Ethical Issue as the Limiting Factor for Epilepsy Surgery

2020 ◽  
Vol 9 (03) ◽  
pp. 097-099
Author(s):  
Satyanarayana Gedela ◽  
Christian Korff
Keyword(s):  
Ethical Issue ◽  
Epilepsy Surgery ◽  
Neurological Disorders ◽  
Focal Epilepsy ◽  
Intractable Epilepsy ◽  
Limiting Factor ◽  
Medical Treatments ◽  
Rasmussen’S Encephalitis ◽  
The Right ◽  
Available Resources

AbstractEpilepsy is one of the most common neurological disorders with almost one-third of these patients becoming intractable to medical treatments. For some of these patients, epilepsy surgery could be the best option. There are lot of disparities in caring of the epilepsy patients. There are multiple limitations in offering epilepsy surgery for the medically intractable epilepsy patients, resulting in almost 19 years gap from the diagnosis of intractable epilepsy to epilepsy surgery. These limitations range from patient or parental fear to lack of available resources. Sometimes we face an ethical issue being the limitation from doing the right thing for the patient. We want to share our experience with one of our patients with symptomatic medically intractable focal epilepsy from Rasmussen’s encephalitis who could not get the epilepsy surgery treatment because of an ethical issue.

scholarly journals Multimodal localization and surgery for epileptic spasms of focal origin: a review

2018 ◽  
Vol 45 (3) ◽  
pp. E4 ◽  
Author(s):  
Taylor J. Abel ◽  
Emma Losito ◽  
George M. Ibrahim ◽  
Eishi Asano ◽  
James T. Rutka
Keyword(s):  
Epilepsy Surgery ◽  
Focal Epilepsy ◽  
Intractable Epilepsy ◽  
Epileptogenic Zone ◽  
Invasive Monitoring ◽  
Current State ◽  
Epileptic Spasms ◽  
Clinical Series ◽  
Postoperative Seizure ◽  
Monitoring Technologies

Epileptic spasms (ES) are a common manifestation of intractable epilepsy in early life and can lead to devastating neurodevelopmental consequences. Epilepsy surgery for ES is challenging because of inherent difficulties in localizing the epileptogenic zone in affected infants and children. However, recent clinical series of resective neurosurgery for ES suggest that not only is surgery a viable option for appropriately selected patients, but postoperative seizure outcomes can be similar to those achieved in other types of focal epilepsy. Increased awareness of ES as a potentially focal epilepsy, along with advances in neuroimaging and invasive monitoring technologies, have led to the ability to surgically treat many patients with ES who were previously not considered surgical candidates. In this study, the authors review the current state of epilepsy surgery for ES. Specifically, they address how advances in neuroimaging and invasive monitoring have facilitated patient selection, presurgical evaluation, and ultimately, resection planning.

Amygdalar neuromelanosis intractable epilepsy without leptomeningeal involvement

2013 ◽  
Vol 12 (1) ◽  
pp. 21-24 ◽  
Author(s):  
Douglas R. Taylor ◽  
Scott D. Wait ◽  
James W. Wheless ◽  
Frederick A. Boop
Keyword(s):  
Epilepsy Surgery ◽  
Mononuclear Cells ◽  
Intractable Epilepsy ◽  
Early Death ◽  
Temporal Lobectomy ◽  
Leptomeningeal Disease ◽  
Rare Presentation ◽  
Leptomeningeal Involvement ◽  
The Right ◽  
Neurological Surgery

