University of Pennsylvania Health System

Penn Neuroscience Update

The Penn Neuroscience Update is dedicated to helping patients, families and their providers understand how conditions, diseases and disorders of the brain, spine and nervous system are being researched, treated and clinically advanced at the Penn Neuroscience Center and through its affiliated programs and services.

Wednesday, August 19, 2015

Exercise and Parkinson’s: What You Need to Know

Most people living with Parkinson’s disease (PD) know that exercise is an important part of managing their disease. But what many do not know is what type of exercise is best. Luckily, research looking at the effects of exercise on PD has grown dramatically in the last 5 to 10 years.

Heather J. Cianci, PT, MS, GCS, physical therapist with the Dan Aaron Parkinson's Rehabilitation Center, shares some important information on recent research that can help you to better plan your home exercise program:
    Parkinson's Physical Therapy
  • If you are not currently exercising, you really should get started. Even if you feel you are not having any difficulties, research suggests that certain types of exercise may actually slow disease progression.
  • Exercise should be both mentally and physically challenging.
  • Exercise should be intensive, which means it should raise your heart rate and make you sweat.
  • Exercise should focus on making your movements as big as possible.
  • You should exercise daily. Just as you take your prescription medications every day, you should exercise every day.
  • Exercise should help you improve in areas where you are having a hard time. If you struggle with getting up from a chair, work on exercises that focus on exactly how you get up and down. If you have trouble with balance, ask your therapist to prescribe exercises specifically focused on that.
Remember, simply moving around during your normal daily activities does NOT count as exercise. It is always better to stand than to sit, but to consider it exercise, you have to move more and work harder! The rehab team at the Dan Aaron Parkinson's Rehabilitation Center can provide more information on exercise and PD.

How to Get Started

As stated above, if you aren’t currently exercising, you should be. It’s important that you take into account your overall fitness level, so that you don’t overdo it. Because of that, talking with your physical therapist is a good first step. This way you can get an exercise plan developed specifically for your needs and work with an expert to determine what you can (and can’t) do safely.

Happy Exercising!

Ready to get started with your exercise plan?
Schedule an appointment with a Parkinson’s disease specialist.

Tuesday, August 4, 2015

Trigeminal Neuralgia: A Patient’s Story

The excruciating pain caused by trigeminal neuralgia (TN) can be so bad that it can often keep individuals from working or participating in any sort of social life, making them prisoners of their pain.

Billie Jean (BJ) Caperelli of Doylestown, Pa., suffered for more than 10 years, with many unsuccessful attempts to get rid of the pain. It wasn’t until she came to Penn Medicine to receive a specialized surgery that she got relief.

Penn Neurosurgery
John Y. K. Lee, MD
This spring, she underwent surgery, a fully endoscopic microvascular decompression (E-MVD), at Pennsylvania Hospital performed by John Y.K. Lee, MD, an associate professor of Neurosurgery and director of the Penn Center for Cranial Nerve Disorders.

Dr. Lee performed the intricate skull-base surgery using an endoscope that is only one tenth of an inch wide, accessing the base of the trigeminal nerve via a one centimeter opening behind Caperelli’s ear.

Caperelli has been pain-free since the surgery, and is hoping for very long-lasting relief. She is grateful to have found Dr. Lee and his team.

Check out Billie Jean’s full story

Wednesday, May 27, 2015

Can New Therapy Stop Epileptic Seizures?

You’ve tried just about everything to get the seizures to stop.

For months, you’ve been on more than two types of anti-seizure medications with maximum dosages—and your seizures are still out of control.

Your epilepsy has been diagnosed as intractable, meaning the drugs aren’t working. So, your doctor recommends surgery. You may hear words such as “resection,” “lobectomy” or “craniotomy.”

The good news is that you may have other options; alternatives to major surgery that may help control your intractable epilepsy.

