Academic outcomes for epileptic children post-surgery

A study of epileptic children indicates that those who had brain surgery struggled in their class post-surgery.

A new study by a University of Toronto Mississauga researcher has taken the first-ever look at the academic outcomes of children with epilepsy who have had brain surgery, and found that they have a higher chance of struggling in class following their surgery.

Psychology professor Mary Lou Smith was co-leader of a team of researchers who studied the arithmetic, spelling, reading and reading comprehension abilities of children after having resective epilepsy surgery, a procedure that involves removing a part of the brain in order to halt seizures. The patients completed standardized tests both before their surgery and about 14 months afterwards, and all received lower scores on the second test in the first three academic areas. The results, Smith says, challenge a commonly-held but false assumption that stopping seizures can free up brain power for better academic performance.

"The surgery stops the seizures, but it's not like we put a new brain in there. These children still have a preexisting brain abnormality," says Smith, a UTM psychology professor, and a senior associate scientist in the Neurosciences and Mental Health Program in the Research Institute of the Hospital for Sick Children. The study published in the June 2015 edition of the journal Epilepsy & Behavior.

Brain surgery is performed on patients who don't respond to drugs, and whose source of seizures can be pinpointed in the brain. Smith says that of the approximately 25 per cent of people for whom drugs don't work, about 30 per cent meet the criteria to have epilepsy surgery. Working with three other researchers from SickKids and UTM -- including two UTM graduates -- Smith examined the academic achievement levels of 136 children ages 5 to 18, most of whom live in Ontario, and who had underwent pediatric epilepsy surgery between 1995 and 2013. All had completed academic testing as part of their pre-surgical and post-surgical neurological evaluations.

In the pre-surgery tests, most of the children displayed low or underachievement in at least one of the academic domains. This is because children with epilepsy are at higher risk of having cognitive problems in areas such as language, problem solving, learning and memory. The children's post-surgery test results, meanwhile, revealed drops in marks when it came to reading, spelling and numeral operations. Most students decreased about two to six points, but some declined by 10 points or more. This means that while brain surgery can help improve patients' quality of lives by stopping seizures, it doesn't necessarily stall or reverse the tendency toward lower-than-average academic performance.

"What I think is happening now is as they're getting older, they're not progressing at the same rate their peers are progressing, and so as a result of that, over time, you see these lower scores, because the difference between their performance and what's expected given their increasing age is widening," Smith says.

Smith cannot say whether the findings are due to the surgery, the epilepsy, or the children's development, but she is now conducting more research to figure out why. Meanwhile, she says, this new study may be useful to families weighing the pros and cons of surgery for their child with epilepsy.

"This is a tremendously challenging decision for parents, and they want to know the risks and benefits," Smith says. "I think this information is very important for health care providers if they're counseling patients, and for pursuing evidence-based practice."

Read more here

Predicting surgery outcomes for epilepsy

This article explains two studies that try to predict surgery outcomes for kids with epilepsy.

Anti-epileptic drugs control seizures and improve quality of life for most people with epilepsy. But for those who find medical treatment ineffective or intolerable, brain surgery is sometimes the next best option. Two studies to be presented at the 68th AES Annual Meeting in December explore the outcomes of brain surgery for children with severe epilepsy.

One study created a decision analysis model to compare how two treatment strategies -medical treatment alone versus brain surgery -- influenced the life expectancy of pediatric patients with refractory epilepsy. Researchers at Boston Children's Hospital developed a decision analysis model with data from the literature. Their findings suggest that surgery increases the odds of a longer life expectancy, compared with medical treatment alone. For example, in a cohort of 10-year old patients, epilepsy surgery in patients with temporal lobe epilepsy yielded 55.2 years of life expectancy, while medical treatment yielded 49.3 years of life expectancy. In extratemporal epilepsy, surgery yielded 54.9 years of life expectancy while medical treatment only yielded 49.3 years. Authors note that the findings suggest that brain surgery is significantly more advantageous than medical treatment alone for eligible children with refractory epilepsy.

A second study examined the effectiveness of resective epilepsy surgery on seizure frequency in children with refractory epilepsy with features of Lennox-Gastaut Syndrome (LGS). Researchers studied 36 patients with LGS who had epilepsy surgery at the Cleveland Clinic for focal, lobar, multilobar resection or hemispherectomy between June 1, 2002 and June 31, 2012. Patients in this study developed epilepsy due to brain lesions or injuries sustained before they were born (17), immediately before or after they were born (10), or between the ages of 2 months and 3 years (9). At the time of surgery, the patients ranged in age from newborn to 18 years, and were experiencing multiple seizures per day.

At follow-up visits conducted 6 months to 6.6 years after surgery, 19 patients were seizure-free. Of the patients still experiencing seizures, two entered late remission 2 years after surgery and five became almost seizure-free, with an average of nine seizures per month. At the last follow-up visit, 24 patients were either seizure-free or had experienced a major reduction in seizure frequency.

"In the past, children with features of Lennox Gastatut syndrome were not considered to be candidates for epilepsy surgery that involves removal of the seizure focus," said Dr. Ahsan Moosa Naduvil, M.D., Staff, section of pediatric epilepsy, Cleveland Clinic Epilepsy Center. "Our study confirms that selected children with early brain lesions may be rendered seizure free with epilepsy surgery."

The authors performed a survival analysis based on the duration of time between seizures, and determined the chance of seizure freedom as 60.1% at 12 months, 51% at 24 months and 40.8% at 30 months or more. According to the authors, the findings suggest that resective epilepsy surgery is an effective treatment option for selected children with LGS secondary to early focal brain lesion or injury.

