motor neurons in the spinal cord (anterior horn cells) and those in the brain stem. In its classical form, ALS does not affect the sensory neurons hence it is called a motor neuron disease. Once the motor neurons in the anterior horn cells and the brainstem die they do not regenerate again and hence ALS is also a neurodegenerative disease causing progressive relentless degeneration of motor neurons.

So the next question arises what causes the death of these motor neurons? Why suddenly in a healthy person the motor neurons start dying? Why is this death irreversible? Why are only the motor neurons affected why not the sensory neurons? Why are other parts of the brain not affected?

No one quite knows the answers to any of the above question. Why is the death so selective that it only affects the motor neurons and spares everything else. As the disease progresses and more and more motor neurons die, the patient is left paralysed (wheelchair or bed bound) not able to eat or swallow with difficulty in speaking. The higher mental functions remain intact so the memory is as sharp as ever and that is what becomes so difficult both for the patient and the caregivers (you can only imagine what it must feel like been trapped in a body which is paralysed). There is a form of ALS which runs in some families, this has been referred to as familial ALS and is genetic in etiology. Mutations in the copper/ zinc superoxide dismutase (SOD) have been implicated in causing ALS. The role of oxidative stress and free radicals has also been mentioned in its pathophysiology but the disease does not respond even if you treat it with anti-oxidants.

Tremendous research is going on around the world in ALS and there are some very prominent labs here in U.S.A. working on it too.  I would advise all patients and their caregivers to get in touch with an ALS specialist as he or she shall be the best informed if any new therapeutic modalities (medicines etc) become available.The ALS association is also a good organization to be in touch with. They can be reached at www.alsa.org.

Even though there is no cure there are a multitude of devices out there that can ease the life for a patient with ALS. My message hence is one of hope and I keep reading and am inspired by patient’s stories of living and winning the battle against ALS.

 Dr. Sethi

 

Your brain on yoga

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Yoga and the brain

Your brain on yoga: its myths and healing powers

 

 

Nitin K. Sethi, MD

 

 

 

 

 

 

Address for Correspondence:

 

Nitin K. Sethi, MD

Department of Neurology

NYP-Weill Cornell Medical Center

525 East, 68th Street

New York, NY 10021 (U.S.A.)

Email: sethinitinmd@hotmail.com

 

 
 

Introduction

 

What is yoga? Yoga literally means union. Union of the self with the inner consciousness is yoga. When one gets skilled in yoga then one can meditate. It is difficult when one tries to meditate for the first time. You close your eyes and the mind is bombarded with thoughts. What happened at work, who said what, things I have to do when I get done with meditation here. Mundane thoughts like these start racing through the mind. In the Bhagavad Gita an ancient Indian text Lord Krishna rightly tells Arjuna “your mind is your best friend but also your worst enemy”. It is indeed very difficult to control the mind, to slow it down and make it calm. In the recent years yoga has gained immense popularity in the west. What is about yoga that is different from traditional exercises like jogging and weight training? Why have so many people incorporated yoga into their hectic schedules? Yoga has been postulated to have dual benefits for the body (exercise) as well as the mind (meditation). What are these benefits of yoga? What is the neuroscience behind meditation? I shall discuss these and other issues briefly in this article.

 

Different types of Yoga

 

            Before we begin let us briefly talk about different types of yoga. I am in no way an authority on yoga and various yogic postures so I shall keep this short. If you seek further information, there are many books which go over the practice of yoga in great detail. In the Bhagavad Gita, Lord Krishna talks about three kinds of yoga namely karma yoga, bhakti yoga and gyana yoga.

Karma yoga as stated in the Bhagavad Gita means that one should do ones prescribed duties without worrying about the fruits. What does that mean and does that have any relevance to the health of our mind? A lot of stress in our daily lives is due to the attachment to results. We all seek something and strive hard to achieve it. This is especially true in a city like New York where I reside. It is hardly 6 am and the city is on the go. People rushing to work and to appointments, constantly on the move. I personally am of the philosophy that hard work never killed anyone. One should do ones prescribed duties. Like for instance I am a doctor and my duty is to my patients. I need to be there for them and take care of them. Karma yoga teaches us the same, do your prescribed duties, as one cannot remain stagnant. Stagnation or boredom is a big killer. When people get depressed they have what has been referred to as anhedonia. The term means the loss of interest in anything pleasurable. Work can and should be a pleasure. It gives us a reason to get out of our homes, meet new and interesting people, meet up with friends and share a coffee during the lunch break. All this keeps our minds healthy. Man is a social animal and the human brain seeks interaction and I feel thrives on it. What does hurt the mind and through the mind-body connection the health of our bodies in turn, is the desire for results. If I am working hard as a doctor because I want to get rich and famous then I am constantly worrying for the fruits of my endeavors. This attachment to the results leads to stress. Stress which may lead to a nervous breakdown, depression and which has been linked to cardiovascular diseases like heart attacks and cerebrovascular diseases like stroke. The philosophy behind Karma yoga is thus intensely appealing. It does not ask us to renounce life. If you love to party, so party (if indeed that is your prescribed work) but do it without getting attached to the results (I hope I meet someone famous there, someone that will help me in climbing up the social ladder).