Getting Under Your Skin

The RNS, or responsive neurostimulation system, may sound like something out of a sci-fi movie, but it’s designed to control seizure frequency - kind of like a wearable device that collects health data and course corrects for seizures.

This advanced type of neuromodulation therapy that anticipates and overrides epileptic seizures is a technology that was pioneered by Brian Litt, MD, of the Penn Epilepsy Center.

Danielle Becker, MD, MS
“It’s approved for people over age 18 and has been shown to reduce seizures in those who have frequent and debilitating seizures,” explains Danielle Becker, MD, MS, neurologist and director of the RNS Program at the Penn Epilepsy Center.

It’s relatively new, but it’s been in development for nearly 15 years. The US Food and Drug Administration (FDA) approved the system in November 2013.

Yes, this is still brain surgery. But it’s not a resection where a part of the brain is removed. The procedure may take anywhere from two to five hours with a hospital stay of up to three days.

Once the device is implanted, the Penn Neurosciences team—including neurologists and surgeons—allows it to collect data for two weeks with no stimulation. Then, data collection continues with an eye toward fine-tuning settings around the spurts of stimulation on seizure patterns.

Kathryn Davis, MD, MTR
Patients can also collect data at home using their own programmer, which behaves like a mini computer. They then transmit information to their physician via the internet.

The device holds promise, but it’s not a cure. “It’s a palliative device,” says Kathryn Davis, MD, MTR, neurologist and medical director of the Epilepsy Monitoring Unity at the Penn Epilepsy Center. “About 65% of patients have shown a meaningful improvement in clinical trial.”

 “My hope is that it will give new options to people with intractable epilepsy, who otherwise had no other choices,” adds Dr. Becker.

Pinpointing The Problem

Still feeling like an implant is just a little too invasive? There are other options.

Laser technology called Visualase® MRI-guided laser ablation is where a laser beam zeroes in on a problem area of the brain that may be causing the seizure and literally burns it out.

Again, this is still brain surgery, but it’s far less invasive than a resection and offers shorter recovery time.

This usually requires “burr holes, which are just small holes in the skull,” Dr. Davis says. “We feed the laser catheter in, and it’s done right in the MRI suite.”

“And they’ll be conservative: Do a little bit, go back and check to see what the extent of the burn was, and extend it if necessary. And then the patients usually go home the next day,” explains Dr. Davis.

In a standard resective surgery, patients would usually have a hospital stay of three or four nights.

Who Stands to Gain?

“Visualase is a less invasive way to treat temporal lobe epilepsy, which is the most common type of epilepsy in adults,” says Dr. Becker.

Penn Epilepsy CenterDr. Davis adds that it is best suited for patients who “have clear hippocampal sclerosis on their imaging.”

Hippocampal sclerosis, also called mesial temporal sclerosis, occurs when scar tissue forms in parts of the temporal lobe when nerve cells in the brain die.

This is a fairly new procedure, so there is still more to learn about its effectiveness. Visualase received US Food and Drug Administration clearance in 2007.

As of December 2014, more than 1,000 cases using Visualase ablation technology had been performed.

“We don’t have long-term outcomes for these patients,” Dr. Davis says. But her patients have been very receptive to it.

And if it doesn’t work? Then, it may be time to consider open surgery.

If you or a loved one is suffering from epilepsy and are interested in learning more about alternatives to major surgery, contact the Penn Epilepsy Center.

Stay up-to-date on the latest treatment options by signing up for our newsletter.

Thursday, May 21, 2015

Someone is Having A Seizure: What Should You Do?

You’re in the grocery store and suddenly you hear a commotion. Another shopper is on the floor—convulsing. You’re terrified. What should you do?

Beyond calling 9-1-1, knowing what to do—and what not to do—when someone is having a seizure could mean the difference between safely allowing the seizure to pass and causing an injury.

How Do You Know If Someone Is Having A Seizure?