Read more here

Sleep apnea screening before surgery

Research claims that people going in for surgery should be checked for sleep apnea due to negative outcomes associated with untreated sleep apnea and serious heart issues.

Scheduled for surgery? New research suggests that you may want to get screened and treated for obstructive sleep apnea (OSA) before going under the knife. According to a first-of-its-kind study in the October issue of Anesthesiology, the official medical journal of the American Society of Anesthesiologists® (ASA®), patients with OSA who are diagnosed and treated for the condition prior to surgery are less likely to develop serious cardiovascular complications such as cardiac arrest or shock.

"OSA is a common disorder that affects millions and is associated with an increased risk of surgical complications, but the condition often goes unrecognized," said Thomas Mutter, M.D., lead author, department of anesthesia and perioperative medicine, University of Manitoba, Winnipeg, Canada. "As many as 25 percent of surgical patients may have OSA, but the vast majority of these patients aren't treated or don't know they have the disorder."

OSA causes the soft tissue in the rear of the throat to narrow and repeatedly close during sleep. The brain responds to each of these "apnea events" by waking the person in order to resume breathing. Since apnea events can happen hundreds of times per night, sleep becomes broken and ineffective and can lead to serious health problems if undetected. Those who are overweight or have high blood pressure are predisposed to developing OSA. It tends to occur in men but women can also develop OSA. Symptoms of apnea may include: heavy snoring, pauses in breathing during sleep and excessive sleepiness during the day.

The study compared postoperative outcomes in 4,211 patients with OSA, who were diagnosed by sleep study either before or after surgery, with a matched control group of patients who did not have the condition. Those who were diagnosed with OSA prior to surgery were prescribed treatment with continuous positive airway pressure (CPAP) therapy. CPAP keeps a patient's airway open by gently delivering pressurized air through a face mask.

The study found that although patients with untreated OSA were at an increased risk of developing cardiovascular complications, patients who were diagnosed and treated with CPAP therapy before surgery were less than half as likely to experience cardiovascular complications such as cardiac arrest or shock.

Additionally, researchers found that respiratory complications were twice as likely to occur in patients with OSA, compared to patients without the condition, regardless of when patients were diagnosed or if CPAP therapy was prescribed.

-MORE- For both cardiovascular and respiratory complications, increasing severity of OSA was associated with increased risk. Age, type of surgery and other diseases were also important risk factors.

The authors acknowledge limitations related to their retrospective study, as well as the potential resources needed to implement widespread screening. Nonetheless, this study adds to the knowledge base of how to care for this increasingly large segment of the population.

An estimated 18 million Americans are thought to have clinically significant OSA and, even more alarming, about 16 million of those people remain undiagnosed.

Read more here

Cosmetic surgery and migraine

A study shows that cosmetic surgery on a person's eyelids may give relief from migraine headaches.

Cosmetic eyelid surgery technique could provide significant relief from migraine, scientists say.

Dr Oren Tessler, from the Louisiana State University Health Sciences Center, is part of a team of plastic and reconstructive surgeons who report a high success rate using a method to screen and select patients for a specific surgical migraine treatment technique.

More than 90 per cent of the patients who underwent this surgery to decompress the nerves that trigger migraines experienced relief, researchers claim.

The study confirms the benefit of surgical treatment for migraines and expands access to it.

The technique offers an alternative to the commonly used endoscopic approach which works down from the scalp under the skin.

There are many cases that are not suitable for this approach, ranging from the patient's anatomical issues to some surgeons' lack of access to endoscopes or experience with them, said researchers.

The research team found that, in a select group of patients, incisions through the upper eyelid resulted in equally effective release and deactivation of the nerves involved in migraines.

The researchers, who also included surgeons from Massachusetts General Hospital and Harvard Medical School, report an overall positive response rate of 90.7 per cent.

Migraine headaches were totally eliminated in 51.3 per cent of the patients, with about a fifth of them experiencing an 80 per cent reduction of symptoms.

Nearly a third of the patients had between 50 and 80 per cent of their symptoms resolved.

Thirty-five patients participated in the study. All suffered from chronic nerve compression migraine headaches confirmed by previous positive response to Botox or nerve block treatments.

Migraine headaches can cause significant pain in one area of the head, often accompanied by nausea, and sensitivity to light and sounds.

The study was published in the journal Plastic and Reconstructive Surgery.

Read more here

Medicine instead of tonsillectomy for children with mild obstructive sleep apnea - Ask a Pediatric Sleep Specialist

This article claims that a specific drug combination can replace the need for a tonsillectomy for children who have mild obstructive sleep apnea.

The anti-inflammatory asthma drug montelukast (Singulair) plus intranasal corticosteroids was an effective initial alternative to surgery for mild obstructive sleep apnea (OSA) in children, a retrospective study showed.

That strategy was associated with normalization of sleep findings in 62%,David Gozal, MD, of Chicago's Comer Children's Hospital, and colleagues found.

Overall, taking into account nonadherence and parents refusing the strategy, 81% were able to avoid surgery, the researchers reported online in Chest.

With "the absence of significant side effects and overall favorable safety profile associated with the use of either intranasal corticosteroids, or of oral montelukast," the combination "may ultimately replace adenotonsillectomy as the first line of treatment in mild OSA," they suggested.

Pediatric sleep apnea can resolve on its own, and that might have accounted for some of the results, Gozal's group acknowledged.

