Archive for the ‘neurosurgeon’ Category

They say laughter is the best medicine. But what if laughter is the disease?

For a 6-year-old girl in Bolivia who suffered from uncontrollable and inappropriate bouts of giggles, laughter was a symptom of a serious brain problem. But doctors initially diagnosed the child with “misbehavior.”

“She was considered spoiled, crazy — even devil-possessed,” Dr. José Liders Burgos Zuleta, ofAdvanced Medical Image Centre, in Bolivia, said in a statement.

But Burgos Zuleta discovered that the true cause of the girl’s laughing seizures, medically called gelastic seizures, was a brain tumor.

After the girl underwent a brain scan, the doctors discovered a hamartoma, a small, benign tumor that was pressing against her brain’s temporal lobe.The doctors surgically removed the tumor, and the girl is now healthy, the doctors said.

The girl stopped having the uncontrollable attacks of laughter and now only laughs normally, the doctors said.

Gelastic seizures are a form of epilepsy that is relatively rare, said Dr. Solomon Moshé, a pediatric neurologist at Albert Einstein College of Medicine in New York. The word comes from the Greek word for laughter, “gelos.”

“It’s not necessarily ‘hahaha’ laughing,” Moshé told Live Science. “There’s no happiness in this. Some of the kids may be very scared,” he added.

The seizures are most often caused by tumors in the hypothalamus, especially in kids, although they can also come from tumors in other parts of brain, Moshé said. Although laughter is the main symptom, patients may also have outbursts of crying.

These tumors can cause growth abnormalities if they affect the pituitary gland, he said.

The surgery to remove such brain tumors used to be difficult and dangerous, but a new surgical technique developed within the last 10 years allows doctors to remove them effectively without great risk, Moshé said.

The doctors who treated the girl said their report of her case could raise awareness of the strange condition, so doctors in Latin America can diagnose the true cause of some children’s “behavioral” problems, and refer them to a neurologist.

The case report was published June 16 in the journal ecancermedicalscience.

Thanks to Michael Moore for sharing this with the It’s Interesting community.

http://www.cbsnews.com/news/girls-uncontrollable-laughter-caused-by-brain-tumor/

Advertisements

Doctors in the US have induced feelings of intense determination in two men by stimulating a part of their brains with gentle electric currents.

The men were having a routine procedure to locate regions in their brains that caused epileptic seizures when they felt their heart rates rise, a sense of foreboding, and an overwhelming desire to persevere against a looming hardship.

The remarkable findings could help researchers develop treatments for depression and other disorders where people are debilitated by a lack of motivation.

One patient said the feeling was like driving a car into a raging storm. When his brain was stimulated, he sensed a shaking in his chest and a surge in his pulse. In six trials, he felt the same sensations time and again.

Comparing the feelings to a frantic drive towards a storm, the patient said: “You’re only halfway there and you have no other way to turn around and go back, you have to keep going forward.”

When asked by doctors to elaborate on whether the feeling was good or bad, he said: “It was more of a positive thing, like push harder, push harder, push harder to try and get through this.”

A second patient had similar feelings when his brain was stimulated in the same region, called the anterior midcingulate cortex (aMCC). He felt worried that something terrible was about to happen, but knew he had to fight and not give up, according to a case study in the journal Neuron.

Both men were having an exploratory procedure to find the focal point in their brains that caused them to suffer epileptic fits. In the procedure, doctors sink fine electrodes deep into different parts of the brain and stimulate them with tiny electrical currents until the patient senses the “aura” that precedes a seizure. Often, seizures can be treated by removing tissue from this part of the brain.

“In the very first patient this was something very unexpected, and we didn’t report it,” said Josef Parvizi at Stanford University in California. But then I was doing functional mapping on the second patient and he suddenly experienced a very similar thing.”

“Its extraordinary that two individuals with very different past experiences respond in a similar way to one or two seconds of very low intensity electricity delivered to the same area of their brain. These patients are normal individuals, they have their IQ, they have their jobs. We are not reporting these findings in sick brains,” Parvizi said.

The men were stimulated with between two and eight milliamps of electrical current, but in tests the doctors administered sham stimulation too. In the sham tests, they told the patients they were about to stimulate the brain, but had switched off the electical supply. In these cases, the men reported no changes to their feelings. The sensation was only induced in a small area of the brain, and vanished when doctors implanted electrodes just five millimetres away.

