Stroke

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Stroke is one of the most common neurological conditions. Also called a cerebrovascular accident (CVA), it can have a devastating outcome. Just as you have a heart attack when the blood supply to the heart is compromised due to a clogged artery in the heart, stroke is similarly a brain attack and occurs when the blood supply to the brain gets compromised. The brain is richly supplied by blood vessels and does not tolerate ischemia (reduced blood supply) well.

There are different types of strokes and here I shall enumerate a few of them. Strokes can broadly be categorized under 2 headings:

1) Ischemic strokes ( when blood supply to the brain is compromised eg a clot in the artery supplying the brain shall cause an ischemic stroke).

2) Hemorrhagic strokes ( when a blood vessel in the brain ruptures, hemorrhage occurs into the surrounding brain structures causing a hemorrhagic stroke).

 

Ischemic strokes can be caused by several different kinds of disease processes and can be further classified either on the basis of the calibre of the blood vessel involved or on the basis of the pathogenic mechanism which caused the stroke.

On the basis of calibre of the blood vessel involved, strokes can be further classified as

1) Large vessel strokes: a big blood vessel in the brain gets blocked. Usually when the doctor refers to a large vessel stroke he means strokes involving large arteries such as the internal carotid artery (ICA), the middle cerebral artery (MCA), anterior cerebral artery (ACA) or the posterior cerebral artery (PCA).

 

2) Small vessel strokes: a small blood vessel in the brain gets blocked. Usually these are the penetrating arteries of the brain which supply the deeper parts of the brain.

Based on the mechanism/cause of ischemic strokes, we can classify strokes as:

1) Atherothrombotic : the stroke occurs due to atherothrombosis, the same mechanism which causes many of the heart attacks. The blood vessels of the brain become hardened and narrowed due to atherosclerosis: an inflammation of the arteries due to deposition of lipoproteins/fat and cholesterol . This deposition of lipoproteins give rise to what we commonly refer to as plaques. This most commonly occurs in people who have risk factors for both stroke and coronary artery disease namely diabetes, hypertension, high cholesterol, smokers etc.

2) Embolic: here a plaque may break off from its primary site such as the heart and travel up to the brain blocking off a brain vessel. Lots of things can embolize to the brain:

-cholesterol plaques

-fat embolism ( commonly seen after one has a long bone fracture. The long bones like tibia and femur are very rich in bone marrow which is rich in fat. When a fracture occurs rarely the fat may embolize via a blood vessel to the brain.

-air embolism ( strange though it may sound even a bubble of air can embolize to the brain and cause a stroke)

Embolic strokes can be of two types:

1) Cardioembolic : a clot embolizes from the heart to the brain.

2) Artery to artery embolic: a clot embolizes from a larger artery commonly the carotid artery in the neck to a small artery in the brain.

Hemorrhagic strokes: just as ischemic strokes, hemorrhagic strokes can also be of various types. Hemorrhagic strokes are usually classified on the basis of the compartment of the brain into which the bleeding occurs.

1) Bleeding can occur into the substance of the brain itself: this is called as primary intracranial hemorrhage (ICH)

2) Bleeding can occur in the subarachoid space of the brain: this is called sub-arachnoid hemorrhage (SAH). I shall be discussing this under a separate heading.

3) Bleeding can occur in either the epidural or subdural space: this is called epidural hematoma (EDH) and subdural hematoma (SDH) respectively.

 

Risk factors for stroke/ CVA

There are numerous risk factors for stroke. As both stroke and coronary artery disease involve blood vessels they share some common risk factors.

Risk factors can be divided into: modifiable and non-modifiable risk factors.

1) Non-modifiable risk factors include:

a) Age: strokes are more common in the older age groups. Strokes do occur in the young and even in children and infants but they have diffferent causes.

b) Sex: there is some sex difference in the incidence of strokes.

c) Race: hemorrhagic strokes are more commonly seen in Asians as compared to Caucasians.

d) Genetic causes: if you have a very strong family history of strokes or coronary artery disease ( example your father had a stroke, his father had a stroke and all at a relatively young age then you too have a high risk of having a stroke at some point in your life). Unfortunately the genes which impart this increased risk have still not been clearly delineated, so no one knows just how much is the risk. If bad cholesterol or high blood pressure and diabetes runs in your family and in you then your risk for strokes and heart attacks is increased.

