Blog #78: CUTTING THE BRAIN IN HALF TO CONTROL EPILEPSY!

            Brain surgeons occasionally cut the brain in half by a CORPUS CALLOSOTOMY operation. It can better control intractable seizures. This procedure cuts the corpus callosum (cc), the major broad structure containing nerve fiber tracts that connects the right and left halves of the brain from front to back of the brain.

Green is the Corpus Callosum

This  brain depiction shows the cc with the overlying brain cortex removed.

      The procedure disconnects spread of epileptic brain activity. It has been performed for over 75 years. It seems to benefit atonic (Atonic seizures, or drop attacks, cause a loss of muscle tone resulting in the person dropping to the ground with loss of awareness. This is the Lennox-Gestaut Syndrome. The fall can result in serious injury.  It is recommended that affected children wear helmets to minimize fall-injury) and tonic seizures (Tonic seizures are a tightening of muscles, especially of the trunk and face, without jerking or falling but with loss of awareness). These two epilepsy forms primarily affect children and are resistant to anticonvulsant medications. Occasionally, CORPUS CALLOSOTOMY is performed to improve grand mal epilepsy, too.

       Paglioli’s research team ¹ found CORPUS CALLOSOTOMY to be safe and effective. Their study revealed that median monthly frequency of drop attacks decreased from 150 per month to, on average, less than one per month.

        Cut the brain in two? How can a person function like that? CORPUS CALLOSOTOMY usually leaves the patient with undetectable changes except for improved seizure control.      

        What does the corpus callosum structure do? Other than allow the right and the left cerebral hemispheres sharing information across it, neuroscientists can’t give complete explanations. Once the cc is cut, sophisticated neuropsychological testing may be required to detect abnormalities that are undetectable to the casual observer.

            Rarely, people are born without a corpus callosum. The absence of the structure is found on routine brain scans done for other reasons, e.g. trauma, headaches and paralysis, etc. Yet, they appear entirely normal on routine interactions and physical examinations.

            One side-effect caused by CORPUS CALLOSOTOMY is described: most people are right-handed and have their language center in the frontal lobe of the left cerebral hemisphere. If a coin is placed in the left hand after CORPUS CALLOSOTOMY, the patient feels the coin in his right brain because the normal human brain senses the opposite body via crossing nerves low in the spinal cord. He’ll detect something is in his hand but he cannot name the object. This is because the information about the perceived object will reach the right hemisphere but the information must then pass over the corpus callosum to get to the language center in the left hemisphere. The information from the right hemisphere can’t get to the naming part of the language center in the left hemisphere because the CORPUS CALLOSOTOMY cut the “bridge.” However, if the same test is done with the object placed in the person’s right hand, the information of what is felt in the hand passes directly to the language center in the left hemisphere after it crossed to the opposite side low in the spinal cord. The person can immediately name what is felt in the opposite right hand since the information does not need to cross the cut corpus callosum, the cut “bridge.”

1)      Paglioli E., Martins AA, Azambuja N, et.al. Selective posterior callosotomy for drop attacks. Neurology 2016; 87: 1968-74. 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.

           

Blog #77: DRIVING PRIVILEGES, PAYING YOUR BILLS AND MORALITY: DRIVING AND THE EXPERIENCE OF A NEUROLOGIST

                 

WASHINGTON, Dec. 7, 2016 (UPI) -- The driver of a Baltimore school bus that hit a car and a transit bus last month, killing six people, including himself, had been involved in at least 12 other crashes in the last five years, the National Transportation Safety Board said Wednesday.

The investigative agency released a preliminary report on the Nov. 1 crash Wednesday, which detailed the incident and the medical history of the school bus driver. "The school bus driver had a history of hypertension, diabetes, and seizures. In the past 5 years, he had been involved in at least 12 crashes or incidents while operating a school bus or personal vehicle," the NTSB report said. "In addition, the week before the crash, paramedics were called ... because the school bus driver was experiencing what witnesses described as a seizure."

The report also says the school bus driver held a medical certificate denoting a medical condition but it had not been filed with the state motor vehicle administration.

I practiced clinical neurology in the state of California. California, Delaware, Nevada, New Jersey, Oregon and Pennsylvania are the only states that require physicians to report people who have been diagnosed with epilepsy to the local official health officer. Knowing that driving privileges are at risk often creates a barrier between the doctor and the patient. Doing the right thing, the moral thing, can be difficult for both parties. Patients often threatened me to not send in a report. “Are you going to pay my mortgage, Doc? If I have to quit my driving, I’ll be in the poor house. You better not send that in.” Many leave in anger.

