Dr. Siddharth Kharkar

1. Why is Epilepsy surgery in India done? Some people have seizures. These happen because of uncontrolled electricity in the brain. This condition is called “Epilepsy”. About 80% patients stop having seizures when they take medications. But 20% people keep having seizures despite taking 2 or more medications. These patients have “Medically resistant epilepsy”. They need Epilepsy surgery to stop their seizures.   2. Is Epilepsy surgery done in India? Yes. All types of epilepsy surgeries can be done in India. In the USA epilepsy surgery is very common. Larger hospitals (like UCSF, where I was educated) do about 2-3 epilepsy surgeries per week. In India, Epilepsy surgery is less common. This is because: –     Patients & doctors are not aware of it. –     Fewer doctors are trained in Epilepsy surgery. –     Cost –     Fear of complications –     But most importantly, many Indians have a sad, hopeless and completely wrong belief that epilepsy is uncontrollable. 3. What are the types of Epilepsy Surgery? There are many types of Epilepsy surgery. RESECTIVE (REMOVAL SURGERY): This is the best Epilepsy surgery. The bad seizure-producing part of the brain is removed. This stops seizures. VAGUS NERVE STIMULATION (VNS): In some cases, resective (removal) surgery is difficult. This can happen if the bad part is too large, or is near important brain parts. In such cases, Vagus Nerve Stimulation (VNS) surgery is done. This is a faster surgery. A small battery is placed in the skin over the chest. A thin wire is attached to a nerve below the neck skin. The VNS device sends small currents to the brain which prevent seizures. OTHER SURGERIES: Other surgeries are done in special situations. For example, corpus callostomy can be done instead of VNS if the patient cannot afford VNS. 4. What tests Need to be done before Epilepsy surgery? The routine tests done before every epilepsy surgery are listed below. We try to answer many questions with these tests: In some patients, we need to do additional tests to answer these questions. In most patients, these tests are not needed. In very rare cases, the location of the bad part is unclear even after these tests. In such cases, we need to record EEG directly from the brain. This is done by placing thin stiff wires in the brain. This process is called stereo-EEG. 5. What is Video EEG Monitoring (Epilepsy Monitoring)? The patient is admitted for continuous EEG monitoring. During this time, we may reduce medications so that the patient has seizures. We try to capture at least 2 seizures of each type. For example, if the patient has one seizure type where he falls down, and another type where he starts smacking his lips, then we capture 2+2 = 4 seizures. If you have seizures frequently, epilepsy monitoring may take just 1-2 days. In other people, it may take 7 days or more. 6. What is the success rate of Epilepsy surgery in India? The success rate of epilepsy surgery is high but not 100%. The success rate depends on the type of epilepsy, and the type of epilepsy surgery. For example: ·       The success rate of Resective surgery can be more than 80%. ·       The success rates of other surgeries are lower, but usually quite good. ·       After VNS, most patients seizures decrease by 50% or more. Specifically, drop attacks, where patients fall and hurt themselves, are significantly reduced. The success rate will be discussed with you after the presurgical tests. 7. Will my medications stop after Epilepsy surgery? The goal of epilepsy surgery is to stop your seizures. Approximately 50% patients are able to stop their medications after Epilepsy surgery. However, other patients need to keep taking their medications. Some patients may be able to reduce their medications. 8. What are the possible complications? Any surgery has some risks of anaesthesia and infection. In resective surgery, there is a concern that surrounding areas may be damaged. This depends on the exact location of the bad part. Surgery needs to be done very carefully if the bad part is close to important brain areas (e.g., speech & memory areas). Thankfully, stopping seizures after resection improves thinking and memory in many people. This is because the healthy parts of the brain work better. All possible complications will be discussed with you after the presurgical tests. 9. What is the cost of Epilepsy surgery? Patients need different evaluations and surgeries, so the cost is different for each patient. Please note that these costs are approximate and change with time. For example: If our patient has frequent seizures and requires a simple resection, the total cost is between 4.5 – 5 lakhs. This is the total cost, including all tests. Test Cost in India STEP 1: EVALUATION MRI Rs. 12,000 PET & MRI-PET fusion Rs. 15,000 functional MRI (fMRI) Rs. 12,000 Video-EEG monitoring (3 days) Rs. 30,000 x 3 = Rs. 90,000 Psychiatry & Neuropsychological testing Rs. 6,000 Total cost of evaluation Rs. 1.35 Lakh STEP 2: SURGERY ITSELF Resective surgery with intraoperative Electrocorticography Rs. 3.5 Lakh TOTAL COST Rs. 4.95 Lakh VNS surgery is very expensive. The major part of the expense is the device, which has to be imported. Test Cost in India VNS procedure cost (cost of placement) Rs. 1.5 Lakh VNS device cost – Demipulse Rs. 8.5 Lakh VNS device cost – Aspire SR Rs. 10.5 Lakh VNS device cost – Sentiva (newest model) Rs. 14.5 Lakh 10. Should I (or my child) have Epilepsy surgery? If a person has medically resistant epilepsy, I usually encourage them to have epilepsy surgery, if: The patient really has medically resistant epilepsy. 1. Patients may be misdiagnosed. For example, people with heart rhythm issues or stress-related seizures may be wrongly diagnosed with epilepsy. 2. Sometimes, the type of medication or the dose may be incorrect for the type of epilepsy. 3. Sometimes, patients have seizures because they don’t take their medications. Possible complications are acceptable to the patient. For example, if someone’s right hand remains very strong

