Treatment module for ‘epilepsy’ during unlock 1.0

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Dr Sumit Singh

While the COVID pandemic has forced us to adapt to a new normal, lives have suddenly fit into the challenging times. Now that masks, sanitizers and social distancing have caught up our regular routine, access to medical checkups remain one of the added troubles for many patients and their caregivers. Even though various relaxations are gradually being provided by the Government, fear of COVID infection keeps many at home.

Epilepsy patients are one of those who require timely medication and regular consultation to avoid complications. Epilepsy is a disorder of the brain characterized by occurrence of epileptic seizures resulting from an excessive electrical discharge inside the brain, and by the neurobiologic, cognitive, psychological, and social consequences of this condition. Furthermore, epilepsy is one of the world’s oldest known medical conditions and people with epilepsy and their families frequently suffer from stigma and discrimination. While other disorders can wait for a review with the doctors, and uninterrupted supply of medicines and a strict compliance of the patient is crucial for the control of epilepsy.

Epilepsy – The Indian Scenario

Epilepsy is a chronic disorder of the brain that affects people worldwide. There are an estimated 65 million people with epilepsy in the world, of whom up to 80% live in resource-poor countries where annual new cases occur between 40 to 70 per 100,000 people in the general population. The estimated proportion of the general population with active epilepsy at a given time is between 4 and 10 per 1000 people. However, some of the studies from developing countries suggest that the proportion is between 7 to 14 per 1000.

India is home to about 10 million people with epilepsy. A recent meta-analysis of published and unpublished studies puts the overall prevalence rate of epilepsy in India at 5.59 per 1,000 population. The prevalence has been found to be 1.9% in the rural population as compared with 0.6% in urban population. There are very few incidence studies from India, and the most recent one suggests an age standardized incidence rate of 27.3/100,000 per year

Another challenge associated with epilepsy management in India is the fact that about three fourths of people with epilepsy may not receive the treatment they need. This is called the “treatment gap”. This may be due to lack of access to or knowledge of anti-epileptic drugs, poverty, cultural beliefs, stigma, poor health delivery infrastructure, shortage of trained professionals, inequitable distributions of available resources in rural areas and high cost of treatment. The magnitude of epilepsy treatment gap in India ranges from 22% among urban, middle-income people to 90% in villages.

Types of Seizures

As different parts of the brain can be affected by epilepsy there are many recognised types of seizure. Seizures are often classified on the basis of the part of the brain where the disruptive excess electrical activity occurs. Focal seizures occur in specific parts of the brain while generalised seizures can affect the whole of the brain simultaneously. Focal seizures can often become generalized. Complex partial seizures are peculiar seizures which are characterized by the patient loosing track of time and space, while not becoming completely unconscious. These type of seizures are most difficult to treat.

Treatment module – Medication and DBS

To diagnose the exact location of the brain that generates the epileptic attacks, EEG, Video EEG MRI, PET and SPECT scan of the patient is performed. Most patients (Up to 90 %) usually respond very well to medical treatment. About 10 % will need surgery of some type, these types of epilepsies are called as Intractable OR “Difficult to control epilepsies”. A teamwork approach is of immense importance in identifying such patients. Usually the surgery for epilepsy consists of removal of a portion of the brain where the abnormality is found. However some types of seizures can’t be operated upon as the exact area of the brain is not localizable, OR the seizures are arising from a very important area of the brain which can’t be removed, OR there are several areas of the brain which are abnormal. In such cases Stimulation of the brain might be needed. Stimulation is of two types Deep Brain Stimulation (DBS) and Vagus Nerve Stimulation (VNS). Here we will talk about DBS.

In DBS the surgery is performed in two phases. In the first phase, two electrodes are implanted in the affected part of the brain through small incisions made in the skull. The placement of the leads is monitored on image guidance system for accuracy and precision further augmented by Intraoperative EEG monitoring. In the second phase, the neurostimulator is placed under the skin of the collarbone and the extension connects it to the leads. Post surgery the amount of current being delivered to the brain is modified by the doctor, by a procedure called as programming. Many patients, who can’t have a part of the brain removed by surgery for epilepsy, show a very promising response to DBS. The surgery can have a significant improvement in the quality of life of patients with epilepsy.

The author is the Chief of Neurology and Co-Chief Stroke, Agrim institute of neuro sciences, Artemis Hospital, Gurugram

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