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What Do My Lab Test Reports Indicate?
Question: What is your overall view on the concerns expressed based on the data provided? If you need further reports (MRI, EEG, CT Scan, etc) please let me know. Thanks
Patient is a close relative. Male, 30 years. Received closed head injuries(TBI) in a road accident in May 2008 while studying for a Master's Degree. He completed his Masters Degree in 2011 and at present appear to be leading a normal life working in a private firm where he has to remember lot of figures and has to deal with clients.
CASE HISTORY:
After his accident his Glasgow Coma Scale was rated as 3.
The CT of the head after the accident demonstrated multiple focal hemorrhagic
lesions with surrounding edema involving both frontal lobes, both parietal lobes and the right temporal lobe. A small amount of blood remained present in the right temporal and right occipital horn of the ventricles.
MRI obtained 4 weeks after the accident demonstrated large areas of isogenic edema in the white matter bilaterally in the frontal lobe region. There was local mass effect on the left side resulting in a left to right subfalcine mid-line shift. Within the central portion of the brain the edema demonstrated finding that suggest of evolving hematoma leading to a impression of focal cerebritis. There was a chronic area of hemorrhage in the right subfrontal region without mass effect.
The MRI taken 1 year after the accident suggested (1) Multiple regions of encephalomalacia and gliosis, presumably due to old trauma. This is most prominent in the anterior right temporal lobe, and then in the left frontal and posterior right frontal lobes. There is evidence of old hemorrhagic contusions in these regions with residual hemosiderin deposition. (2) Multiple punctate foci of old contusions predominantly in the bifrontal white matter, including the U-fibres. (3) Atrophy of the right hippocampus (4) Mild generalised cerebral atrophy, as well.
3T MRI Brain done on 10th Oct. 2012 and compared with MRI taken on 12th August 2009 showed (1)No significant interval change in the porencephalic cysts and hemosiderin deposition. (2)Mild progression of gliosis within bilateral frontal and right temporal lobes.
*CT OF HEAD TAKEN ON 29 DEC. 2010 indicated no acute intracranial process. Areas of encephalomalacia bifrontal lobes and right temporal lobe may be related to remote trauma. Left anterior frontal scalp and left preseptal hematoma without a fracture indentified.
EEG (Awake EEG record with H/V and P/S) taken on 15th XXXXXXX 2011 stated "Background well formed and symmetrical. No seizure activity. No XXXXXXX waves. No focal abnormal activity. Good Driving response to p/s. Imp: Normal EEG. No seizure activity.
Seizure History:
2008: 03 times (Nov 8, Dec 17 & 26)
2009: 03 times (Mar 17, May 10, XXXXXXX 1, & Aug 11)
2010: 05 times ( XXXXXXX 1, Mar 1, Jun 1, Aug 11 & Dec 29)
2011: 01 time ( Jun 15)- this one was attributed to food poisoning. Since then seizure free.
Medication:
MEDICATION DETAILS
STARTING DATE MEDICATION
8-Nov-08 PHENYTOIN SODIUM
100 MG 1-0-1
26-Dec-08 PHENYTOIN SODIUM
100 MG 2-0-2
17-Mar-09 CARBAMAZEPINE
200 MG 2-0-2
10-May-09 CARBAMAZEPINE 200 MG 2-0-2,
LEVETIRACETAM XR 500 MG 1-0-1
20-Aug-10 CARBAMAZEPINE 200 MG 2-0-2,
LEVETIRACETAM XR 500 MG 2-0-2,
LAMOTRIGINE 100 MG 2-0-2
Reduced to 2-0-1 since Aug. 2014.
REMARKS: The SODIUM (ISE) level was found to be 145.0 mEq/L(12 Aug 09) & 128(10 Oct 12) against the Reference Range of 135-150 mEq/L, the POTASSIUM level was 3.9(10 Oct 12) against Ref.Std 3.5 - 5.5 mEq/L & the SERUM CARBAMAZEPINE LEVEL (florescence polarization) was found to be 7.9 mcg/ml(12 Aug 09) and 11.4(10 Oct 12) against the Reference Range of 4-8 mcg/ml (along with other anticonvulsants) and 6-12 mcg/ml (without other anticonvulsants)
In the light of the above background, there have been various concerns among his well wishers
which center around questions like:
(1) Is it possible to state, based on EEG/MRI studies at a later date that no further seizures are possible under normal circumstances and whether healing of the Multiple bihemispheric regions of gliosis, encephalomalacia and old hemorrhages is possible or it does not matter?
