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intractable epilepsy

Purpose of hospitalization for epilepsy

Purpose of hospitalization for epilepsy The basis of epilepsy treatment is to properly identify the type of epilepsy attack and take antiepileptic drugs for the attack. However, if drug treatment at the outpatient department does not improve the condition, or if it is difficult to identify the type of epilepsy by a short-term examination at the time of outpatient treatment, a more detailed examination is required, so the patient is admitted to the hospital. .. In addition, according to the Epilepsy Practice Guidelines 2018, it is written that “If seizures are not suppressed for more than a year even if single or combination therapy is given with two or more appropriately selected antiepileptic drugs, surgery should be considered.” Therefore, we may be hospitalized in consideration of surgery.

Specific in-hospital examination

① Long-time video brain wave monitoring

An electroencephalogram is an electric current generated by nerve cells in the brain. When a seizure occurs, a large current flows in the brain, so a characteristic waveform can be seen. Long-term video EEG monitoring records this EEG and shoots a video to observe the patient’s seizure situation to determine the type of seizure and which part of the brain the seizure originated from. .. The inspection period is from one day to one week.

② MRI or CT

Images the inside of the brain and examines abnormal parts of the brain.

③ PET

This is a test to see the metabolism of glucose required for brain activity. At the site of the attack, glucose metabolism is usually reduced and increased only during the attack. It is used in combination with MRI during epilepsy surgery or when you want to have a more detailed examination.

④ SPECT

This is a test to check the blood flow in the brain. Blood flow is usually low at the site of the attack, but increases only during the attack. By observing this change, it is possible to identify where in the brain the seizure occurs and to what extent in the brain the attack spreads. It may be used in addition to MRI and PET.

⑤ Magnetoencephalography (MEG)

It is a test to identify the site where an epileptic seizure occurs by measuring the weak magnetic force generated by the activity of the brain and grasping the position and magnitude of the abnormal magnetism.

⑥ Neuropsychological examination

It tests the patient’s memory and intelligence. A single test can take several hours and may be divided into several days during hospitalization. If you are doing video EEG, a clinical psychologist will visit the hospital room and inspect it.

Specific treatment during hospitalization

① Surgery

If the seizures do not improve after more than a year of medication, surgery may be considered. However, the type of epilepsy determines whether surgery is possible. The epilepsy that can be operated is as follows.

  • Medial temporal lobe epilepsy
  • Partial epilepsy

Of these, those in which damage or abnormality is found in the resectable part of the brain ・ Of the partial epilepsy, those in which no damage or abnormality is found in the brain but the epileptic region can be found to some extent by examination such as electroencephalogram are as follows. It is a street.

  • Focal epilepsy due to extensive lesions in one hemisphere
  • Intractable epilepsy surgery method with atonic seizure

I will introduce the surgery for these from now on.

Focus resection

The part of the brain where excessive excitement occurs during an epileptic attack is called “focus”. This is an operation to cut off the focus and remove it.

Block surgery

If the focus is on the motor and language-related parts of the brain, paralysis and speech disorders will always occur when excised. Also, if the area where the seizure occurs is extensive, it may not be possible to remove it. In such cases, surgery is performed to prevent the excitement from being transmitted by cutting off the route through which the epileptic seizure is transmitted without removing the focal point.

Vagus nerve stimulation (VNS therapy)

It is a treatment method that reduces seizures by implanting electrodes in the vagus nerve and electrically stimulating them at regular intervals. The length of hospital stay for surgery is several days to a week, and electrical stimulation begins at the time of outpatient visit after discharge. For epilepsy where the effect of antiepileptic drugs is low, it can be expected to have the effect of reducing the frequency of seizures when used in combination with antiepileptic drugs.

② Diet-Ketogenic diet-

The brain normally works with glucose as energy. However, when this glucose is deficient in the body, it burns fat to make ketone bodies and use it as an alternative energy source. A ketogenic diet is a diet that reduces carbohydrates, increases fat, and makes it easier for the body to make ketone bodies. It is said to be effective mainly for patients with pediatric West syndrome and myoclonic weakness epilepsy. However, because of side effects such as hypoglycemia, nausea, constipation, diarrhea, and developmental disorders, the ketogenic diet should be performed under the supervision of a doctor or dietitian during hospitalization.

Epilepsy hospitalization costs and length of stay

The length of hospital stay varies depending on the type of examination / surgery and may range from days to months. The cost of hospitalization also varies depending on the type of treatment and whether you enter a hospital or a private room. Taking the example of Chiba University Hospital as an example, “The total hospitalization fee and surgical fee including preoperative examination, intracranial electrode placement and focal resection are about 2 million yen”. Since Japan has a well-developed insurance system, patients who are worried if the treatment cost is too high can reduce their out-of-pocket expenses by using the following systems.

A system available to epilepsy patients

  • Independence support medical system (mental outpatient medical care)
  • High-cost medical treatment system
  • Medical expenses subsidy system for persons with severe physical and mental disabilities
  • Health insurance injury and illness allowance
  • Pediatric Chronic Specific Disease Treatment Research Project

For example, by using the high-cost medical treatment system, the treatment cost can be reduced to 100,000 yen or less per month for many people, depending on their annual income. In addition, in the case of children, the subsidy system for specific pediatric chronic diseases provides full public funds for medical expenses during hospitalization. If you have any concerns about medical expenses, talk to a social worker at the hospital.

Flow after being discharged safely

If you have had surgery, you should have an intelligence test and memory test on a regular basis even after you are discharged to check the effects of the surgery compared to before the surgery. Also, although surgery is aimed at eliminating seizures, it is basically necessary to continue taking antiepileptic drugs for several years after surgery. If no seizures are observed during that time, the drug may be gradually reduced and the drug may be completely stopped.

References

Epilepsy practice guidelines 2018

Minds Guidelines Library

Epilepsy net diagnosis and treatment

Chiba University Hospital Neurosurgery Epilepsy and Treatment

Illness can be seen vol.7 Brain / nerve (published by Medic Media Co., Ltd.)

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