Vagus Nerve Stimulator for Epilepsy : Advanced Epilepsy Treatment Options Available in India

There are several ways to treat epilepsy. How well each treatment works varies from one person to another. Vagus Nerve Stimulation therapy is a form of treatment for people with epilepsy whose seizures are not controlled with medication.

Vagus nerve stimulation (VNS Therapy) is designed to prevent seizures by sending regular, mild pulses of electrical energy to the brain via the vagus nerve. These pulses are supplied by a device something like a pacemaker.

·         The VNS device is sometimes referred to as a "pacemaker for the brain." It is placed under the skin on the chest wall and a wire runs from it to the vagus nerve in the neck.

·         The vagus nerve is part of the autonomic nervous system, which controls functions of the body that are not under voluntary control, such as the heart rate. The vagus nerve passes through the neck as it travels between the chest and abdomen and the lower part of the brain.

What is the surgery like?

·         The surgeon first makes an incision along the outer side of the chest on the left side, and the device is implanted under the skin. A second incision is made horizontally in the lower neck, along a crease of skin, and the wire from the stimulator is wound around the vagus nerve in the left side of the neck. The brain itself is not involved in the surgery.

·         The device (also called an implant) is a flat, round battery, about the size of a silver dollar—that is, about an inch and a half (4 cm) across—and 10 to 13 millimeters thick, depending on the model used. Newer models may be somewhat smaller.

·         The procedure usually lasts about 50 to 90 minutes with the patient under general anesthesia. Usually the person can go home later the same day. Sometimes you may need to stay overnight in the hospital for observation.  

How is VNS used?

·      The neurologist (or licensed professional) programs the strength and timing of the impulses according to each patient's needs. The settings can be programmed and changed by placing a wand over the generator on the left side of the chest. The wand is connected to a handheld computer.

·         For all patients, the device is programmed to go on (give stimulation) for a certain period (for example, 7 seconds or 30 seconds) and then to go off (stop stimulation) for another period (for example, 14 seconds or 5 minutes). The device is set to give stimulation at regular intervals during the day, usually with 30 seconds of stimulation alternating with 5 minutes of no stimulation. The patient is usually not aware that it's operating.

·         Holding a special magnet near the implanted device (generator) triggers the device to deliver another burst of stimulation, outside of the programmed intervals. For people with warnings (auras) before their seizures, activating the stimulator with the magnet when the warning occurs may help to stop the seizure.

·         Settings (also called stimulation parameters) set by the neurologist typically include a stimulation amplitude of 1.0 to 3.0 mA (milliamperes), a stimulation frequency of 20 - 30 Hz (hertz), and a pulse width of 130 - 500 microseconds. By adjusting these settings, the doctor not only may be able to control more of the patient's seizures, but often can also relieve side effects. One study, for instance, found that changing the pulse width eliminated pain that some patients were experiencing.

·         The battery for the stimulator lasts approximately 5-10 years, depending on the settings used.

What can VNStherapy do during a seizure?

Some people have a warning or aura which is a simple focal (or 'simple partial') seizure that tells them that they are going to have a further seizure. When this happens, they can pass a special magnet over the stimulator to give extra stimulation. This may stop the aura from developing into another seizure or may reduce how long it takes to recover afterwards.

The magnet can be worn on their wrist like a watch or on their belt. For people who have no warning before a seizure, someone else could use the magnet when a seizure happens.

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What causes epilepsy in children? : NeuroSurgery offered at Best Hospitals in India

What is epilepsy?

Epilepsy is a type of brain disorder which leads to a sudden change in how the brain works. It can cause people to have repeated (several or many) seizures called epileptic fits (convulsions), for short periods of time. The seizures happen because there is an uncontrollable electrical discharge from the nerve cells in the brain. This may create a short term disturbance in the way the brain works and cause odd sensations and abnormal movement or behaviour.

Epiliptic seizures are not usually dangerous. But, a person can be at risk if they are in a dangerous environment (eg swimming in a pool or beach, driving a car), or if they become unconscious. Injuries can happen at school, at work, at home or other places.