Bhakti Yoga the word “bhakti” literally means faith. So what does bhakti yoga mean and is there a relevance to the state of our mental and physical wellness? The way bhakti yoga is described in Indian texts like the Bhagavad Gita is having faith in god. The human brain needs to believe in something. If you are religious you would believe in god (does not matter what your religion is or who is the god you believe in). If you are not religious you may believe in yourself or a close friend. Again bhakti helps the mind in turning inwards. They say faith can move mountains. People have faith and have been able to overcome physical hurdles or go through an intensely draining experience like been diagnosed with cancer.

            Gyana Yoga also called Jnana yoga or Dhyana yoga: refers to the yoga of knowledge. In the Gita this yoga refers to seeking the ultimate knowledge and in a way introspection, trying to make a union with the inner self. It also refers to leading a disciplined life in which one remains detached from extraneous sensory objects. In today’s world we are constantly wired. How many times in the space of a day do we check our emails or are talking on the cellphones. The mind just like any other organ of the body needs rest. Needs time to reflect, time to organize its thoughts. Many writers prefer to work in solitude, away from cellphones, televisions sets blaring out the same news and even the Internet.

 

Neuroscience of meditation

 

In a thought-provoking article, Deshmukh talks about the neuroscience behind meditation 1. Deshmukh likens meditation to an art, the art of being serene and alert in the present moment instead of a constant struggle to adapt and change to various external stimuli. As per Deshmukh, when one is meditating there is more efficient management of attentional energy, one may be totally engaged or totally disengaged. During meditation there is a simultaneous, participatory consciousness rather than a dualistic, sequential attentiveness. Thus meditation helps in changing the response of our mind to external stimuli. One can be a part of the external world yet at the same time be detached from its influence. This as Deshmukh points out leads to a natural sense of well-being and spontaneous joy.

Does a meditative mind function better? Does a meditative mind lead to a meditative brain? Meaning do the benefits of meditation on the mind translate into benefits for the brain too. Does regular practice of mediation lead to physiological and neurochemical changes in the brain? Hopefully science shall yield answers to the above questions soon.

 

 

Mind-body connection

 

Thus there is some evidence though not all scientific suggesting the benefits of yoga for the mind and the brain. That the mind is connected to the body has been emphasized recently. So changes in the milieu of the mind (and brain) affect the body and the reverse is also true. This mind-body connection works both in health and disease. A healthy brain and mind live in a healthy body and vice versa. Is it possible to use this mind-brain connection to promote healing? Can you use the power of the mind to fight cancer of the breast or to overcome a stroke that has left you weak on one side of the body? There is some evidence to suggest in the affirmative. I strongly feel that patients do well when you treat them as a whole, not just the body system that is giving them trouble. 

 

 

Benefits of yoga for the body

 

The concept of yoga benefiting the body is far easier to comprehend. The physical aspect of yoga involves various asana (postures or poses). These help in toning the muscles and improving balance and station (posture). Yoga may benefit people suffering from chronic back pain by strengthening the muscles of the back. Patients with Parkinson’s disease or those with mild to moderate Alzheimer’s dementia would likely benefit from some yoga exercise done under proper supervision. This would improve their stiffness as well as balance. I stress the “under proper supervision” part here as some of the advanced postures have the risk of causing injury 2.

 

 

Conclusion

 

 

            Yoga may have the unique capacity to benefit both the mind and the body. Further studies exploring the neuroscience behind yoga shall reveal the secrets behind this ancient science.

 

 


 

References

  1. Deshmukh VD. Neuroscience of meditation. Scientific World Journal 2006 Nov 16; 6:2239-53.
  2. PK Sethi, A. Batra, NK Sethi, J Torgovnick, E. Tortolani. Compressive cervical myelopathy due to sirsasana, a yoga posture: a case report. The Internet Journal of Neurology.2007.Volume 6 Number 1.

 

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MS treatment related issues

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Let us continue to talk about some issues which arise during the treatment of multiple sclerosis.

 

1) How does the disease pan out: Let me try to give you a broad overview of what to expect if you have been diagnosed with multiple sclerosis. I want to stress that this by no way applies to every patient, because each patient’s disease behaves in its own unique way. Initially as I stated earlier, multiple sclerosis has a remitting and relapsing course. You have an attack, it causes some deficits (weakness, numbess, vision loss or gait and balance problems) and then the attack remits and patient may come back to his or her baseline functioning (meaning there are no residual deficits left behind). When multiple sclerosis behaves in this manner it is said to have a relapsing and remitting course (RELAPSING AND REMITTING MULTIPLE SCLEROSIS OR RRMS).

As the disease progresses though and the patient continues to have more attacks, it is seen that the patient does not remit or revert back to the baseline (meaning that some deficits are left behind like some residual weakness or numbness, some problems with balance, tremors etc). When this occurs the patient starts to incur some disability and the disease is said to enter a progressive course (SECONDARY PROGRESSIVE MULTIPLE SCLEROSIS OR SPMS).