However, "the combined evidence from in vitro experiments showing marked reductions in tonsillar and adenoid tissue proliferation with application of corticosteroids or montelukast, and the experience garnered from clinical trials using either intranasal corticosteroids alone or oral montelukast alone," support a real effect.

Prospective randomized controlled trial evidence is "sorely" needed, the group concluded.

Until such a trial is done, it would be premature to offer the drug combo routinely,Christopher Carroll, MD, medical director of surgical critical care at Connecticut Childrens Medical Center in Hartford, commented in an interview with MedPage Today.

Nevertheless, "I don't think there's any problem with trying this before going to surgery," he suggested, noting that its OSA resolution rate was fairly competitive with the 75% rate found for surgery in a recent review.

"We tend to think that surgery is definitive and is curative 100% of the time, but that's just not true," he said. "And it carries a significant risk."

The retrospective review included 836 otherwise healthy children ages 2 to 14 who were clinically and polysomnographically diagnosed with mild OSA at three centers.

Among them, 752 accepted open-label treatment with a combination of oral montelukast and an intranasal corticosteroid for 12 weeks, with continued montelukast for 6 to 12 months if symptoms persisted at subsequent polysomnographs or a recommendation for surgery if they worsened.

Predictors of nonresponse were older age (odds ratio 2.3 for age older than 7, 95% CI 1.43-4.13) and obesity (OR 6.3 with BMI z score over 1.65, 95% CI 4.23-11.18).

Read more here

New surgery option for people with migraines

This is an interesting area of literature that is developing with a small number of articles comparing efficacy and surgical techniques.
For instance, see this article  JR


UT Southwestern is offering a new surgery to help people who suffer from migraine headaches.

A new surgery for migraine headache relief is being pioneered at UT Southwestern Medical Center in Dallas, and the results thus far have been incredibly promising.

The news comes by way of a release from UT Southwestern, which tells the story of 18 year-old Meredith Messerli, whose prospects of being able to attend college were hampered by persistent, debilitating migraine headaches, which were so life-altering that the teen missed two years of high school as a result of her hypersensitivity to light and a headache that literally never went away. “Once I got a headache, it never went away,” Meredith explained in a recent interview. “Having a headache for that long changes your personality. You don’t want to talk to anyone. You don’t want to do anything.”

For years, Meredith and her family searched for medical answers to her severe migraines, which in themselves still remain a partial mystery to researchers. She and her family had consultations who tested her for a wide range of different causes and prescribed almost fifty different types of medicines. She was even admitted to the hospital several times for for weeks in order to receive D.H.E. 45 treatments, which is considered to be a last-resort medication prescribed for migraines. However, this past summer, Meredith underwent a novel procedure for migraines at UT Southwestern, which has since then relieved her never-ending headaches.

The procedure, known as nerve decompression surgery, has recently gained in popularity as an alternative therapy for chronic headache sufferers that has shown to offer migraine headache relief to those who have not been able to find relief elsewhere. The first stage of the procedure is a process for identifying the compressed nerves that are causing the migraine, usually through the use of Botox and nerve blocks. Once the problem areas have been identified, surgeons sever the tiny muscles and tissues that cause the compression of these nerves, thus relieving the pain once and for all.

Migraine surgery involves first identifying the compressed nerves through a clinical history and exam or use of Botox and nerve blocks. Then, the pressure causing the migraines is relieved by severing tiny muscles and other tissues pressing on and irritating these headache-trigger nerves.

Dr. Bardia Amirlak, an Assistant Professor of Plastic Surgery at UT Southwestern who performed the surgery on Meredith, has quickly established himself as a leading pioneer of the surgery, having successfully performed more than 100 such procedures over the past two years. Dr. Amirlak has refined the surgery with his own method of using an endoscope to target smaller blood vessels, and as a result, has also improved on the procedure’s outcome. “This surgery is an option for patients with chronic headaches, nerve-compression headaches, occipital neuralgia, new daily persistent headaches, episodic migraines, and chronic migraines,” said Dr. Amirlak. “However, before considering surgery, all patients should first be evaluated by a neurologist and try medical management.”

From Dr. Amirlak’s own accounts, the surgery is quickly becoming a popular approach to migraine headache relief, thanks to its relatively high success rate: Amirlak reports that 60 percent of his patients get complete relief after the surgery, and for the remaining 40 percent, nearly 90 percent of those experience at least a 50 percent reduction in pain.

As a result, he is currently performing two to three migraine surgeries a week. “Patients are coming from all over the country as well as from other countries,” he said.

Of course, the surgery is not an option for everyone looking for relief from migraines, as the procedure is an invasive one. “Not all migraine sufferers are candidates. We must be careful selecting candidates for this type of surgery,” Dr. Amirlak. However, the doctor does believe that is a particularly well-suited surgery for young patients like Meredith who are otherwise healthy, but whose migraines are having major life-altering consequences. “I would rather operate on a young patient to prevent lifelong pain and suffering than to wait many years after their school, work, and social life has suffered. Here at UT Southwestern we are trying to establish standard protocols for migraine surgery in children,” he added.

Both Meredith and her family attest to Dr. Amirlak’s commitment to helping her get out of pain, and his expertise in the field of treating migraines. “He spent an hour talking to us. He seemed really passionate about helping people, and we felt we had a bond with him,” Meredith said, adding, “I wouldn’t be in college right now if not for Dr. Amirlak. I can do everything I used to do before. I’m excited to be myself again.”