A seizure is uncontrolled brain activity, which can lead to uncontrolled movements and behavior. When someone is experiencing a generalized chronic seizure, they may:
  • Fall or collapse
  • Become unconscious
  • Convulse or shake
  • Stiffen and relax their muscles
  • Scream, grunt, or snort
  • Clench their teeth
  • Flail, twitch, or jerk their arms and legs
  • Drool
  • Become confused afterward

How Long Do Seizures Last?

The typical duration of a seizure lasts between one to three minutes. If it lasts longer than five minutes, you should call 9-1-1.

“Longer seizures can be damaging to the brain,” says Timothy Lucas II, MD, PhD, neurosurgeon at Penn Medicine. “This is because seizures can use up the brain’s supply of oxygen and glucose, leading to a secondary brain injury.”

Four Other Signs You Need To Call 911 When A Seizure Occurs:

  • If the person has trouble breathing afterward or does not awaken after the convulsing has stopped
  • If the person has another seizure shortly after the first
  • If the person becomes injured or starts getting aggressive
  • If the person has a known health condition, such as diabetes or heart disease, or is pregnant

When Someone Is Having A Seizure...

Now that you know how to spot a seizure, it’s very important to know how to best help.

Step 1: Don’t Put Anything in the Person’s Mouth.
“There’s an old wives’ tale that when someone is having a seizure, you should put something in the person’s mouth,” says Kathryn Davis, MD, MTR, neurologist and medical director of the Epilepsy Monitoring Unit at the Penn Epilepsy Center. “That is something you absolutely should not do.”

Here’s why: The person can clamp down on the object, bite off a piece, and choke on it. If you put your hand in their mouth, they could bite down on it.

The object will not prevent the person from choking on their tongue. “I’ve never heard of someone choking on their tongue,” Dr. Davis adds.

Step 2: Move The Person To A Safe Space.
“This doesn’t always mean hoisting the person around,” cautions Dr. Lucas. “It means getting them out of the way of any imminent threat.”

The Location The Threat What To Do
Stairs A fracture or head injury from falling down the stairs Take the person to the platform of the last step and lay them on their side.
Bathtub Drowning If the person is in the tub, make sure the head is above water to get air.

Drowning. “The seizure may only last a minute, but a minute under water can be dangerous,” says Dr. Lucas. Make sure the person is able to get air during the seizure and for a few minutes afterward until consciousness returns.
Kitchen Stabbing injury “If they are handling a sharp knife, take it from them, and remove any nearby,” says Dr. Lucas.

Step 3: Turn The Person Onto Her Side.
“The person can produce lots of saliva, which they could choke on,” explains Danielle Becker, MD, MS, neurologist and director of the RNS Program at the Penn Epilepsy Center. “Also, this can help keep the person’s airways clear, since the diaphragm can’t contract.”

When Someone Is Having A Seizure, Dr. Lucas says DO NOT…
  • Try to hold the person down: This can cause injury and won’t make the seizure stop.
  • Leave when the seizure is over: Wait a few minutes to make sure the person can breathe normally and returns to a normal state of awareness. If they still can’t breathe or still seem disoriented, call 9-1-1.
  • Offer them anything until they are alert: Avoid choking by waiting to offer water, pills, or food.
Stay up-to-date on the latest treatment options for your seizure disorder by signing up for our newsletter.

Wednesday, May 20, 2015

13 Terms Explaining How Laser Ablation Stops Seizures

If you or a loved one has been living with uncontrollable seizures, your doctor may mention a treatment option called “laser ablation.”

Kathryn Davis, MD, MTR
“It’s like giving patients a choice between open or laparoscopic surgery,” says Kathryn Davis, MD, MTR, neurologist and medical director of the Epilepsy Monitoring Unit at the Penn Epilepsy Center. “People have a similar response. Because it’s much less invasive, it’s more appealing to patients.”

