EPILEPSY MONITORING AND SURGERY
BAJAJ ALLIANZ CENTER FOR COMPREHENSIVE EPILEPSY CARE (BACEC)
The Bajaj Allianz Centre For Comprehensive Epilepsy Care is one of the largest centre in India catering to the diagnosis, treatment, awareness and overall welfare of people with epilepsy. In 2015, the comprehensive epilepsy care program of the department of Neurology of this Institute received a facelift when Bajaj Allianz made a generous contribution to augment its facilities and services. Since then, the program had been named as Bajaj Allianz Centre For Comprehensive Epilepsy Care. This centre aims at facilitating and augmenting epilepsy care through a comprehensive care approach backed by sound academic and technological foundations.
This unit is located on 7th floor ‘A’ wing. CONTACT NUMBER -020 4015 1792.
Mission and Vision:-
Medical, surgical, psychosocial and occupational management of persons with epilepsy.
To widely disseminate the knowledge regarding epilepsy and its management among all strata of health care providers and public in order to improve the standards of epilepsy care and dispel the myths, fears and stigma of epilepsy.
Undertake clinical, applied, basic science and translational research and evolve cost-effective investigative and treatment strategies.
Objectives and Functions:-
1.Patient care at tertiary level: The outpatient program of this centre includes evaluation on newly referred patients on a daily basis, review and follow up of more than 120 patients through the two epilepsy clinics, outpatient sessions for evaluation of speech disorders, neuropsychological concerns, occupational needs and behavioural problems and counselling sessions. The experienced epileptologists with special training attend to each patient and offer appropriate recommendations for investigations, management and counsel patients regarding their disorder. The psychosocial issues related to epilepsy are dealt with by expert psychologist/medical social workers and occupational therapist.
The inpatient services is based on the epilepsy monitoring unit with four video-EEG suits running round the clock for the diagnosis of various epilepsy syndromes. We routinely perform 1-2 epilepsy surgeries every week for difficult-to-treat epilepsies which are refractory to drugs. We perform approximately 700 VEEGs and 60-70 epilepsy surgeries every year. Majority of our patients are seizure-free and medication-free after surgery
2. Patient care at community level: We conduct an outreach community-based epilepsy clinics per month in a rural set-up. On an average 50 patients are seen in each clinic. In addition to basic care, patients who require advanced care are referred to RMNC. Through these community-based epilepsy care programs, we educate the primary and secondary care physicians, and educate the public about epilepsy.
3. Research: Active research in the field of epilepsy is an important mission of BACEC. Ongoing research projects include various newer research modalities in pre surgical evaluation of refractory epilepsy including multimodality imaging in temporal lobe and extra temporal epilepsy, positron emission tomography-magnetic resonance imaging (PET-MRI) co-registration.
Procedure Performed: -
VEEG 0-2 hrs.
VEEG 2-4 hrs.
VEEG 6 hrs.
VEEG 12 hrs.
VEEG 24 hrs.
Routine EEG 0-2 hrs. Adult and Paediatric
Polysomnography grade I
Polysomnography grade II
PSG with CPAP titration grade I
PSG with CPAP titration grade II
MSLT (Multiple Sleep Latency Test)
List of Epilepsy Surgeries
Mesial Temporal lobe sx
Focal cortical dysplasia sx
Vagal nerve stimulation
Phase 2 invasive monitoring
Movement disorders Surgeries
DBS for Parkinson Ds
DBS for essential tremors
DBS for dystonia
Selective posterior rhizotomy
Spinal cord stimulators
Intradiscal RF ablation
Facetal nerve ablation
ECOG (Electro Corticography)
SSEP (Somato Sensory Evoked Potential)
MEP (Motor Evoked Potential)
Awards Stereo tubes technique:
A novel substitute for intraoperative MRI in epilepsy surgeries poster presentation by Dr Nilesh Kurwale at European Epilepsy congress 2016, awarded as best innovation poster.