In 2024, Epilepsy surgery cost in India is between Rs. 2 Lakh and Rs. 15 lakhs (USD 2500 to USD 18,000). This includes the cost of evaluation and of the surgery itself. This article’s purpose is to educate patients so that they can properly plan their finances. It is critical to know that Epilepsy surgery can be affordable in most cases. Anticipating Epilepsy surgery cost in India correctly will prevent financial surprises. At the same time, it is useful to know which therapies are very expensive. This will prevent unanticipated financial problems. You need to pay attention to the evaluation cost. Sometimes, the cost of evaluation can be more than the surgery itself. I recommend reading the article, to understand the process. But if you are in a hurry then click here to download the quick sheet [Epilepsy Surgery Cost in India – Calculation sheet]. Table of Contents Why is Epilepsy surgery cost in India variable? How is Epilepsy surgery in India done? Step 1: Epilepsy surgery evaluation cost in India A. Simple Epilepsy surgery evaluation cost in India B. Complex Epilepsy surgery evaluation cost in India C. Very complex Epilepsy surgery evaluation cost in India Step 2: Epilepsy surgery cost in India (The surgery itself) Resective (Removal) Epilepsy surgery cost in India Vagus Nerve Stimulator (VNS) Epilepsy surgery cost in India Cost of other epilepsy surgeries in India What is the minimum cost of Epilepsy surgery in India? Calculation sheet for Total Epilepsy surgery cost in India: Summary: Epilepsy surgery cost in India Dr. Siddharth Kharkar NeuroPlus Epilepsy & Parkinson’s Clinic – Dr. Kharkar Why is Epilepsy surgery cost in India variable? Epilepsy surgery cost in India is variable because each person needs different tests & surgeries. To understand this, you need to understand how Epilepsy surgery in India is done. So, How is Epilepsy surgery in India done? You can read the Epilepsy surgery in India article to get a detailed description of the process. The same process is described briefly here. This will help you understand how to calculate the Epilepsy surgery cost in India. The process of Epilepsy surgery involves two steps: Step 1: Evaluation: This is also called Epilepsy surgery evaluation. This is a set of tests. They tell us which is the abnormal part of the brain, what problems could happen if we take it out etc. Step 2: The surgery itself: There are many different types of surgeries. But the two most common surgeries are resective (removal) epilepsy surgery & Vagus Nerve Stimulation (VNS) surgery. To calculate Epilepsy surgery cost in India correctly, the cost of evaluation needs to be taken into account. So, when calculating the epilepsy surgery cost in India, we need to calculate the cost of evaluation + the cost of the surgery itself. Type of room & Foreign nationals The cost can be much higher based on the kind of room that you want. Most of these costs are for general ward admissions. The costs for a single/luxury room can be much higher, depending on the hospital. The cost can be higher for Foreign nationals. In general, most private hospitals charge foreign nationals about 30% more than Indian citizens. Let us first talk about the cost of epilepsy surgery evaluation in India. Step 1: Epilepsy surgery evaluation cost in India Epilepsy surgery evaluation may be simple, complex or extremely complex. The complexity of this evaluation depends on your MRI, EEG and type of seizures. A. Simple Epilepsy surgery evaluation cost in India Epilepsy surgery evaluation starts with a basic set of tests. Some of these tests locate the abnormal brain part producing seizures. The f-MRI scan, psychiatric & Neuropsychological evaluations us understand if we can safely remove this area. High-resolution MRI:The abnormal areas producing seizures can be very small. Therefore, a high-resolution MRI (3 Tesla or 3T MRI) needs to be done. Special methods are used to detect very small abnormalities. These may detect small abnormal areas missed on earlier scans. A 3T MRI using special techniques can detect very small abnormal areas. These areas may not be visible on low resolution MRIs. 2. PET scan & PET-MRI fusion:A PET scan measures which areas of the brain are using less glucose. Usually, the abnormal area and normal areas around it use less glucose. These areas are less bright on PET images. Ideally, the PET scan and the MRI scan should be overlaid over one another (see figure below). This process is called PET-MRI fusion. This is a critical part of the evaluation, without which abnormal areas in the brain may be missed. A 3T MRI using special techniques can detect very small abnormal areas. These areas may not be visible on low resolution MRIs. 3. Video EEG monitoring:The patient is admitted to the hospital. Video and EEG are recorded continuously. 2-3 seizures are recorded. Both the video and EEG are carefully studied. Video EEG is very comfortable. Sometimes, patients may get bored because they need to stay in the hospital. 4. Functional MRI (fMRI) scan:Functional MRI is a special MRI. Functional MRI (fMRI) shows which brain part is processing language, controlling movement etc. Functional MRI helps us to find brain areas controlling lanauge and limb movement. 5. Neuropsychological & Psychiatry assessment:A neuropsychologist is a person who measures the functioning of your brain by making you solve simple puzzles, draw objects, remember lists and so on.A psychiatrist helps us to understand your mental health and willingness for surgery. He/she helps to treat any underlying issues such as depression, anxiety etc. Please note that the cost of Video EEG monitoring in India is different for each patient. Each day of Video-EEG monitoring costs about Rs. 30,000 (USD 360) in India. We need to capture 2-3 seizures of each seizure type. This may take just one day or up to 1 week. Let us calculate the cost using 3 days. The approximate cost of these tests in India is as follows: Test Cost in India Cost in India in US dollars 3 Tesla MRI Rs. 12,000 USD

Please note: Here we will only be talking about the early symptoms of Parkinson’s disease. When you go to a doctor, he/she will examine you to detect the early signs of Parkinson’s disease [Video: Parkinson’s patient examination on YouTube]. Let us talk about the early symptoms of Parkinson’s: The 4 earliest symptoms of Parkinson’s disease are constipation, decreased sense of smell, thrashing in sleep, and depression. These are called “pre-motor” symptoms. 4 other symptoms can also appear early before movement problems: fatigue, anxiety, urinary urgency, and soft or lowered voice. A few years later, movement problems begin. There are 4 cardinal movement symptoms: tremor, slowness (bradykinesia), stiffness (rigidity), and unsteadiness (postural instability). 4 other early movement-related symptoms include small handwriting (micrographia), shuffling walk, stooped posture, and reduced arm swing. In summary: These are the 16 early symptoms of Parkinson’s disease. Caused by Details 4 earliest symptoms (pre-motor) 1. Constipation 2. Problems with smell (Anosmia) 3. REM behavior disorder (RBD) in sleep 4. Depression 4 less common pre-motor symptoms 1. Back pain with no apparent cause 2. Cramping of hands or feet 3. Fatigue 4. Subtle problems in using hands for fine jobs like typing or cooking 4 cardinal (most important) movement problems 1. Tremor (uncontrolled shaking) 2. Slowness (bradykinesia) 3. Stiffness (Rigidity) 4. Instability while standing or walking 4 other movement problems 1. Decrease in facial expressions (Hypomimia) 2. Problems with speech (low volume) 3. Problems swallowing (dysphagia) 4. Shuffling gait and/or festinating gait Let us talk about these 16 early symptoms of Parkinson’s disease. 