Here are 13 terms you might hear as you discuss laser ablation with your medical team. Understanding these terms can help you decide whether laser ablation is the right next step for you.

1. Ablate or ablation

Ablation literally means “the surgical removal of body tissue.” In neurosurgery, that usually means resecting, or cutting out, the part of the brain that’s prompting the seizures. But with laser ablation, the technique is similar to burning the brain tissue instead of cutting it. The procedure requires tiny incisions that allow the laser beam to target the brain tissue.

2. Craniotomy

Whenever you see the suffix “omy,” it means that a body part or tissue is being surgically removed. A craniotomy means the surgeon is removing a chunk of the cranium, or skull bone, to access the brain.

Laser ablation may allow patients to skip a craniotomy.

3. Dissolve

This is what happens to laser-ablated brain tissue. “You burn it. It liquefies. It’s gone,” explains Dr. Davis. “And it’s not going to regenerate.”

4. Epileptologist

The clinical teams that handle seizures at Penn Epilepsy Center include neurologists. These are doctors who specialize in conditions of the brain and nervous system—everything from memory to movement disorders.

An epileptologist is also a neurologist, but with a particular focus on epilepsy and other seizure-related disorders. In addition to treating patients, epileptologists, like Dr. Davis, may also lead clinical trials to test new medications or procedures to treat epilepsy.

“Any patient considering laser ablation needs to discuss it with an epileptologist and a neurosurgeon,” advises Dr. Davis.

5. FDA-approved

The US Food and Drug Administration (FDA) requires that medical devices, and the claims the manufacturers make, go through rigorous evaluations to make sure they’re safe for patients and effective for certain conditions.

6. Hippocampal sclerosis

The hippocampus is a structure in the temporal lobe. It is behind your eyes and almost between your ears.

The hippocampus is responsible for nearly 80% of temporal lobe seizures, reports the Epilepsy Foundation.

“The best patients for laser ablation are the ones who have clear hippocampal sclerosis in brain MRI,” says Dr. Davis. That means an MRI clearly shows hardening of the tissue in this area of the brain.

7. Intractable epilepsy

Intractable, or refractory, means your seizures have not been successfully controlled with medications. If medications haven’t worked, laser ablation may be a possible next step.

8. Laser

A laser is a very hot, high-energy beam of light. The laser used during the laser ablation procedure is precisely aimed at the brain tissue causing the seizure. The beam is only about the width of a pencil tip, which means it’s very unlikely to hit the healthy surrounding brain tissue.

9. MRI-guided

Magnetic resonance image (MRI) machines have long been used to take images of the brain. During laser ablation, the patient is put in an MRI machine. The surgeon uses the images to see exactly where the laser beam is being directed.

10. Minimally invasive

Even though lasers are removing the brain tissue, “this is still brain surgery,” cautions Dr. Davis. “You are removing part of the brain.”

However, minimally invasive means your skull is not surgically opened to access the brain. With laser ablation, a 3.2 millimeter incision is made in the skull.

The benefits of the minimally invasive approach are that:
  • Healthy brain tissue can stay intact instead of being removed to get to the area causing the seizures.
  • Patients can have less hair removed.
  • The procedure doesn’t require as many stitches.
  • The recovery time is quicker than traditional brain surgery.
“Most patients can go home the next day,” Dr. Davis says.

11. Stereotactic

If you’ve ever played darts, you know that the dart doesn’t bounce all over the board. It lands on a tiny dot, hopefully the bull’s-eye. Stereotactic procedures work similarly.

When you hear the word “stereotactic,” think of words like pinpoint or target.

12. Temporal Lobe

“The most common type of adult onset epilepsy is temporal lobe epilepsy,” says Dr. Davis, “meaning their seizures begin in the temporal lobe of the brain. These patients are often good candidates for laser ablation.”

13. Visualase

This is the commercial name for the laser ablation system used at Penn Medicine. More than 1,000 Visualase procedures had been performed on patients nationwide since it gained FDA approval for neurosurgery in 2007.

