Baylor Scott & White Neurology - Dallas

Diagnostic Neurology

The Neurodiagnostics Department at BUMC offers routine electroencephalograms and extended evaluations on elective and acutely ill patients in the epilepsy monitoring unit (EMU) as well as in the Intensive Care Units (ICU). We have a six bed expandable EMU and capability of portably monitoring patients in most beds in the hospital. Awake craniotomy brain stimulation, Wada evaluations, and Epilepsy cortical mapping are also available.

Epilepsy/Seizures

Baylor University Medical Center, part of Baylor Scott & White Health is a level 4 Epilepsy center. At Baylor Scott & White Neurology - Dallas, our comprehensive specialists team includes an epileptologist, neurologists, neurosurgeons and a full team to run our Epilepsy Monitoring Unit (EMU). We are dedicated to caring for our patients who have a spectrum of neurological disorders with an experienced neurologist in a caring compassionate manner.

Listen to Dr. Shamim's interview on KERA news radio "Vital Signs" series covering epilepsy

What is a seizure?
A chemical imbalance or structural abnormality in the brain can result in abnormal electrical activity that results in clinical symptoms called seizures. The symptoms depend on the part of the brain involved falling along a spectrum ranging from mild sensory symptoms, staring spells, confusional spells, motor movements, generalized convulsions and more. Seizures may be provoked by general systemic conditions or may be part of a disorder known as epilepsy.

What is epilepsy?
Epilepsy is the occurrence of two or more seizures in a person which has not been provoked by other systemic illnesses or circumstances. Epilepsy is a fairly common condition which occurs in 0.5% to 1% of the population. Epilepsy is a very treatable condition and many patients with epilepsy can live very normal lives.

What are epilepsy medications?
Epilepsy medications are used to suppress the abnormal electrical activity in the brain to prevent seizures. There is a long list of epilepsy medications which have been designed and created over the last century. Some medications are ideal for certain seizure types while others have a broader spectrum of utility. Seizure medications are often picked based on the seizure type, the presence of other diseases, side effects and cost.

What is intractable epilepsy?
When a patient who has epilepsy has been compliant on two or more seizure medications and their seizures remain uncontrolled that patient is said to have intractable epilepsy. Occasionally a patient who is thought to have intractable epilepsy may actually have other conditions that mimic seizures which are why the medications were not working. These patients need to be evaluated in an epilepsy monitoring unit to confirm their seizure type or the possibility of an alternative diagnosis. Once a patient has been confirmed to have epilepsy which is originating from a specific part of the brain and that this epilepsy is intractable they may be considered for epilepsy surgery.

What is epilepsy surgery?
Epilepsy surgery involves evaluation for localization of a seizure focus in a patient who has intractable epilepsy. Once we are able to see that the focus is localized the patient is further evaluated to see if there is any eloquent or important brain function in that region. If that part of the brain is confirmed through careful testing to have very little function, it can often be safely removed. The success of epilepsy surgery has varied from 40% to 90% in different patient populations. Evaluation for epilepsy surgery does not require a patient to go on and have surgery and not all patients who are evaluated are found to be surgical candidates. Other surgical implanted devices are being used to reduce the frequency of seizures such as vagal nerve stimulator’s, deep brain stimulators and responsive neural stimulators when intractable patients are found to not be surgical candidates.

How do I know if I am epilepsy surgery candidate?
Patients who have intractable epilepsy localized to a specific focus in the brain may be a candidate for epilepsy surgery. Careful evaluation of a patient's history, imaging, and electroencephalograms by an experienced epileptologist is necessary in conjunction with a neurosurgical evaluation. Epilepsy surgery is not taken lightly and involves a team approach to the patient, involving a well-trained epileptologist, neurosurgeon, psychologist, technicians involved with patient monitoring and many other support staff.

What else needs to be considered when treating epilepsy?
Apart from surgery and medications, epilepsy care also involves addressing issues such as employment, ability to travel, safety, cognitive slowing due to disease or medications themselves, and financial constraints. Each patient is an individual and their care should be carefully discussed with his or her physician and no one treatment is universal for all.

What do I do if my family member has a seizure?
Make sure the patient's airway is clear by laying them on their side and lean them forward so if anything is in their mouth it wall fall out. Make sure they're in a place where they will not get hurt and move items that may injure them away from them. There is no reason to put anything in the mouth of a patient having a seizure and this has been shown to be dangerous. If your loved one is known to have epilepsy and you are familiar with your loved one's spells you should call 911 in the following circumstances: he or she has a seizure that lasts more than two minutes, has repeated back to back seizures, is not waking up from the spell, shows any difficulty with breathing, or you feel unsure of the circumstances. For a patient who has never had a seizure before, call 911 right away.