As I stated earlier patients in SPMS stage start to get disabled whether it is due to excessive weakness, fatigue or problems with balance or a disabling tremor. As doctors we try to grade their progression in this stage and there are various scales we use. One of the most commonly used scale is the Expanded Disablility Status Score or EDSS. This is a 10 point scale and when a patient reaches midway like around 5 to 6, he or she starts to need assistance with walking and further on may need a wheelchair for ambulation.

The intention behind using the interferons and other immunomodulatory drugs like copolymer (Copaxone) is to prevent or rather delay the progression from a RRMS to a SPMS.

Hence the rationale behind treating all patients aggressively from the onset. Once the patient is in a SPMS state, the medications are continued and different medications might be added to try to halt and delay the disease progression.

 

Till now we do not have any drugs which change the natural history of the disease (meaning cure it!!), all we have are medications which may delay the progression.

 

 There are a certain subgroup of MS patients who have a progressive downhill course right from the onset of the disease (meaning in them the disease does not follow a relapsing and remitting pattern rather they continue to incur more and more neurological deficits). These patients as you can imagine have a poorer outcome and this pattern of disease progression has been referred to PRIMARY PROGRESSIVE MULTIPLE SCLEROSIS OR PPMS

 

Healthy brain and a healthy mind

What do you want to learn about?

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I would like to request the readers of my blog or the visitors to my website http://braindiseases.info to tell me what they would like to read or learn more about. I am trying to get more information about MS and ALS out there. I would appreciate if you either drop me an email or write a post about conditions pertaining to you even a very specific question. That would enrich this discussion and make it more worthwhile to all the readers at large.

Please read my new posts about issues pertaining to MS treatment on my website http://braindiseases.info .

Personal Regards,

Nitin Sethi, MD

Issues that come up during MS treatment

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Let us now talk about some issues which come up when you are diagnosed with MS.

1) What happens next?

so you are diagnosed with multiple sclerosis what now? Do you need to start  some multiple sclerosis drug immediately? This is a tough question and something which only your doctor can best decide after reviewing all investigations and MRI brain scans. Multiple sclerosis is in its typical form has a relapsing and remitting course. By that I mean, a patient may present with an acute attack of MS like weakness or unsteadiness or loss of vision in an eye (optic neuritis) but then the attack remits and the patient may come back to his or her baseline with at times no residual signs and symptoms. Then there may be a length of time when the patient experiences no fresh attacks. So the question is when do we start treating the disease. Research has shown that even though the patient may have no clinical attack (no overt manifestations of MS), the disease is still relentless and proceeding in the brain. How do we know this? Simple if you repeat the MRI in even an asymptomatic patient, the MRI shall show new lesions (meaning new plaques are seen in the brain MRI suggesting radiological progression of the disease).

Further research has also shown that these lesions (plaques) in the brain add up and contribute to the final disability. The more the number of plaques in the brain (we refer to this as the plaque burden), the more is the final disability and the cognitive difficulties experienced by the patient.

So now the thinking among MS specialists is to treat early and to treat aggressively. The longer you wait, the more is the damage to the myelin and axons (nerve bundles) in the brain. That said and done each patient’s disease behaves in a unique way. There are a small group of patients who have what is called as benign MS. These patients show little or no disease progression over years both clinically and radiologically. Why some patients have this benign form of the disease no one knows but remember it is very difficult if not impossible to know at the onset if a patient is going to have a benign form of MS or not. Hence usually MS specialists would recommend treating right from the onset.

2) Which interferon to use and which is better?

This is another issue which comes up during MS treatment. There are 3 different kinds of interferon available on the market: interferon beta 1b (marketed as Betaseron) and interferon beta 1a (marketed as Avonex and Rebiff).  Without going too much into detail, there is some evidence to suggest that interferon beta 1 b (Betaseron) may be more effective than interferon beta 1a (Avonex).

Betaseron has to be given three times a week (every alternate day) and it has to be injected subcutaneously (under the skin). Avonex on the other hand needs to be given just once a week and it is given intramuscular (inside the muscle and thus more painful shot than a subcutaneous shot). That said and done since Avonex is given once a week it is far more convenient and does not interfere with a patient’s lifestyle as compared to something which needs to be given three times a week.

There is also the issue of neutralizing antibody formation. Simply put it has been seen that if someone takes interferon for a long time, the body starts to form antibodies against it. These antibodies have been referred to as neutralizing antibodies and if a patient has a high titre of these antibodies, it may neutralize the effect of the interferon (meaning make the interferon less effective). Some research has shown the patient’s who take Betaseron develop neutralizing antibodies at a higher rate as compared to those on Avonex or Rebiff. Again your doctor shall guide you through this decision making process.

 

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Headache

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Headache

 We have all suffered from a headache at some point in our life. Thus headache is among the most common neurological disorder seen in the out patient neurological clinic. I shall discuss headaches under 2 headings:

1) Primary headaches such as migraines (both common and classical), tension type headache and episodic cluster headaches.