Parvizi said a crucial follow-up experiment will be to test whether stimulation of the brain region really makes people more determined, or simply creates the sensation of perseverance. If future studies replicate the findings, stimulation of the brain region – perhaps without the need for brain-penetrating electrodes – could be used to help people with severe depression.

The anterior midcingulate cortex seems to be important in helping us select responses and make decisions in light of the feedback we get. Brent Vogt, a neurobiologist at Boston University, said patients with chronic pain and obsessive-compulsive disorder have already been treated by destroying part of the aMCC. “Why not stimulate it? If this would enhance relieving depression, for example, let’s go,” he said.

http://www.theguardian.com/science/2013/dec/05/determination-electrical-brain-stimulation

Thanks to Kebmodee for bringing this to the attention of the It’s Interesting community.

 

How far should doctors go in attempting to cure addiction? In China, some physicians are taking the most extreme measures. By destroying parts of the brain’s “pleasure centers” in heroin addicts and alcoholics, these neurosurgeons hope to stop drug cravings. But damaging the brain region involved in addictive desires risks permanently ending the entire spectrum of natural longings and emotions, including the ability to feel joy.

In 2004, the Ministry of Health in China banned this procedure due to lack of data on long term outcomes and growing outrage in Western media over ethical issues about whether the patients were fully aware of the risks.

However, some doctors were allowed to continue to perform it for research purposes—and recently, a Western medical journal even published a new study of the results. In 2007, The Wall Street Journal detailed the practice of a physician who claimed he performed 1000 such procedures to treat mental illnesses such as depression, schizophrenia and epilepsy, after the ban in 2004; the surgery for addiction has also since been done on at least that many people.

The November publication has generated a passionate debate in the scientific community over whether such research should be published or kept outside the pages of reputable scientific journals, where it may find undeserved legitimacy and only encourage further questionable science to flourish.

The latest study is the third published since 2003 in Stereotactic and Functional Neurosurgery, which isn’t the only journal chronicling results from the procedure, which is known as ablation of the nucleus accumbens. In October, the journal World Neurosurgery also published results from the same researchers, who are based at Tangdu Hospital in Xi’an.

The authors, led by Guodong Gao, claim that the surgery is “a feasible method for alleviating psychological dependence on opiate drugs.” At the same time, they report that more than half of the 60 patients had lasting side effects, including memory problems and loss of motivation. Within five years, 53% had relapsed and were addicted again to opiates, leaving 47% drug free.

(MORE: Addicted: Why We Get Hooked)

Conventional treatment only results in significant recovery in about 30-40% of cases, so the procedure apparently improves on that, but experts do not believe that such a small increase in benefit is worth the tremendous risk the surgery poses.  Even the most successful brain surgeries carry risk of infection, disability and death since opening the skull and cutting brain tissue for any reason is both dangerous and unpredictable. And the Chinese researchers report that 21% of the patients they studied experienced memory deficits after the surgery and 18% had “weakened motivation,” including at least one report of lack of sexual desire. The authors claim, however, that “all of these patients reported that their [adverse results] were tolerable.” In addition, 53% of patients had a change in personality, but the authors describe the majority of these changes as “mildness oriented,” presumably meaning that they became more compliant. Around 7%, however, became more impulsive.

The surgery is actually performed while patients are awake in order to minimize the chances of destroying regions necessary for sensation, consciousness or movement.  Surgeons use heat to kill cells in small sections of both sides of the brain’s nucleus accumbens.  That region is saturated with neurons containing dopamine and endogenous opioids, which are involved in pleasure and desire related both to drugs and to ordinary experiences like eating, love and sex.

(MORE: A Drug to End Drug Addiction)

In the U.S. and the U.K., reports the Wall Street Journal, around two dozen stereotactic ablations are performed each year, but only in the most intractable cases of depression and obsessive-compulsive disorder and after extensive review by institutional review boards and intensive discussions with the patient, who must acknowledge the risks. Often, a different brain region is targeted, not the nucleus accumbens. Given the unpredictable and potentially harmful consequences of the procedure, experts are united in their condemnation of using the technique to treat addictions. “To lesion this region that is thought to be involved in all types of motivation and pleasure risks crippling a human being,” says Dr. Charles O’Brien, head of the Center for Studies of Addiction at the University of Pennsylvania.

