Case Studies

Mumbai, 4th October, 2013: After six months of intensive rehabilitation treatment by the paediatric neurology and neurorehabilitation team, one-year old baby Sanjot Kaur is now responding to the treatment given for severe brain damage, which was incurred due to non accidental head injury.

Non accidental head injury – earlier known as shaken baby syndrome- is a well recognised clinical entity. The incidence in India is still unknown. However, international studies quote approximate incidence is 24 to 34 per 100000 children younger than 1 year. It is a major cause of long term neuro-disability. Stringent child protection laws and processes are as important as the medical management.

Sanjot, a 6-month old baby was diagnosed with a brain injury in March 2013 when her mother found her unconscious at the Day Care Centre. “On the fourth day when I went to collect her, she was completely unconscious. I asked the caretakers if something had happened but they said the baby had been sleeping for a very long time,” says Sanjot’s mother Danvir.

After the baby did not respond to the treatment being given at she was immediately rushed to Kokilaben Dhirubhai Ambani Hospital which is well-equipped to handle such cases with an expert team of paediatric neurologists and one of the few in the city to have a Paediatric neurology department.

Dr Pradnya Gadgil, Consultant, Paediatric Neurology, Kokilaben Dhirubhai Ambani Hospital said, The MRI Brain showed evidence of bleeding in certain areas of the brain. There was also evidence of significant brain injury- ie injury to the brain parenchyma. The ophthalmologic examination showed bleeding in the retina. The pattern of neuroimaging and ophthalmological ie - eye examination findings was quite typical of abusive head injury. We indeed investigated for other possible causes of such injury but could not detect any.

The baby came to us in a state of coma. We first brought her seizures under -control and used our neuroprotection strategies to prevent secondary injuries to her brain.

She further emphasizes, “Due to severe brain injury the baby currently shows the development of a four-month old after more than five months of intense neuro-rehabilitation.

The recovery is gradual and requires long term neurorehabilitation.

A medico legal case was registered by the Hospital. However, the franchise owner of the day care center said that the baby must have suffered the brain damage while travelling in an autorickshaw or car with her mother, whereas the parents allege that the baby was forcefully shaken to stop her from crying.

Today, almost after 5 months of the event the baby has made significant progress. She has had no seizures. She is now trying to sit with support, laughs, babbles and plays with toys.

About Centre for Children

Care of sick children has been one of the cornerstones in our planning and the centre delivers complete services for robust child health. We provide specialised support for children with development problems, epilepsy, autism, cerebral palsy, infectious diseases, cancer, orthopaedics and genetic disorders.

The centre has dedicated Paediatric ICUs (PICU) and Neonatal ICUs (NICU) to provide special care to critically ill children and newborns. The centre is equipped with High Frequency Jet Ventilation (HFJV) for children with complex lung problems and Neonatal Transport Incubator to transfer critically ill babies to the hospital.

For children with neurological problems the centre has state of art EEG facilities, various neuroimaging options (3T MRI, Nuclear medicine, etc), facilities for metabolic and genetic workup, etc. There is a well trained team of doctors including Paediatric Neurologist and Epileptologist, Neurosurgeons, Paediatric Orthopaedic surgeon, Paediatric Intensivists and a fully equipped child development centre.

 

16 year old girl came to Dr Pradnya Gadgil from West Bengal with a history of frequent seizures since the age of 8. She was experiencing seizures 3-5 times every week. She had suffered from a brain injury when she was extremely sick in the newborn period requiring NICU admission. She had a mild delay in developmental milestones but currently going to a mainstream school in 9th standard.

Multiple anti-epileptic medications were tried to no avail. The frequent seizures significantly limited her schooling, socialising with friends, and participating in simple things like picnics, etc.

Parents had visited multiple hospitals in India and even abroad hoping for a cure. They were refused epilepsy surgery.

We performed a presurgical evaluation which included video EEG, an Ictal SPECT scan, an MRI brain with tractography and a neuropsychological evaluation. MRI showed brain injury in multiple places. However, the evaluation revealed that we could treat her seizures by operating an area on the right side of the brain. There was a risk of her developing weakness post-surgery – ideally, we needed to perform awake surgery. The team (including her parents) felt this wasn’t possible.

Epilepsy surgery was performed using intraoperative monitoring- ECoG, Cortical stimulation, MEPs, etc. She woke up with weakness on one side but this improved to near normal in a few days of neurorehabilitation.

Her seizures have completely stopped since the surgery. She is now back to school-in 10th std.

This was a unique case as ideally, this patient would have needed two-stage surgery. We managed to achieve seizure freedom with one-stage surgery. This was made possible as we have highly advanced techniques of intraoperative monitoring and a dedicated multidisciplinary epilepsy surgery team.

 

8-year-old boy came to Dr Pradnya Gadgil with a history of seizures since 6 years of age. His seizures were not coming under control despite many anti-epileptic medications. His academic grades were also dropping. In addition to these problems, he was developing weakness in one side of his body. He had tests performed elsewhere, which showed a supposedly normal MRI.

We performed a detailed presurgical evaluation consisting of Video EEG, MRI brain, Functional MRI, Ictal SPECT, PET scan and neuropsychological evaluation. This revealed that a small area of the brain was malformed and highly epileptogenic. Unfortunately, this was also the area which was responsible for controlling the movement of one side of his body. This was also the reason for his grades worsening (as his IQ was normal).

Parents were very keen on getting the surgery done despite significant possible risks.

We planned a tailored respective epilepsy surgery with Dr Abhaya Kumar using intraoperative monitoring. This intraoperative monitoring done by Dr Gadgil enabled us to successfully resect the epileptogenic area of the brain without causing any complications.

Post-surgery not only is the patient seizure-free but his weakness has also improved. He is able to use his right hand to write like before and has resumed normal schooling.