Specifically, The California Health & Safety Code 103900(a) (2010) states: “Every physician and surgeon must immediately report to the local health officer individuals 14 years of age and older whom they have diagnosed as having a disorder characterized by lapses of consciousness.” Reports made because the physician acted reasonably and in good faith and believed will serve the public interest, the doctor shall not be civilly or criminally liable.

However, it is NOT the physician who decides if any particular patient should drive or not; it’s the official motor vehicle agency—with guidance by special medical panels. My experience has been that not all epilepsy patients have their driving restricted. If the patient and the doctor report that the seizures occur only during sleep (“nocturnal seizures”) the DMV often allows driving. But, periodic medical follow/up and reports to the DMV should show no seizures are occurring. The DMV decides how long a person must be seizure-free? Seizure-free 6 to 24 months is a routine observation period. 

Doing the right thing, the moral thing, can be difficult. I have followed patients whose licenses had been revoked for 6-24 months and then restored because they have been seizure-free. However, occasional follow-up visits have consisted of this scenario: “Are you taking your anticonvulsant medications as prescribed?” “Oh, yes, Doctor.” “Have you had any seizures?” Some have said, “Would you have to report to the DMV?” When I respond, “Yes,” patients have told me, “No, Doctor, I’ve been fine.” The doctor and patient are thus deprived of the opportunity to improve care by changing dosages or medications to give better seizure control. If the doctor fails to report to the health official, the physician is liable for damages by accident victims.

I have learned of news reports such as, “The driver lost control of his vehicle that jumped the curb and crashed into a group of people on the sidewalk.” As a neurologist dealing with epilepsy that affects one of every one hundred people, my response would be, “I hope it’s not one of my epilepsy patients.” What else would cause drivers to lose control? Alcohol? Drugs? An epileptic black out?     

In the other 44 states that don’t require doctors to report their epilepsy patients, it is hoped that patients will cease driving on their own and/or will report themselves to their DMVs. How many individuals report themselves? We can sympathize with their moral dilemmas. “Are you going to pay my mortgage if you stop me from driving, Doc? Will I kill myself or others?”

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.

Blog #76: Recognizing Epileptic Seizures Is Not Easy

            I gave a presentation: IS IT A LEARNING DISORDER, A HEARING PROBLEM, AUTISM OR EPILEPSY? to school psychologists in Newport Beach, California, last month in order to raise epilepsy awareness. These are all prominent reasons why children fall behind in school work. Correct diagnosis is the key to greater life-success. 

            Three million American children and adults are living with epilepsy. Millions more are touched by their epilepsy including: family members and friends, educators, counselors and health providers. They all need to be alert to the symptoms of “non-convulsive epilepsy.” 

More education is needed. The general population has little awareness of this condition. 

            Typical presentations of unrecognized epilepsy include individuals complaining that they just can’t keep up in their work and/or studies. A complaint of sudden, brief, confusion spells suggests possible non-convulsive seizures. These seizures can last seconds or longer. Medical and psychotherapy professionals don’t usually put an epilepsy possibility at the top of their diagnostic considerations. Complex partial seizures and petit mal, or “absence” non-convulsive epilepsies do not exhibit obvious convulsive limb shaking, tongue and lip biting and loss of bladder/bowel control. I often hear the lament: “No one knew what was wrong with my nephew for the longest time. They thought he had a learning disorder. They finally diagnosed epilepsy.”

            Clues for non-convulsive seizures causing mental difficulties and mental slowness are derived from observation of the individual. Sudden facial expression changes suggestive of staring, loss of contact with their environment and not responding to questions, or losing train-of-thought all put forward the possibility of non-convulsive epileptic seizures. Most reliable for diagnosis is to have family and friend-observers test the person during apparent mental blank outs or sudden, inappropriate, “spacey,” quizzical facial expressions. During this time observers should ask the person to perform some action in order to test intact consciousness. Ask the person to: “put your right thumb on your left ear,” or “stick out your tongue and lift your right leg,” etc. During such a spell they won’t do it. Brain scans, EEGs and other laboratory tests are often normal and can’t be relied upon to diagnose epilepsy.

            In my clinical experience, the observer’s report may be the only “data” the neurologist gets to consider this non-convulsive epilepsy diagnosis. A trial of antiseizure medications can be prescribed despite all the negative formal testing. The non-convulsive epilepsy diagnosis is supported if medications minimize or stop these “little” spells.

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.