 

As you may realise the above risk factors are non-modifiable, meaning there is precious little you can do to change them. You cannot stop aging, change your race or sex or modify the genes that you were born with !!! Not at this juncture at least. Maybe in the future science shall advance to the extent that we can modify these bad genes.

 

Modifiable risk factors:

There are numerous modifiable risk factors for strokes and CAD. I shall list them out as follows:

1) Hypertension: hypertension or high blood pressure (BP) is the number one modifiable risk factor for both strokes and heart attacks.  Hypertension has rightly  been called the Silent Killer. It usually does not cause any overt symptoms and people are unaware that they have a high blood pressure. At times vague complaints of headache and fatigue may make them seek medical attention where a blood pressure evaluation shall disclose that they are hypertensive. (hypertensive meaning one who has high BP).

2) Diabetes mellitus: diabetes mellitus (DM) too increases the risk of strokes and CAD especially when the blood sugar is uncontrolled and constantly elevated. People who have DM may not know that they have diabetes for a long time as initial signs and symptoms may be subtle. In the setting of uncontrolled blood sugar they may have complaints of polyuria ( too much and too frequent urination), polyphagia ( hungry and always eating, most of the diabetics are obese) and polydipsia ( feeling thirsty all the time). As the disease advances complications of diabetes emerge namely poor wound healing, frequent urinary tract infections, heart attacks, strokes, eye-problems (cataracts and retinal problems leading to impaired vision), nerve problems ( neuropathy) and kidney problems ( renal insufficiency sometimes requiring dialysis).

3) Smoking: people who smoke have a much higher risk of getting a heart attack or a brain attack. The toxins in cigarette smoke damage the lining of the blood vessels in both the heart and the brain.  No amount of smoke is good for the heart or the brain. One should quit completely to lower this risk of heart and brain attacks.

4) Sedentary life-style/ lack of exercise:  a sedentary life-style also predisposes to strokes and heart attacks. People who are obese especially those with central obesity ( fat around the tummy) have higher risk of strokes and heart attacks.

5) Hypercoaguable states: certain people have factors in their blood which make their blood more coaguable, meaning the blood clots more readily. Examples include patients who have diseases like lupus, sickle cell anemia etc.

6) Dyslipidemia or bad cholesterol:  as many of you know there are many types of cholesterol found in our bodies. Not all cholesterol is bad. People who have more bad cholesterol (increased low density lipoproteins, increased very low density lipoproteins) and low levels of good cholesterol (high density lipoproteins) have higher risk of strokes and heart attacks.

 

Treatment of stroke: before I talk about the treatment of stroke, I rather talk a bit about stroke prevention. Prevention is always better than cure. Stroke prevention involves modification of the risk factors for stroke. Smoking cessation is the key as smoking is an important risk factor for stroke. Smokers get atherosclerosis at an earlier age than non-smokers (their arteries get hardened). Smoking cessation may involve behavioral therapy as well as use of nicotine patches and gums. People who have hypertension should ensure that their hypertension is adequately treated. Nowdays we recommed aiming for blood pressures of 120/70 mm Hg or even less. There are many drugs out there for the effective treatment of high blood pressure. The same is true for diabetics and euglycemia (getting blood sugar as close to normal) is the goal. This may be achieved either by pills (oral hypoglycemic drugs) or with insulin. Recommendations are to reduce Hb A1C (also called glycosylated hemoglobin to below 7). The importance of regular physical exercise cannot be overstated. I would recommned some cardio-vascular exercise like brisk walking or jogging. This is good both for the brain as well as the heart. Diet too plays an important role in stroke and dietary modifications may be one way to reduce your risk for strokes and heart attacks. Eating a diet rich in fish oils, poly unsaturated fatty acids, green leafy vegetables and fruits helps to naturally lower your cholesterol down. Recently the benefits of cooking in olive oil have been emphasised.

