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Posted by ccf neuro M.D. on June 02, 1997 at 18:52:27:
In Reply to: seizures post brain tumor surgery posted by Lee Gill on May 28, 1997 at 18:18:39:
: Dear Doctors: On April 15th of 1996, I had a benign meninginoma removed at Barrows Neurological Center by Dr. Spetzler in Phoenix Az. After the surgery Dr. Spetzler said that the surgery went well and I may continue with normal activities including work as a Pharmacist and driving within in 2 weeks. It is now 1 yr and 2 months later and eventhough, I feel I am doing well, a seizure disorder study has been ordered including an invasive procedure of placing plastic strips under possibly affected brain areas. Depending on outcome, surgery may be recommended to remove the part or parts of the brain causing the seizures.. My brain tumor overlapped both the 3 and 4th cranial nerves on the right side of the brain. I have since had surgery to help correct double vision to not much avail. I still have to occlude my right eye. On the latest MRI done in April of 1997. My Neurologist from Barrows pointed out a "graying" of the right hippocampus. My concern, is number one the invasive portion of the siezure studies but especially the surgery to remove the hippocampus. My understanding is that the hippocampus is responsible for control of thought processes. As I am going to school to retrain in Computer Science, I hope you can value my concern. Dr. **** has me on 1 Dilantin 100mg qid. and 0.5mg Klonipin bid. We have tried a number of other medications, all of which I seem to have too many adverse reactions to. In addition I have high cholesterol and triglycerides, which rules out several of the potential medications. I intend to participate in phase one of the seizure studys with no invasive procedures until I can get a better understanding of what I will gain and or lose as far as mental processes and life-style quality. My seizures mainly occur and night and have never been of the Grand Mal type. All have been mixed Partial Seizures. None of the siezures have shown on EEG's or have any of them been observed my medical personnel. What are the risks of the invasive study where platic strips impregnated with electrodes and the procedure of numbing the side of the brain to local speech centers. Am I better off continuing without surgery and/or is The Gamma Knife a possibility. I really don"t want to spend another 6 months getting back to the point of health I am at now. I currently am able to take classes and to have a 3.62 Grade point average. I am gradually able to take short hikes and generally enjoy life. Do the Benefits outweigh the risks?? I would appreciate any help you can give me and references for my type of surgery. Sincerely, Lee Gill R.Ph. 05/28/97.
Lee, You raise some important issues commonly faced in the evaluation for surgical treatment of epilepsy. The Cleveland Clinic has one of the world's largest experiences in epilepsy surgery. Here, we first video-EEG monitor all patients, including the placement of "sphenoidal" electrodes, two small wires that go underneath the skin near the TMJ to sit just beneath the temporal lobes of the brain without actually getting into the brain itself. We will typically withdraw a person from their antiepileptic drugs during this period, and use some common simple maneuvers to increase the odds of seizures occurring during this monitoring period. Only if and when we video record seizures and look at the EEG in conjunction with the video, to see if the seizures are all coming from one general region of the brain, do we consider more invasive testing. Additional tests we often use include a special thin slice MRI of the brain, a PET scan, and WADA or amobarbitol testing--- this invasive procedure is done for purposes of assessing how dominant each hippocampus is for memory, as well as to determine which side of the brain is language dominant. We only do this test if we would be specifically considering removing parts of the brain that might incorporate these functions (hippocampus and/or nearby temporal lobe). The placement of subdural grids is reserved for those exceptional instances in which, despite having obtained all this other data, the exact origin of the seizures is still unclear. Risks of the placement of these grids include meningitis or brain abscess, brain swelling (which can be very dangerous on occasion), cerebrospinal fluid leaks, and bleeding, along with the usual general risks of general anesthesia (heart attacks etc.). Most people do fine despite all these risks, but the experience level of both the surgeon placing the grids AND the expertise of the neurologists interpreting the data gathered from them are absolutely CRITICAL factors in weighing the risks and benefits. Generally speaking, even the
consideration of epilepsy surgery is resreved for those with DISABLING, medically refractory epilepsy; in other words, for those for whom there is really no other effective treatment option. The patient must be medically healthy also (i.e. no major heart/lung disease that might make general anesthesia dangerous). Some newer drugs that have come out that may have at least an additive role for partial seizures include Neurontin, Lamictal, Felbatol (rarely used due to liver damage and anemia problems that are rarely associated with the drugs use but potentially fatal, which has greatly limited its marketing). Soon, an outstanding drug, vigabitrin, will be approved by the FDA and is an excellent first line drug option. The hippocampus itself, in response to your inquiry about its function, is mostly responsible for one thing--- MEMORY; if you remove too much of the dominant hippocampus, you may be left in a state where you can literally not form ANY new memories and this is extraordinarily disabling from a cognitive and occupational standpoint. The most common condition to afflict the hippocampus and cause it to generate seizures is known as mesial temporal sclerosis (MTS). If you would be interested in a second opinion regarding your specific, obviously complex case, it may honestly be worth a trip all the way to Cleveland for someone like you. Alternatively, UCLA medical center in Los Angeles may be a closer alternative for you. Our number at the Cleveland Clinic is 1-800-223-2273 (ext 45559)--- I'd suggest an appointment with either Dr. Hans Luders, our chairman or Dr. Morris, the head of our epilepsy section, for such a particularly complex case. Information provided in the Neurology Forum itself is intended for general medical informational purposes only. The actual diagnosis, treatment of, and management options for your disease should be strictly in conjunction with your treating physician(s). We hope you find the information provided useful. I should also add that our patient education department does
have some general pamphlets on epilepsy and epilepsy surgery. They can be reached at: 216-444-2656.
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