(2) On what basis and when can a decision be taken as to reduce the dosage of the present medications and to reduce the number of medications to, just say, Carbamazepine? Which doctor (Neurologist/Neurosurgeon) can take this decision?
(3) If no change is to be made in the present medication, when is the best time to make a review?
(4) Will the present medication and its possible continuation come in the way of married life and progeny? Also your views on side effects as reported in fulminant liver failure in a patient on carbamazepine and levetiracetam treatment.
(5) When he decides to get married, it would be necessary for him to reveal his background about medications? Generally how this is handled as seizures is considered a risk to an individual’s life?
(6) Is it possible to get a seizure, in a TBI case, due to pressure on the mind or too much of mental work, inspite of being on anti-convulsive medications?
(7) What is your call on likely seizures in the future and how they can be averted? If any further information required about the patient, please let me know.
If you give one answer and cover your opinion on the above issues, it provides a good guidance for the patient to take further decisions in life.
Whether you have on hand the following reports is important
1. Updated case history
2. Prescription
3. MRI reports of 10/12 Oct. 2012 and 12 Aug 2009
4. EEG reports of 2009 & 2011
If you need Seizure details & earlier MRI reports kindly let me know.
There was problem in uploading the documents. If any repetition, kindly ignore.
Patient is a close relative. Male, 30 years. Received closed head injuries(TBI) in a road accident in May 2008 while studying for a Master's Degree. He completed his Masters Degree in 2011 and at present appear to be leading a normal life working in a private firm where he has to remember lot of figures and has to deal with clients.
CASE HISTORY:
After his accident his Glasgow Coma Scale was rated as 3.
The CT of the head after the accident demonstrated multiple focal hemorrhagic
lesions with surrounding edema involving both frontal lobes, both parietal lobes and the right temporal lobe. A small amount of blood remained present in the right temporal and right occipital horn of the ventricles.
MRI obtained 4 weeks after the accident demonstrated large areas of isogenic edema in the white matter bilaterally in the frontal lobe region. There was local mass effect on the left side resulting in a left to right subfalcine mid-line shift. Within the central portion of the brain the edema demonstrated finding that suggest of evolving hematoma leading to a impression of focal cerebritis. There was a chronic area of hemorrhage in the right subfrontal region without mass effect.
The MRI taken 1 year after the accident suggested (1) Multiple regions of encephalomalacia and gliosis, presumably due to old trauma. This is most prominent in the anterior right temporal lobe, and then in the left frontal and posterior right frontal lobes. There is evidence of old hemorrhagic contusions in these regions with residual hemosiderin deposition. (2) Multiple punctate foci of old contusions predominantly in the bifrontal white matter, including the U-fibres. (3) Atrophy of the right hippocampus (4) Mild generalised cerebral atrophy, as well.
3T MRI Brain done on 10th Oct. 2012 and compared with MRI taken on 12th August 2009 showed (1)No significant interval change in the porencephalic cysts and hemosiderin deposition. (2)Mild progression of gliosis within bilateral frontal and right temporal lobes.
*CT OF HEAD TAKEN ON 29 DEC. 2010 indicated no acute intracranial process. Areas of encephalomalacia bifrontal lobes and right temporal lobe may be related to remote trauma. Left anterior frontal scalp and left preseptal hematoma without a fracture indentified.
EEG (Awake EEG record with H/V and P/S) taken on 15th XXXXXXX 2011 stated "Background well formed and symmetrical. No seizure activity. No XXXXXXX waves. No focal abnormal activity. Good Driving response to p/s. Imp: Normal EEG. No seizure activity.
Seizure History:
2008: 03 times (Nov 8, Dec 17 & 26)
2009: 03 times (Mar 17, May 10, XXXXXXX 1, & Aug 11)
2010: 05 times ( XXXXXXX 1, Mar 1, Jun 1, Aug 11 & Dec 29)
2011: 01 time ( Jun 15)- this one was attributed to food poisoning. Since then seizure free.
Medication:
MEDICATION DETAILS
STARTING DATE MEDICATION
8-Nov-08 PHENYTOIN SODIUM
100 MG 1-0-1
26-Dec-08 PHENYTOIN SODIUM
100 MG 2-0-2
17-Mar-09 CARBAMAZEPINE
200 MG 2-0-2
10-May-09 CARBAMAZEPINE 200 MG 2-0-2,
LEVETIRACETAM XR 500 MG 1-0-1
20-Aug-10 CARBAMAZEPINE 200 MG 2-0-2,
LEVETIRACETAM XR 500 MG 2-0-2,
LAMOTRIGINE 100 MG 2-0-2
Reduced to 2-0-1 since Aug. 2014.