Women who have epilepsy
Careful consideration of epilepsy medication should be given in any woman in her reproductive years. The seizure disorder and or the medications can have an effect on a fetus or breastfeeding baby and medications should ideally be adjusted prior to pregnancy. Most women with epilepsy are able to have normal children with careful guidance.

What is brain mapping?
Brain mapping is the process by which abnormal seizure foci of the brain are localized and normal function is localized as well. Noninvasive brain mapping begins with a careful history and physical exam and includes neuropsychological evaluations, MRI, CT, SPECT scan, functional MRI and rarely magnetoencephalography. More invasive procedures may be necessary such as Wada evaluations and direct brain recordings and stimulations.

Epilepsy Monitoring Unit (EMU)

Your neurologist may have asked that you have further work up for your spells which involves an elective admission to the Epilepsy Monitoring Unit (EMU) at Baylor University Medical Center, which is located at 3500 Gaston Avenue, on the third floor of the Truett building. You will have to be driven by someone else to and from your hospital stay. During this visit you will be asked to stay in a monitored room where you will have a continuous electroencephalogram (EEG) with simultaneous video recording for the purpose of capturing your spells.

The evaluation of a patient's spells in an EMU is the gold standard for figuring out if a patient's spells are related to epilepsy or not. Up to half of patients admitted to the EMU are found to have other types of spells that are not epilepsy and may well have been the reason that the medications had not been working in the past. Patients who do have epilepsy may have further classification of their epilepsy type and their medications adjusted accordingly. Finally some patients with epilepsy can be evaluated for various surgical options. After your visit, a full report will be sent to your regular neurologist with our findings and recommendations.

Because your visit at the EMU may be limited to a few days, it is vital that we do our best to try to capture your typical spell. For this reason, you may be asked to reduce your sleep, have lights flashed, or be asked to breath fast at intervals and your medications may be reduced prior to the admission.

During your stay you will be admitted under the care of an epileptologist who will supervise a team of nurses and technologist specifically trained for your visit.

Your regular neurologist will need to get pre-authorization for your stay in the EMU from your insurance company and refer you to us. You will get a call from Baylor Scott & White Neurology – Dallas (469.800.7680) to schedule your visit. On occasion, some patients may need to see Dr. Shamim in the clinic prior to their admission, if their neurologist requests.

Smoking is not permitted in the EMU and nicotine patch can be provided during your stay. WIFI is available in the EMU room.

On the day of admission to the EMU

You are asked to report to the Admissions office on the ground floor of the Jonsson Building at Baylor University Medical Center in Dallas. Entrance to the Jonsson building is from Junius Street and visitor parking is across the street from Admissions also on Junius street. After you have been checked into admissions you will be directed to go to the EMU on the third floor of the Truett building which can be reached internally without going back to your car.

Headache

Chronic Daily Headache
Chronic daily headaches are headaches that occur at least fifteen days out of the month. They are common in people who have a history of episodic migraines. Symptoms include:

• Pain on both sides of the head
• Increased pain with physical activity
• Sensitivity to light
• Nausea or vomiting

Tension-type chronic headaches have a pressing sensation, while a migraine chronic headaches have a throbbing or pulsing feeling. Patients suffering from this condition often have an underlying headache at all times, yet they also suffer from episodic migraines regularly. Physicians attempt to prevent pain by prescribing medications that will not give the patient a rebound headache; these include beta-blockers, antidepressants, or anti-seizure medications. It is often helpful to educate patients about headaches and the importance of attention to routine as well.

Cluster Headache
Cluster headaches are one of the most painful headaches and are usually felt on one side of the head or behind one eye. They cause a drooping eyelid, nasal congestion, watery eyes, or enlarged pupils. Cluster headaches have a cyclical pattern, occurring multiple times over a few weeks, then not again for months or even years. Patients suffering from these headaches are often more comfortable pacing or moving around rather than being still. Physicians have many treatments that aim to prevent or lessen this pain; this ranges from various medications to nerve blocks or local anesthetics.

Menstrual Migraine
A menstrual migraine is a migraine that occurs during a woman's menstrual cycle. Migraines are related to hormone levels, so when a woman's estrogen drops before she begins her period, she is more likely to develop a migraine. Physicians recommend taking non-steroidal anti-inflammatory medications, though the specific selection depends on the pain level of the migraine. These should be taken two days before the menstrual cycle begins and continued until it is finished.

