WILTIMS #488-92: Neurology - Epilepsy

This is the third catch-up post in the past couple hours. Make sure not to miss one! Here is Nephrology - Part I and Nephrology - Part II.

Last week I started my four week rotation in Neurology. This is my last rotation of third year! Woohoo! Each week of this rotation I am on a different team, starting with epilepsy on week 1.

Epilepsy is super boring. Well, epilepsy as a collection of disorders is actually really interesting, but treating epilepsy patients in the hospital is usually really boring because the patients are rarely actually seizing when you're standing there. Usually they had a seizure at home and were brought in to the hospital once they've stabilized. Then our job is to figure out if they truly had a seizure, why they had one if they did, and keep them from seizing again (usually by starting or raising the dose on the same cure-all anti-seizure meds).

A sample EEG with a seizure on the right half

The mainstay of epilepsy diagnosis is the electroencephalogram (EEG), which is always depressing. Either it will confirm a diagnosis of seizures, which is never fun, or it shows that there weren't any seizures while it was recording, which either means that the patient's problems are not caused by seizures, or that the EEG just got unlucky and there normally are seizures.

MIL: When doctors adjust the level of drainage for a ventriculostomy (tube that removes cerebral spinal fluid (the juice your brain floats in)), they counterintuitively talk about increasing the ventriculostomy to wean off of it. This is because the number that they are increasing is the amount of intracranial pressure (ICP) above which the ventriculostomy tube will start draining. A great analogy that a nurse shared was it was like raising the height of the overflow pipes from a dam; if you raise the height, the dam has to hold more water before it overflows. Lower numbers mean less stress on the dam/brain.

TuIL: Seizures on EEG look as if the squiggly lines have increased in every way: frequency (they're more common), amplitude (they're taller), and rhythmicity (they have a consistent pattern).

WIL: Shivering suppression can hide seizures in patients being treated with therapeutic hypothermia after a cardiac arrest. A common treatment used after the heart stops for a prolonged time is to lower the body temperature. But this can cause violent shivering as the body tries to maintain homeostasis. The drugs used to stop the shivering are paralytics that prevent the muscles from contracting. This works great, but if the patient is having seizures (as ~30% will, post-cardiac arrest) then the paralytics will stop you from discovering the seizures. Even though the patient isn't able to twitch or spasm, the brain might still be being damaged by the silent seizures.

ThIL: There are four broad kinds of sedating drugs: benzodiazepines (like versed), opioids (like fentanyl), alpha-2 adrenergic agonists (like precedex), and propofol (which is in a class of its own as we don't even understand its mechanism).

FIL: Nemaline myopathy is an atypical muscular dystrophy that results in weakness in skeletal muscles, typically most severely affecting the face, neck and limbs.

WILTIMS #345-346: A little fun and a little weekend

Another "weekend", another call day. Thankfully, Sunday was already my third of four on-call shifts, so I'm pumping them out early. It sure would be nice to have a couple days off in a row though.

Friday was our first game of the flag football season at my school. Whereas the first and second year students each field a handful of teams, with all our our classmates dispersed to hospitals throughout the tri-state area, my whole class of 200+ students only is fielding one team. This week we only managed 6 players, but by the "luck" of the draw, were playing the scrappiest of first-year teams and won handedly.

Remembering back, playing flag football with some second- and third-year students in front of the ER during my first weeks on campus was really the first time I felt like I had really made it to med school. Now I'm the third year, strolling lazily out of the hospital with my stethoscope and crumpled patient list. It's a nice reminder that I'm over half-way done.

FridayIL: Finding the cause of a first-time seizure is actually worst prognostically than not finding one. Statistically, if we find the cause, you are more likely to have more seizures in the future, but if we work you up and can't find an answer, then odds are, you won't have another.

SundayIL: Rhinitis medicamentosa is nasal congestion brought on by extended use of topical decongestants. Essentially, your body adapts to the decongestant and causes the baseline state to be a mildly congested one. Yet another medical condition caused by treating a medical condition. Only use medications as instructed!

WILTIMS #245-8: Mega-post 2 - The Revenge

Friday: Today I got to give another presentation about the science behind smoking and lung cancer at a local school for a club that I'm involved in at our school. Compared to the very upscale middle school at which we had previously presented, this was a much rougher school in a poorer neighborhood, but I think I had even more fun and had a better chance of making an impact.

FridayIL: Though they can cause sedation, benzodiazepines cannot cause full blown anesthesia or coma.