REMARKS: The SODIUM (ISE) level was found to be 145.0 mEq/L(12 Aug 09) & 128(10 Oct 12) against the Reference Range of 135-150 mEq/L, the POTASSIUM level was 3.9(10 Oct 12) against Ref.Std 3.5 - 5.5 mEq/L & the SERUM CARBAMAZEPINE LEVEL (florescence polarization) was found to be 7.9 mcg/ml(12 Aug 09) and 11.4(10 Oct 12) against the Reference Range of 4-8 mcg/ml (along with other anticonvulsants) and 6-12 mcg/ml (without other anticonvulsants)
In the light of the above background, there have been various concerns among his well wishers
which center around questions like:
(1) Is it possible to state, based on EEG/MRI studies at a later date that no further seizures are possible under normal circumstances and whether healing of the Multiple bihemispheric regions of gliosis, encephalomalacia and old hemorrhages is possible or it does not matter?
(2) On what basis and when can a decision be taken as to reduce the dosage of the present medications and to reduce the number of medications to, just say, Carbamazepine? Which doctor (Neurologist/Neurosurgeon) can take this decision?
(3) If no change is to be made in the present medication, when is the best time to make a review?
(4) Will the present medication and its possible continuation come in the way of married life and progeny? Also your views on side effects as reported in fulminant liver failure in a patient on carbamazepine and levetiracetam treatment.
(5) When he decides to get married, it would be necessary for him to reveal his background about medications? Generally how this is handled as seizures is considered a risk to an individual’s life?
(6) Is it possible to get a seizure, in a TBI case, due to pressure on the mind or too much of mental work, inspite of being on anti-convulsive medications?
(7) What is your call on likely seizures in the future and how they can be averted? If any further information required about the patient, please let me know.
If you give one answer and cover your opinion on the above issues, it provides a good guidance for the patient to take further decisions in life.
Whether you have on hand the following reports is important
1. Updated case history
2. Prescription
3. MRI reports of 10/12 Oct. 2012 and 12 Aug 2009
4. EEG reports of 2009 & 2011
If you need Seizure details & earlier MRI reports kindly let me know.
There was problem in uploading the documents. If any repetition, kindly ignore.
Brief Answer:
Your point wise answers follow here:
Detailed Answer:
Hi XXXX,
Thanks for being on healthcaremagic.com.
I am Dr.Ajay Panwar,a neurologist,here to answer your query.
You have been quite elaborate in providing all the medical details and I have taken necessary time to have been through them.Please see the answers point wise to the questions asked by you as following:
1)It can not be said with surety that no seizures will occur in future,though there have been a large gap (of almost 4 years) since last seizure(june 2011),which goes in favour of decreased recurrence of seizures.However,it is not conclusive to say that he will not have it again.Old hemorrhages gliosis and encephalomalacia.Gliosis and encephalomalacia are permanent changes that stay as such for life.They are however,a dead tissue.
2)A Neurologist should now try tapering the antiepileptic drugs slowly decreasing the dosages and then removing the drugs one by one.In the process,if seizure does not occur-it's a positive point.However,if seizure occur again,his antiepileptics have to continued.Target is to attempt tapering the drugs after a 2-3 years of seizure free period.
3)Review can be done every 2-3 months,after slightly reducing the dose once.Like today if we make Carbamazepine say 2-1 for example,after 2-3 months we can again try making it 1-1 and see if seizure occur or not.Similarly,further tapering.
4)Antiepileptics medicines should not devoid one from marrying or getting kids.He being a male will have no problem in these issues.Liver function tests should be monitored periodically,say,initially 6 monthly and then yearly after one year-while on these medications.Fulminant hepatic failure has rare incidence.
5)Seizure is generally not life taking,if action is taken at proper time.It is inhumane to say that one with seizures should not marry.Telling the truth is your decision.A logical person should understand the issues.There can be no medical guidelines about it.
6)Stress may have some role in precipitating seizures.However,exact causative role when a person is on regular medicines is not defined.However,lack of sleep does precipitate seizures.
7)As I already said,that a large gap since the last seizures decreases the chances of future seizures,but it may happen again.There can be no conclusive statement about it.
Hope I have answered your query.If you have any further questions,I shall be glad to answer else,please close the thread-rate it and write a review as your rating will be of help to me.
Dr.Ajay Panwar,
MD,DM(Neurology)
Your point wise answers follow here:
Detailed Answer:
Hi XXXX,
Thanks for being on healthcaremagic.com.