2) Secondary headaches such as headaches associated with brain tumors, temporal arteritis (giant cell arteritis), headaches associated with subarachnoid hemorrhage and meningitis.

 

Primary Headaches:

 

1) Migraine: migraine is the most common primary headache disorder. It commonly starts in adolescense and affects women more than men. Migraine is of 2 types:

a) Common Migraine: this is the common variety of migraine in which the headache is not accompanied or preceeded by any aura. Patients usually have complaint of episodic headaches which have a typical character. Headaches are typically unilateral (though the headache may shift from side to side in different episodes) and are accompanied by nausea and vomiting. Patients may complain of dizziness and also usually are sensitive to bright lights and loud sounds at the time of their headache. Sensitivity to loud sounds is called phonophobia and that to bright lights is referred to as photophobia. During an acute attack patients usually feel and look sick and prefer to lie in a quiet dark room. Shaking the head makes the headache worse. Sleep naturally aborts an attack with patients waking up headache free.

b) Classical Migraine: this is migraine with aura. Patients experience an aura at the onset of the headache. The aura is usually visual and patients may complain of seeing bright flashing lights or spots/ halos in front of their eyes (referred to as scintillation scotoma or fortification spectra). Many different types of visual auras have been described, you can see the pictures of some of them by googling scintillation scotoma and looking under images.

 

2) Cluster headache: this is another type of primary headache disorder which predominantly affects young to middle aged men. Episodic cluster headache is characterized by episodes of intense unilateral headache usually around the peri-orbital area (pain is centered around the eye) associated with nasal congestion, lacrimation (tearing from the eyes) and nasal stuffiness. The headache usually awakens the patient at the same time every day and may be so intensely uncomfortable that some patients have been known to commit sucide. These episodes of daily headache may last for a few weeks and then abate spontaneously only to recur at a later date.

 

3) Tension type headache: this is a rather common type of primary headache disorder. More commonly seen in women, tension type headache is characterized by holocranial headache (the whole head hurts) or the patient may complain of tightness or a vise like sensation around the head (especially the nape of the neck).

 

A point to remember is that patients may have 2 or more types of headaches. For example a person suffering from migraine may also admit to having tension type headaches.

 

Pathophysiology of Migraines: Let us now discuss what causes migraines. The brain itself is insensitive to pain. Let me give a rather crude but effective example. If you take a knife and drive it through the brain, you shall feel no pain. The pain sensitive structures in the brain include the blood vessels which course through the brain, the venous sinuses (think of them as large reservoirs where the venous blood in the brain drains to) and the meninges. The meninges or the covering of the brain are richly supplied by nerves and hence are very sensitive to pain. Thus when one has inflammation of the meninges (condition referred to as meningitis), one has pain in the nape of the neck and headache.

There are many theories to explain the pathophysiology of migraine headaches, the one most accepted is referred to as the trigeminovascular hypothesis. According to this hypothesis, the blood vessels in the brain are innervated by branches of the trigeminal nerve. During a migraine attack, initially the blood vessels constrict (go into a spasm) and then dilate. That is time the patient complains of a throbbing headache, characteristic of a migraine. The pain is referred to the distribution of the trigeminal nerve (this nerve supplies the skin of the face) hence the complaint of pain in the temple and around the eyes. Hence migraine is rightfully thought to be a vascular condition.

 

The diagnosis of migraine is clinical (that means your doctor shall be able to make the diagnosis without ordering major tests). If there are elements in the history which are atypical for migraine then your doctor may order an imaging study such as an MRI scan of the brain. Usually this is done when there is a suspicion of a brain tumor.

Other atypical signs include:

1) weakness or numbness on one side of the body.

2) new onset headache in the middle aged or elderly.

3) headache associated with projectile vomiting (remember migraine too can be associated with nausea and vomiting).

4) headache which first presented with a seizure.

 

Once the diagnosis of migraine is secured then the question of treatment arises. There are a couple of aspects in the treatment of migraine which demand attention. The first is the treatment of an acute attack (you are suffering from an acute migraine headache, how to abort the attack and relieve the pain? What medication is the most effective? What if the medicine does not abort the headache attack?).

The second is the prophylatic treatment of migraine (treatment initiated so that you never have the attack in the first place).

There are different medications used to treat the acute attack of migraine and those for prophylatic therapy. I shall discuss them one by one.

 

Treatment of acute migraine attack: 

An acute attack of migraine can be debilitating. Effective treatment which quickly aborts the headache is the need of the hour. Any of the common pain-killers like aspirin, acetaminophen (tylenol), ibuprofen (motrin) is effective in the treatment of an acute migraine attack. The secret for the drug to be effective is that they should be taken right at the onset of the headache. Let me explain, you feel the migraine starting-a dull aching around the eye, the typical aura–if you take the tablet right now then it shall abort your headache. But if you decide to wait and the migraine attack evolves further into a classical unilateral throbbing headache with sensitivity to light and loud sounds, it is more than likely that either the pain killer shall not work or for it to work you shall have to take more than usual amount of the medication (more pills to break the attack). Also remember that most patients during a migraine attack feel nauseous and some may even throw up so it may be hard to keep the pill down.