 

Management of an acute stroke:

Brain Tumors

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Let us now turn our attention to brain tumors. My aim here shall be to discuss how brain tumors present in different age-groups, the most common type of tumors in different age groups, how brain tumors are diagnosed ( what work-up doctors do in the hospital) and finally touch on the management of different types of brain tumors.

Brain tumors can present in any age-group right from the neonatal and pediatric age-groups till the adult ages. Different types of brain tumors are seen in different age-groups.

First what exactly is a brain tumor?  A tumor refers to a group of cells which can multiply and proliferate relentlessly. Normally the growth of cells in the body occurs in a controlled and programmed fashion. At times for reason which are still been elucidated this control is lost and a group of cells in a tissue/organ may start to multiply in a haphazard fashion. When this occurs in the brain it leads to a brain tumor. Different types of brain tumors may arise depending upon which cell in the brain starts to multiply. Tumors can arise from neurons in the brain, the cells of the lining of the brain (meninges) and from the supporting cells in the brain (glial cells),

Each of these tumor type has its own natural history meaning the age when it presents (pediatric Vs adult), where it arises in the brain (location) and its aggressiveness ( how quickly it grows in the brain, how much does it spread, how much it invades the surrounding healthy brain tissue). As you can now imagine each of these tumors is thus treated in its own unique way–some with anti-tumor (chemotherapy) drugs, some solely by surgery and others by radiation therapy ( not all tumors are sensitive to radiation). Some require a combination of the above mentioned modalities: surgery, chemotherapy and radiotherapy.

Tumors are also classified in another way: benign Vs malignant. What does it mean when your doctor tells you “ you have a benign brain tumor”.  When we as doctors refer to a tumor as benign we mean that its natural history is one of slow growth (the tumor may either never increase in size or may grow only over years), its invasive potential is very low ( the tumor does not invade into surrounding healthy brain tissue) and it is not aggressive. Benign brain tumors like meningiomas may not warrant any treatment, they may be discovered incidentally when you have an imaging study (MRI or CT scan) for some reason and your doctor may decide not to do anything apart from keeping you under observation and periodically repeating  your imaging study.

There is a catch to this though. Even though your tumor may be benign it might be in a place (location in the brain) where it leads to some deficits. If it is near your brain stem and cerebellum it may press on your auditory nerve and lead to loss of hearing, some benign brain tumors can cause seizures. So the treatment has to be tailored to each individual case. Some benign brain tumors may warrant treatment.

Its Friday, lets take a short break. When I come back I shall discuss how tumors present ( what are the warning signs that someone has a brain tumor).

Personal Regards,

Dr. S

So lets now talk a little about how brain tumors present clinically. Brain tumors may present in a variety of ways. They may be completely silent and discovered only accidentally. Let me give you an example. Person is asymptomatic, he has a minor fall and doctor orders a CT scan or MRI and a brain tumor is found incidentally. Maybe the same tumor would have presented clinically a little while later after having enlarged in size.

Common ways that brain tumors present are as follows:

1) Headache: there is no particular pattern of headache which is specific for a brain tumor. No brain tumor is found in the majority of patients who are worked up for headaches. Most of the headaches are due to migraines, tension headaches and other common causes of headaches. But new onset headache in a middle aged person, headache which wakes one up from sleep or occurs in the morning on awakening, headache with nausea and projectile vomiting are warning signs that something might be brewing up. Also change in the character or frequency of headache in a person who has had headaches in the past makes doctor think about the possibility of brain tumor.

2) Seizures: frequently brain tumors may present with seizures. Thus whenever a person especially middle aged or elderly presents with an unprovoked seizure, a neuroimaging study is warranted to rule out the possibility of brain tumor.

3) Focal neurological signs: let me explain what I mean by that. New appearance of neurological signs like weakness or numbness in an arm or leg, unsteadiness of gait, loss of vision in one part of the visual field, difficulty with speech or weakness of one side of face all warrant work up for the possibility of brain tumor under the correct circumstances.