I am Dr.Ajay Panwar,a neurologist,here to answer your query.
You have been quite elaborate in providing all the medical details and I have taken necessary time to have been through them.Please see the answers point wise to the questions asked by you as following:
1)It can not be said with surety that no seizures will occur in future,though there have been a large gap (of almost 4 years) since last seizure(june 2011),which goes in favour of decreased recurrence of seizures.However,it is not conclusive to say that he will not have it again.Old hemorrhages gliosis and encephalomalacia.Gliosis and encephalomalacia are permanent changes that stay as such for life.They are however,a dead tissue.
2)A Neurologist should now try tapering the antiepileptic drugs slowly decreasing the dosages and then removing the drugs one by one.In the process,if seizure does not occur-it's a positive point.However,if seizure occur again,his antiepileptics have to continued.Target is to attempt tapering the drugs after a 2-3 years of seizure free period.
3)Review can be done every 2-3 months,after slightly reducing the dose once.Like today if we make Carbamazepine say 2-1 for example,after 2-3 months we can again try making it 1-1 and see if seizure occur or not.Similarly,further tapering.
4)Antiepileptics medicines should not devoid one from marrying or getting kids.He being a male will have no problem in these issues.Liver function tests should be monitored periodically,say,initially 6 monthly and then yearly after one year-while on these medications.Fulminant hepatic failure has rare incidence.
5)Seizure is generally not life taking,if action is taken at proper time.It is inhumane to say that one with seizures should not marry.Telling the truth is your decision.A logical person should understand the issues.There can be no medical guidelines about it.
6)Stress may have some role in precipitating seizures.However,exact causative role when a person is on regular medicines is not defined.However,lack of sleep does precipitate seizures.
7)As I already said,that a large gap since the last seizures decreases the chances of future seizures,but it may happen again.There can be no conclusive statement about it.
Hope I have answered your query.If you have any further questions,I shall be glad to answer else,please close the thread-rate it and write a review as your rating will be of help to me.
Dr.Ajay Panwar,
MD,DM(Neurology)
Above answer was peer-reviewed by :
Dr. Pradeep Vitta
My original question was addressed to Dr.A.S XXXXXXX whose details had appeared on the screen and it mentioned that he was going through the details. Is it that he forwarded my query to you?
I am glad that you have given your analysis in such a way that it makes sense, provides guidance and that is perhaps the best advice for which I thank you. One small request is that you block the name of the person making the query (which otherwise you do it and which I hope you will also do it in my case which I appreciate).
1.What is your view on EEG Neurofeedback treatment to cure seizures? There was an article by
Dr.P.K.Jha, a Neurosurgeon based in XXXXXXX on 'Alpha Mind'(article attached) and Neurofeedback (http://www.neurocareindia.com). Have you had occasion to browse on the subject of neurofeedback for cure of seizures? The idea is to take advantage of latest research. Hence your guidance.
2.I came across a case of medical doctor who suffered TBI in 2003 and had his first seizure after eight years and he still had few more seizures. As such, from what you have come across TBI seizures, are there any particular type of damages to a particular part of brain where you can predict when seizures can happen inspite of medication?
3.In addition to liver function test, do you also advise Abdomino-pelvic ultrasonography as among other things it also indicates the condition of the liver.
4.Is the medication of Levetiracetam, Lamotrigine and Carbamazepine not known to have effects on the offsprings after marriage?
5.The patient regularly attends gym and has developed good muscles. At present he is having 9-6 job and attends gym for 1 hour at 9pm. He is in a happy state of mind except that he has not settled down in a job to match with his qualification. Earlier in 2013for 9 months he was in a job with no fixed hours resulting in lack of sleep. Your comments.
6.In case of health problems, is it recommended that drugs containing quinolines (Ciprofloxacin, etc), anti-histamines, etc are to be avoided? Any specific drug in tablet, liquid and injectable form to be avoided?
Thank you very much.
Following doc which were available have been uploaded:
1.CT scan of head on 29 Dec 2010, date of seizure (see seizure record)
2.EEG on 12 Aug 2009 - descriptions. For EEG on 15 XXXXXXX 2011, actual
Graphs running into several pages available.
I find that the system is not accepting uploading of more than one document. If you upload a second document, it will overwrite on the first. Hence I have retained only No.1(CT Scan)
I am glad that you have given your analysis in such a way that it makes sense, provides guidance and that is perhaps the best advice for which I thank you. One small request is that you block the name of the person making the query (which otherwise you do it and which I hope you will also do it in my case which I appreciate).