4 Earliest Symptoms of Parkinson’s Disease Most people know that Parkinson’s disease causes problems with movement. But did you know it can produce non-movement (also called non-motor) symptoms as well? In fact, non-motor symptoms can occur many years before movement problems. The 4 most common non-motor symptoms are remembered using the short-form: CARD. These letters stand for: C = Constipation. People with Parkinson’s disease almost always have constipation. Constipation happens before any of the movement problems. Constipation can be a very early symptom of Parkinson’s disease. Some researchers think that Parkinson’s disease starts in the gut. Or more specifically, in the intestines. According to this theory, a virus or virus-like particle (prion) first infects the intestines. It then moves upwards through a long nerve called the “Vagus Nerve”. It reaches the brain, where it destroys the cells that produce dopamine. You can read more about this theory here: [What causes Parkinson’s disease?] & here (external link). This is one theory why constipation is so common in Parkinson’s disease.Read more about how to manage this uncomfortable problem: [Constipation in Parkinson’s disease]. 4 Earliest symptoms of Parkinson’s disease 1. Constipation 2. Anosmia (Decrease in the ability to smell) 3. REM Behavior Disorder (RBD) 4. Depression A = Anosmia Anosmia means being unable to smell. Parkinson’s disease  patients may have trouble smelling their food. Their sense of taste may change. In the later stages, even harsh smells like rot may be difficult for the patient to smell. People with Parkinson’s disease may have difficulty smelling before they develop any other symptoms. R = REM Sleep Behavior Disorder (RBD) REM Sleep Behavior Disorder (RBD) is a problem related to dreams. When a person without Parkinson’s disease sleeps, the body is paralyzed. Thus, he/she cannot move or act out their dreams. This is a normal process. When Parkinson’s patients sleep, this does not happen. So, they may act out their dreams. Patients with Parkinson’s disease may move excessively while sleeping, sometimes talking or hitting whoever is near them. Parkinson’s patients may start talking when sleeping. They may walk or run while sleeping, and sometimes thrash wildly. These movements can be violent. They can hurt the patient or the person sleeping beside them. This problem of moving while dreaming is called REM Sleep Behavior Disorder (RBD) . You can read more about sleep problems with Parkinson’s here: [Sleep problems in Parkinson’s disease]. Also, here is a good website (external link: Sleepfoundation.org) explaining RBD in greater detail. D = Depression Depression is common in Parkinson’s disease. It may happen many years before the movement problems. It can also be a severe problem later in the illness. Read about treatments for depression here: [How can I reduce depression & anxiety?] Depression is common in Parkinson’s disease. Just like many of the other problems, it is treatable. 4 less common premotor symptoms The CARD symptoms are the most common early symptoms of Parkinson’s disease. However, some patients may have other early symptoms as well. They are important to know. These symptoms may be dismissed as “vague” or “strange” at first. 5 less common pre-motor symptoms 1. Back pain with no apparent cause 2. Cramping of hands or feet 3. Fatigue 4. Subtle problems in using hands for fine jobs like typing or cooking 4 cardinal motor problems Usually it is these problems which cause you to go to the doctor. Although most patients report these motor problems as their earliest symptoms, now we know that the most common early symptoms of Parkinson’s are non-motor (not related to movement). Movement problems start a few years after the pre-motor problems.There are 4 cardinal signs of movement in Parkinson’s disease. One or more of these cardinal problems can be part of the early symptoms of Parkinson’s disease. 4 Cardinal signs of Parkinson’s disease 1. Slowness (Bradykinesia, Hypokinesia or Akinesia) 2. Uncontrolled shaking (tremor) 3. Stiffness (rigidity) 4. Unsteadiness & shuffling gait. 1. Shaking = Tremor. This is the most widely recognized sign of Parkinson’s disease. The shaking begins in one hand or one leg. This shaking happens even when the person is completely at rest. Even when he/she is sitting and doing nothing. So, it is also called “rest tremor”. You can see a video example of a rest tremor below. This video has been posted by Dr. Osama Amin & Dr. Saad Shiwani of Kurdistan on youtube: The shaking of hands/legs may continue when the hands/legs are moved. For example, the person’s hands may shake when he is trying to hand over some papers to another person. Shaking

Neuromodulation, including Vagus nerve stimulator (VNS) for Epilepsy in Mumbai Each year brings fantastic new developments in the treatment of Epilepsy! Neurostimulation devices use electrical currents to prevent seizures. 3 such devices have been approved. Fantastically, these devices can be used in patients who could not have surgical treatment before ! Vagus Nerve Stimulator (VNS) ============================= Relatively minor surgery. A small battery is connected to a nerve just below the skin, in the neck. Reduces all kinds of seizures, but especially those causing sudden falls (“Drop Attacks”) On average, reduces seizures by 50 %. Deep Brain Stimulation (DBS) ============================= “Medium” level surgery. A small hole is made in the skull, and a very thin wire is inserted into the brain. Useful in seizures coming from one area in the brain (Focal seizures), especially the temporal lobe. On average, reduces seizures by 50 %. Responsive Neurostimulation (RNS) ================================== Relatively major surgery. Phenomenal device that detects seizure activity as soon as it happens, then sends a small shock to abort it. Currently, it reduces seizures by 50 % But it is a programmable device – future detection algorithms may make it much more effective.   ***********************************Written by:Dr. Siddharth D Kharkar For more information: visit https://drkharkar.com/Targted Keywords – Neurostimulation in the Treatment of Epilepsy, responsive neurostimulation (RNS), Neurostimulation for Drug-Resistant Epilepsy, neurostimulation for epilepsy seizures in hindi Caution: This information is not a substitute for professional care. Do not change your medications/treatment without your doctor’s permission.