Stay up-to-date on the latest treatment options for your seizure disorder by signing up for our newsletter.

The Truth About Medical Marijuana And Epilepsy Treatment

The Wall Street Journal, The New York Times, and Time Magazine have all weighed in on medical marijuana. Even CNN’s Dr. Sanjay Gupta is calling for a revolution to legalize the drug, the site reports.

Marijuana And Epilepsy TreatmentSo far, 23 states and Washington, D.C., have legalized medical marijuana in some form, according to the National Conference of State Legislatures.

Patients and parents desperate to manage severe cases of epilepsy like Dravet syndrome, which is treatment-resistant and involves multiple seizures, have looked to medical marijuana for relief.

But not everyone is fully on board.

“We’ve already had patients come to us and say that the only thing they’ll take is marijuana instead of proven therapy,” says Kathryn Davis, MD, MTR, neurologist and medical director of the Epilepsy Monitoring Unit at the Penn Epilepsy Center. “That’s frightening.”

A Tangled Web

The controversy surrounding the use of medical marijuana for epilepsy is caught up in Charlotte’s web. Not the children’s storybook, but Charlotte Figis, a 5-year-old from Colorado who was given marijuana oil to manage her seizures - and it worked, according to an August 2013 report by CNN.

Medical marijuana for a five-year-old? It’s not what you think. Charlotte was having over 300 seizures a week, each lasting at least 30 minutes, and even the strongest medications weren’t working. Her parents desperately sought relief for her chronic seizures and this provided that relief. 

But even after showing success in small clinical trials, medical marijuana may not actually be the magical potion for seizures after all.

“Initially, it was just one child who had a dramatic improvement with medical marijuana, and that received a lot of publicity,” warns Dr. Davis. “The press highlighted this so much on very little scientific data - or no scientific data - and it was all over the news. It’s a very hot topic, but it’s an unstudied topic. We need to be careful.”

The Root Of The Problem

The marijuana plant consists of more than 400 chemicals. But the ones that concern people seeking relief from seizures are: THC, or tetrahydrocannabinol, and CBD, or cannabidiol.

Each of these components has a very specific role.

“THC causes the psychoactive effects of ‘getting high,’” explains Danielle Becker, MD, MS, neurologist and director of the RNS Program at the Penn Epilepsy Center. “CBD does not cause psychoactive effects, but has shown some positive effects on certain body systems and may prevent seizures.” 

Extracted as an oil from the cannabis plant, highly concentrated CBD—as in 98% CBD to 2% THC- has been proven to manage certain seizures quite well in small clinical trials, says a December 2014 report from the American Epilepsy Society (AES).

But marijuana has inconsistent amounts of these particular cannabinoids, Dr. Becker adds. That is where the controversy lies: No law regulates how much of each a person receives and what amounts are effective. And even with a greater concentration of CBD to THC, the risks may actually outweigh the benefits.

Medical Marijuana On Trial

Researchers found that one-third of nearly 60 children and adolescents receiving the cannabis extract had a reduction in seizures by 50% or more, according to a December 2014 report from AES.

However, in this same group, nearly 50% also experienced:
  • More seizures or new seizures
  • Sleeplessness and fatigue
  • Developmental decline (including an intubation and a death)
In yet another smaller study, a cannabis extract called Epidiolex was given to 23 patients, who averaged 10 years of age and had severe forms of epilepsy, such as Dravet syndrome and Lennox-Gastaut Sydrome.

Nine of the 23 patients reduced their seizures by more than 50%, states the December 2014 AES report. One-third of the Dravet syndrome patients became seizure-free.

“Medical Marijuana is much less defined in children and contains many different compounds along with THC and CBD in inconsistent concentrations,” explains Dr. Becker. “THC has been associated with possible increase in seizures.”