1.What is your view on EEG Neurofeedback treatment to cure seizures? There was an article by
Dr.P.K.Jha, a Neurosurgeon based in XXXXXXX on 'Alpha Mind'(article attached) and Neurofeedback (http://www.neurocareindia.com). Have you had occasion to browse on the subject of neurofeedback for cure of seizures? The idea is to take advantage of latest research. Hence your guidance.
2.I came across a case of medical doctor who suffered TBI in 2003 and had his first seizure after eight years and he still had few more seizures. As such, from what you have come across TBI seizures, are there any particular type of damages to a particular part of brain where you can predict when seizures can happen inspite of medication?
3.In addition to liver function test, do you also advise Abdomino-pelvic ultrasonography as among other things it also indicates the condition of the liver.
4.Is the medication of Levetiracetam, Lamotrigine and Carbamazepine not known to have effects on the offsprings after marriage?
5.The patient regularly attends gym and has developed good muscles. At present he is having 9-6 job and attends gym for 1 hour at 9pm. He is in a happy state of mind except that he has not settled down in a job to match with his qualification. Earlier in 2013for 9 months he was in a job with no fixed hours resulting in lack of sleep. Your comments.
6.In case of health problems, is it recommended that drugs containing quinolines (Ciprofloxacin, etc), anti-histamines, etc are to be avoided? Any specific drug in tablet, liquid and injectable form to be avoided?
Thank you very much.
Following doc which were available have been uploaded:
1.CT scan of head on 29 Dec 2010, date of seizure (see seizure record)
2.EEG on 12 Aug 2009 - descriptions. For EEG on 15 XXXXXXX 2011, actual
Graphs running into several pages available.
I find that the system is not accepting uploading of more than one document. If you upload a second document, it will overwrite on the first. Hence I have retained only No.1(CT Scan)
Brief Answer:
Thanks for appreciation.Your answers follow here.
Detailed Answer:
Hi,
Thanks for being in follow-up and appreciating.
Your query was not a direct query for Dr.A.S XXXXXXX and it was put open in neurology specialist's category,which was picked up by me.Anyway,I tried my best to do justice with the query and I am glad that you appreciated.Rest of the name blocking issues are upto the moderators and the site admin.
I have been through the documents uploaded and here I answer your queries one by one-
1)Regarding neurofeedback therapy for seizures,the concept is new in XXXXXXX its costly and most of the seizure patients are not maintained on this therapy.So,there are no statistics to support effectiveness of the therapy.However,it appears logical and promising.If affordable for one,should give it a try.
2)If TBI injures cerebral cortex of any of the lobes ,it increases the risk of seizures.Injury to deep tissue like thalamus or basal ganglia does not increase the risk that much.However,sometimes even no apparent injury after TBI may land into seizures.So,risk can be high or low according to regions of injury.There can be no absolute Yes or No.
3)Ultrasound is not indicated for monitoring.It is to be done only if Liver functions come deranged.This is absolute here.
4)Levetiracetam,Lamotrigine,Carbamazepine or any other drug only affects fetus if fetus is in constant touch with the medicine like through mother's placenta.Father does not carry the baby,so no chances of fetal impairment.
5)Its good that even due to lack of sleep,he did not have any seizure in 2013.Adequate rest and sleep is must.Take precautions now onwards.
6)Out of commonly used drugs,cephalosporin ,aminoglycosides and quinolones antibiotics.Mental disorder drugs like antipsychotics antidepressants.Beta blockers,aspirin and thyroxine are epileptogenic.Actually,there is a long list and the key point is-don't take drugs unnecessarily and don't miss necessary drugs.Missing necessary drug due to the fear of getting seizure may again lead to physical stress on the body causing seizures.There is no drug which if taken,is definite to cause seizure.
Hope I have answered your query.If you have any further questions,I shall be glad to answer else,please close the thread-rate it and write a review as your rating will be of help to me.
Dr.Ajay Panwar,
MD,DM(Neurology)
Thanks for appreciation.Your answers follow here.
Detailed Answer:
Hi,
Thanks for being in follow-up and appreciating.
Your query was not a direct query for Dr.A.S XXXXXXX and it was put open in neurology specialist's category,which was picked up by me.Anyway,I tried my best to do justice with the query and I am glad that you appreciated.Rest of the name blocking issues are upto the moderators and the site admin.
I have been through the documents uploaded and here I answer your queries one by one-
1)Regarding neurofeedback therapy for seizures,the concept is new in XXXXXXX its costly and most of the seizure patients are not maintained on this therapy.So,there are no statistics to support effectiveness of the therapy.However,it appears logical and promising.If affordable for one,should give it a try.