Emergency Epilepsy surgery poster presentation by Dr Sandeep Patil at Neuropedicon 2016, awarded as best poster award.
Hemispherotomy in catastrophic epilepsy poster presentation by Dr Sujit Jagtap at Maharashtra Association of Neurology conference 2017, awarded as best poster award
Paediatric frontal lobe epilepsy: Clinical, electroencephalographic, imaging characteristics and surgical outcome; poster presentation at ECON 2017 at Bangalore, India by Dr Sujit Jagtap
Infantile Epilepsy surgery: Do it early for better outcome; poster presentation by Dr Sandeep Patil at Maharashtra Association of Neurology conference 2017
4 bedded Video EEG lab covered by 24 hrs. Technicians support.
Advanced Sleep Lab (45 channel).
Invasive monitoring facility.
Stereo EEG facility.
Advanced operating theatres including Neuro navigation, Microscopes, Drills.
Intraoperative Neuromonitoring- ECOG, SSEP, MEP, Mapping.
DBS for Epilepsy
A small research unit with a epilepsy specimen laboratory, which stores all the surgical specimen snap freezed at -156 degrees for DNA, RNA and protene extraction.
CONTACT NUMBER -020 4015 1792.
E-mail ID:- firstname.lastname@example.org
Epilepsy Surgery FAQs
1. What is epilepsy?
Epilepsy is a chronic condition in which patients experience recurrent seizures without any provoking cause because of chronic underlying brain etiology. Seizure is just a symptom of epilepsy disorder. Epilepsies can be associated with brain malformations, tumours, previous ischemic insults, infection, birth related injuries etc. Very few patients can have genetic component as well for epilepsy.
2. What are different types of epilepsies?
There are major three types of epilepsies. In first type, no cause can be found out irrespective of all the tests and investigations. These are called as idiopathic one. In other one, there is some obvious cause in brain like tumor or malformation or previous birth injury related changes responsible for epilepsy. These are called as symptomatic epilepsy, which are treatable. The third type is actually a grey area between these where we strongly suspect that there is should be some cause, but with present investigations we cannot find it. These are labelled as cryptogenic one, which should be investigated further.
3. What are treatment modalities for epilepsy?
Single episode of seizure does not constitute epilepsy and hence most of the times you don’t need any treatment. However once epilepsy is diagnosed with careful clinical history and EEG by experienced neurologist or physician, standard modality of treatment is antiepileptic medications. However, if seizures doesn’t respond to antiepileptic medications i.e. they become drug resistant, they can be evaluated and successfully treated with surgery. If surgery does not appear to be feasible after evaluation is complete, such patients can be treated with palliative procedures.
4. What is drug resistant epilepsy?
Generally, patient is prescribed one drug at first and dose is escalated gradually over weeks to control the seizures. 50% of patients benefits from single drug only and epilepsy is controlled. In those, which continue to have seizures after first drug, second drug is started which generally relieves another 15% patients. However, if patient continues to have seizures even after two drugs, the chances of controlling seizures with third drug is minimal. Hence, patients who continue to have seizure after trying two drugs for adequate time, are labelled as drug resistant. Generally, idiopathic epilepsies are well controlled on one medication, but symptomatic and cryptogenic epilepsies, which have something abnormal in their brain do not respond to medications and mostly becomes drug resistant.
5. What is epilepsy surgery?
In 35 from 100 patients diagnosed to have epilepsy, drugs cannot control epilepsy. Most of the time, these patients have something visibly abnormal in their brain. So, logically if we can deal with abnormality which is visible on MRI brain, we can practically cure epilepsy. Surgery for epilepsy are some surgeries on brain, where we remove or alter the abnormal currents in brain circuits so as to stop/alter/modify the seizures and improve the quality of life of person affected with epilepsy.