4) A brain tumor may be discovered as a work up of malignancy somewhere else in the body. Let me explain. Someone has lung cancer, as a work up a MRI scan of the brain is done and metastatic spread of cancer is noted to the brain (metastatic tumor: the tumor did not arise in the brain, rather spread to the brain from the primary source, in the above example it is the lung).

Next we shall turn our attention to the different kinds of brain tumors.

Personal Regards,

Dr. S

Lets now talk about the different kinds of brain tumors. As I stated earlier different kinds of tumors can arise in the brain ( depending upon the cell of origin). The most common primary brain tumors are those that arise from t glial cells. These tumors include astrocytomas.

Astrocytomas are graded as per a classification developed by the World Heath Organization (WHO). On the basis of the WHO classificiation these tumors are graded from I to IV.

Grade I and II astrocytomas are also called low grade astrocytomas ( what do you mean by low grade? Well the tumor is not so malignant, it lacks the invasive character of a high grade tumor, grows more slowly and increases in size over  years)

 

Grade III and IV astrocytomas are also called high grade astrocytomas. (these tumors are more malignant, invasive, increase in size over months and thus life expectancy is shorter)

 

Grade IV astrocytoma is more commonly referred to as Glioblastoma multiforme or rather as GBM. This tumor has a poor prognosis and a short life expectancy.

There are other types of brain tumors. I shall list a few of them out here and comment on them as we go along.

1) Meningiomas

2) Acoustic Neuromas/ vestibular schwannoma

3) Ependymomas

4) Oligodendrogliomas

5) Optic nerve gliomas

6) Craniopharyngiomas

7) Germ cell tumors.

8) Pineal glad tumors

9) Pituitary gland tumor-pituitary microadenoma and macroadenomas

10) Medulloblastoma

11) Neuroblastoma

12) central neurocytoma

13) Ganglioglioma

14) Retinoblastoma

Next we shall go over some aspects of diagnosis and management of brain tumors.

I hope you all are enjoying this Saturday morning.

Personal Regards,

Dr. S

Let us now discuss a few aspects regarding the management of brain tumors. First what are the tests usually carried out to detect and diagnose a brain tumor? As you can imagine the most commonly done tests are the ones that involve imaging the bain. Either a CT scan or an MRI brain is done. Usually during these tests a dye (also called contrast) is given. The dye/ contrast helps to highlight the tumor from the surrounding background and aids in visualization of the extent of its spread and the surrounding brain edema. Some tumors enhance, that is they take up the dye and look bright while others do not enhance.

If we are dealing with a primary brain tumor, by that I mean a tumor which arises from the brain itself and stays in the brain (does not spread) then nothing else may be needed. But if we are dealing with a metastatic brain tumor (for example a lung tumor which has spread to the brain), more imaging may need to be done. This includes imaging the chest, abdomen and pelvis to look for how far the tumor has spread.

Sometimes tests may be more invasive. The CT scan or MRI brain only shows the mass lesion, it does not tell what kind of tumor it is histopathologically. Remember not all masses in the brain  are tumors, infections too can present with mass lesions (brain abscesses). For example a patient is noted to have a mass/ lesion on MRI brain. The doctor cannot tell what it is and may like to get a biopsy of the lesion. Biopsy means getting a small amount of the tissue and looking under the microscope to identify what it is. This procedure is carried out in the OR by a neurosurgeon.

So to summarize some of the investigations which may be carried out during the work-up of a brain lesion include:

1) blood tests

2) Chest X-ray

3) EKG (electrocardiogram)

4) CT scan of the brain with and without contrast

5) MRI of the brain with and without contrast.

6) EEG (electroencephalogram): remember some patients present with seizures and are then detected to have a brain tumor on testing.

7) CT scan of the chest, abdomen and pelvis.

 

Treatment of brain tumors: the treatment of brain tumors is complex and frequently involves multiple specialities like neurology, neurosurgery, neuro-oncology and radiation oncology. Simply put the treatment depends upon a number of factors. These are:

1) Location of the tumor in the brain–is it easily accessible surgically or is it deep in the brain and cannot be approached surgically?