David Linden, professor of neuroscience at Johns Hopkins and author of a recent book about the brain’s pleasure systems calls the surgery “horribly misguided.”  He says “This treatment will almost certainly render the subjects unable to feel pleasure from a wide range of experiences, not just drugs of abuse.”

But some neurosurgeons see it differently. Dr. John Adler, professor emeritus of neurosurgery at Stanford University, collaborated with the Chinese researchers on the publication and is listed as a co-author.  While he does not advocate the surgery and did not perform it, he believes it can provide valuable information about how the nucleus accumbens works, and how best to attempt to manipulate it. “I do think it’s worth learning from,” he says. ” As far as I’m concerned, ablation of the nucleus accumbens makes no sense for anyone.  There’s a very high complication rate. [But] reporting it doesn’t mean endorsing it. While we should have legitimate ethical concerns about anything like this, it is a bigger travesty to put our heads in the sand and not be willing to publish it,” he says.

(MORE: Anesthesia Study Opens Window Into Consciousness)

Dr. Casey Halpern, a neurosurgery resident at the University of Pennsylvania makes a similar case. He notes that German surgeons have performed experimental surgery involving placing electrodes in the same region to treat the extreme lack of pleasure and motivation associated with otherwise intractable depression.  “That had a 60% success rate, much better than [drugs like Prozac],” he says. Along with colleagues from the University of Magdeburg in Germany, Halpern has just published a paper in the Proceedings of the New York Academy of Sciences calling for careful experimental use of DBS in the nucleus accumbens to treat addictions, which have failed repeatedly to respond to other approaches. The paper cites the Chinese surgery data and notes that addiction itself carries a high mortality risk.

DBS, however, is quite different from ablation.  Although it involves the risk of any brain surgery, the stimulation itself can be turned off if there are negative side effects, while surgical destruction of brain tissue is irreversible. That permanence—along with several other major concerns — has ethicists and addiction researchers calling for a stop to the ablation surgeries, and for journals to refuse to publish related studies.

Harriet Washington, author of Medical Apartheid:  The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present, argues that by publishing the results of unethical studies, scientists are condoning the questionable conditions under which the trials are conducted. “When medical journals publish research that violates the profession’sethical guidelines, this serves not only to sanction such abuses, but to encourage them,” she says. “In doing so, this practice encourages a relaxing of moral standards that threatens all patients and subjects, but especially  the medically vulnerable.”

(MORE: Real-Time Video: First Look at a Brain Losing Consciousness Under Anesthesia)

Shi-Min Fang, a Chinese biochemist who became a freelance journalist and recently won the journal Nature‘s Maddox prize for his exposes of widespread fraud in Chinese research, has revealed some of the subpar scientific practices behind research conducted in China, facing death threats and, as the New York Times reported, a beating with a hammer. He agrees that publishing such research only perpetuates the unethical practices. Asked by TIME to comment on the addiction surgery studies, Fang writes that publishing the research, particularly in western journals, “would encourage further unethical research, particularly in China where rewards for publication in international journals are high.”

While he doesn’t have the expertise to comment specifically on the ablation data, he says “the results of clinical research in China are very often fabricated. I suspect that the approvals by Ethics Committee mentioned in these papers were made up to meet publication requirement. I also doubt if the patients were really informed in detail about the nature of the study.” Fang also notes that two of the co-authors of the paper are advertising on the internet in Chinese, offering the surgery at a cost of 35,000 renminbi, about $5,600.  That’s more than the average annual income in China, which is about $5,000.

Given the available evidence, in fact, it’s hard to find a scientific justification for even studying the technique in people at all. Carl Hart, associate professor of psychology at Columbia University and author of the leading college textbook on psychoactive drugs, says animal studies suggest the approach may ultimately fail as an effective treatment for addiction; a 1984 experiment, for example, showed that destroying the nucleus accumbens in rats does not permanently stop them from taking opioids like heroin and later research found that it similarly doesn’t work for curbing cocaine cravings. Those results alone should discourage further work in humans. “These data are clear,” he says, “If you are going to take this drastic step, you damn well better know all of the animal literature.” [Disclosure:  Hart and I have worked on a book project together].