2)If TBI injures cerebral cortex of any of the lobes ,it increases the risk of seizures.Injury to deep tissue like thalamus or basal ganglia does not increase the risk that much.However,sometimes even no apparent injury after TBI may land into seizures.So,risk can be high or low according to regions of injury.There can be no absolute Yes or No.
3)Ultrasound is not indicated for monitoring.It is to be done only if Liver functions come deranged.This is absolute here.
4)Levetiracetam,Lamotrigine,Carbamazepine or any other drug only affects fetus if fetus is in constant touch with the medicine like through mother's placenta.Father does not carry the baby,so no chances of fetal impairment.
5)Its good that even due to lack of sleep,he did not have any seizure in 2013.Adequate rest and sleep is must.Take precautions now onwards.
6)Out of commonly used drugs,cephalosporin ,aminoglycosides and quinolones antibiotics.Mental disorder drugs like antipsychotics antidepressants.Beta blockers,aspirin and thyroxine are epileptogenic.Actually,there is a long list and the key point is-don't take drugs unnecessarily and don't miss necessary drugs.Missing necessary drug due to the fear of getting seizure may again lead to physical stress on the body causing seizures.There is no drug which if taken,is definite to cause seizure.
Hope I have answered your query.If you have any further questions,I shall be glad to answer else,please close the thread-rate it and write a review as your rating will be of help to me.
Dr.Ajay Panwar,
MD,DM(Neurology)
Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
Greater clarity with your reply. Patient has the necessary guidance to apply coarse corrections to his life style. Now for more than a year, he has been having good sleep for min 8 hours or more. I presume you are ok with his gym workout, which he relishes. Few queries which you would like to answer to strengthen his thinking on his problems.
1.EEG reports of Aug 2009 said "background scanty and symmetrical". The one of 10 Oct. 2012 said "Background well formed and symmetrical". Both said "Normal EEG. No seizure activity". What is the significance of this impression? When should he have his next EEG, say before or after 6 to 12 months of tapering the medication or both? Does it reflect any trend towards seiure?
2. Similarly when should he have next MRI and its utiity?
3. Before I contact you on a future occasion, what reports, including diagnostic ones, would be relevant to you in providing guidance about medication or diagnosis?
4. Have you formed any opinion about institutions (NIMHANS, BGS Global Hospital) that claim providing life time relief from seizures? I visited these institutions long back. They are overloaded with patients that you get the feeling that it is a gamble call that costs lot of time and money. If you have any suggestions, it is welcome. If you come across any developments that will be of interest to the patient, if possible please forward details to YYYY@YYYY .
I acknowledge with thanks your understanding and support.
1.EEG reports of Aug 2009 said "background scanty and symmetrical". The one of 10 Oct. 2012 said "Background well formed and symmetrical". Both said "Normal EEG. No seizure activity". What is the significance of this impression? When should he have his next EEG, say before or after 6 to 12 months of tapering the medication or both? Does it reflect any trend towards seiure?
2. Similarly when should he have next MRI and its utiity?
3. Before I contact you on a future occasion, what reports, including diagnostic ones, would be relevant to you in providing guidance about medication or diagnosis?
4. Have you formed any opinion about institutions (NIMHANS, BGS Global Hospital) that claim providing life time relief from seizures? I visited these institutions long back. They are overloaded with patients that you get the feeling that it is a gamble call that costs lot of time and money. If you have any suggestions, it is welcome. If you come across any developments that will be of interest to the patient, if possible please forward details to YYYY@YYYY .
I acknowledge with thanks your understanding and support.
Brief Answer:
Next EEG and MRI to be done before starting tapering the drugs.
Detailed Answer:
Hi,
Thanks for being in follow-up and appreciating.
Of course,his gym workout is on the healthier side.
Here the answers follow pointwise,for your queries:
1)Both the EEG were normal,waves on the lower margin of the normal range(scanty) does not make a difference.EEG should be repeated before starting tapering the drugs as a protocol.However,since he has not been among seizures,it is 99% confirmed to come normal again.But,protocol is a protocol and has to be followed for that 1% chance.And,if it comes abnormal for that 1% part-tapering has to be deferred.It is not needed once successful tapering has been done and seizure has not occurred again.EEG abnormal or epileptogenic,means ongoing electrographic seizure which can convert into a real seizure,if proper drug is not given.
2)Likewise,MRI has to be repeated before tapering starts to see the deviation from baseline MRI.It will have no effect on tapering(unlike abnormal EEG) however,It will be just for records,that if seizure occur again in future,then we will have a reference MRI to compare with,if there would be any change in MRI at that time.