Which circumstances can provoke Seizures? This article is for patients with Epilepsy. For factors which are severe enough to provoke seizures even in non-epileptic patients, read the following article below. Please note that this other article is essential to read even if you have Epilepsy – it is necessary for you to to avoid these provoking agents as well [Provoked seizures: Click here]. Here is the list of circumstances (taken from the article above) which can precipitate seizures if you have Epilepsy. Factors that Can Precipitate Seizures if You Have Epilepsy High fever (Children) Lack of sleep Stress Menses Missing your Anti-Epileptic dose Let us talk about these factors in detail. If my child has a Seizure when he has a high fever, does it mean that he/she has Epilepsy? In the vast majority of cases: No, the child does not have Epilepsy. Children can have seizures when they have a fever. Seizures which happen during a high fever are called “Febrile Seizures”. They usually occur in children. In the vast majority of cases (>90%), Febrile Seizures do not indicate the onset of (or lead to the development of) Epilepsy. Rarely, however, some Epilepsy syndromes which happen in Children may present initially with Febrile Seizures. Some researchers multiple febrile seizures in childhood may slightly scar some brain parts, e.g. the “mesial temporal lobes”. This scarring may cause Epilepsy in adulthood. The risk of this happening is minimal, and many doctors believe it is almost zero. If a child has pre-existing Epilepsy, then a high fever can precipitate a seizure. This is less common in Adults. Does lack of sleep lead to Seizures? Yes, definitely. If you have Epilepsy, you should sleep for 8 hours a day. No excuses, no exceptions. Lack of sleep may precipitate seizures. Lack of sleep is a very strong precipitant of Seizures in certain Epilepsy Syndromes, especially Juvenile Myoclonic Epilepsy (JME). If patients with JME don’t sleep well, they get many jerks of the body in the morning. If they are lucky, that is all that happens. Unfortunately, sometimes they also get a whole body generalized seizure. Lack of sleep can precipitate all kinds of Seizures. Video-EEG monitoring is an unusual situation when the patient is admitted to the hospital, hooked up to the EEG, and everyone is waiting for a seizure to happen so that it can be studied. If seizures don’t occur by the third day, guess what the doctor and patient conspire to do: Sleep deprivation! The patient sleeps for only 4 hours in the night. Sure enough, many of these patients have a seizure the next day, regardless of their Epilepsy Syndrome. Does alcohol precipitate seizures? Excessive intake of alcohol can precipitate seizures in a person with Epilepsy. Excessive intake of alcohol may precipitate seizures. Some people who drink huge quantities of alcohol may get seizures, even if they dont have Epilepsy. Does Stress precipitate Seizures? Yes, it seems to. 25% of patients with Epilepsy report that Stress precipitates their seizures (Nakken et al. 2005). No one quite understands why this happens; some people believe that hormonal imbalances may play a role. Stress may precipitate both Epileptic seizures & Non-Epileptic attacks. Note: Here we are talking about stress precipitating seizures in Epilepsy, due to an increased abnormal tendency of the Brain to have seizures. But, stress can cause seizure-like attacks even when the Brain has NO tendency to have seizures – These are called “Psychogenic Non-Epileptic Seizure-like-attacks” or PNES, described in another article (click here). It is very important to find out if you have Epilepsy worsened by stress OR if you have PNES – both are real problems with good solutions, but the treatments are different. Considering that 1/4th of patients report a worsening of seizures when they are stressed out, learning stress reduction & relaxation techniques would be an excellent idea. Certain people may be more susceptible to depression and anxiety at certain times of the year. Some people may need a counsellor or psychiatrist to sort out these issues. You can read more about depression and anxiety and methods to reduce them here: [visual-link-preview encoded=”eyJ0eXBlIjoiZXh0ZXJuYWwiLCJwb3N0IjowLCJwb3N0X2xhYmVsIjoiIiwidXJsIjoiaHR0cHM6Ly9lcGlsZXBzeXBhcmtpbnNvbnMuaW4vaWYtaS1oYXZlLWVwaWxlcHN5LWhvdy1jYW4taS1yZWR1Y2UtZGVwcmVzc2lvbi1hbnhpZXR5LyIsImltYWdlX2lkIjotMSwiaW1hZ2VfdXJsIjoiaHR0cHM6Ly9lcGlsZXBzeXBhcmtpbnNvbnMuaW4vd3AtY29udGVudC91cGxvYWRzLzIwMTkvMTAvQ2xpbmljTG9nb1NtYWxsLnN2ZyIsInRpdGxlIjoiSWYgSSBoYXZlIEVwaWxlcHN5LCBob3cgY2FuIEkgcmVkdWNlIERlcHJlc3Npb24gJiBBbnhpZXR5PyIsInN1bW1hcnkiOiJDb21tZW50IiwidGVtcGxhdGUiOiJ1c2VfZGVmYXVsdF9mcm9tX3NldHRpbmdzIn0=”] Can Menses precipitate Seizures? What are “Catamenial Seizures”? Yes. Some, but not all women, may complain of worsening of seizures around their menses. This worsening is due to the high levels of a hormone called “Estrogen” in the body. These seizures are called “Catamenial Seizures”. Some women report that they have seizures around menses. If a lady with Epilepsy is started on anti-epileptics and stops having all seizures, the seizures around Menses may also stop. In some cases, all seizures except those around Menses may stop. These women may need a slight increase in the dosage of their anti-epileptics during these times, for additional protection. Your doctor may use medications called Benzodiazepines (for example, Clobazam) to provide this extra protection. In some of these patients, increasing the anti-epileptic dose may not help either. If traditional anti-epileptics don’t work, certain other medications including Acetazolamide or in rare cases a hormone called “Progesterone” may be helpful. Can missing your Anti-Epileptic medication precipitate Seizures? Well… Yes, of course. I think there are two main reasons for not taking medications on time. 1. Many people don’t like taking their anti-epileptic medications. A lot of people initially have trouble accepting the diagnosis of Epilepsy. This is understandable. It is a somewhat difficult disorder to understand, and the apprehension and complexity of treatments can be overwhelming. This is one of the reasons I wrote this guide. One of the ways we can learn to accept the diagnosis is to increase our knowledge about the disease. Some patients hate their medications! Once we accept the diagnosis, the resentment or apprehension while taking Anti-Epileptic medications disappears. 2. Some people forget to take their medications on time. Please allow me to give you a few tips that I have found helpful with my patients: Take medications at the same time every day: e.g. 9 AM and 9 PM. Use your smartphone to set reminders for this time. OR take your