(MORE: Top 10 Medical Breakthroughs of 2012)

Moreover, in China, where addiction is so demonized that execution has been seen as an appropriate punishment and where the most effective known treatment for heroin addiction— methadone or buprenorphine maintenance— is illegal, it’s highly unlikely that addicted people could give genuinely informed consent for any brain surgery, let alone one that risks losing the ability to feel pleasure. And even if all of the relevant research suggested that ablating the nucleus accumbens prevented animals from seeking drugs, it would be hard to tell from rats or even primates whether the change was due to an overall reduction in motivation and pleasure or to a beneficial reduction in desiring just the drug itself.

There is no question that addiction can be difficult to treat, and in the most severe cases, where patients have suffered decades of relapses and failed all available treatments multiple times, it may make sense to consider treatments that carry significant risks, just as such dangers are accepted in fighting suicidal depression or cancer.  But in the ablation surgery studies, some of the participants were reportedly as young as 19 years old and had only been addicted for three years.  Addiction research strongly suggests that such patients are likely to recover even without treatment, making the risk-benefit ratio clearly unacceptable.

The controversy highlights the tension between the push for innovation and the reality of risk. Rules on informed consent didn’t arise from fears about theoretical abuses:  they were a response to the real scientific horrors of the Holocaust. And ethical considerations become especially important when treating a condition like addiction, which is still seen by many not as an illness but as a moral problem to be solved by punishment.  Scientific innovation is the goal, but at what price?
Read more: http://healthland.time.com/2012/12/13/controversial-surgery-for-addiction-burns-away-brains-pleasure-center/#ixzz2ExzobWQq

Thanks to Dr. Lutter for bringing this to the attention of the It’s Interesting community.

 

near-death-experience-1

 

You careen headlong into a blinding light. Around you, phantasms of people and pets lost. Clouds billow and sway, giving way to a gilded and golden entrance. You feel the air, thrusted downward by delicate wings. Everything is soothing, comforting, familiar. Heaven.

It’s a paradise that some experience during an apparent demise. The surprising consistency of heavenly visions during a “near death experience” (or NDE) indicates for many that an afterlife awaits us. Religious believers interpret these similar yet varying accounts like blind men exploring an elephant—they each feel something different (the tail is a snake and the legs are tree trunks, for example); yet all touch the same underlying reality. Skeptics point to the curious tendency for Heaven to conform to human desires, or for Heaven’s fleeting visage to be so dependent on culture or time period.

Heaven, in a theological view, has some kind of entrance. When you die, this entrance is supposed to appear—a Platform 9 ¾ for those running towards the grave. Of course, the purported way to see Heaven without having to take the final run at the platform wall is the NDE. Thrust back into popular consciousness by a surgeon claiming that “Heaven is Real,” the NDE has come under both theological and scientific scrutiny for its supposed ability to preview the great gig in the sky.

But getting to see Heaven is hell—you have to die. Or do you?

This past October, neurosurgeon Dr. Eben Alexander claimed that “Heaven is Real”, making the cover of the now defunct Newsweek magazine. His account of Heaven was based on a series of visions he had while in a coma, suffering the ravages of a particularly vicious case of bacterial meningitis. Alexander claimed that because his neocortex was “inactivated” by this malady, his near death visions indicated an intellect apart from the grey matter, and therefore a part of us survives brain-death.

Alexander’s resplendent descriptions of the afterlife were intriguing and beautiful, but were also promoted as scientific proof. Because Alexander was a brain “scientist” (more accurately, a brain surgeon), his account carried apparent weight.

Scientifically, Alexander’s claims have been roundly criticized. Academic clinical neurologist Steve Novella removes the foundation of Alexander’s whole claim by noting that his assumption of cortex “inactivation” is flawed:

Alexander claims there is no scientific explanation for his experiences, but I just gave one. They occurred while his brain function was either on the way down or on the way back up, or both, not while there was little to no brain activity.

In another takedown of the popular article, neuroscientist Sam Harris (with characteristic sharpness) also points out this faulty premise, and notes that Alexander’s evidence for such inactivation is lacking:

The problem, however, is that “CT scans and neurological examinations” can’t determine neuronal inactivity—in the cortex or anywhere else. And Alexander makes no reference to functional data that might have been acquired by fMRI, PET, or EEG—nor does he seem to realize that only this sort of evidence could support his case.

Without a scientific foundation for Alexander’s claims, skeptics suggest he had a NDE later fleshed out by confirmation bias and colored by culture. Harris concludes in a follow-up post on his blog, “I am quite sure that I’ve never seen a scientist speak in a manner more suggestive of wishful thinking. If self-deception were an Olympic sport, this is how our most gifted athletes would appear when they were in peak condition.”