The Verdict

The truth is that marijuana may not help all types of epilepsy. In fact, it may actually make some types worse, says Dr. Davis. Until a large clinical trial shows that it’s effective for reducing seizures, medical marijuana is not the best answer for seizure control.

However, this doesn’t mean you are out of options.

“If patients are in a situation where they take multiple medications, and they’re still having seizures, then we should be talking about our surgical options,” says Dr. Davis. “There are actually an expanding number of surgical and epilepsy device options that do have outcome data supporting them. Epilepsy surgery is the only known cure for drug resistant partial onset epilepsy.”

Stay up-to-date on the latest treatment options for your seizure disorder by signing up for our newsletter.

Monday, April 27, 2015

Introducing the New Penn Neuroscience Center

On February 23, 2015, the Penn Neuroscience Center officially opened, with the mission of providing a new level of specialty care for those suffering from or at risk for complex neurological disorders.

Penn Neuroscience CenterThe outpatient facility joins together our neurology, neurosurgery, neurodiagnostics, neuropsychology and neuro-ophthalmology expertise and the neurologic and psychiatric services of the Penn Memory Center. All longtime partners in the care of patients with complex neurological diseases such as epilepsy, Parkinson’s disease and MS; neurosurgical disorders of the spine, including congenital disease, arthritis-related disc problems and tumors of the spine and brain, including brain cancers, as well as neurodegenerative diseases such as Alzheimer’s disease, the Penn Neuroscience Center allows for enhanced collaboration, information-sharing and united front in caring for patients with these debilitating illnesses.

“The Penn Neuroscience Center was designed to create a unique, personalized patient experience” explains Frances E. Jensen, MD, chair of neurology. “In each treatment area, there may be a neurologist, a neurosurgeon, and a psychiatrist; as well as nurses and social workers. What this does is provide the patient with the kind of personalized medicine that is unmatched in the region.”

What the Center Means to Patients

The Penn Neuroscience Center was carefully planned with the best possible patient experience in mind. The new streamlined approach to neurological care does this by increasing access to comprehensive services and fully engaging patients and families in their care.

Located at 3400 Civic Center Boulevard on the 2nd floor of the Perelman Center for Advanced Medicine, the Center consists of 56 exam rooms and 16 dedicated rooms for neurodiagnostic and psychiatric testing in the following areas:
  • Neurosurgery
  • Neuro-ophthalmology
  • Neurology
  • Penn Memory Center
  • Neuropsychology
  • Psychiatry
  • Neurodiagnostics (EEG, EMG, NVL)
“We truly care about our patients and how the disease impacts all aspects of your life. This Center has brought us together to provide the kind of personalized care that people want and deserve,” says M. Sean Grady, MD, chair of neurosurgery.

Oftentimes, neurosurgeons and neurologists work together in order to provide the best possible patient care. Many conditions can be treated without surgery, with a treatment plan (usually involving medication) put together and monitored by a neurologist. If medical intervention fails or is not acceptable for the condition, the neurologist will request the assistance of a neurosurgeon to evaluate the potential for a surgical treatment. Problems that are structural in nature may respond best to neurosurgical intervention. While there is a good deal of overlap between all neurological specialists in a clinical setting, there are some key differences, described below:

What is a Neurologist?

Neurologists focus on disorders of the nervous system, brain, spinal cord, nerves, muscles and pain. Common neurological disorders include: stroke, Alzheimer's disease, headache, epilepsy, Parkinson's disease, sleep disorders, multiple sclerosis, pain, tremor, brain and spinal cord injuries, brain tumors, peripheral nervous disorders and amyotrophic lateral sclerosis.

What is a Neurosurgeon?

A neurosurgeon diagnoses and treats patients with injury to or diseases of, the brain, spine or peripheral nerves. A neurosurgeon may provide either surgical or non-surgical care depending on the nature of the injury or illness.

Interested in scheduling an appointment? Call 800-789-PENN (7366).