3)Just the EEG,MRI and schedule of the medicines tapered,sequentially.I mean a proper documentation for the time course,nothing special.
4)NIMHANS is the most reputed and institute for neurology in the country and I have a couple of friends neurologists working over there.Really good but overloaded institute.I am not sure about it that any institute in the world can claim that they can cure seizures for lifetime for sure.No one can take a guarantee.If somebody takes one,he is fooling the patient as well as the science.I am sure NIMHANS never takes such a guarantee.The advantage is,you go to a good place,you get the treatment on the correct protocol.That's all about it.
Surely,I shall communicate anything,I found in the interest of the patient.
Hope I have answered your query.If you have any further questions,I shall be glad to answer else,please close the thread-rate it and write a review as your rating will be of help to me.
Dr.Ajay Panwar,
MD,DM(Neurology)
Next EEG and MRI to be done before starting tapering the drugs.
Detailed Answer:
Hi,
Thanks for being in follow-up and appreciating.
Of course,his gym workout is on the healthier side.
Here the answers follow pointwise,for your queries:
1)Both the EEG were normal,waves on the lower margin of the normal range(scanty) does not make a difference.EEG should be repeated before starting tapering the drugs as a protocol.However,since he has not been among seizures,it is 99% confirmed to come normal again.But,protocol is a protocol and has to be followed for that 1% chance.And,if it comes abnormal for that 1% part-tapering has to be deferred.It is not needed once successful tapering has been done and seizure has not occurred again.EEG abnormal or epileptogenic,means ongoing electrographic seizure which can convert into a real seizure,if proper drug is not given.
2)Likewise,MRI has to be repeated before tapering starts to see the deviation from baseline MRI.It will have no effect on tapering(unlike abnormal EEG) however,It will be just for records,that if seizure occur again in future,then we will have a reference MRI to compare with,if there would be any change in MRI at that time.
3)Just the EEG,MRI and schedule of the medicines tapered,sequentially.I mean a proper documentation for the time course,nothing special.
4)NIMHANS is the most reputed and institute for neurology in the country and I have a couple of friends neurologists working over there.Really good but overloaded institute.I am not sure about it that any institute in the world can claim that they can cure seizures for lifetime for sure.No one can take a guarantee.If somebody takes one,he is fooling the patient as well as the science.I am sure NIMHANS never takes such a guarantee.The advantage is,you go to a good place,you get the treatment on the correct protocol.That's all about it.
Surely,I shall communicate anything,I found in the interest of the patient.
Hope I have answered your query.If you have any further questions,I shall be glad to answer else,please close the thread-rate it and write a review as your rating will be of help to me.
Dr.Ajay Panwar,
MD,DM(Neurology)
Above answer was peer-reviewed by :
Dr. Pradeep Vitta
6th April 2015.
Your reply makes sense. I need to clarify on the following:
1. If I have understood correctly, before the next tapering is done EEG is needed to rule out even 1% abnormality.
2. Is there any protocol, say, that tapering is to be done every alternate year? Some 20 years ago the practice was that a person starting on anti-epleptic drug would be required to take the medication for 5 years and if there was no seizure during this period, then the tapering would be done over a period of 1 year or so..(I was not sure if the upload was successful,but now I have uploaded it). My question is whether EEG, MRI or CT Scan is needed on the day the seizure happens, whether it will throw some light which will help in diagnosis. Is there anything that you make out of the CT scan uploaded now? If so within how many hours of seizure it should be done.
3. The very first tapering was done in Aug. 2014 , the last seizure being in XXXXXXX 2011. Lamotrigine 100mg was reduced from 2-0-2 to 2-0-1. So far it is fine. Other two viz. Levetiracetam XR 500mg 2-0-2 and Carbamazepine 200 mg 2-0-2 being continued. When we should seek for further tapering? How you would have addressed this issue?
Thanks and regards
Your reply makes sense. I need to clarify on the following:
1. If I have understood correctly, before the next tapering is done EEG is needed to rule out even 1% abnormality.
2. Is there any protocol, say, that tapering is to be done every alternate year? Some 20 years ago the practice was that a person starting on anti-epleptic drug would be required to take the medication for 5 years and if there was no seizure during this period, then the tapering would be done over a period of 1 year or so..(I was not sure if the upload was successful,but now I have uploaded it). My question is whether EEG, MRI or CT Scan is needed on the day the seizure happens, whether it will throw some light which will help in diagnosis. Is there anything that you make out of the CT scan uploaded now? If so within how many hours of seizure it should be done.