Read more here

Epilepsy surgery can improve children's behavior and mood

Children who undergo specific types of epilepsy surgery have shown to have their mood and behavior to be substantially improved post-surgery.

Certain types of epilepsy surgery led to significant improvements in children's mood and behavioral problems, a researcher said.

Children undergoing left-side resections were more likely to show neuropsychiatric symptom improvements if the target was in the frontal rather than the temporal lobe, while those having right-side surgeries had improvements irrespective of site, said Elizabeth Andresen, PhD, of theCleveland Clinic's Neurological Institute.

Relatively little improvement was seen in mood or behavioral symptoms in children with left-side temporal lobe seizure foci, but the baseline symptom burden was relatively lower to begin with, she said at a press briefing prior to her platform talk at the annual meeting of the American Epilepsy Society.

Andresen noted that neuropsychiatric complaints are extremely common in children with epilepsy. Previous studies have found a nearly five-fold increase in risk of such disorders in such children compared with the general population, and a 2.5-fold risk increase relative to children with other chronic diseases.

Some other studies have found improvements in such symptoms following epilepsy surgery, she said, but they had not examined whether the benefit varied with the surgical site, either by hemisphere or by lobe.

The study was based on a combination of child self-reports and parental assessments using standard instruments, administered before and after 100 surgeries in pediatric epilepsy patients. Of 54 left hemisphere resections, 38 were in the temporal lobe and 16 in the frontal lobe; of 46 right-sided surgeries, 26 were in the temporal lobe and 20 in the frontal.

At patients' neuropsychological evaluation after surgery, 83% were seizure-free. At last follow-up an average of 5 years after surgery, 57% of the cohort still had not had a recurrence of seizures. Patients were from 5 to 16 years of age (mean 11) at surgery, with mean duration of epilepsy symptoms of 5.3 years (SD 3.6).

In children with left-side resections, normalized T-scores for anhedonia, social anxiety, and withdrawn/depressed symptoms declined significantly for those with frontal lobe targets compared with temporal lobe patients.

• Anhedonia: 59 pre, 50 post in frontal lobe; 50 pre, 50 post in temporal lobe (P=0.009)
• Social anxiety: 59 pre, 42 post in frontal lobe; 49 pre, 48 post in temporal lobe (P=0.001)
• Withdrawn/depressed: 59 pre, 55 post in frontal lobe; 58 pre, 50 post in temporal lobe (P=0.039)

For right-sided surgeries, targets in both lobes were associated with declines in a "social problems" composite. Normalized T-scores for this measure declined from 69 to 64 with frontal lobe procedures and from 59 to 56 with temporal lobe resections (P=0.001 with respect to time and P=0.005 between groups).

Depression was significantly relieved after surgery when Andresen and colleagues analyzed the entire 100-patient cohort. Among the 25 patients rated as depressed prior to surgery, 64% were no longer depressed at follow-up.

Similarly, anxiety resolved in 60% of children with presurgical symptoms, Andresen reported.

She noted that 6% of children who had no symptoms of depression before surgery developed symptoms by the time of follow-up, and 11% of the cohort showed new postsurgical anxiety. But she said rates of emergent depression and anxiety symptoms were similar in a group of epileptic children not undergoing surgery who underwent the same neuropsychological testing.

Read more here

Sleep apnea symptoms persist after adenoid and tonsil removal in children

A study claims that children with severe obstructive sleep apnea saw residual sleep apnea symptoms following an adenotonsillectomy procedure.

Children with severe obstructive sleep apnea before adenotonsillectomy were more likely to experience residual symptoms after surgery, according to findings in a retrospective study.

Researchers evaluated data from 283 children younger than 3 years (mean age, 22 months). Each child underwent a preoperative polysomnogram between 2002 and 2010.

Of the study population, 61.8% were boys and 84.8% were black. According to their BMI, 46.7% of the children were obese, whereas 33.1% were classified as having a healthy weight. At baseline, 65.7% of the children had a severe apnea hypopnea index (>10).

Seventy of the children also underwent a post-adenotonsillectomypolysomnogram after a mean time of 7.7 months. Compared with the children who only underwent a preoperative polysomnogram, those who had preoperative and postoperative polysomnograms were younger (23 vs. 20 months; P=.002), shorter (81 cm vs. 79 cm; P=.04) and weighed less (13 kg vs. 11 kg; P=.01). They were also more likely to have had a severe index before surgery (22 vs. 35; P=.002) and lower mean minimal oxygen saturations (83% vs. 77%; P<.001).

Fifteen of the 70 children had residual obstructive sleep apnea (index, >5) and a significantly higher preoperative index (P=.02) compared with those without residual symptoms. However, these 15 children had a mean apnea hypopnea index that dropped from 55 to 21 (P=.03), whereas mean minimum oxygen saturations increased from 74% to 82% (P=.09) after surgery.

“Our data support the finding that, although [adenotonsillectomy] leads to a dramatic improvement in this age group, a high proportion of this population will have residual [obstructive sleep apnea],” the researchers wrote. “Although this proportion gives some insight into residual disease after [adenotonsillectomy] in this young population, the result is flawed because of the retrospective design of the study and the fact that only 25% of the children treated received postoperative [polysomnogram].”

Read more here

Predictors of success of epilepsy surgery

New research uses different factors to determine the potential success of epilepsy surgery.

According to this research, developed by researchers of the UPM, CSIC and the Princesa Hospital, personality style, intelligence quotient and hemisphere of seizure origin are factors that would help to predict successfully these surgeries, what would be helpful for surgeons. Researchers reached these conclusions by using predictive models based on machine learning techniques.