How long does a seizure last? What is “Status Epilepticus”? Almost all seizures end in about 1 minute. Rarely, seizures may go on for a much longer period of time. If a seizure goes on for more than 5 minutes, the patient is said to be in a condition called “Status Epilepticus”. Status Epilepticus is a medical emergency – the patient needs to be given rescue medications to stop the seizure immediately. Such a patient needs to be rushed to the nearest hospital immediately. When many seizures happen one after the other in rapid succession, then again the person is said to be in Status Epilepticus. This again is a medical emergency. Although any epilepsy patient may get Status Epilepticus, it is uncommon and unlikely to happen if you have not had prolonged seizures before. As mentioned in the first line of this answer, almost all (>90%) of seizures end in about 1 minute or less. What are the 2 most common reasons for harm during a seizure? Most seizures do not result in permanent bodily harm. There are two main reasons for bodily harm during a seizure. These are worth highlighting: Reasons for Bodily Harm During a Seizure 1. Trauma due to hitting body parts 2. Aspiration / Choking The entire concept of first-aid during a seizure is to prevent these two things. What can I do to prevent aspiration? When a foreign body goes into the wind-pipe or lungs, it is called aspiration. If the foreign body is large enough (e.g. a stick or coin) it may block the wind-pipe leading to choking. If it is a liquid – such as the person’s own vomit – then it may go into the lungs and produce an infection of the lungs (pneumonia). In summary: Aspiration is to be prevented at all costs. Thus, for preventing aspiration: Do NOT put anything into the mouth of the patient while he/she is having a seizure. Do NOT put your hand in the patient’s mouth – your fingers could be cut off. Turn him/her to one side, so that any vomit flows out from the mouth. After you are absolutely sure that the seizure has ended completely, you can remove any large food objects in the mouth. Do NOT give the patient any food or water until the seizure ends completely and he/she is completely conscious. What can I do to prevent injuries during a seizure? If the patient has frequent seizures, then some preparation to avoid injuries is justified. Try to avoid furniture with glass or very hard metal corners which can result in injury. Consider carpeted floors or wood floors instead of stone floors. In children who have multiple daily seizures with drop-attacks, consider using a plastic helmet at all times to prevent head injury. As soon as you see a seizure happening: Try to prevent the patient from falling and hitting the ground hard. If possible, ease him/her to the ground. Remove all surrounding hard furniture. Should I video-tape the seizure on my smartphone? The eyes can only see what the mind already knows, and additionally, human memory is fallible. Especially if there are two people around it makes perfect sense to record the seizure in it’s entirety, from beginning to end. While recording, make sure that the entire body is visible. Do not change the camera angle excessively and do not end the video recording before the seizure ends. In fact, even after the seizure ends talk to the patient – ask him/her his/her name, what happened, and ask him/her to name a few things around the house and finally to hold up both arms. A good video recording can provide completely invaluable information to your treating physician. If you bring 2-3 (or even more!) such video recordings to your doctor, the nature of your seizures becomes crytal clear. This helps tremendouly in choosing medications and if required, considering surgery. This is a lot of information! How do I remember this in an emergency? Don’t worry: Click on the image below to download it. Print it and put it up in your home. Epilepsy A4 English Caution: This information is not a substitute for professional care. Do not change your medications/treatment without your doctor’s permission.

Can Epilepsy be genetic? Yes. We get our genes from our Parents. They determine a lot of our features: our height, our skin colour, our eye colour, hair colour and so on. Genes also contain the information required to make the brain, the lungs, the liver and other organs of our body. Therefore, if we have abnormal genes while growing up, we may develop abnormalities of the brain. We are now discovering that in many patients, the cause of Epilepsy is abnormal genes. Just for the sake of completion, allow me to mention that there are two other causes of Epilepsy: Injury to the brain after birth Auto-immunity (when our own immune system reacts against our brain) You can read more about these causes in this article (“What is the cause of Epilepsy?” – Click here). How do abnormal genes produce Epilepsy? Abnormal Genes can produce Epilepsy by one of 3 mechanisms. The table below has one example of each mechanism: How Does It Cause Epilepsy? Example Which Epilepsy Syndrome Does It Produce? By producing abnormal brain cells: Abnormal sodium channels in brain cells SCN1A Dravet syndrome By disrupting brain structures, e.g., by producing too many wrinkles on the surface of the brain ADGRG-1 Polymicrogyria By causing chemical (metabolic) problems: Problems in transporting glucose to the brain SLC2A1 GLUT-1 deficiency syndrome Genes causing Epilepsy – By producing abnormal brain cells Our brain cells contain may pores. These pores are called “Channels”. There are separate channels for specific chemicals. Thus, there are special channels for sodium, another set of special channels for potassium, and so on. If there is a problem with one of these channels, the disease is called a “Channelopathy”. The Sodium channels are most commonly affected. Abnormal sodium channels can cause sodium to flood into the brain cell. This causes a small surge of electricity. If this electricity becomes uncontrolled, you can have a seizure. If you want to read about the exact genes, click the plus sign below. This is a list of important genes causing Channelopathy: Genes causing Channelopathy Genes causing Epilepsy – By disorganizing brain structure The brain is a masterpiece of organization. Each cell is usually it’s God-given perfect place. Sometimes, the cells are okay but their organization is disrupted. This may cause problems such as: Too many wrinkles on the brain (polymicrogyria) Too few wrinkles on the brain (lissencephaly) Thickening of parts of the brain surface (Focal Cortical Dysplasia) Scarring of the brain part behind the ears (Mesial Temporal Sclerosis) etc… Out of these problems, number 3 (Focal Cortical Dysplasia) is very important. If you want, you can click on the + sign below. You can see all the known genes which can cause such problems: Genes causing structural problems Genes causing Epilepsy – By causing Chemical problems Our brain, like the rest of our body, is a finely tuned chemical factory. It burns glucose for energy. This “burn” is a “slow burn”. Energy is gradually extracted, step-by-step. The waste products are sent to the liver/kidneys to be de-toxified or thrown out. If this process is faulty, Brain cells do not get enough energy, or are exposed to toxic substances. This can cause seizures/Epilepsy. This faulty process is called an “Inborn Error of Metabolism”. There is a huge number of genes that produce errors of Metabolism. The list is so large that it is not possible to describe each one here! But that does not mean many people are affected by these genes. In fact, only a few patients with epilepsy have Inborn Errors of Metabolism (IEMs). Doctors typically test for these problems only if there are suspicious features such as consanguinity, repeated episodes of low blood sugar etc… Here is a list of the important genes from a research paper. You can click here for the full version of the paper (Sharma et al 2017). Footnote: Footnote: In some cases, the genes from both parents are perfectly normal. But while the baby is growing in the womb, his/her normal genes may become abnormal. These are called “Somatic mutations”. This is a developing concept in Epilepsy, and therefore not discussed in detail here.   Caution: This information is not a substitute for professional care. Do not change your medications/treatment without your doctor’s permission.