 

Now we have more effective and migraine specific medications available. These medications which are commonly referred to as TRIPTANS include medications by the name of sumatriptan  (brand name Imitrex),  rizatiptan  (Maxalt), naratriptan (Amerge, Naramig), zolmitriptan (Zomig), eletriptan  (Relpax), almotriptan(Axert, Almogran), and frovatriptan (Frova, Migard). The triptans are 5HT 1D and 1B receptor agonists (meaning that they act on the serotonin receptors in the brain to exert their anti-migraine effects).  They are available in the tablet form to be taken orally (by the mouth). Some like sumatriptan can also be administered via the sub-cutaneous route (under the skin) or via the nostril as a spray. This is specially advantageous when the patient is having nausea and is throwing up. Your doctor may prescribe you a triptan. The various triptans differ from one another in their speed of action, side-effects and their efficacy. So if you do not have a positive response to one triptan, it is still worthwhile trying out another.

 

Another medication effective in the treatment of an acute migraine attack is DHE or dihydroergotamine. DHE is usually given intravenously (via a vein) but as compared to the triptans it has more side-effects and hence is not the first choice to treat an acute migraine attack. You may be given this medication if you land up in the emergency room with a bad attack of migraine that has not responded to the conventional pain-killers and triptans.

 

Other medications which are also effective in treating an acute attack of migraine include the opioids (morphine and codeine containing drugs). We as doctors avoid using these drugs because of their significant addictive potential. Patients may get addicted to their use and then start abusing the drugs.

 

Prophylatic therapy for migraine attacks: The idea behind migraine prophylaxis is to use a medication which prevents the migraine headache from coming on in the first place. If you can prevent an attack of headache from happening then you do not need to treat it. Makes sense you would say!!!

There are many different classes of drugs which have demonstrated efficacy in migraine prophylaxis. Let us discuss some of them. Some of the commonly used drugs for migraine prophylaxis are those that belong to a class called beta blockers. Drugs included under this class  commonly used to treat migraine include Inderal (propanolol). The tricyclic antidepressants are also commonly used and are effective in migraine prophylaxis–drugs such as Elavil (amitriptyline). Recently a number of anti-seizure drugs have demonstrated their efficacy in migraine prevention. Topiramate is one such drug which had gained much popularity in recent years. It is marketed under the brand name Topamax. The calcium channel blockers are also used. A popular drug in this class used for migraine prophylaxis is verapamil.

Changing your lifestyle and identifying your migraine triggers is the key to achieving good control of these disabling headaches. Common migraine triggers are:

1) Lack of sleep

2) Too much sleep–lets assume you normally sleep for 7 hours a night, now one night you oversleep–it is possible you may wake up with a headache.

3) Alcohol intake–migrainers have a more sensitive brain and thus if they drink too much, it can trigger off an attack. They are especially sensitive to red wine and it is best to avoid it.

4) Certain foods act as migraine triggers–commonly implicated are aged cheeses and chocolate.

5) Excessively stimulating environment–example you go to a rock concert:  loud music, bright lights, a beer here and there–the perfect migraine combo.

6) STRESS ! STRESS ! STRESS!  

Doctors frequently ask their patient’s to maintain a headache diary. This is basically a diary maintained by the patient in which the patient documents each and every headache attack. What precipitated it, what brought on relief from the headache, things eaten around that time etc. If you maintain a good headache diary for a month, you shall be able to identify your migraine triggers and thus avoid them.

SPECIAL TYPES OF MIGRAINE HEADACHES

1) Familial hemiplegic migraine–as the name suggests it is familial, meaning that it runs in the family. In this special type of migraine, patients usually develop episodic hemiplegia (weakness/ numbness on one half of the body) around the time the headache attack occurs. The hemiplegia resolves once the attack of migraine is over. Familial hemiplegic migraine is thought to occur due to vasoconstriction (spasm of the blood vessels of the brain).

2) Retinal artery migraine–as the name suggests, here the migraine process involves the retinal artery and does presents with visual symptomatology.

3) Basilar artery migraine–here the migraine process involves the basilar artery or its branches in the brain-stem. Patients have sign and symptoms reflecting involvement of the artery and superficially it may seem that they are having a stroke.

4) A number of migraine variants have been described in young children. Young children may not have the classical headache, or they may be unable to express that they are having headaches. A few of the migraine variants described in children include:

a) benign paroxysmal vertigo—children have episodic attacks of vertigo and may throw up during an attack.

b) abdominal migraine-children present with episodic abdominal pain.

c) alternating hemiplegia of childhood–here children have weakness which shifts from one side of the body to the other.