Neurocutaneous melanosis (NCM) is a rare, congenital neuroectodermal dysplasia generally resulting in early death from neurological decline due to leptomeningeal involvement. Nonmeningeal CNS epileptogenic lesions presenting in later childhood in the absence of leptomeningeal disease are rare. This report summarizes a rare presentation and curative epilepsy surgery. The authors discuss the case of a 14-year-old girl with NCM who originally presented with intractable partial-onset seizures. The MRI, PET, and SPECT studies subsequently revealed a focal epileptogenic source in the right temporal lobe. Results of video-electroencephalography monitoring concurred with the imaging findings, and a right temporal lobectomy was performed including the medial structures. Following surgery, histopathological features of the lesion included multiple scattered mononuclear cells with brown pigmentation in the amygdala specimen. The patient remains seizure free 2 years postresection, and no longer needs medication for seizure management. This patient presented with an atypical CNS manifestation of NCM that is curable by epilepsy surgery. Her intractable epilepsy developed secondary to amygdalar neuromelanosis, which had no associated leptomeningeal melanosis, an uncommon occurrence. As evidenced by the lack of seizure activity following resection, the patient's quality of life greatly improved after neurological surgery.

Biochemical and Histopathological Evaluation of the Radioprotective Effects of Melatonin Against Gamma Ray-Induced Skin Damage

2019 ◽  
Vol 12 (1) ◽  
pp. 72-81 ◽  
Author(s):  
Dheyauldeen Shabeeb ◽  
Masoud Najafi ◽  
Ahmed Eleojo Musa ◽  
Mansoor Keshavarz ◽  
Alireza Shirazi ◽  
...  
Keyword(s):  
Gamma Ray ◽  
Histopathological Examination ◽  
Radical Scavenging ◽  
Limiting Factor ◽  
Skin Damage ◽  
Exposed Skin ◽  
Male Wistar Rats ◽  
Time Periods ◽  
Skin Damages ◽  
The Right

Background:Radiotherapy is one of the treatment methods for cancers using ionizing radiations. About 70% of cancer patients undergo radiotherapy. Radiation effect on the skin is one of the main complications of radiotherapy and dose limiting factor. To ameliorate this complication, we used melatonin as a radioprotective agent due to its antioxidant and anti-inflammatory effects, free radical scavenging, improving overall survival after irradiation as well as minimizing the degree of DNA damage and frequency of chromosomal abrasions.Methods:Sixty male Wistar rats were randomly assigned to 4 groups: control (C), melatonin (M), radiation (R) and melatonin + radiation (MR). A single dose of 30 Gy gamma radiation was exposed to the right hind legs of the rats while 40 mg/ml of melatonin was administered 30 minutes before irradiation and 2 mg/ml once daily in the afternoon for one month till the date of rat’s sacrifice. Five rats from each group were sacrificed 4, 12 and 20 weeks after irradiation. Afterwards, their exposed skin tissues were examined histologically and biochemically.Results:In biochemical analysis, we found that malondialdehyde (MDA) levels significantly increased in R group and decreased significantly in M and MR groups after 4, 12, and 20 weeks, whereas catalase (CAT) and superoxide dismutase (SOD) activities decreased in the R group and increased in M and MR groups during the same time periods compared with the C group (p<0.05). Histopathological examination found there were statistically significant differences between R group compared with the C and M groups for the three different time periods (p<0.005, p<0.004 and p<0.004) respectively, while R group differed significantly with MR group (p<0.013). No significant differences were observed between C and M compared with MR group (p>0.05) at 4 and 20 weeks except for inflammation and hair follicle atrophy, while there were significant effects at 12 weeks (p<0.05).Conclusion:Melatonin can be successfully used for the prevention and treatment of radiation-induced skin injury. We recommend the use of melatonin in optimal and safe doses. These doses should be administered over a long period of time for effective radioprotection and amelioration of skin damages as well as improving the therapeutic ratio of radiotherapy.