What is an EEG? “EEG” is the short-form of  “Electro-Encephalo-Graphy”. The literal translation is: -Electro = Electrical– Encephalo = head– Graphy = Representation Therefore, “Electro-Encephalo-Graphy” or EEG means “Graphs of the electrical activity inside your head”. An EEG records electrical signals from your brain. If my EEG is normal, does it mean that I do not have Epilepsy? No. A normal EEG cannot guarantee that you do not have Epilepsy. The diagnosis of Epilepsy is based on your clinical condition, rather than any one particular test. This is because there is no perfect test for Epilepsy. A 1 hour EEG is normal in 50% of patients with generalized Epilepsy. Even more disappointingly, the EEG is normal in up to 70% of patients with focal Epilepsy. A longer EEG (for example 4 hours) may show epileptiform abnormalities missed on a shorter EEG. Also, if you are sleep deprived, the chances of your brain having small sparks that can be seen on EEG increases. Therefore, many doctors will ask you to sleep for only 4 hours the night before the EEG. This is called a “Sleep-Deprived EEG”. Many doctors will ask you to sleep only for 4 hours before the EEG test. If my EEG is abnormal, does it mean that I have Epilepsy? Usually, with two caveats. First, rarely, a person who does not have Epilepsy may still have Epileptiform discharges on their EEG. We doctors don’t know what that means. Perhaps these people are at a slightly higher risk of seizures. However, this increase in risk, if at all present, is minimal. Treatment with anti-epileptics is not required unless the person is actually having seizures. Avoiding sleep deprivation, stress and excessive consumption of alcohol would be very reasonable. Abnormal tunnels in the walls of cells can cause Epilepsy. Second, occasionally, normal waves on the EEG may be mistaken for epileptiform discharges. There are many normal waveforms (such as “Wickets”) which look sharp and may be mistaken for abnormal electrical sparks. A second review of the EEG may be helpful in such a scenario. Indeed many epilepsy experts will ask other experts about their opinion when they encounter a particularly odd-looking shape on the EEG. Here is an excellent paper that describes Epilepsy genes causing channelopathy [Bartolini et al 2020]. A EEG may help to figure out whether you are likely to have more seizures – i.e. whether you have epilepsy. What are “Epileptiform Abnormalities”? As explained here, the different parts of our brain communicate with each other using electricity. Usually, this electricity is very strictly regulated. Occasionally, however, a small part of the brain may have an electrical storm. This electrical storm produces abnormal bursts in electricity which can be detected by the EEG. These abnormal bursts can produce many different kinds of shapes on the EEG, including spikes, short buzzes, and so on. These abnormal shapes are called “Epileptiform Abnormalities”. What “Epileptiform Abnormalities” does an EEG show? The type of Epileptic Abnormalities seen on an EEG depend on the type of seizures that you have./’ I have described them below for you to understand your EEG report properly. It may be worthwhile to look up the abnormality noted in your EEG report and find it in the tables below. Depending on which part of the brain (see figure below) is producing these sparks, they are called Frontal, Central, Temporal, Parietal or Occipital. Sometimes, to indicate the exact location, a combination of these words is used. The exact location may identify your Epilepsy Syndrome. For example “Centro-Temporal” spikes are seen in an epilepsy syndrome called Rolandic Epilepsy. The brain is divided into 4 lobes. If you have seizures that start in one part of your brain (Focal Seizures), then you usually get one of two epileptiform abnormalities: Spikes/Sharps: These are like a little electrical spark. The electrical spark produces a pointy wave on the EEG. If it is very pointy it is called a spike (<70 msec), whereas if it somewhat spread out it is called a sharp. Sometimes, a spike/sharp may be followed by a slow, gentle wave on the EEG, almost as if the brain was trying to quieten down the electrical storm. This particular sequence of events is called a “Local Spike-and-wave” An electrical spike is a huge, rapid burst of energy that quickly stops within 1 second. Fast activity: These are “buzzes” of abnormal electrical activity. They produce a hair-brush pattern on the EEG. Your EEG report will indicate the location as well, for example: “short episodes of temporal fast activity were seen”. Fast-activity or electical buzzes on the EEG last around 2-3 seconds If you have buzzes on the EEG, it may indicate that you have Focal Cortical Dysplasia (FCD). FCD is described in more detail here. If you have seizures that start all over the head at once (Primary Generalized Seizures), then you may get other kinds of epileptiform abnormalities on your EEG: Generalized spike-and-wave: The word “Generalized” means “all-over”.These are similar to the spike-and-wave described above, except that these sparks happen all over the head.- They are sometimes seen more prominently in the front of the head, and sometimes it may be difficult to differentiate between a truly generalized spike-and-wave and a frontal spike-and-wave.- They may have multiple spikes in which case they are called “Polyspike-and-wave”. Polyspike-and-wave is seen in Juvenile Myoclonic Epilepsy (JME).- Your epilepsy syndrome determines the speed (technically, frequency) of these spike-and-wave discharges. For example: 3 Hz Childhood Absence Epilepsy Less than 3Hz Lennox – Gastaut Syndrome (LGS) More than 3 Hz Juvenile Absence Epilepsy (JAE) or Juvenile Myoclonic Epilepsy (JME) Generalized spike-and-waves are seen in Absence epilepsy. They are also seen in the other syndromes described above. Generalized Paroxysmal Fast Activity (GPFA): These are similar to the fast activity described above, except it happens all over the head. Children with Lennox-Gastaut Syndrome (LGS)may have GPFA on their EEG.However, all patients with GPFA do not have Lennox-Gastaut Syndrome – This is a common misconception, even amongst doctors. Even if your child has GPFA on his/her EEG, he/she may not have