 

 

“Your  mind is your best friend and your worst enemy”

Lord Krishna in the Bhagavad Gita

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When and how to seek a second opinion: a patient’s perspective

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I originally wanted to publish this in the New York Times as I wrote it primarily for patients and care-givers. They did not accept it. It seems they rather devote a page to which model makes how much money or who is dating who rather than publish something like this. I always wanted this to be freely accessible to patients and care-givers. That is the reason I started this blog and my website http://braindiseases.info in the first place. It is my way of giving back to my patients. I owe a lot to them and they are my first and foremost teachers. The article is hopefully going to appear in the Internet Journal of Neurology soon. Here is a small piece of the article. I cannot publish the entire piece as then I would be in copyright violation.

 

When and how to seek a second opinion-a patient’s perspective

 

NK Sethi 1, PK Sethi 2

 

1 Department of Neurology, Comprehensive Epilepsy Center, NYP-Weill Cornell Medical Center, New York, NY (U.S.A.)

2 Department of Neurology, Sir Ganga Ram Hospital, New Delhi (India)

 

 

 

 

 

 

 

Address for Correspondence:

NK Sethi, MD

Department of Neurology

Comprehensive Epilepsy Center

NYP-Weill Cornell Medical Center

525 East, 68th Street

New York, NY 10021 (U.S.A.)

Email: sethinitinmd@hotmail.com

 

There are times when a second opinion is not only appropriate, its necessary. This is true both from the patient’s as well as the doctor’s perspective. Since the patient technically has more to lose, it is imperative that patient’s know when and how to seek a second opinion. This is more significant in clinical neurology especially when one is handed down a diagnosis of a neurodegenerative condition like young onset Parkinson’s or Huntington’s disease. Diagnosis of a disease like amyotrophic lateral sclerosis (ALS) is essentially like signing off on a death sentence. Patients and caregivers are distraught and may not know what to do. Some may trust their doctor and agree to his or her management plan. But what if he is wrong? Maybe there is something out there that may help me. Maybe my doctor does not know about it. Even if the diagnosis is correct some may not be comfortable with the line of care. It is at times like these that the question of seeking a second opinion crops up.

 

Nourishing and nurturing your brain: from the things we eat to the things we do

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Nourishing and nurturing your brain: from the things we eat to the things we do

 

 

Nitin K. Sethi, MD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address for Correspondence:

 

Nitin K. Sethi, MD

Department of Neurology

NYP-Weill Cornell Medical Center

525 East, 68th Street

New York, NY 10021 (U.S.A.)

Email: sethinitinmd@hotmail.com


            The human brain is indeed complex made of millions of small cells called neurons working in close harmony with each other. Its capacity far exceeds that of any supercomputer designed as of yet by man. This fist full of about 1500 grams of tissue is the seat of our emotions, our memory, our senses and serves as the motherboard for all other body systems. This delicate supercomputer of ours is enclosed in a resilient bony skull able to withstand significant trauma. Our brain like our body needs to be nurtured and nourished.

 

Nourishing the brain: brain foods and more

 

            What we eat does to an extent determine the health of our brain. Recently the concept of brain foods has come into vogue. This refers to foods that have been postulated to boost brain power, improve memory and functioning of the brain. So what are these foods that have been postulated to help keep the brain young?

 

Omega 3- fatty acids: belong to the family of unsaturated fatty acids. The important ones among them include alpha linolenic acid, eicosapentaenoic acid and docosahexaenoic acid. Fatty acids form an important constituent of cell membranes. They thus perform important roles in various cell functions including cell to cell transmission and help maintain stability of cell membranes. A growing body of work has shown the beneficial effects of omega 3-fatty acids in prevention of atherosclerosis. The data showing a beneficial effect of fish oils is more robust for the cardiovascular system while no consisting relationship between fish consumption and stroke reduction has been documented. So while the data may not be robust, it probably makes sense to increase the omega 3-fatty acid content in your diet. I would advise replacing some of the saturated fats with polyunsaturated fatty acids rich in omega -3s like canola oil, walnut and olive oil.

 

Numerous other foods have been touted to promote brain heath. Some of these include avocado, various legumes (rich source of protein for vegetarians), oatmeal, peas, soybeans (again a good source of protein for vegetarians), wheat germ, fish like tuna, yogurt, brown rice, brussels sprouts and eggs among others. The brain just like any other organ of the human body needs a balanced nutritious diet consisting of the right mix of carbohydrates, proteins, fats, vitamins and minerals.

 

Role of Ginkgo biloba in enhancing memory: the extract of the Ginkgo leaves has been used for medicinal purposes for years. It contains flavonoid glycosides and terpenoids and is thought to enhance memory and concentration. Studies though have yielded conflicting results. While some studies on patients with Alzheimer’s dementia showed a benefit, others did not and benefits were attributed to a placebo effect. Ginkgo biloba affects the coagulation of blood and can interfere with other anticoagulants like warfarin and aspirin. It might be reasonable for people who have dementia or an early stage of dementia called mild cognitive impairment (MCI) to take Ginkgo biloba. Its use in healthy young adults as a memory enhancer is probably ill advised.