2) Size of the brain tumor–is it small or is it large? Can it be safely removed without causing weakness, loss of memory or speech problems?

3) Number of tumors in the brain–a solitary lesion usually can be surgically removed while multiple lesions cannot.

4) Type of the brain tumor: as I stated earlier different tumors behave in different ways. Some are slow growing while others grow quite fast. Some are sensitive to radiation while others are not. Some respond to one type of chemotherapy (cancer drugs) while others do not.

 

The different modalities used in the treatment of brain tumors are:

 

1) Surgery–the neurosurgeon resects the tumor. For some tumors especially those caught early, this may be all that is needed. In others after surgery you may need radiation to the brain and/or chemotherapy.

 

2) Radiation–this may either be whole brain radiation (meaning that the whole brain is radiated) or radiation just to the tumor and the surrounding areas. While radiation involves no surgery, it too carries its own side-effects. Radiation may cause cognitive deficits and at times necrosis of the surrounding brain tissue.

 

3) Chemotherapy: different types of chemotherapy drugs are used in the treatment of brain tumors. Some of these are a group of drugs called nitrosoureas with names like BCNU and CCNU.

 

Other aspects of care include rehablitation–this may include physical therapy, occupational therapy and speech therapy.

Seizures, convulsion, fit, epilepsy

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  • Seizures/ Convulsions/ Fits/ Epilepsy

      

    Let us now talk a little about seizures. Seizures are among the most common neurological conditions encountered by physicians.  What is a seizure? Simply put it is a short-circuit of your brain. Brain cells also called neurons communicate with each other via electrical charges.  This communication process is highly organized and smooth most of the times. Rarely for various reasons ,which I shall elaborate later on in the article, things go awry and the result is a seizure ( lots of brain cells firing at the same time in a disorganized manner). So seizure is nothing but a hypersynchronous discharge of brain cells.

    Is there any difference between a seizure and a convulsion?  Well the answer is yes and no. The terms can be used interchangeably and essentially  mean the same thing. But usually as neurologists when we use the term convulsion we mean the patient was “shaking” visibly. The type of seizure you see in a movie–lot of thrashing around, person losing consciousness, falling down, drooling, biting his tongue or lips, losing control of his bladder ( many people may pee on themselves during a big convulsion) and then is confused and disoriented as help arrives. Pretty dramatic, you cannot miss it. You see someone doing that and you know he is having a convulsion and you call for help.

    Seizures though can be very subtle, so subtle that even an attentive and doting parent might miss it.  Short arrest of behavior ( staring spells), losing train of thought in the middle of a sentence, sudden speech arrest, short rapid jerks of the arms and legs on waking up in the morning, a strange smell ( the classical smell described is that of burning rubber), abnormal behavior at night while sleeping: these may all represent seizures.

    It is important to recognize these myriad manifestations of seizures. Sometimes these may be missed and people continue to suffer from seizures for years.

    So that brings me to the next point I want to discuss with you. HOW DO WE DIAGNOSE SEIZURES??  Easy, most of the time it is by a good history. A thorough history taken by a physician ( need not be a neurologist or an epileptologist) can usually give the physician a pretty good idea if you indeed did have a seizure. So when asked try to give as thorough a history as possible: how did the episode start? what were you doing at that time? did it occur during sleep? did you smell something strange? did you lose consciousness and completely black out or were you just confused and disoriented? could you understand people around you at that time? did you shake? if yes did the whole body shake or one side shook? did you bit your tongue or pee on yourself? were you confused after the episode and if yes how long did it take for you to come back to normal?

    As you can see lots and lots of questions. Sometimes you may not know the answer to all of them by yourself ( you were passed out, how can you know!!!!) well in that case we try to get information from family and friends, a bystander who saw the episode, the emergency medical service people who were called to help you.

    Once your physician feels that you may have had a seizure, then come the questions:

    1) Why did you have a seizure and what was the cause of the seizure.