Epilepsy surgery is effective in reducing both number and frequency of seizures, particularly in patients withtemporal lobe epilepsy (TLE). However, a significant proportion of these patients continues suffering seizures after surgery.

In order to have information about the results before surgery, researchers from the Computational Intelligence Group of the Schools of Computing UPM assessed the influence of a battery of medical and psychological factors using predictive models developed from machine learning approaches.

They have identified three "very relevant" elements: the hemisphere of seizure origin, intelligence quotient and personality style (applying the Rorschach test). Researchers have obtained a success rate of 90% in terms of predicting the outcome after surgery by using advanced mathematical models for its combination.

From the researcher's point of view, this study opens the door for integration of complex mathematical models in previous assessment of surgeries. The team of medical assessor will have numerical results about the success of the surgery which are known as decision support tools.

Read more here

Predicting seizures in children during pre-surgical monitoring

A recent study shows how seizures are predicted in children during pre-surgical monitoring.

Long–Term–Monitoring (LTM) is a valuable tool for seizure localization/lateralization among children with refractory–epilepsy undergoing pre–surgical–monitoring. The aim of this study was to examine the factors predicting occurrence of single/multiple seizures in children undergoing pre–surgical monitoring in the LTM unit. Majority of the admissions (92%) admitted to the LTM–unit for pre–surgical workup had at–least one seizure during a mean length of stay of 5.24 days. Home seizure–frequency was the only predictor influencing occurrence of single/multiple seizures in the LTM unit. Patients with low seizure–frequency are at risk for completing the monitoring with less than the optimum number (<3) of seizures captured.

Methods

• Chart review was done on 95 consecutive admissions on 92 children (40 females) admitted to the LTM-unit for pre-surgical workup.
• Relationship between occurrence of multiple (≥3) seizures and factors such as home seizure-frequency, demographics, MRI-lesions/seizure-type and localization/AED usage/neurological-exam/epilepsy-duration was evaluated by logistic-regression and survival-analysis.
• Home seizure-frequency was further categorized into low (up-to 1/month), medium (up-to 1/week) and high (>1/week) and relationship of these categories to the occurrence of multiple seizures was evaluated.
• Mean length of stay was 5.24 days in all 3 groups.

Results

• Home seizure frequency was the only factor predicting the occurrence of single/multiple seizures in children undergoing presurgical workup.
• Other factors (age/sex/MRI-lesions/seizure-type and localization/AED-usage/neurological-exam/epilepsy-duration) did not affect occurrence of single/multiple seizures or time-to-occurrence of first/second seizure.
• Analysis of the home-seizure frequency categories revealed that 98% admissions in high-frequency, 94% in the medium, and 77% in low-frequency group had at-least 1 seizure recorded during the monitoring.
• Odds of first-seizure increased in high vs. low-frequency group (p=0.01).
• Eighty-nine percent admissions in high-frequency, 78% in medium frequency, versus 50% in low-frequency group had ≥3 seizures.
• The odds of having ≥3 seizures increased in high-frequency (p=0.0005) and in medium-frequency (p=0.007), compared to low-frequency group.
• Mean time-to-first-seizure was 2.7 days in low-frequency, 2.1 days in medium, and 2 days in high-frequency group.
• Time-to-first-seizure in high and medium-frequency was less than in low-frequency group (p<0.0014 and p=0.038).

Read more here

Epilepsy in mouse cured by cell transplant

Researchers were able to control epilepsy and seizures in mice by transporting brain cells.

In an effort to put an end to the debilitating consequences of recurrent seizures and ineffective treatments for epilepsy patients, a cell transplant may be the key.

Researchers from the University of California San Francisco (UCSF) published a study on May 5 in Nature Neuroscience detailing a one-time medial ganglionic eminence (MGE) cell transplant that was able to control the seizures of mice with epilepsy.  MGE cells are a type of progenitor cells that could differentiate into interneurons, or nerve cells that inhibit signaling.

The transplant prevented overactive signaling of nerve cells and was performed in the hippocampus region of the brain that is responsible for learning and memory functions and linked with seizures.  

"These cells migrate widely and integrate into the adult brain as new inhibitory neurons," said Scott Baraban, professor in residence of neurological surgery at UCSF. "This is the first report in a mouse model of adult epilepsy in which mice that already were having seizures stopped having seizures after treatment."

Epilepsies are known to induce violent muscle contractions and, in other cases, loss of consciousness and control which can lead to serious injuries. The condition is a result of excessive and abnormal firing of nerve signals in the brain.

Researchers transplanted these inhibitory cells, which were able to reduce the uncontrollable signals, eliminating seizures in half of the mice and drastically reducing impulsive seizures in the other half.  Specifically, the MGE cells were taken from mouse embryos and, when implanted, they migrated and spawned into interneurons to repair the broken neural system in epileptic mice.

Other positive outcomes from the most recent study included reduced agitation and hyperactivity in mice. The mice also performed better in exercises that tested their learning and memory skills.

In another study, more progress has been done to help predict seizures in epileptic patients who are limited by current treatment options. In this case, electrodes are surgically implanted between the skull and brain and communicate to another electrode in the chest. The data accumulated from this device monitors when a seizure is likely to occur.

According to the Centers for Disease Control and Prevention (CDC), two-thirds of people with epilepsy receive the best outcomes by using drugs to control seizures, while the remaining population only benefit partially and experience a recurrence of seizures. However, researchers say some of these therapeutic options have no significance at all.