6. Why to go for epilepsy surgery?
If your seizures are controlled on one or two drugs, then there is no need for surgery. However, when you have to take more than two medications and you continue to have seizures, surgery is rational choice for following reasons.
a. Seizures are bad to experience and you lose many privileges in life like employment, driving, swimming and sports. Adding further drug is not going to control your seizures. You will be under constant threat of having seizure and will be dependent on companion for routine activities.
b. 3-5 patients out of 100 die with epilepsy every year. Thus, 15 out of 100 patients will die in next five years from epilepsy. However chances of dying from epilepsy surgery is just 2 % and its one time risk.
c. Epilepsy medications have many side effects which include bone problems, weight gain, mood problems, cognitive decline and loss of memory. More medications you take, more chances of cognitive decline over time period.
d. Also, with every seizure, some neurons die of ischemia and capacity of brain goes down. It’s a slow process of memory and cognitive decline.
e. Even financially, if you are on two medications, your monthly maintenance comes to around 5000/ month i.e. .60,000 annually. The cost of epilepsy surgery with all investigations, hospitalization is close to 2 lakhs.
7. What are steps for epilepsy surgery?
Once you are categorized as drug resistant epilepsy and being considered for epilepsy surgery, you will have to undergo three major steps. Pre-surgical evaluation followed by a consensus decision and finally surgery. In pre-surgical evaluation, we decide the exact parts of your brain which is responsible for this epilepsy with various tests, clinical evaluations etc. And a team of doctor specialists from various related fields meet together to discuss and reach a consensus about the type of surgery you will need. A final plan is decided in the multidisciplinary meeting.
8. What is pre-surgical evaluation for epilepsy surgery?
Pre-surgical evaluation consist of three main domains. Most important is video EEG followed by investigations like MRI, PET scan, SPECT scan. This MRI scan done here is not the routine MRI but customized scan which will depend on your video EEG recordings. Neuropsychological evaluation is also a crucial part of presurgical evaluation which provide important insight about the localization and possible problems you will be having after surgery. Once all these investigations are ready, it is generally discussed in meetings to reach a consensus about the plan.
9. What is EEG and video EEG and their necessity?
Video EEG is nothing but simultaneous recording of EEG along with video camera focused on you all the time. You will be admitted and EEG leads will be attached to you. You will be under camera for 24 hours while your EEG on. When you will have seizure, it will record the exact movements you do during your seizure activity and simultaneous EEG recordings. This will give us the exact idea of the area of your brain responsible for producing these seizures. Generally, we record 3-10 episodes of seizure and hence patients generally stay for 5-7 days in hospital. We generally stop your drugs so that more seizures can be obtained in short time. It is safe as you are having seizures in controlled environment of hospital, equipped with doctors and nurses all the time. During the same hospitalization, you will undergo neuropsychological evaluation and MRI and PET testing as and when required. Plan is finalized once at the end of your hospitalization.
10. What is cost for pre-surgical evaluation?
Approximate cost of hospitalization and pre-surgical evaluation is approximately 70 thousand and further cost of surgical treatment is approximately 1.5 lac. making total of 2.25 lac. However it varies from case to case basis and in some patients these costs can be brought down to almost all inclusive 1.5 lac.
11. What are different types of epilepsy surgeries?
Epilepsy surgeries are mainly of two types. In patients where we find a small, focal brain area responsible for epilepsy, we go for resection of that area. These surgeries are called curative surgeries where once that area is removed; patient will be mostly free of epilepsy. However, there is a group of patients in which a large area is responsible or we could not define a small area or removing complete area is not feasible; surgeries are meant to just reduce seizure frequency and improve quality of life. These surgeries are called palliative surgeries.
12. What are improvement chances for epilepsy surgery?
Chances of seizure control depend on many variables and varies between 50-90%. If there is tumor or malformation or localized area which could be removed completely, then 90% patient achieves freedom from epilepsy. However, outcome is in the magnitude of 50% with palliative surgeries. Outcome typically depends on the responsible pathology. Overall, 60% patients definitely better with epilepsy surgery over long term. If MRI shows some lesion which could be removed, then 9 out of 10 people can achieve seizure freedom and almost 6 out of 10 patients can be off medicine.