 

Role of vitamins and minerals in promoting brain health: Vitamins and minerals are also referred to as micronutrients. The body needs them albeit in small amounts for its well being. Vitamins and minerals are involved in diverse cellular functions. Deficiency of certain vitamins has been implicated in causing neurological diseases. Vitamin B1 also called thiamine is a water soluble vitamin. Deficiency of vitamin B1 causes a disease caller Beriberi. It presents clinically as a peripheral neuropathy (the peripheral nerves get involved). Deficiency is commonly seen in alcoholics and those with marginal diets like the elderly. Thiamine deficiency in heavy alcoholics may cause other neuro-psychiatric problems. Wernicke’s encephalopathy and Korsakoff psychosis occur in alcoholics and present clinically with confusion, gait, balance and memory problems. Foods that are rich in vitamin B1 include whole-grain cereals, bread, red meat, legumes, green leafy vegetables and brown rice. I would recommend vitamin B1 supplementation in the elderly and those who drink heavily. Ideally all people who drink a moderate amount on a regular basis should take one multi-vitamin a day.

Vitamin B12 deficiency can occur in people who have pernicious anemia or inflammatory bowel diseases like Crohn’s. Deficiency of B12 also called cyanocobalamine may present with neuropsychiatric manifestations (referred to as megaloblastic madness). It may also cause loss of vision (amblyopia) and weakness of the legs due to involvement of the spinal cord (the spinal cord involvement is referred to as sub-acute combined degeneration of the spinal cord). Meat and meat products like liver, beef, mutton, fish and egg are rich sources of B12. Hence vitamin B12 deficiency occurs mostly in pure vegetarians. In these groups, yes, vitamin B12 indeed does nourish the brain and in fact is vital for it to function normally.

Vitamin E is much in vogue today and has been aggressively touted as an anti-oxidant important for everything from aging gracefully to preventing cancer. Again there is yet no scientific evidence that it indeed does help in all this. Vitamin E deficiency causes ataxia and balance problems (ataxia of vitamin E deficiency). Deficiency occurs in people who for some reason cannot absorb the vitamin from the gut. Wheat germ, vegetable oils, whole grains and nuts are good sources of this vitamin. No one knows what the ideal dose of this vitamin should be. Even giving supratherapeutic doses (mega doses of 1000 IU and above) of vitamin E to patients who had neurodegenerative conditions like Alzheimer’s dementia did not result in any observable benefit.

This is a good time to talk about the role of various anti-oxidants in promoting and maintaining brain health. A variety of anti-oxidants are nowadays been marketed as a visit to any of the health stores shall reveal. These have been touted for their anti-cancerous properties as well as their cardiovascular and cerebrovascular benefits. Among them coenzyme Q10 and alpha lipoic acid are popular. There has been no proven benefit of coenzyme Q 10 when controlled trials have been done in patients with Parkinson’s disease or even in ALS. My personal view is that if someone has a strong family history of Alzheimer’s dementia, Parkinson’s disease or ALS, it may be reasonable to advice supplementation as these preparations are relatively safe with no major side-effects. Studies have shown that when you give them to patient’s who already have an advanced neurodegenerative condition like Parkinson’s disease they seem to be ineffective, no one though knows that if you take these supplements from a young age (before the onset of the disease), would they lessen the chances of developing Parkinson’s disease or dementia in the later life. Meaning do they actually promote brain health? I usually do recommend alpha lipoic acid supplementation in my diabetic patients with neuropathy. In health men and women, I would recommend taking them in moderation as there is no proven benefit.

 

 

Role of exercise in promoting brain health: “ The brain too needs to jog everyday” exercise is a natural aphrodisiac for the brain. It promotes the release of endorphins and other feel good neurotransmitters. The benefits of regular exercise in promoting brain heath have been documented repeatedly. Even people who have neurodegenerative conditions like Alzheimer’s dementia and Parkinson’s disease seem to do well if they exercise as compared to those that don’t. These patients are less prone to fall and have improved assessments on care-giver rating scales. My personal belief is that exercise promotes brain healing and improves synaptic transmission. Recently cognitive exercises have come into vogue. Brushing with your left hand (if you right handed), playing mind-games like crossword puzzles and scrabble have been documented in some studies to slow down the progression of dementia and improve memory and concentration. People who are high functioning and use their brain regularly like lawyers and teachers have a lower incidence of developing later life cognitive problems as compared to a construction worker whose job is more manual and does not involve the use of these higher mental functions. “ Use it or lose it!!!”

 

 

 “ Do not just exercise your body, exercise your brain too”

 

 

The mind-brain connection: How to keep your mind healthy

 

One should not only have a healthy brain but a healthy mind too. Inner peace, calmness, introspection, tranquility are essential qualities that nurture the mind and help to maintain its internal equilibrium. Meditation, been spiritual and doing yoga are ways by which that elusive inner peace can be obtained ensuring a healthy mind as well as brain. One should never forget the healing powers of the mind. Some cancer patients and patients who have had a devastating stroke have been able to overcome their illness and disability due to the healing power of their minds. One should harness this power in a positive direction because the mind can be your best friend as well as your worst enemy. Protect your mind against depression as attacks of major depression make one prone to later life dementia. Have healthy relationships that nurture and nourish your mind.