"Our results are an encouraging step toward using inhibitory neurons for cell transplantation in adults with severe forms of epilepsy," said Barbaran. "This procedure offers the possibility of controlling seizures and rescuing cognitive deficits in these patients."

Read more here

Compulsive Eating Eased by Brain Surgery

A 10-year old girl who suffered compulsive eating caused by a benign brain tumor has the compulsive eating under control after brain surgery to remove the tumor.

Removal of a rare type of benign brain tumor helped bring a young girl's compulsive eating under control, doctors report.

The 10-year-old had what's known as a hypothalamic hamartoma -- a tumor in or around the brain's hypothalamus. One of the symptoms of this type of tumor is extremely early (precocious) puberty, as well as compulsive eating and excessive weight gain.

As reported online April 9 in the Journal of Neurosurgery: Pediatrics, by age 10 the girl already weighed 227 pounds and was gaining an average of five more pounds each month. Medication and counseling did nothing to curb her overeating.

Despite the fact that there was no record of it having been done before, neurosurgeons at the University of Texas-Houston and Children's Memorial Hermann Hospital in Houston decided to remove the girl's hypothalamic hamartoma in an effort to curb her overeating. The doctors called it a "last-ditch effort."

"The decision to proceed with this surgery was undertaken with great thought and after numerous discussions with the patient's family," Dr. David Sandberg, one of the study authors, said in a journal news release. "We were cautious about proceeding with a major operation in which the probability of success was completely unknown."

However, the surgery went well, the girl's appetite immediately lessened and she began eating smaller portions. Eighteen months after the surgery, her weight was still the same as it was before the operation. But it no longer increased, which was the goal of the surgery.

"The patient, her family, and treating physicians were all delighted with the outcome," Sandberg said.

Read more here

Minimal resections equally effective as larger resections in some epileptic children

This article discusses how minimal resections are shown to be equally as effective as larger resections in some children who have epilepsy.

Smaller lesionectomy resections in the surgical treatment of seizures appear to be just as effective as larger resections in select children, sparing patients the functional and developmental deficits associated with the larger resections, a new study suggests.

Lesionectomy, or removal of abnormal lesions seen on MRI, has been well documented to control seizures for the majority of patients with epilepsy; however, when patients with intractable epilepsy have normal MRI findings, the procedure is more complicated, lead author Prasanna Jayakar, MD, director of the Neuroscience Center and chairman of the Brain Institute at Miami Children's Hospital in Florida, told Medscape Medical News.

"In children with normal MRIs, surgeries are guided by functional abnormalities that are often diffuse and lead to large resections involving an entire lobe or multiple lobes," he said. Although large resections are better for controlling seizures, they may involve critical regions and risk functional outcomes.

To determine whether such large resections can be safely avoided, Dr. Jayakar and his team developed a minimally resective strategy, dubbed "functional lesionectomy," in which integrated data from various modalities helps identify the "epicenter" of functional abnormalities for removal.

Their early findings with this novel technique offer important evidence suggesting that the approach does not compromise outcomes.

"Generally most centers believe that children with normal MRI require large resections in order to achieve seizure control," he said. "To our knowledge this is the first such report of restricted resections in this patient population."

Their findings were presented here at the American Epilepsy Society (AES) 66th Annual Meeting.

Intractable Partial Epilepsy

The researchers reported on the outcomes of 25 children with MRI-negative, intractable partial epilepsy who underwent focal corticectomies at Miami Children's Hospital between 2005 and 2011.

The modalities used to identify the epileptogenic region included 3-dimensional electroencephalography (EEG) source localization, single-photon emission computed tomography (SPECT), positron emission tomography (PET), and invasive EEG data that used co-registration software.

The results showed seizure freedom in 3 of 7 (43%) children with type I focal cortical dysplasia, 7 of 12 (58%) children with type II focal cortical dysplasia, and 3 of 6 (50%) with mild malformations of cortical development.

Resections were considered complete in 7 patients and incomplete in 18; however, the outcomes were unrelated to completeness of resection, suggesting that smaller resections did not worsen outcomes.

A greater number of convergent functional modalities was associated with improved outcome, and all 3 of the histopathologic classes were seen in each Engel outcome class.

Most children with Engel class IV outcomes showed data convergence of fewer functional modalities than that seen in almost all children in more favorable outcome classes.

In all cases, the corticectomies were convergent with scalp EEG, and 11 of 12 cases used 3-dimensional EEG for the localization of scalp interictal data.

Ictal SPECT scans showed convergent, focal hyperfusion in 10 of 15 patients, and 12 of 17 patients who underwent PET had convergent regions of hypometabolism. Two had highly localized, convergent hypermetabolic areas.

Intraoperative electrocorticography showed convergent interictal or ictal discharges in 23 children, and 24 experienced ictal onset in corresponding regions in extraoperative subdural monitoring.

Spark Interest

According to epilepsy expert Sanjeev Kothare, MD, the functional lesionectomy concept is indeed in its early stages, but the approach's potential should spark interest.

"As of now, small is not good because we believe that one should resection the entire epileptogenic zone for seizure freedom, [but] there may be a role for this approach in select cases," said Dr. Kothare, senior epileptologist at Boston Children's Hospital and associate professor at Harvard Medical School in Massachusetts.

"If proved by other centers and by a larger series of patients, it would mean that minimal resection of the seizure onset zone could help in reduction of seizure burden, and improved quality of life, without irreversible damage to eloquent cortex and irreversible loss of function, such as vision, language, motor and memory."