One child in every 20 will have a seizure during their childhood, often with a high temperature (febrile convulsion). This is not epilepsy. Most children who have febrile convulsions do not go on to have epilepsy. Only about one in 200 children have epilepsy.

Children with epilepsy can usually lead a normal and active life but will need to take be careful with certain activities.

It is important to know what to do and how to help your child if they have a seizure.

Signs and symptoms

The symptoms of the seizure depend on what parts of the brain are affected. What happens during a seizure lets doctors know what parts of the brain are involved.

Signs and symptoms may include:

• Sensory disturbances - is when you/your child experiences tingling, numbness, changes to what you/your child sees, hears or smells, or unusual feelings that may be hard to describe.
• Abnormal body movements - limp, stiff or jerking movements that may come with loss of consciousness and shallow or jerky breathing
• Abnormal behaviour - is when you/your child may be confused or have automatic movements such as picking at clothing, chewing and swallowing or appearing afraid
• All of the above

Types of seizures

There are many different types of seizures and they can be generally classified into two groups:

Focal seizures

Focal seizures happen when the seizure activity begins in only one part of the brain. It usually affects one side of the body and you/your child may or may not lose consciousness.

These include:

• Simple partial seizures
• Complex partial seizures

Generalised seizures

Generalised seizures happen when the seizure activity begins all over the brain. The person's conscious state is always affected.

These include:

• Tonic-clonic seizures, sometimes called 'grand mal' or major seizures.
• Absence seizures, sometimes called 'petit mal' or starring seizures.
• Myoclonic, atonic and tonic seizures.

Diagnosis of epilepsy

It is important that your/your child's epilepsy is correctly diagnosed and treated by a children's doctor (paediatrician) or a doctor who specialises in childhood disorders of the brain (paediatric neurologist). To diagnose epilepsy the doctor will need a very detailed description of your child's seizures, medical history, development, learning and behaviour. A home video recording of your child's seizures is very helpful if they happen often or are predictable.

Tests

Special test are needed in some children with epilepsy. Your child's doctor will talk to you about the following tests if they are needed.

• Blood tests:to check your child's sugar, calcium, magnesium and salt levels.
• EEG:is a recording of brainwave activity. (More information on EEG factsheet).      
• CT or MRI:gives us pictures of the brain. (More information on MRI or CT factsheets).
• Video EEG monitoring:detailed EEG done in hospital. (More information on Video EEG monitoring factsheet).

What causes epilepsy in children?

Many different disorders of the brain may be associated with epilepsy.

For some patients the epileptic disorder is congenital, that is, the child is born with the predisposition to have epilepsy. In other patients, the epileptic disorder is acquired, as a result of brain damage that occurred after birth.

The congenital epilepsies could be the result of the child having a gene that is responsible for the epileptic disorder; these are the genetic types of epilepsy. Alternatively, congenital epilepsy may be the result of factors that interfere with the development of the brain during gestation, resulting in brain malformations.

In acquired epileptic disorders, the damage might occur at the time of birth, for example the case of newborns that have oxygen deprivation during labor and delivery; or intracranial bleeding, as seen in some children born prematurely. Also, the brain damage may occur any time after birth. For example, epilepsy could be a complication of infections in the brain (meningitis, encephalitis), head injuries with brain damage, brain tumors, or intracranial bleeding.

Are seizures bad for children?

Presently there is no indication that short-lasting seizures will result in any brain damage. However, prolonged seizures, especially generalized tonic-clonic seizures, in some cases could result in brain damage, but this is very unusual.

Although brain damage is not likely, children can be injured at the time of the seizures. For example, in the atonic seizures there is a sudden loss of muscle power and, if this happens when the patient is standing, it is followed by a fall that might result in injuries to the face and/or mouth. Similar types of physical injuries can happen with other seizures.