3. The very first tapering was done in Aug. 2014 , the last seizure being in XXXXXXX 2011. Lamotrigine 100mg was reduced from 2-0-2 to 2-0-1. So far it is fine. Other two viz. Levetiracetam XR 500mg 2-0-2 and Carbamazepine 200 mg 2-0-2 being continued. When we should seek for further tapering? How you would have addressed this issue?
Thanks and regards
Brief Answer:
EEG comes abnormal,if it done in a time frame close to seizure occurrence.
Detailed Answer:
Hi,
Thanks for being in follow-up and appreciating.
I hope I could not make it clear on EEG issue-
1)EEG is not so sensitive that it can rule out even 1% abnormality.On the other hand,this statement actually means that if a patient did not have any seizure for so long(almost 3 years),we are not expecting any abnormal discharges in the brain,so 99% chances are that EEG will be normal.EEG comes abnormal only if done within a few hours of the seizure onset.
2)Tapering is to be started after 2-3 years(depends on the treating doctor) of seizure free interval.Drug is to be tapered and stopped over a period of one year,the dose being reduced every 2-3 months.Dose reduction is planned so that time from starting tapering to stopping the drug is one year.EEG should be done within a few hours of the seizure to get maximum information about the brain discharges(exact time not defined,but upto 24 hours usually,background slowing persists).MRI or CT(MRI preferable) should also be done close to the time of the seizure to see if there is any change from the previous scan.That may serve to give an idea ,whether any brain pathology has further evolved causing seizure.Here again,no time limit defined.but it should be atleast within a few days of the seizure.
3)In the present scenario,I would have made lamotrigine 1-0-1 from 2-0-1 in 2 months.Then 1-0-0 in another 2 months and finally stopping it another 2 months later.If no seizures,then I would have started tapering carbamazepine on the similar lines and may be over 18-24 months(rather than 12 months,as he is on a 3 drug therapy) I would have completely stopped the treatment,levetiracetam being stopped in the end.
So,accordingly you can discuss the treating doctor to go for tapering,now.
I am afraid to say that I could not find CT Scan uploaded in the documents.May be some error in uploading. You can also mail it to YYYY@YYYY with subject as Attention: Dr Ajay Panwar and I will get it from the website.
Hope I have answered your query.If you have any further questions,I shall be glad to answer else,please close the thread-rate it and write a review as your rating will be of help to me.
Dr.Ajay Panwar,
MD,DM(Neurology)
EEG comes abnormal,if it done in a time frame close to seizure occurrence.
Detailed Answer:
Hi,
Thanks for being in follow-up and appreciating.
I hope I could not make it clear on EEG issue-
1)EEG is not so sensitive that it can rule out even 1% abnormality.On the other hand,this statement actually means that if a patient did not have any seizure for so long(almost 3 years),we are not expecting any abnormal discharges in the brain,so 99% chances are that EEG will be normal.EEG comes abnormal only if done within a few hours of the seizure onset.
2)Tapering is to be started after 2-3 years(depends on the treating doctor) of seizure free interval.Drug is to be tapered and stopped over a period of one year,the dose being reduced every 2-3 months.Dose reduction is planned so that time from starting tapering to stopping the drug is one year.EEG should be done within a few hours of the seizure to get maximum information about the brain discharges(exact time not defined,but upto 24 hours usually,background slowing persists).MRI or CT(MRI preferable) should also be done close to the time of the seizure to see if there is any change from the previous scan.That may serve to give an idea ,whether any brain pathology has further evolved causing seizure.Here again,no time limit defined.but it should be atleast within a few days of the seizure.
3)In the present scenario,I would have made lamotrigine 1-0-1 from 2-0-1 in 2 months.Then 1-0-0 in another 2 months and finally stopping it another 2 months later.If no seizures,then I would have started tapering carbamazepine on the similar lines and may be over 18-24 months(rather than 12 months,as he is on a 3 drug therapy) I would have completely stopped the treatment,levetiracetam being stopped in the end.
So,accordingly you can discuss the treating doctor to go for tapering,now.
I am afraid to say that I could not find CT Scan uploaded in the documents.May be some error in uploading. You can also mail it to YYYY@YYYY with subject as Attention: Dr Ajay Panwar and I will get it from the website.
Hope I have answered your query.If you have any further questions,I shall be glad to answer else,please close the thread-rate it and write a review as your rating will be of help to me.
Dr.Ajay Panwar,
MD,DM(Neurology)
Above answer was peer-reviewed by :
Dr. Pradeep Vitta
Answered by
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