Reorganization of the Right Arcuate Fasciculus Following Left Arcuate Fasciculus Resection in Children With Intractable Epilepsy

2011 ◽  
Vol 26 (10) ◽  
pp. 1246-1251 ◽  
Author(s):  
Dhruman Goradia ◽  
Harry T. Chugani ◽  
Rajkumar Munian Govindan ◽  
Michael Behen ◽  
Csaba Juhász ◽  
...  
Keyword(s):  
Intractable Epilepsy ◽  
Arcuate Fasciculus ◽  
The Right

scholarly journals Examining resource availability and usefulness in a National Health Service Research Interprofessional Postdoctoral Fellowship Program

2021 ◽  
Vol 3 (1) ◽  
Author(s):  
Jennifer L. Bryan ◽  
Megan E. Gregory ◽  
Charnetta R. Brown ◽  
Annette Walder ◽  
Joshua D. Hamer ◽  
...  
Keyword(s):  
Resource Availability ◽  
Fellowship Training ◽  
Perceived Usefulness ◽  
Service Research ◽  
Fellowship Program ◽  
Services Research ◽  
Research Fellowship ◽  
The Right ◽  
Postdoctoral Fellowship ◽  
Available Resources

AbstractPostdoctoral fellowships are costly: institutions incur substantial monetary costs, and fellows suffer the opportunity cost of delaying entry into their professional careers. Nevertheless, fellowship training is a beneficial academic investment; the right resources can attract high-quality candidates and maximize return on investment for all parties. This study examined the availability and perceived utility of training resources in a national, multisite interprofessional health services research fellowship program and examined differences in resource perception between alumni and directors as well as M.D. and Ph.D. alumni. One-hundred thirty-one alumni and 15 directors from a multisite interprofessional postdoctoral fellowship completed surveys regarding fellowship resources. Results from the fellowship sample as a whole revealed that mentoring and seminars were the most commonly available resources in fellowships and alumni from the same site often disagreed about resource availability. When we compared alumni and directors’ responses from the same site, we found they often disagreed about resource availability, with directors often being more likely to respond that the resource is available than the alumni. Finally, M.D. alumni reported availability of more resources and found resources to be more useful overall than Ph.D. alumni. Mentoring and seminars are important and commonly provided resources for trainees in fellowship programs; however, M.D.s and Ph.D.s vary in perceived usefulness of other resources, suggesting that one resource does not fit all. Given the gap, postdoctoral fellows may benefit from direct communication of available resources. Moreover, as Ph.D. fellows reported less resource availability and usefulness, attention should be given to meeting their unmet needs. Taken together, this will optimize their fellowship experience, thus better preparing them for their career and, ultimately, their impact on health care.

Informed Consent in the Military: Fighting a Losing Battle Against the Anthrax Vaccine

2002 ◽  
Vol 28 (2-3) ◽  
pp. 325-343
Author(s):  
Ruth K. Miller
Keyword(s):  
Informed Consent ◽  
Service Member ◽  
Individual Choice ◽  
Civilian Life ◽  
Medical Treatments ◽  
Employment History ◽  
Receive Treatment ◽  
The Right ◽  
The Military ◽  
To Receive

In civilian life, an individual has the right to refuse medical treatment in almost any circumstance. While a patient who refuses treatment may face adverse consequences such as prolonged illness, our society recognizes the importance of individual choice in health matters. Members of the military, however, enjoy no such right. Service members are required to submit to certain medical treatments as a part of their employment contract. Refusing such treatments is disobeying an order, and the service member then faces the prospect of a dishonorable or “other than honorable” discharge, and even imprisonment. Disobeying an order to receive treatment can thus result in the equivalent of a felony conviction on the individual's employment history forever.

Relationship between hospital surgical volume, lobectomy rates, and adverse perioperative events at US epilepsy centers

2013 ◽  
Vol 118 (1) ◽  
pp. 169-174 ◽  
Author(s):  
Dario J. Englot ◽  
David Ouyang ◽  
Doris D. Wang ◽  
John D. Rolston ◽  
Paul A. Garcia ◽  
...  
Keyword(s):  
Relative Risk ◽  
Epilepsy Surgery ◽  
Intractable Epilepsy ◽  
High Volume ◽  
Population Based ◽  
Treatment Center ◽  
Surgical Volume ◽  
Related Factors ◽  
Perioperative Morbidity ◽  
Low Volume