Read more here

Surgery and Epilepsy in Children

This article discusses epilepsy in children and when medications can be discontinued following surgery. Also there is a discussion of when surgery should be considered as a treatment. JR

Around one in every hundred people worldwide is affected by epilepsy, with 40 per cent of them developing the condition before the age of 15. If patients with epileptic fits do not respond to antiepileptic drugs, epilepsy surgery can be used to remove the part of the brain that is responsible for the fits so that the patient can be free of them. Afterwards, the prompt discontinuation of medication is of significant therapeutic interest. 

Until now, it was not known when the most favourable time was for this without running an increased risk of further fits. Now, an international team of researchers, with collaboration from the MedUni Vienna, has discovered that discontinuing medication even immediately after the operation represents a promising approach.

At the MedUni Vienna and the Vienna General Hospital, the Epilepsy Centre in the Children's Department, which is run by Martha Feucht and Gudrun Gröppel, was involved in the "Time to Stop" study group. The study has now been published in the highly respected journal Lancet Neurology. The study included 766 children and young adults with epilepsy. The result: "If the epilepsy surgery was one hundred per cent successful, patients no longer need to take antiepileptic drugs. 

Early and rapid discontinuation of the medication after the operation does not influence the subsequent outcome of the recovery," says Feucht. "On the contrary, early discontinuation 'unmasks' any inadequate surgical results and therefore leads to new diagnostic procedures more quickly." Most centres have so far waited at least two years before even discussing any attempt to discontinue medication. "This means a major improvement in the quality of life of children affected by the condition, and better chances of post-operative development that is as free from problems as possible," explains the MedUni scientist.  "Epilepsy surgery procedures are already being carried out on small children aged just a few months. The younger the patients are, the more important these findings are for them." 

Two types of epilepsy suitable for surgical intervention

There are generally two types of epilepsy that are amenable to surgical intervention: symptomatic and cryptogenic epilepsy. The condition is referred to as being symptomatic if there is a known cause (e.g. a tumour or following birth trauma), while the term cryptogenic means "hidden". In this case, the cause is unclear. There is also a condition known as genetic epilepsy, which is primarily hereditary and which can be treated very effectively with medication.
 
Read more here

Asthma drugs may help children avoid sleep apnea surgery

A study looks into how an asthma medication may alleviate sleep apnea symptoms in some people.

A new study suggests that a common asthma drug may be able to help children with sleep apnea avoid surgery.

Children with obstructive sleep apnea may be tired by day, have trouble paying attention in school, and have other behavioral problems because they are not getting enough quality sleep at night.

Surgery to remove the tonsils and adenoids is often recommended, but many parents are reluctant to subject their kids to any type of surgery.

New research in the September 2012 issue of Pediatrics suggests an allergy andasthma drug -- montelukast (Singulair, which just went generic) -- may lessen symptoms in children with non-severe apnea and potentially allow them to skip the surgery.

Sleep apnea is marked by pauses in breathing while asleep. Sleep apnea is often a result of an obstruction in the airway, with severity of children's sleep apnea linked to the size of tonsils and adenoids. These pauses can occur throughout the night and disrupt sleep.

Asthma Drug Improves Apnea Symptoms

Forty-six children with non-severe sleep apnea received the asthma drug or aplacebo for 12 weeks. The kids who received the drug showed improvements in tests measuring the degree of their sleep apnea, their sleep-related symptoms, and the size of their adenoids compared to their counterparts who didn't. There were no side effects seen among kids who took the study drug.

Study authors are quick to caution that this study is small and it's preliminary. Bigger studies following more children for longer periods of time are needed before this treatment is offered to any kids with sleep apnea.

Michael Rothschild, MD, also urges caution in interpreting the new findings. He is the director of pediatric otolaryngology at Mount Sinai Medical Center in New York City.

It's too early to recommend montelukast for the treatment of sleep apnea in kids. But, "it does make sense," he says. "The drug reduces inflammation in the nose and adenoids."

That said, longer follow-up is needed. "Let's do a big, long-term study in a bigger group of kids and follow them for six months or one year."

Until then, if you think your child has sleep apnea, the first step is to confirm this suspicion. "With kids, the risk is not stopping breathing, but more that it is disturbing their sleep," he says.

Sleep apnea in children may be measured in several ways. These include:

• The gold standard sleep study conducted overnight in a lab
• A home sleep study where children are hooked up to a monitor while they sleep
• Videotaping of the child in the throes of what parents believe to be an apnea episode

Drug May Be Band-Aid, Not Cure

Parents also need to know that while no one wants their children to undergo surgery, removal of tonsils and adenoids is safe. "Parents often say 'anything but surgery,' and 99.9% of the time, they are terrified of anesthesia," Rothschild says.

Yosef Krespi, MD, is the director of the Center for Sleep Disorders at the New York Head & Neck Institute of Lenox Hill Hospital in New York City.

He says the allergy and asthma drug may be more of a Band-Aid, but is likely not a cure for sleep apnea in kids. "The follow-up is too short and the number of cases is too limited," he says.

There are often several factors that cause sleep apnea, and this only addresses one of them, he says.

Read more here

New Laser Surgery can help Children with Epilepsy

Removing part of a patient's brain is the traditional way to cure certain kinds of epilepsy, but the complications can be worse than the seizures themselves.

Now, there is a new high-tech and low-risk way to erase epilepsy. It is a medical first.