And these takedowns have company. Paul Raeburn in the Huffington Post, speaking of Alexander’s deathbed vision being promoted as a scientific account, wrote, “We are all demeaned, and our national conversation is demeaned, by people who promote this kind of thing as science. This is religious belief; nothing else.” We might expect this tone from skeptics, but even the faithful chime in. Greg Stier writes in the Christian post that while he fully believes in the existence of Heaven, we should not take NDE accounts like Alexander’s as proof of it.

These criticisms of Alexander point out that what he saw was a classic NDE—the white light, the tunnel, the feelings of connectedness, etc. This is effective in dismantling his account of an “immaterial intellect” because, so far, most symptoms of a NDE are in fact scientifically explainable. [ another article on this site provides a thorough description of the evidence, as does this study.]

One might argue that the scientific description of NDE symptoms is merely the physical account of what happens as you cross over. A brain without oxygen may experience “tunnel vision,” but a brain without oxygen is also near death and approaching the afterlife, for example. This argument rests on the fact that you are indeed dying. But without the theological gymnastics, I think there is an overlooked yet critical aspect to the near death phenomenon, one that can render Platform 9 ¾ wholly solid. Studies have shown that you don’t have to be near death to have a near death experience.

“Dying”

In 1990, a study was published in the Lancet that looked at the medical records of people who experienced NDE-like symptoms as a result of some injury or illness. It showed that out of 58 patients who reported “unusual” experiences associated with NDEs (tunnels, light, being outside one’s own body, etc.), 30 of them were not actually in any danger of dying, although they believed they were [1]. The authors of the study concluded that this finding offered support to the physical basis of NDEs, as well as the “transcendental” basis.

Why would the brain react to death (or even imagined death) in such a way? Well, death is a scary thing. Scientific accounts of the NDE characterize it as the body’s psychological and physiological response mechanism to such fear, producing chemicals in the brain that calm the individual while inducing euphoric sensations to reduce trauma.

Imagine an alpine climber whose pick fails to catch the next icy outcropping as he or she plummets towards a craggy mountainside. If one truly believes the next experience he or she will have is an intimate acquainting with a boulder, similar NDE-like sensations may arise (i.e., “My life flashed before my eyes…”). We know this because these men and women have come back to us, emerging from a cushion of snow after their fall rather than becoming a mountain’s Jackson Pollock installation.

You do not have to be, in reality, dying to have a near-death experience. Even if you are dying (but survive), you probably won’t have one. What does this make of Heaven? It follows that if you aren’t even on your way to the afterlife, the scientifically explicable NDE symptoms point to neurology, not paradise.

This Must Be the Place

Explaining the near death experience in a purely physical way is not to say that people cannot have a transformative vision or intense mental journey. The experience is real and tells us quite a bit about the brain (while raising even more fascinating questions about consciousness). But emotional and experiential gravitas says nothing of Heaven, or the afterlife in general. A healthy imbibing of ketamine can induce the same feelings, but rarely do we consider this euphoric haze a glance of God’s paradise.

In this case, as in science, a theory can be shot through with experimentation. As Richard Feynman said, “It doesn’t matter how beautiful your theory is, it doesn’t matter how smart you are. If it doesn’t agree with experiment, it’s wrong.

The experiment is exploring an NDE under different conditions. Can the same sensations be produced when you are in fact not dying? If so, your rapping on the Pearly Gates is an illusion, even if Heaven were real. St. Peter surely can tell the difference between a dying man and a hallucinating one.

The near death experience as a foreshadowing of Heaven is a beautiful theory perhaps, but wrong.

Barring a capricious conception of “God’s plan,” one can experience a beautiful white light at the end of a tunnel while still having a firm grasp of their mortal coil. This is the death of near death. Combine explainable symptoms with a plausible, physical theory as to why we have them and you get a description of what it is like to die, not what it is like to glimpse God.

Sitting atop clouds fluffy and white, Heaven may be waiting. We can’t prove that it is not. But rather than helping to clarify, the near death experience, not dependent on death, may only point to an ever interesting and complex human brain, nothing more.

http://blogs.scientificamerican.com/guest-blog/2012/12/03/the-death-of-near-death-even-if-heaven-is-real-you-arent-seeing-it/