Object Epilepsy surgery remains significantly underutilized. The authors recently reported that the number of lobectomies for localized intractable epilepsy in the US has not changed despite the implementation of clear evidence-based guidelines 10 years ago supporting early referral for surgery. To better understand why epilepsy surgery continues to be underused, the authors' objective was to carefully examine hospital-related factors related to the following: 1) where patients are being admitted for the evaluation of epilepsy, 2) rates of utilization for surgery across hospitals, and 3) perioperative morbidity between hospitals with low versus high volumes of epilepsy surgery. Methods The authors performed a population-based cohort study of US hospitals between 1990 and 2008 using the Nationwide Inpatient Sample (NIS), stratifying epilepsy surgery rates and trends as well as perioperative morbidity rates by hospital surgical volume. Results The number of lobectomies for epilepsy performed at high-volume centers (> 15 lobectomies/year) significantly decreased between 1990 and 2008 (F = 20.4, p < 0.001), while significantly more procedures were performed at middle-volume hospitals (5–15 lobectomies/year) over time (F = 16.1, p < 0.001). No time trend was observed for hospitals performing fewer than 5 procedures per year. However, patients admitted to high-volume centers were significantly more likely to receive lobectomy than those at low-volume hospitals (relative risk 1.05, 95% CI 1.03–1.08, p < 0.001). Also, the incidence of perioperative adverse events was significantly higher at low-volume hospitals (12.9%) than at high-volume centers (6.1%) (relative risk 1.08, 95% CI 1.03–1.07, p < 0.001). Conclusions Hospital volume is an important predictor of epilepsy surgery utilization and perioperative morbidity. Patients with medically refractory epilepsy should be referred to a comprehensive epilepsy treatment center for surgical evaluation by an experienced clinical team.

scholarly journals Chronic (Rasmussen’s) Encephalitis in an Adult

2003 ◽  
Vol 30 (3) ◽  
pp. 263-265 ◽  
Author(s):  
Richard Wennberg ◽  
Sukriti Nag ◽  
Mary-Pat McAndrews ◽  
Andres M. Lozano ◽  
Richard Farb ◽  
...  
Keyword(s):  
Visual Field ◽  
Right Visual Field ◽  
Loss Of Consciousness ◽  
Mild Head Injury ◽  
Partial Seizures ◽  
Complex Partial Seizures ◽  
The Past ◽  
Rasmussen’S Encephalitis ◽  
The Face ◽  
The Right

A 24-year-old woman was referred because of incompletely-controlled complex partial seizures. Her seizures had started at age 21, after a mild head injury with brief loss of consciousness incurred in a biking accident, and were characterized by a sensation of bright flashing lights in the right visual field, followed by numbness and tingling in the right foot, spreading up the leg and to the arm, ultimately involving the entire right side, including the face. Occasionally they spread further to involve right facial twitching with jerking of the right arm and leg, loss of awareness and, at the onset of her epilepsy, rare secondarily generalized convulsions. Seizure frequency averaged three to four per month. She was initially treated with phenytoin and clobazam and subsequently changed to carbamazepine 800 milligrams per day. She also complained that her right side was no longer as strong as her left and that it was also numb, especially the leg, but felt that this weakness had stabilized or improved slightly over the past two years.

Empirical methods for assessing meaningful neuropsychological change following epilepsy surgery

1996 ◽  
Vol 2 (6) ◽  
pp. 556-564 ◽  
Author(s):  
Stephen M. Sawrie ◽  
Gordon J. Chelune ◽  
Richard I. Naugle ◽  
Hans O. Lüders
Keyword(s):  
Epilepsy Surgery ◽  
Intractable Epilepsy ◽  
Practice Effects ◽  
Cutoff Score ◽  
Regression To The Mean ◽  
Neuropsychological Battery ◽  
Reliable Change ◽  
Medical Interventions ◽  
The Mean ◽  
Test Retest Reliability