Robin and Khris Dysart say their son Keagan had gelastic seizures that sounded like laughter three times every hour.

A craniotomy was the best chance for a cure. Surgeons may have to take out normal brain tissue to move the lesion causing the seizures. Complications can include paralysis, uncontrolled urination, and death.

Keagan’s mother Robin says, "There were lists of children who have died."

Dr. Angus Wilfong adds, "You can't put back brain that you wish you hadn't taken out."

To avoid taking out any brain, Dr. Angus Wilfong and Dr. Daniel Curry of Texas Children's Hospital developed a low-risk, minimally invasive, MRI-guided laser surgery to cure epilepsy.

Keagan was one of their first patients.

The instrument used is smaller than the size of a pencil lead piece, according to Dr. Wilfong.

The doctors navigated their way to Keagan's deep-seated lesion.

With the MRI, they were able to see in real time exactly where they were in Keagan's brain. The doctors watched the laser destroy the lesion and cure Keagan's epilepsy.

"That's exactly what's happening and it's really amazing to see."

Today, Keagan is seizure free.

Robin says, "Now, the world has opened up to him."

He loves basketball and says, "I've been practice dribbling."

His life has been forever changed by a laser.

Texas Children's Hospital is the first in the world to perform the MRI-guided laser surgery to cure epilepsy.

The procedure was adopted from a technique to treat brain tumors.

It's now being used for kids and adults. The doctors tell us some of their patients go home the day after their brain surgery.

RESEARCH SUMMARY

BACKGROUND: Gelastic seizures are epileptic events characterized by bouts of laughter. Laughter-like vocalization is usually combined with facial contraction in the form of a smile. Gelastic epilepsy is very rare and occurs slightly more commonly in boys than in girls. Of every 1000 children with epilepsy, only one or at the very most, two children will have gelastic epilepsy. (SOURCE: www.epilepsyfoundation.org, www.ncbi.nlm.nih.gov/pubmedhealth)

The gelastic and other types of seizures are often very difficult to control. It is rare for anyone to have their seizures controlled for more than a few weeks or months at a time. The best outcome is probably seen in those children (and adults) who have a benign tumor in the hypothalamus (the hamartoma or astrocytoma) causing their epilepsy. Successful surgery in these children and adults may improve not just their seizure control but also improve their behavioral and even learning problems. (SOURCE: epilepsy.org.uk)

TREATMENT: The type of treatment prescribed will depend on several factors including the frequency and severity of the seizures as well as the person's age, overall health, and medical history. The majority of epileptic seizures are controlled through drug therapy. Patients may take a drug called anticonvulsants, to reduce the number of seizures they experience. Patients may also make changes to their diet. In certain cases in which medications and diet are not working, surgery may be used. (SOURCE: www.ncbi.nlm.nih.gov/pubmedhealth, www.webmd.com)

LATEST BREAKTHROUGHS: Real-time MRI-guided thermal imaging and laser technology is now being used to destroy lesions in the brain that cause epilepsy and uncontrollable seizures. The surgery is performed by first mapping the area of the brain where the lesion is located using magnetic resonance imaging. The catheter is inserted through the skull in the operating room and then the patient is transferred to an MRI unit where the ablation of the lesion is performed. The MRI confirms probe placement in the target, and the magnetic resonance thermal imaging allows the surgeon to see the ablation of the lesion by the laser heat as it happens with an automatic feedback system that shuts the laser off when the heat approaches nearby critical brain structures.

Read more here

ICU Might Not Be Necessary After Sleep Apnea Surgery

After undergoing surgery for obstructive sleep apnea, patients require close monitoring but may not need to be in an intensive care unit, according to a new study.

Obstructive sleep apnea is a disorder in which a person experiences abnormal pauses in breathing while they sleep. Sleep apnea can put people at risk of high blood pressure, stroke and heart problems.

Treatments include losing weight and continuous positive airway pressure (CPAP) devices, although some people may need surgery.

The surgery itself carries risks, however, the experts note. These include post-operative breathing difficulties, so patients are often placed in ICUs afterward.

But is that always necessary? To find out, researchers at the Pacific Sleep Centre in Singapore reviewed the cases of nearly 500 sleep apnea patients who had surgery between early 2007 and mid-2010. The surgeries included nasal, palate and tongue procedures.

The overall complication rate was 7 percent, according to the study, which appears online March 19 in the Archives of Otolaryngology -- Head & Neck Surgery.

Patients who undergo surgery for sleep apnea will end up with small lower jaws, making airway access difficult for anesthesiologists, the researchers noted. Another risk is dangerously slowed breathing due to anesthetics such as muscle relaxants and narcotics.

While routine admission to the ICU may not be necessary for all patients who've just had sleep apnea surgery, all patients should be closely monitored in the recovery or high-dependency area (one step below intensive care) for at least 3 hours after surgery, the researchers suggested.

"In conclusion, we strongly recommended that the clinician manage the patient with OSA [obstructive sleep apnea] with caution and prudence, with the understanding that these patients have a higher risk of airway compromise and respiratory depression intraoperatively and postoperatively," they wrote.

Dr. Lisa Liberatore, an ear, nose and throat specialist at Lenox Hill Hospital in New York City, said sleep apnea patients often have other medical issues that may raise surgical risks.

Because of the risks, surgeons should proceed with caution and patients should first try other, non-surgical treatments, she said.

"I recommend that the patient use CPAP first and lose at least 20 to 30 pounds before doing any surgery," Liberatore said.

Read more here