13. What are complications with epilepsy surgery?
Complications are very infrequent in epilepsy surgery with major complications like motor deficits, language deficits, vegetative states and disabilities in 3-5% magnitude. Other treatable complications like infections, prolonged hospitalizations, transient deficits, speech problems, mood problems, visual field deficits are common and do not alter the normal daily life. Overall, epilepsy surgery is safe surgery and it improves quality of life of many patients and their care takers significantly.
14. What is usual post operative course for epilepsy surgery?
For most of the procedures, patient stays for one week in hospital after surgery. It depends upon the type of surgery patient is undergoing. If it is a major surgery, then patient may spend 3-5 days in intensive care units and another week in ward followed by rehabilitation services. Palliative surgeries take longer durations. It also depends on patient’s preoperative condition.
15. What is usual recovery and return to job period for epilepsy surgery?
When a patient who is doing job undergoes epilepsy surgery, we typically advise a two weeks period for complete recovery and returning back to original job. However it may depend upon the nature of job and surgery done.
16. How is epilepsy surgery financially better that medical management?
If you are advised epilepsy surgery, then you must be taking at least two drugs and mostly failed another two cheaper drugs like phenytoin sodium (EPTOIN) and phenobarbitone ( GARDINAL). The monthly expenditure of newer epilepsy drugs is nearly around 3000-5000 INR. Apart from this, loss of job and expenses of maintaining a constant companion accounts further. The cost of epilepsy surgery in our unit is just 2-2.5 lac depending on type of hospitalization. It can be further brought down if you qualify for financial support from many trust across India which funds epilepsy surgery.
1. What is spasticity?
Increase tone of muscles is called as spasticity however generally spasticity means stiffness and difficulty in free movements of joints through its full range. Our movements are planned by brain and executed by a fine checks and balances of feedbacks mechanisms through nerves and spinal cord to brain. But when brain is diseases as in cerebral palsy or the connection is breached as in spinal cord injury, these feedbacks are affected and results in spasticity or stiff limbs.
2. What are problems with spasticity?
In spasticity, muscles are under continuous contracted state hence joints become stiff. There are many problems with spasticity. Mainly, range of movements of joints is decreased and joint become immobile and tendons and muscles go in state of permanent contractures or shortening. Secondly, this can lead to pressure sores at multiple locations. Thirdly, as muscles are contracting continuously, they are working without any goal, but this causes energy expenditure and patients lose weight.
3. What are diseases associated with spasticity?
There are many diseases associated with spasticity however important and common are
a. Cerebral Palsy
b. Severe Head Injury
c. Spinal cord injury.
d. Multiple sclerosis
e. Spastic paparesis
4. What are current modalities to treat spasticity?
Treating spasticity is of utmost importance for early ambulation and prevention of contractures and bedsores. Physiotherapy is mainstay of preventing spasticity. Oral medications are standard initial care for early and mild spasticity however dose of oral medicines needed to control severe spasticity is associated with severe side effects like dizziness, hypotension and many others. Hence simple surgical treatments are utilized for relieving spasticity.
5. What is baclofen pump installation?
Baclofen is oral medicine helpful in spasticity however dose related side effects are more in severe spasticity. Hence, a small pump is put in body which deliver very small amount of baclofen but directly at the site of action i.e. CSF space around the spinal cord. Baclofen pumps are safe, simple, easy to implant and standard of care in western countries in spasticity management. Patient need to come for refill of pumps every three months. Refilling can be done with simple injection at OPD basis. Life of these pumps can range from 5-8 years and more.