What is an MRI? MRI stands for Magnetic Resonance Imaging. An MRI machine takes very clear pictures of your brain using a magnetic field. https://www.shutterstock.com/image-photo/mri-machine-hospital-room-482984881 MRI machines are graded based on the strength of the magnetic field they can produce. If an MRI can create a powerful magnetic field, it produces very clear pictures of the Brain. Magnetic fields are measured in units called “Tesla.” Here are some typical MRI (Magnetic) Strengths: 1.5 Tesla – Most common. 3 Tesla – Almost all Epilepsy centres have a 3Tesla MRI machine. 7 Tesla – Strongest MRI approved for human use so far. Only manufactured by Siemens. Only a few hospitals in the world have this machine. As you can imagine, a low strength MRI can fail to display tiny Brain abnormalities. Therefore, when a patient comes to an Epilepsy center, frequently, the first thing done is to get a brain MRI at high strength (at least 3Tesla). If the MRI does not display an abnormality, does it mean that I do not have Epilepsy? No. In many cases, the brain abnormality can be so small that it cannot be detected even with an MRI. A 3Tesla MRI (the most common MRI at Epilepsy centres), fails to display brain abnormalities in roughly 50% of patients with Epilepsy. As MRI strength continues to grow (e.g. 9T  & beyond), the number of people with Epilepsy in whom we cannot see the problem will decrease. If the MRI displays an abnormality, does it mean that I definitely have Epilepsy? No. No one is perfect. Any MRI done on a person is bound to show some variations from normal. https://www.shutterstock.com/image-photo/brain-disease-diagnosis-medical-doctor-diagnosing-1525567082 Beyond a certain age (say 40 years), the effects of ageing become visible on the MRI. There may be changes caused by high blood pressure, by diabetes, by trauma, and so on. Very few of these things seen on an MRI are capable of producing seizures. The critical question is: Does the thing seen on the MRI look like it can produce seizures? Answer this question requires expertise. A trained radiologist takes a very close look at the MRI and tries to identify it’s exact nature (more below). If he/she thinks that the abnormal thing is capable of producing Epilepsy, he labels it “Epileptogenic”. If an abnormal thing seen on the MRI is thought to be capable of producing Epilepsy, it is called an “Epileptogenic Lesion”. What are the different kinds of “Epileptogenic Lesions” seen on an MRI? Let’s talk about the most common ones. Let’s list them first, before looking at what the MRIs look like: Epileptogenic Abnormality Meaning Lissencephaly Fewer wrinkles on the brain Polymicrogyria Too many wrinkles on the brain Focal Cortical Dysplasia Part (focal) of the brain surface (cortex) is abnormally formed (dysplasia) Nodular Heterotopia Abnormal bunch of cells stuck in strange locations inside the brain Tuberous Sclerosis The brain has many large bumps (tubers) on the surface and nodules deep inside (subependymal nodules) Mesial Temporal Sclerosis The inner surface of the temporal lobes (behind our ears) is scarred Sturge-Weber There are too many blood vessels over some parts of the brain, and the brain surface below these blood vessels is abnormal Cavernoma A bunch of thin-walled blood vessels that slowly leak blood Gliosis Scarring of the brain due to any reason, e.g. trauma due to a vehicular accident, stroke, etc. https://upload.wikimedia.org/wikipedia/commons/9/9d/Lissencephaly.jpg https://upload.wikimedia.org/wikipedia/commons/1/1d/TSC.png https://www.shutterstock.com/image-photo/neurosurgeon-cutting-brain-specimen-abnormal-vessel-1163324815 https://upload.wikimedia.org/wikipedia/commons/1/1d/TSC.png Even if an Epileptogenic lesion is not found, can the MRI help in diagnosing my disease? Yes! In some people, Epilepsy is caused by a chemical (Metabolic) problem. In these people as well, characteristic MRI changes (e.g. deposition of heavy metals) may help in diagnosing your condition. For example, see the list below. This is just for reference, and not to be memorized: Metabolic Disease Producing Epilepsy Cause MRI Findings Non-Ketotic Hyperglycinemia Too much of a substance called Glycine Swelling and formation of fluid balloons in structures called the pyramidal tract, MCP, and dentate nuclei Maple Syrup Disease Problems in handling some kinds of proteins Swelling of the entire brain The white matter can become extremely bright Zellweger Syndrome Abnormal bubbles inside cells Polymicrogyria & heterotopia (just behind the ears) White matter has not developed the normal coating of fat Menke’s Disease Accumulation of copper Skull bones may be in pieces (wormian bones) Chronic subdural bleeds Brain shrinks White matter swells Copper accumulates in basal ganglia Blood vessels become tortuous Note: MRI findings in other metabolic causes of seizures are given below, just for completion. This part is not necessary for you to read: Metabolic Disease Producing Epilepsy Cause MRI Findings Methyl-Malonic Aciduria Problems in handling some kinds of proteins & fats Swelling of small structures deep inside the brain called Globus Pallidi Glutaric Aciduria Type 1 Problems in handling some kinds of proteins Grooves on the side of the brain (Sylvian fissures) become very wide Hydroxy Glutaric Aciduria Unknown Swelling of white matter just below the brain surface (U-fibers) Deep structures (especially Dentate Nucleus) show injury Molybdenum Cofactor Deficiency Accumulation of a toxic substance called sulfite The surface of the brain becomes very bright as if it is starved of oxygen Congenital Creatine Deficiency Low levels of essential enzyme activity No creatine inside cells MELAS Abnormal mitochondria inside cells Stroke-like lesions that move from one place to another Leigh’s Disease Unknown Deep structures start to die (Basal Ganglia & Dentate nucleus) with accumulation of a chemical called lactate Neuronal Ceroid Lipofuscinosis Accumulation of fatty pigments (lipofuscin) The back of the brain shrinks White matter can become “dark” Caution: This information is not a substitute for professional care. Do not change your medications/treatment without your doctor’s permission.