AbstractTraditional methods for assessing the neurocognitive effects of epilepsy surgery are confounded by practice effects, test-retest reliability issues, and regression to the mean. This study employs 2 methods for assessing individual change that allow direct comparison of changes across both individuals and test measures. Fifty-one medically intractable epilepsy patients completed a comprehensive neuropsychological battery twice, approximately 8 months apart, prior to any invasive monitoring or surgical intervention. First, a Reliable Change (RC) index score was computed for each test score to take into account the reliability of that measure, and a cutoff score was empirically derived to establish the limits of statistically reliable change. These indices were subsequently adjusted for expected practice effects. The second approach used a regression technique to establish “change norms” along a common metric that models both expected practice effects and regression to the mean. The RC index scores provide the clinician with a statistical means of determining whether a patient's retest performance is “significantly” changed from baseline. The regression norms for change allow the clinician to evaluate the magnitude of a given patient's change on 1 or more variables along a common metric that takes into account the reliability and stability of each test measure. Case data illustrate how these methods provide an empirically grounded means for evaluating neurocognitive outcomes following medical interventions such as epilepsy surgery. (JINS, 1996, 2, 556–564.)

scholarly journals Utility of diffusion tensor imaging studies linked to neuronavigation and other modalities in repeat hemispherotomy for intractable epilepsy

2016 ◽  
Vol 17 (4) ◽  
pp. 483-490 ◽  
Author(s):  
Erin N. Kiehna ◽  
Elysa Widjaja ◽  
Stephanie Holowka ◽  
O. Carter Snead ◽  
James Drake ◽  
...  
Keyword(s):  
Diffusion Tensor Imaging ◽  
Diffusion Tensor ◽  
Intractable Epilepsy ◽  
Seizure Freedom ◽  
Rasmussen’S Encephalitis ◽  
Initial Procedure ◽  
Surgical Options ◽  
Failed Surgery ◽  
Association Fibers

OBJECT Hemispherectomy for unilateral, medically refractory epilepsy is associated with excellent long-term seizure control. However, for patients with recurrent seizures following disconnection, workup and investigation can be challenging, and surgical options may be limited. Few studies have examined the role of repeat hemispherotomy in these patients. The authors hypothesized that residual fiber connections between the hemispheres could be the underlying cause of recurrent epilepsy in these patients. Diffusion tensor imaging (DTI) was used to test this hypothesis, and to target residual connections at reoperation using neuronavigation. METHODS The authors identified 8 patients with recurrent seizures following hemispherectomy who underwent surgery between 1995 and 2012. Prolonged video electroencephalography recordings documented persistent seizures arising from the affected hemisphere. In all patients, DTI demonstrated residual white matter association fibers connecting the hemispheres. A repeat craniotomy and neuronavigation-guided targeted disconnection of these residual fibers was performed. Engel class was used to determine outcome after surgery at a minimum of 2 years of follow-up. RESULTS Two patients underwent initial hemidecortication and 6 had periinsular hemispherotomy as their first procedures at a median age of 9.7 months. Initial pathologies included hemimegalencephaly (n = 4), multilobar cortical dysplasia (n = 3), and Rasmussen's encephalitis (n = 1). The mean duration of seizure freedom for the group after the initial procedure was 32.5 months (range 6–77 months). In all patients, DTI showed limited but definite residual connections between the 2 hemispheres, primarily across the rostrum/genu of the corpus callosum. The median age at reoperation was 6.8 years (range 1.3–14 years). The average time taken for reoperation was 3 hours (range 1.8–4.3 hours), with a mean blood loss of 150 ml (range 50–250 ml). One patient required a blood transfusion. Five patients are seizure free, and the remaining 3 patients are Engel Class II, with a minimum follow-up of 24 months for the group. CONCLUSIONS Repeat hemispherotomy is an option for consideration in patients with recurrent intractable epilepsy following failed surgery for catastrophic epilepsy. In conjunction with other modalities to establish seizure onset zones, advanced MRI and DTI sequences may be of value in identifying patients with residual connectivity between the affected and unaffected hemispheres. Targeted disconnection of these residual areas of connectivity using neuronavigation may result in improved seizure outcomes, with minimal and acceptable morbidity.

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