MondayIL: Subarachnoid hemorrhage is most often caused by "berry" aneurysms. These are little berry-like bubbles that sometimes form around the junctions between the blood vessels of arteries in the circle of Willis in the brain. They weaken the vessel walls, much like if you poked into a balloon with your finger, causing a thinner, finger-shaped bubble to protrude from the otherwise normal balloon. If the balloon were ever going to pop, it'd pop in that thin bubble.

Tuesday: Snow day!

WednesdayIL: Bupropion (Wellbutrin) is an antidepressant that is also used to aid in smoking cessation. Patients were so upset by seeing that they were being prescribed an antidepressant, even if it was for a different indication, that the company started producing the same drug under a second name (Zyban) so that people would take the prescription without worrying about the stigma of being on antidepressant medication. What does this say about our society's feelings on mental illness?

TIL: If a brain lesion causes a gaze preference (someone's eyes skew to one side at rest), you can usually differentiate from symptoms caused by ischemia (loss of blood flow) or seizures. If ischemia is the cause, then the patient will look toward the side of the head that the lesion is on, whereas seizures cause the patient to look away.

Hemorrhagic stroke often causes headache and lethargy, whereas an ischemic stroke does not.

Seizures can confusingly cause the symptoms of a stroke, like muscle weakness, in the hours and days post seizure.

For carotid stenosis (hardening of the arteries supplying the brain due to athlerosclerotic plaque formation) the original treatment was to cut open the neck and carotid artery to physically scrape out the plaque on the artery walls - this is called a carotid endarterectomy. Once stents were invented everyone hoped that it would be a great, less invasive alternative to the major surgery that is the endarterectomy. But they quickly realized that the act of placing the stent increased the risk of breaking off a part of the plaque and causing a stroke - exactly what we were trying to prevent in the first place. So now, surgery is the first line treatment again and stents are only used if surgery is contraindicated.

Oculus uterque means "both eyes."

WILTIMS #195: Mama bears

TIL: If a UTI spreads up from the bladder into the ureters and kidneys, normal UTI antibiotics will no longer effectively treat the infection. This is because they often clear from the bloodstream very quickly and concentrate in the bladder (this is why we use them for UTIs). But since they clear so well through the kidneys, they never reach a high enough concentration to kill the bacteria there before moving straight down the urinary tract.

Aicardi syndrome is a genetic condition caused by a malformation of the brain. Specifically, the corpus callosum which connects the two hemispheres of the brain, is absent. Children born with this syndrome often have severe seizures and very specific retinal tears called lacunae. The incidence if about 1 in every 150,000 live births and the prognosis for development and lifespan is generally very poor.

Things I already knew: Parents of developmentally disabled children are fiercely intimidating people. We had a panel of mothers of kids with chronic health conditions come speak to our entire class which had donned its white coats and ties (and dresses, etc.) - that's an intimidating audience! But these women had learned to manage whole teams of doctors and navigate the most confusing parts of the health system, so 200 medical students were nothing to worry over.

WILTIMS #151: Little of this, little of that

Yet another packed day. Three hours of dubiously useful lecture, a few hours of review for neuroscience, a kickball game and finally a documentary movie put on by the Ethics in Medicine Club. No rest for the wicked? Actually, a fellow movie watcher was jokingly annoyed with some other friends of ours for ditching the screening... to volunteer with sick children at a local hospital.

TIL: Epilepsy is a disease and seizures are symptoms. By a similar token, there are no treatments for epilepsy, only treatments for seizures. This may seem like silly semantics, but the serious point is that medications can temporarily alleviate the symptoms of epilepsy, but none effectively fight the underlying cause(s).

The organic causes of impotence can be summarised by a convenient, if unwieldy, acronym:

WILTIMS #58: Why so serous?

We only had one 2-hour anatomy lab on the schedule today, so I don't have much to report. We were dissecting the parotid and temporal regions of the head (above, in front of and below the ear). It was not the most elegant dissection thanks to the slapdash layouts of the nerves, blood vessels and glands in relation to the bones and muscles, but we made do and managed to see most of what we were supposed to see.

The salivary glands: #1 parotid,
#2 submandibular, #3 sublingual

TIL: The parotid gland and pancreas are the only two glands that produce amylase, the enzyme that breaks down starches into sugar. The parotid gland secretes serous fluid, including the amylase enzyme, into the mouth via a duct that can, on rare occasions, become occluded causing the sides of the face to swell. This condition is easily confused with the mumps, which also results in the swelling of the parotid gland, but from the inflammatory action of the mumps virus rather than the obstruction of the parotid duct.

Seizures originating in the temporal lobe are associated with the perception of an strange smell. These seizures can be caused by radiation from the treatment of salivary gland cancers located in the parotid gland.