    2) what kind of seizure was it ?( I shall come to this later)

    3) was the seizure a one time event or can it occur again?

    4) Does it need to be treated?

    5) if it warrants treatment what medication is required?

    6) will the medication ensure that you do not have a seizure again?

    7) how long do you need to take this medication?

    8) can you drive? does the seizure place any restriction on your lifestyle?

    9) if the medication does not work: what do you do then?

    I shall tackle these questions one by one. Enough information for now, I need a break!!!

    Personal Regards,

    Dr. S

      

    Seizures/ convulsions/fits/Epilepsy

      

    So we take off from where we left and discuss about the different types of seizures. Broadly there are two types of seizures: generalized and partial.

     

    1) Generalized seizures as the name suggests come from the whole brain, that is the whole brain malfunctions and misfires. As the whole brain is malfunctioning it is but natural that the person shall lose consciousness and is amnestic for the event and for some period of time afterwards. These are the classical big seizures you see in movies with the falling, frailing arms and legs and tongue biting. What many people do not know is that generalized seizures can be more subtle: staring spells seen in children are a type of generalized seizures called Absence Seizures.

     

    2) Partial seizures or focal seizures as the name suggests come from one part of the brain i.e. only a part of the brain has the seizure. As a result consciousness is usually retained albeit it may be impaired. The patient may have his or her eyes open and one part of his body the arm or leg may be shaking but he is not able to respond adequately if you call out to him. Focal seizures are further subdivided depending upon whether the manifestations are primarily motor, sensory, autonomic or psychic.

     

    3) Partial seizure with secondary generalization: the name is self explainatory. The seizure starts off from a focal area in the brain and then spreads and soon the whole brain is involved. Most of the seizures are partial with secondary generalization but patients and even attentive bystanders might not volunteer the history that initial symptoms were focal. It is very important you tell your doctor exactly what happened right at seizure onset: did you smell something strange? did you have a funny taste in your mouth or a strange sensation in your belly? did one part of the body shake first and then the seizure spread to other body parts.  The strange feelings noted at seizure onset are called auras and they help us in localizing where in your brain did the seizure come from. It is very very important that you give a good history about this because the medications used to treat generalized seizures are at times different from the ones effective against partial seizures. I shall come back to the medications at a later date.

     

    Numerous other types of seizures have been described especially in children and there quite a few epileptic syndromes seen in the pediatric age-groups. I shall comment on these briefly as we go along.

    Enough typing for now. Its freezing outside here in New York City and I think I need a cup of coffee to jump start my brain.

     

    Dr. S

     

    Seizures/ Convulsions/ Fits/Epilepsy

    Now that we know a little something about seizures in general, lets turn to managment of seizures and epilepsy. As a work-up of why one had a seizure and to determine its cause, your physician may order a few tests. The mostly commonly ordered tests include something called an electroencephalogram or EEG in short and an imaging test of the brain either a CT scan also called a CAT scan or more commonly a MRI scan (MRI stands for magnetic resonance imaging).

    Let us talk a little about these tests. An EEG is actually very similar to an EKG (electrocardiogram). Basically electrodes are placed on the surface of your head (completely painless procedure) and then one looks at the brain waves for about 30 mins and tries to find out if and where does the brain misfire. An imaging study like a CT scan or MRI scan is done to rule out the presence of anything structural inside the brain that might be the cause of the seizure like a brain tumor or a vascular anomaly. It is important to rule out a structural cause for a seizure as its presence guides the managment.

    You have something inside the brain which does not belong there, you may need a neurosurgical opinion to get it out. Most of the times in people who have epilepsy no structural cause is found on neuroimaging and then the treatment turns to how to manage/control/prevent further seizures. It is thought in these patients the problem is at the cellular level, something which we cannot see on imaging studies. If there is nothing to be seen, there is nothing to be taken out.