Parkinson’s disease is the most common Bradykinesia cause. But, there are many non-Parkinson’s causes of Bradykinesia. It is important to know non-Parkinson’s diseases which can also cause Bradykinesia. The treatment of each disease is different. Let us discuss this topic in a systematic fashion. Book An Appointment Noticing stiffness or slowness in routine activities? Reach out for timely consultation before symptoms worsen. Is it really Bradykinesia? The literal definition of Bradykinesia would include all kinds of slow movements. But, doctors think of bradykinesia differently. Most doctors use that word for involuntary slowness caused by problems in the brain. So, slow movements due to the following reasons is not Bradykinesia. Slow movements that are not Bradykinesia 1. Voluntarily slow movements due to pain 2. Voluntarily slow-walking due to fear of falling over 3. Stiff joints causing slowness 4. Stiff Muscles causing slowness 5. Overactive nerves causing stiff muscles Let us look at these problems in detail. The examples may appear complicated. Don’t worry. Understanding the concepts is more important. 1. Voluntarily slow movements due to pain: A person in pain moves that body part slowly and carefully. If that body part is in the legs (for example – knees) the person may walk slowly to avoid pain. This is not bradykinesia. Examples: Painful hip arthritis, knee arthritis, ligament tears, infections of the legs… Knee pain or stiffness can make your walking slow. This is NOT bradykinesia. 2. Voluntarily slow walking due to fear of falling over: Some people have a problem with balance. The balance system includes sensory nerves in the legs, spinal cord and the little brain (cerebellum). For obvious reasons, these people walk carefully. The walk with their feet wide apart. They make sure each step they are taking is safe. They are especially slow and deliberate when walking on uneven ground. This is not bradykinesia. It is a conscious, purposeful, voluntary decision. This type of slow gait is a “Cautious gait”. Examples: Diabetic neuropathy, Vitamin B12 deficiency, HIV, compression of the spinal cord… People who are unsteady, walk slowly and carefully. This is NOT bradykinesia. 3. Stiff joints causing slowness: Joints may become stiff because of immobility. This may happen after casting for fractures. Joints can also become stiff because of inflammation. Diseases like Rheumatoid arthritis & Ankylosing Spondylitis can lead to joint swelling and stiffness. People with stiff joints are unable to make big movements. Their steps may be small, and they may walk slowly. This is not bradykinesia. Examples: Frozen shoulder, knee osteoarthritis, Rheumatoid arthritis, Ankylosing Spondylitis… 4. Stiff muscles causing slowness: This is relatively uncommon. Some conditions can cause painful swelling and fibrosis of muscles. Others conditions can cause them to be in a state of perpetual contraction. Surely, if the muscles are inflamed, painful and stiff, movements will become slow. Examples: Neuromyotonia, Fibrosis secondary to Emery-Dreifuss, dermatomyositis… Stiff muscles or joints can make movements slow. Note that there is some subtlety here. Stiff muscles can also be a symptom of Parkinson’s. If the slowness is due to stiff muscles, it is not bradykinesia. On the other hand, if both the slowness and stiffness are due to a brain problem, then it is bradykinesia. Differentiating one from the other requires care, and medical expertise. 5. Overactive nerves causing stiff muscles: This is the rarest reason. Most doctors will see only 1-2 cases like this in their life-time. Examples: Stiff-man syndrome due to GAD-65 antibodies Book An Appointment Early diagnosis of bradykinesia can change the course of treatment. Don’t delay — consult a neurologist today. Are other symptoms of Parkinson’s present? As noted before, Parkinson’s disease is the most common of all the bradykinesia causes. Parkinson’s disease has many symptoms other than Bradykinesia. Not all these symptoms need to be present. But at least some of these symptoms need to be present to make a diagnosis of Parkinsonism. 4 Cardinal signs of Parkinson’s disease 1. Slowness (Bradykinesia, Hypokinesia or Akinesia)2. Uncontrolled shaking (tremor)3. Stiffness (rigidity)4. Unsteadiness Other than these 4 symptoms, patients with Parkinson’s disease have other symptoms too. The 16 most important symptoms of Parkinson’s are described in another article. [16 early symptoms of Parkinson’s disease]. There are many problems with movement in Parkinson’s disease. What if you don’t have any of these symptoms? Then, we need to carefully look for non-Parkinson’s cause of Bradykinesia. 3 Non-Parkinson’s causes of Bradykinesia These are conditions of the Brain which cause involuntary slowness. These conditions are limited in number. Simple tests such as an MRI of the brain, blood tests and talking can help to rule out these problems. Disease Treatment 1. Damage to the front of the brain Examples: – Tumors – Strokes – Hydrocephalus (too much water) etc… The person forgets how to do something. For example, the patient may forget how to take the next step. In the purest sense, even this is not bradykinesia. It is called “frontal Apraxia”. Treatment is varied. e.g. Hydrocephalus is treated by a shunt. 2. Hypothyroidism Thyroid hormone tablets 3. Severe depression Counselling, antidepressants Hydrocephalus is a condition in which there is too much water inside the brain. Treatment is a shunt surgery. A thin pipe is inserted, just below the skin. This pipe drains excess water from the head into the stomach. Book An Appointment Slow or difficult movements affecting daily life? Take the first step towards answers and better care now. The importance of being careful Sometime, patients may be mis-diagnosed to have Parkinson’s disease. This is uncommon, but not difficult. Look at the person below. He has a kind of hydrocephalus called Normal Pressure Hydrocephalus (NPH). NPH is one of the non-Parkinson’s causes of Bradykinesia. Look at how he is truly slow with his movements, especially walking. Sometimes, he appears “stuck” to the ground. https://www.youtube.com/watch?v=hziyFfJTrQo Imagine how easy it is to diagnose Parkinson’s disease here. But, this person does not have Parkinson’s disease. This patient with NPH will improve after a small surgery called shunting. But, if this patient is mis-diagnosed and gets Parkinson’s medications instead, there will be no improvement. Bottom-line First, the doctor verifies if you really have bradykinesia. Parkinson’s disease is the most common of