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Hydrocephalus Surgery and Treatment in India - Best Neurosurgery Hospitals in India

Hydrocephalus also known as "water in the brain," is a medical condition in which there is an abnormal accumulation of cerebrospinal fluid (CSF) in the ventricles, or cavities, of the brain. This may cause increased intracranial pressure inside the skull and progressive enlargement of the head, convulsion, tunnel vision, and mental disability. Hydrocephalus can also cause death.

The clinical presentation of hydrocephalus varies with chronicity. Acute dilatation of the ventricular system is more likely to manifest with the nonspecific signs and symptoms of increased intracranial pressure. By contrast chronic dilatation (especially in the elderly population) may have a more insidious onset presenting, for instance, with Hakim's triad (Adams triad).

Symptoms of increased intracranial pressure may include headaches, vomiting, nausea, papilledema, sleepiness or coma. Elevated intracranial pressure may result in uncal and/or cerebellar tonsill herniation, with resulting life threatening brain stem compression.

In infants with hydrocephalus, CSF builds up in the central nervous system, causing the fontanelle (soft spot) to bulge and the head to be larger than expected. 
Early symptoms may also include:

* Eyes that appear to gaze downward (Sundowning)
* Irritability
* Seizures
* Separated sutures
* Sleepiness
* Vomiting

Symptoms that may occur in older children can include:

* Brief, shrill, high-pitched cry
* Changes in personality, memory, or the ability to reason or think
* Changes in facial appearance and eye spacing
* Crossed eyes or uncontrolled eye movements
* Difficulty feeding
* Excessive sleepiness
* Slow or restricted movement
* Vomiting

Signs and tests

When a health care provider taps fingertips on the skull, there may be abnormal sounds that indicated thinning and separation of skull bones. Scalp veins may appear stretched or enlarged.

Part or the entire head may be larger than normal. Enlargement is most commonly seen in the front part of the head. Head circumference measurements, repeated over time, may show that the head is getting bigger.

The eyes may look "sunken in." The white part of the eye may appear above the colored part of the eye, given the eyes a "setting-sun" appearance. Reflexes may be abnormal.

A head CT scan is one of the best tests for identifying hydrocephalus. Other tests that may be done include:

* Arteriography
* Brain scan using radioisotopes
* Cranial ultrasound (an ultrasound of the brain)
* Lumbar puncture and examination of the cerebrospinal fluid (rarely done)
* Skull x-rays

Treatment
Hydrocephalus treatment is surgical, generally creating various types of cerebral shunts. It involves the placement of a ventricular catheter (a tube made of silastic), into the cerebral ventricles to bypass the flow obstruction/malfunctioning arachnoidal granulations and drain the excess fluid into other body cavities, from where it can be resorbed. Most shunts drain the fluid into the peritoneal cavity (ventriculo-peritoneal shunt), but alternative sites include the right atrium (ventriculo-atrial shunt), pleural cavity (ventriculo-pleural shunt), and gallbladder. A shunt system can also be placed in the lumbar space of the spine and have the CSF redirected to the peritoneal cavity (Lumbar-peritoneal shunt). An alternative treatment for obstructive hydrocephalus in selected patients is the endoscopic third ventriculostomy (ETV), whereby a surgically created opening in the floor of the third ventricle allows the CSF to flow directly to the basal cisterns, thereby shortcutting any obstruction, as in aqueductal stenosis. This may or may not be appropriate based on individual anatomy. This is the treatment.

Shunt complications
Examples of possible complications include shunt malfunction, shunt failure, and shunt infection, along with infection of the shunt tract following surgery (the most common reason for shunt failure is infection of the shunt tract). Although a shunt generally works well, it may stop working if it disconnects, becomes blocked (clogged), infected, or it is outgrown. If this happens the cerebrospinal fluid will begin to accumulate again and a number of physical symptoms will develop (headaches, nausea, vomiting, photophobia/light sensitivity), some extremely serious, like seizures. The shunt failure rate is also relatively high (of the 40,000 surgeries performed annually to treat hydrocephalus, only 30% are a patient's first surgery) and it is not uncommon for patients to have multiple shunt revisions within their lifetime.

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