    Let me lay down some basic tenents of treatment:

    1. A single provoked seizure may not warrant treatment. What does that mean? Well basically if you had a seizure which was  because of something you did like used a drug of abuse (cocaine etc), alcohol  in excess ( a drinking binge with the buddies may cause what we doctors call “rum fit”), did not sleep for a couple of nights, some antibiotics and anti-depressants have been known to cause a seizure: then you may not need to be treated. Just do not abuse the drug again and you shall be fine. No more seizures no need to be on long term anti-seizure medications.

    2. A single unprovoked seizure may not warrant treatment. Sometimes a person may have a single seizure for which no provoking cause can be found inspite of a thorough search for one. Your EEG and scan is normal.Your doctor may decide just to observe you and not start any drug treatment. Why you may ask we do this? Well the reason is simple. Studies have shown that as many as 70% of single unprovoked seizures may not recur ever. So why treat someone with anti-seizure medications with their risk of side-effects. It is better at times to just watch. If seizures recur your doctor at that time might decide to treat you.

     

    We shall stop now, the sun is out, central park is calling, I am going to head out for a run.

     

    Personal Regards,

    Dr. S

     

    Seizures/fits/convulsions/ epilepsy

     Management/ treatment of seizures: let us now turn to the treatment of seizures. I shall discuss this broadly under two headings:

    1) acute management of seizures: what do you do and what happens in the hospital setting if one has a seizure?

    2) management of seizures over the longer term or rather I should say ongoing treatment of someone who has epilepsy.

     

    Let us start with acute management of seizures. Some of us have seen people around us have a seizure either at home, outside or in the workplace. What do you do? Whom do you call? Is the person who is having a seizure going to die if we do not do something? Crude as it may sound here, the seizure itself never kills a patient it is the circumstances surrounding the seizure which may prove lethal. Let me explain further. Most of the seizures stop by themselves in a few minutes (though it may seem hours to the person witnessing the seizure). More often than not, the seizure has already stopped by the time  EMS (emergency medical services) arrive on the scene. The patient has stopped shaking and is just confused or may have even fallen asleep. So more often than not there is no active intervention needed on the part of the EMS. All they may do is check the patient’s vitals, maybe give him some supplemental oxygen and then transport him to the nearest hospital for further evaluation. There that was simple wasn’t it? However let me paint another scenario. Person is standing by the side of the subway track waiting for the train. Has a seizure and falls onto the tracks. Cracks his skull open, may get run over by the train if not pulled out by someone. There-in lies the problem with seizures and epilepsy and which patients find the most unsettling. The uncertainity, the possibility of having a seizure at the wrong place and at the wrong time. Deaths have occurred when people have had a seizure while driving, swimming or even while taking a bath in the tub.

     

    So if you see someone having a seizure, do not panic and follow some simple guidelines. I shall list them out for you.

    1. Do not try to physically restrain the patient. You try to hold down his arms or legs you may cause more harm than good like a dislocated shoulder.

    2. Just try to ensure that the patient is not hurting himself: like if he is hitting his head on the hard floor while having a seizure you may try to gently hold his head or put a cushion under it.

    3. Remove anything from the surroundings which has the potential for causing injury: things like a hot stove, sharps,

    4. Do not put anything like a spoon or your finger into the patient’s mouth to prevent it from shaking. The patient may bite your finger off or may choke.

    5. If possible gently turn the patient’s head to the side, this causes the tongue to fall away opening the airway and lets the oral secretions (saliva) drip out from the side of the mouth and prevents aspiration.

    6. I have encountered people with certain misconceptions like having the patient smell something pungent (smelling salts, a stinking shoe) aborts the seizure. These things do not work, you are wasting your time and not helping the patient.

    7. Once you have made certain the patient is safe, better to utilize the time to call EMS. Tell them clearly what you saw and did. Give a good history. Usually once the seizure stops the patient is not immediately responsive, you may hear sonorous respirations as if he is in a deep sleep.

    Time for a break!!! This took longer than I thought.

    Dr. S

    So lets pick up from where we left off a couple of days ago. Lets talk about the acute managment of a seizure in the hospital setting. A person is brought to the hospital by the EMS and is still having a convulsion as he is wheeled into the ER. We call this Status Epilepticus ( a potentially life threatening condition when a patient has been having a seizure for greater than 30 mins or has had multiple seizures in near about the same amount of time without regaining consciousness inbetween).

