What Would You Do?

A Case Study of Seizure Disorder and Brain Function

Directions: Please read the following story & discussion questions at the end. Respond on the Week 2 Discussion Forum with your thoughts.

Jack Hamilton is seven years old. He is an only child and much loved by his parents, Karen and Jeff, and by his extended family of grandparents, aunts, uncles, and cousins. Jack has always been a very active boy. He loves hockey, baseball, swimming at the local pool, climbing trees, and playing with his golden retriever, Jump.

Shortly before Jack's seventh birthday, he had a small seizure. He was out playing with his dad and Jump in the yard, when suddenly he stopped, his right arm twitched a little and he seemed disoriented for a few seconds. Afterward he said he was fine, but his mother Karen thought he was quieter than usual. Both his parents watched him more closely in the following days. Soon he had another couple of episodes of muscle twitching and weakness. During these seizures, Jack also stared blankly, moving his head slightly back and forth, and for a minute or two could not respond to his parents. When the seizures ended, Jack had no memory of them. Jack's parents took him to their pediatrician, Dr. Madeline Sierra, who listened as Jack's parents described his symptoms.

"Do you think it's epilepsy?" Karen asked. "Epilepsy is one possibility," replied the doctor. "It is a relatively common problem and there are some very good treatments for it." Dr. Sierra went on to explain: "The brain uses electrical energy. The cells of the brain, called neurons, emit a small electrical charge when they send messages to other cells. This is how the brain communicates and runs your mind and body." Dr. Sierra interrupted her explanation for a moment to show them a diagram of a neuron.

"In epilepsy, the neurons somehow get out of control," Dr. Sierra continued. "The electrical activity increases to a level that the brain can not manage. That produces what we call seizures, where people lose control of their voluntary behaviors for a brief time. Sometimes seizures are nothing more than short

lapses of consciousness. Other times they involve convulsions or involuntary movements."

Jack's tests were done right away, and his parents met again with Dr. Sierra. Jack's symptoms were escalating. He had daily seizures, and they included disorientation as well as uncontrollable repetitive movements on the right side of his body. He often felt tired and weak after the seizures.

"Here is the output from Jack's EEG exam." Dr. Sierra showed them a printout. There is a particular pattern of spikes here that shows his seizure activity. Based on these tests and some other indications, I believe Jack's seizures are what we call 'partial' seizures. This means that they only involve part of the brain.

"However," the doctor added, "if we do not find a way to reduce or control the current level of seizure activity I am afraid that Jack's brain will begin to show some damage, regardless of how much of it is now involved. Fortunately, there are several treatment options available to us. Let's start with a seizure medication."

Dr. Sierra prescribed medication to help treat Jack's disorder. The first medication didn't succeed, so Dr. Sierra then tried another. After some time and other combinations of medications, it became clear that this type of treatment would be problematic for Jack. His seizures were becoming more severe and more frequent. The doctors ordered more tests and then Dr. Sierra met with Jeff and Karen.

Dr. Sierra pulled out Jack's records. "Here is a picture from Jack's new MRI scan. Look at this area in the left side of the brain. We are beginning to see some slight abnormalities here that indicate Jack's brain is starting to be damaged by the seizures."

"I believe that Jack has a disorder called Rasmussen Syndrome. Unfortunately, we don't know what causes it. Some people suspect it may be some type of viral infection, but we don't know for sure. It involves the type and frequency of seizures we are seeing in Jack and usually occurs in children of about Jack's age. I must warn you that it is a progressive and potentially serious illness that often does not respond to medication."

Dr. Sierra went on to describe another type of more drastic treatment that might work in Jack's case.

"The upper part of the brain, the cerebrum, is divided into two halves, or two hemispheres," Dr. Sierra explained. "In

some cases of severe seizure disorders, seizure activity seems to be concentrated in one half or hemisphere of the brain. This is the case in Jack's illness."

"What do you mean, 'removing'? You take out his brain?" Karen was horrified.

"In Jack's case, his seizure activity is located primarily in the left hemisphere of his brain. Sometimes, we can control or even eliminate seizure activity by removing the portion of the brain which is suffering. We call this a functional hemispherectomy."

"What do you mean, 'removing'? You take out his brain?" Karen was horrified.

"Not his entire brain, just the parts that show abnormal activity. In Jack's brain, that would mean a large part of his left hemisphere. We would remove Jack's left temporal lobe, part of his left frontal lobe, and perhaps some areas in his parietal and occipital lobes. We would also sever the corpus collosum, the band of tissue that connects the two hemispheres and allows them to communicate. We would leave intact Jack's thalamus, amygdala, hippocampus, and other deep structures of the brain."

Dr. Sierra looked at their worried faces. "It sounds terrible, but there have been quite a number of these surgeries performed. We have an excellent team of specialists with a great deal of experience performing this type of surgery and with the rehabilitation that would follow. In cases like Jack's, where medications are not working, it can lead to a significantly better quality of life for the patient. Believe it or not, and I know it is difficult to believe, this may be our best option."

 

• What decision do you recommend to the family? Why or why not go ahead with surgery?

• What other kinds of questions would you have about the surgery? Can you find the answers?

• If Jack had the surgery, would his level of functioning get better, worse, or stay the same over time?

• Other than reducing his seizures, how else might Jack's thinking or behavior be affected by losing these parts of his brain?

• What types of abilities would he still retain, because the brain structures would remain intact?

• What might the family do to help Jack recover after such a surgery?