December 23, 2019
Imagine the pain of Arun (name changed), a 10-year-old falling prey to seizures accompanied by sudden onset of laughter, followed by a fall and loss of consciousness for 15 to 20 times a day. This resulted in the child's complete loss of grip of his life and he had to give up attending school due to the disruptions caused by seizures. Despite receiving treatment from multiple hospitals and being on anti-epileptic drugs, his seizures continued that left his parents helpless, till he was taken to the comprehensive epilepsy centre at Apollo Hospitals Sheshadripuram.
Apollo Hospitals, Sheshadripuram
The team of expert doctors comprising Dr. Ravi Mohan Rao, Senior Consultant Neurosurgery and head at the Department of Neuro Sciences and Dr. Sujit Kumar, Neurologist and Epileptologist, found him to have gelastic seizures which were originating from the left frontal lobe of his brain. The evaluation was conducted with the cutting-edge technology of video electroencephalogram (EEG) that Apollo Hospital has. An MRI of the brain revealed a focal cortical dysplasia (an area of abnormal neurons) in the left frontal lobe. Further precise evaluation with the help of a Positron Emission Tomography (PET) showed reduced metabolism in the same area that characterises the region of the brain causing seizures, medically known as the epileptogenic zone.
With absolute precision and high-quality care, the 10-year-old's treatment began. “He underwent an epilepsy surgery with excision of the abnormal dysplastic area. A technique called electrocorticographic guidance was used which records abnormal electrical activity directly from the brain. Intraoperative ultrasound was also done to delineate the abnormal area and also to guide the placement of electrodes to record the abnormal electrical activity. The seizures which were about 20 per day, stopped immediately after the surgery,” says Dr. Ravi Mohan Rao, Senior Consultant Neurosurgery at the Department of Neuro Sciences. Since the last one year, the child is leading a happy life and has resumed classes in school and now plays with his friends with a bright smile, thanks to the Apollo doctors.
The situation was no different for Rhea (name changed), another 10-year-old who had been suffering from seizures since six years of age characterised by staring and a slight head turning towards the right. Her seizures would sometimes spread, leading to a fall and convulsions. While she had a normal birth and development history, Rhea suffered from three to four seizure episodes every month from 4 years of age. She was on three antiepileptic drugs which did not provide her much relief until she was taken to the Apollo Hospitals.
Meticulous observation and evaluation from the expert hands of Apollo, found her seizures to be arising from the temporal lobe of the brain as per her video EEG. However, surprisingly, the MRI of the brain showed that the region was normal. A PET MRI scan done showed a large area of hypometabolism in the temporal-parietal-5.53/ 1000 popoccipital regions which are located in the cerebral cortex of the human brain. While normally for a right-handed person, language function is present in the left temporal of the brain, a special test called language fMRI found that Rhea's language function was present in both the temporal lobes.
Dr. Sujit Kumar, Neurologist and Epileptologist, says: "The first thing we tried to do in her case was identifying where exactly the seizure arose in the temporal lobe, as the MRI conducted earlier did not reveal any lesion. Also, a mapping of the language areas had to be done in order to keep those areas intact during the surgery. We made a plan to do an invasive EEG with subdural grid and strip electrodes to distinguish the language areas and the seizure origin. When the patient underwent the surgery, a 48-contact grid, which is a rectangular network of electrodes, recording electrical activity directly from the brain surface, was placed on the suspected brain region. The seizures were recorded from the grid and brain mapping was successfully done.”
Rhea underwent an extended temporal lobectomy including anterior temporal lobectomy with amygdalohippocampectomy, sparing the language areas. Following the procedure, she did not show any signs of language disturbances. Until now she has been seizure-free for the last four years and does not have to depend on any anti-epileptic drug. She is living her life just like any other 10-year-old.
Understanding the prevalence of paediatric epilepsy in India
As per recorded meta-analysis data, the prevalence of paediatric epilepsy in India has been estimated to be 5.53/1000 population. However, good studies regarding paediatric epilepsy are lacking. Studies from India have reported that incidence rates vary from 0.2 to 0.6 per 1,000 population. The incidence rates reported from India are comparable with developed countries and lower than most of the developing countries which range from 1.0 to 1.9 per 1,000 in a year. There are no studies on epidemiological trends with time on paediatric epilepsy. With better access to health care, the reported number of cases seems to be increasing.
Common causes of paediatric epilepsy
Highlighting the common factors that result in paediatric epilepsy, Dr. Rao says, “Febrile seizures, neurocysticercosis, neonatal hypoglycemia, perinatal asphyxia, and developmental malformations of the brain are considered to be the most common causes of paediatric epilepsy. Among patients with an early insult to the brain, with time, epileptogenic networks form, resulting in epilepsy."
Signs that you must watch out
Children with epilepsy usually present with generalized seizures which are easy for the parents to recognize, owing to the fall and subsequent convulsive movements. However, a small percentage of children can have periods of unresponsiveness either in isolation or with some movements of lips, hands or legs, called complex partial seizures. These are more difficult to recognize.
Treating and preventing paediatric epilepsy
A lot of care should be taken during delivery to prevent a lack of oxygen supply to the baby’s brain. Also following delivery, hypoglycemic episodes should be recognized and treated early, Head Injuries and brain infections should receive prompt treatment. Febrile seizures must receive prophylactic treatment for their subsequent prevention.
Dr. Kumar says, “At Apollo Hospitals Sheshadripuram, our comprehensive epilepsy management team has started state of the art treatment for medically refractory epilepsy which cannot even be diagnosed by MRI of the brain. We perform an invasive EEG called ‘Stereotactic EEG’ wherein, with minimally invasive methods, depth electrodes are placed in parts of the brain believed to be responsible for epilepsy. Further, recordings from these electrodes are studied to identify the focus of epilepsy. By stimulation of these electrodes, it is also possible to identify areas responsible for speech and movements of hands and legs, near the epileptic focus and spare these regions. The delineated focus is then operated and removed by epilepsy surgery, resulting in complete seizure freedom without any unwanted side effects.”