 

Someone once rightly said and I quote “ Your mind is your best friend, do not hurt him for whomsoever or whatsoever”.

HIV related neurological conditions

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HIV or human immunodeficiency virus causes AIDS or acquired immunodeficiency syndrome. The HIV virus affects every level of the neural axis, by that I mean that the virus affects the brain, the spinal cord, the nerves as well as the muscles. I shall discuss the neurological manifestations associated with HIV infection in this section starting with the brain.

HIV manifestations in the brain: the brain may be affected soon after the patient gets infected with the HIV virus. Research has shown that soon after entering the human body, HIV virus can be found in the brain. Its first manifestation may be in the form of an aseptic meningitis. The patient has characteristic signs and symptoms of a viral meningitis with headache, neck stiffness, photophobia, body aches and myalgias but when the spinal fluid is analysed no organisms are seen, though the cell count in the spinal fluid may be elevated. This attack of aseptic meningitis subsides on its own (no antibiotics are required).  All that is needed is bed rest and some hydration. The HIV virus then enters a dormant state in the brain, remaining silent, causing no overt manifestations.

In the later stages of HIV infection (when the virus has multiplied extensively in the body and the patient’s viral load is high and CD4 counts are low) the virus again manifests in the brain clinically. Viral load refers to the amount of virus in the body usually expressed as the number of viral copies in the blood. CD4 count refers to the number of CD4 cells present in the blood. The CD4 cells are a group of immune cells, the HIV virus selectively destroys CD4 cells and thus makes a patient immunodeficient and prone to opportunistic infections.  Opportunistic infections refers to infections which normally do not occur in a person with an intact immune system, in people who have immunodeficiency these infections are a major cause of morbidity and mortality. A number of these infections have been associated with late stage infection with HIV. These include:

1) CNS toxoplasmosis

2) Cryptococcal meningitis

3) Progressive multifocal leukoencephalopathy (PML)

4) Cytomegalovirus infections (CMV infections)

5) Tubercular infections of the brain–tubercular meningitis and tuberculoma

6) Various fungal meningitis

HIV affects other levels of the neural axis. It involves the spinal cord causing a vacuolar myelopathy causing stiffness and weakness of the legs and bladder/ bowel problems.

It affects the peripheral nerves and can cause painful neuropathies. The neuropathy associated with HIV infection is usually distal, painful and symmetrical. The drugs used to treat HIV infections are quite strong and some of them too have been implicated in causing neuropathies. HIV can also cause a Gullian Barre Syndrome like presentation. This is an acute peripheral inflammatory demyelinating polyneuropathy (AIDP) which at times can prove fatal due to involvement of the respiratory muscles.

HIV can also involve the muscles causing diffuse proximal muscle weakness (HIV myopathy). Some of the antiretroviral drugs have again been implicated in causing a toxic myopathy.

HIV infection can also involve the brain diffusely (by that I mean no focal or mass lesions are found). This diffuse involvement of the brain causes AIDS dementia complex or what is also referred to as HIV encephalopathy. The virus involves the subcortical parts of the brain and causes psychomotor slowing, cognitive deficits and memory problems.

 

Let us now discuss the above one by one.

 

1) CNS toxoplasmosis: CNS toxoplasmosis is one of the most common opportunistic infections seen with HIV/AIDS. It is caused by Toxoplasma gondii and usually presents with intracranial space occupying lesions. By that I mean, it causes lesions in the brain that occupy space much like any other mass such as tumor (cancer). The lesions due to Toxoplasma may either be single or multiple in number and clinically may present with a seizure (as they irritate the brain) or if they lie near the motor strip they may present with weakness or numbness on one side of the body. If they are multiple in the brain they may cause encephalopathy (patient is obtunded and poorly responsive). How is the diagnosis secured? The diagnosis of CNS toxoplasmosis is usually quite easy as the lesions are readily seen on either a CT scan of the brain or an MRI. Your doctor may order the test with contrast to see the surrounding edema and to differentiate them from other similar appearing lesions.

As I stated earlier the diagnosis is relatively easy if there are multiple lesions. The problem arises when there is only one lesion. Then CNS toxoplasmosis has to be differentiated from other disease processes which too may present with a solitary intracranial lesion, especially primary CNS lymphoma. It is important that the correct diagnosis be made as the treatments for the two differ widely. So in cases like these, we neurologists may order other tests such as a Thallium SPECT (single photon emission computed tomography) which is a special type of scan able to differentiate between infection (toxoplasmosis) and tumor (CNS lymphoma) or a biopsy of the lesion may be attempted. Biopsy of course is an invasive procedure and hence we try hard to avoid it.

At times we emprically treat the patient for CNS toxoplasmosis (as treatment is relatively simple and free from side-effects). The CT scan is repeated after 2 weeks of therapy, if the size of the lesion has regressed then it implies that we are dealing with CNS toxoplasmosis. If the lesion has not regressed in size after treatment for 2 weeks or has increased in size, then the possibility of it representing a solitary CNS lymphoma increases.

 

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