    There are a couple of things which doctors do in this setting. I shall list them out.

    1) Protect the airway, check the vitals, maintain the circulation and oxygenation/breathing (ABC). We make sure that the patient is breathing and oxygenating well ( no obstruction to his airways), sometimes when the patient is not breathing well on his own, the doctors might put a tube down the throat into the trachea and put the patient on a ventilator ( a machine which does the work of breathing for the patient until he/she can breathe on his own). If the blood pressure is low, intravenous fluids may be administered.

    2) A quick search is made for the cause/etiology of seizures. Blood is checked for the blood sugar level, electrolytes ( sodium, calcium, magnesium etc). One of the common causes of seizures especially in people with diabetes is low blood sugar. Either the patient takes too much of his diabetic pills/ insulin or the patient may have missed a meal letting his blood sugar fall to a dangerously low level.

    In such a case intravenous dextrose ( a form of sugar) stops the seizure immediately.

    3) To stop the seizure acutely certain medications may be administered. These commonly belong to the benzodiazepines group of medications with names like Diazepam (valium) or Lorazepam (ativan) followed by a longer acting anti-seizure medication like Dilantin (phenytoin).

    4) Once the seizure stops the work-up begins to find the etiology of the seizure ( remember the MRI and EEG I talked about before).

     

    Depending upon the cause of the seizure, its risk of recurrence, the type of seizure ( partial Vs generalized), the doctor may prescribe an anti-seizure medication ( we call them anti-epileptic drugs or AEDs).  There are many different AEDs in the market. Each drug has its own mechanism of action, the kind of seizures it is most effective in controlling, side-effect profile and recommended dosage for seizure control.

     

    Your doctor shall discuss this with you in detail. Please remember a number of AEDs can potentially interact with other medications which you may be taking for blood pressure etc. So remember to tell your doctor a complete list of your medications. Also some AEDs lower the efficacy of birth control pills, thus women with epilepsy may be advised to use alternate methods of contraception.

    An important point here especially for pregnant women with epilepsy. Some AEDs have been linked to cause major congenital malformations in babies like cleft lip, cleft palate and spinal column deformities (spina bifida). Pregnant women with epilepsy remain a high risk group-they need close supervision by a doctor well versed with the use of AEDs during pregnancy. Some AEDs are best avoided in pregnancy while others have a relatively safer track record when it comes to the incidence of major congenital malformations.

    I hope this small discourse on seizure is informative. I shall tackle brain tumors next.

    Personal Regards,

    Dr. S

      

Questions about epilepsy?

Ask Dr S:

neurologistnyc@yahoo.com

 

Braindiseases.info

 

 

 

 

Introduction

braindiseases2 Comments

Hello and welcome to brain disease weblog. Well introductions first. I am a qualified neurologist in NYC with interests in general clinical neurology and epilepsy. The human brain has always fascinated me from a young age and hence after finishing my residency in internal medicine, I decided to further specialize in Neurology and sub specialize in Epilepsy. Whenever I go on the internet looking for information about specific neurological diseases and conditions, it always bothers me that there are very few patient oriented sites. The ones which do exist either disseminate rudimentary information or charge a fee for it.

Patient’s are usually not able to access quality review articles written by experts in the field published in leading neurology journals like Neurology, Journal of Neurology Neurosurgery and Psychiatry, European Neurology or New England Journal of Medicine. Of course these articles are more scientific and difficult for a lay person to understand.

Hence the purpose of this blog. It is my attempt in a small way to disseminate information regarding common neurological conditions in a way that you can understand. Information which is current, comprehensive and mostly importantly accurate.

Before we start I want to remind you what I was taught in my medical school:

” not reading ( your textbooks) is like sailing on uncharted seas but not seeing the patient is like not going to the sea at all”

There is no substitute to an actual visit to your physician. You can read about the disease you feel you have but always always do consult your physician.

Hope you find the information here useful.

Personal Regards,

NS