6. What are problems with baclofen pumps?
Baclofen pump installation is overall safe procedure. However, implant related problems are reported in approx 10-15 % of cases including kinking of catheter, blockage or failure to deliver drug or infection of pump needing revision. Cost of baclofen procedure is prohibitive for Indian population which is approximately 5 lakhs with need for follow up every three months to refill the drug. If baclofen drug delivery stops for any reason like pump failure or inability to come for follow up and refill, patient slips into baclofen withdrawal syndrome which can be fatal at times.
7. What is selective posterior rhizotomy?
As discussed above, our movements are fine tuning of checks and balances of various feedback mechanisms at the level of spinal cord supervised by brain input. In spasticity, these feedback mechanisms become hyperactive due to absence of brain supervision. In selective posterior rhizotomy procedure, we do selective deafferentiation meaning reducing the hyperactive inputs from muscles hence affecting the reflex arc. This decreases the muscle nerve input to nerve thus reducing the spasticity. This is done at the level of nerve roots joining the spinal cords.
8. What are the tests needed for this procedure?
This procedure per say does not need any special tests however detailed evaluation by physiotherapist for grade of spasticity, muscle power, gait or walking pattern of patient are needed. Overall assessment for predicting the benefit to patient is carried out in OPD basis. In cerebral palsy cases, we need to go for IQ testing and other evaluations to predict the outcomes of surgery. Few blood tests as initial screening for surgical fitness are carried out. Primary fitness to undergo surgery is also evaluated.
9. What is done in this surgery?
This surgery is highly specialized surgery and needs multitude of technological gadgets at backend at operation theatre apart from especially trained neurosurgeon. A small incision is taken at midback level in midline. After identifying the nerve roots and spinal cord, we identify incoming nerves to spinal cord. After fine dissection under microscope, these nerves are split into fine fibers. These individual fibers are stimulated to grade the muscle response and classified as normal or abnormal response on the basis of graph they produce. Selectively, those fibers with abnormal response were divided to optimize the outcomes.
10. What are the outcomes of surgery?
Surgery is very effective and reduction of spasticity is noted immediately after surgery in post operative period. This relief of spasticity is long lasting and many times permanent. Patient is typically discharged after 7-8 days of surgery and sent to rehabilitation unit. Post operative physiotherapy and rehabilitation training program is of utmost importance for optimum outcomes. No need of regular follow up is needed once patient attends rehabilitation program. Improvements are noted in gait, walking speed, walking distance, independent ambulation and confidence of patient.
11. What are complications of surgery?
Selective posterior rhizotomy is safe, simple and effective procedure if performed by trained neurosurgeon under optimum operative theatre infrastructure. Few patients complain of hyperesthesia for few weeks. Few have temporary urinary complaints like difficulty in micturition and may need urinary catheter for couple of weeks. Temporary constipation can be observed. Weight gain is observed in few patients.
12. What is selective peripheral neurectomy?
When spasticity is focal meaning limited to any one limb or one side of body in that case we selectively cut a specific nerve to get rid of unwanted spasticity. This has similar principle of disturbing the reflex arch and feedback mechanism however this procedure is done under local anesthesia and day care procedure so that patient can go home the same day. Efficacy of this procedure is long lasting and improves ambulation and walking. These are cost effective procedure with expenses upto 30 thousands and much cheaper compared to botox injections which are offered to patients.
13. Which are the patients which are benefitted most with neurectomy?
Selective peripheral neurectomies are mainly used in rehabilitation of post stroke patients with hemiplegia or monoplegia and severe spasticity affecting ambulation. Other indications include focal spasticity of any origin affecting one side observed in spinal cord injuries. Hemiplegic form of cerebral palsy patients are hugely benefitted with selective peripheral neurectomies.
On national epilepsy day in 2016, we organized a small marathon and walkathon for epilepsy patients. Few of those patients who underwent epilepsy surgery participated and completed 100 meter run. This event helped us to create awareness about safety of epilepsy surgeries and neutralizing the stigma of epilepsy surgeries.