Migraine
Migraines are severe headaches often accompanied by nausea, vomiting, and heightened sensitivity to sound and light. The cause of migraines is unknown, but it is believed to be a combination of genetic and environmental factors. Patients experiencing migraines are often most comfortable in a dark, quiet place. To treat migraines, physicians prescribe pills ranging from ibuprofen to more intense medications such as triptans. In addition, caffeine is sometimes helpful to relieve pain.

Rebound Headache
Rebound headaches are headaches that occur as a response to an overuse of headache medication. If a patient takes a headache medicine daily or for a long period of time, they can develop a headache as the effects of the medication wear off. This is often a sign of a rebound headache. To treat this issue, physicians will help the patient reduce or stop the intake of the problematic medication. The headaches will likely get worse before they improve. Physicians can prescribe preventive headache medications for the future that will not cause rebound headaches.

Status Migraine
A status migraine is a migraine that lasts for over 72 hours. Status migraines sometimes require hospital visits in order to prevent dehydration from vomiting; physicians can insert an IV for rehydration and pain medication. If a patient suffers migraines regularly, there are preventive medications that can be prescribed to try to avoid the onset of a migraine.

Imaging

Magnetic Resonance Imaging, Computed Tomography, and Positron Emission Tomography are performed routinely by nuclear medicine and neuroradiology. A highly trained neuroradiology team is available for acute and elective interventions including aneurysm coiling, acute stroke thrombectomy, carotid stenting, and diagnostic angiograms at BUMC.

Memory disorders/dementia

Dementia refers to a progressive worsening of a person's cognitive function. The most common type of dementia is Alzheimer's Disease. At this time there is no cure for Alzheimer Disease, but medications do exist that help give some symptomatic relief. It is important to figure out what kind of dementia a patient has since some dementias have specific treatments and can even be stopped from getting worse. In addition, knowing the specific diagnosis helps families and patients allocate their resources to better care and to help define expectations.

There are some dementias that can be treated and often times be stopped from getting worse. It is important to be evaluated for these other types of dementias to ensure we do not miss a treatable type of dementia. Typical work up starts with a detailed and careful history. In fact, a good history usually has most of the answers. Further details can be gathered with Computed Tomography or Magnetic Resonance Imaging and blood work. Rarely, some patients will need spinal fluid evaluations, electroencephalograms, and various Positon Emission Tomographic testing.

Your primary care physician may refer you to a neurologist if you are not following the typical pattern that most Alzheimer disease patients exhibit. The neurologist may offer additional work up as described above and may help guide you to more recent treatment trends. Dementia research is ongoing and new trials are being developed each year.

Movement disorders

Movement disorders occur when muscles move uncontrollably or don't move when you want them to. The symptoms of a movement disorder largely depend on the type of condition you may have. People may have varying degrees of symptoms associated with the severity of the movement disorder and depending on the type of neurological issue.

Neuropathy

A disease or dysfunction of one or more peripheral nerves, typically causing numbness or weakness, usually in the hands and feet.

Nonepileptic seizures

What is a nonepileptic seizure?
There are several types of spells in which people briefly experience a loss of control, with symptoms such as convulsions, unresponsiveness, sensory changes, and more.  Epileptic seizures are most common and are accompanied by abnormal electrical discharges in the brain which can be seen on the electroencephalogram (EEG). Most patients with epilepsy are able to control their seizures with anti-seizure medications.

Nonepileptic seizures (NES) are diagnosed in 20-30% of persons admitted to epilepsy centers across the United States.  During these very distressing spells, there are no abnormal electrical discharges on the EEG. These spells are found to be connected to personal distress or life problems that may be happening now or have happened in the past. Unlike epilepsy, nonepileptic seizures often change in their symptoms over time and do not usually respond very well to anti-seizure medications.

How is a nonepileptic seizure diagnosed?
They are diagnosed by careful evaluations involving a  complete history of a patient's background and detailed descriptions of the patient's events. In addition, the patient goes through testing, at an Epilepsy Monitoring Unit (EMU).  It is important to be evaluated by an experienced doctor who specializes in epilepsy to confirm the correct diagnosis.

What causes nonepileptic seizures?
Causes of NES are many but generally are related to the body’s way of coping with emotional stress.  They may include specific disturbing events (recent or in the past), very high life stress or losses, or internal conflicts. These stressors can produce a wide variety of neurologic symptoms such as convulsions, paralysis, loss of awareness, sensory changes, or even pain.  Sometimes patients with NES have gotten so used to just trying to live their lives, they do not notice the amount of tension or conflict that they are experiencing.

Common reactions to being diagnosed
A diagnosis of nonepileptic seizure can be frustrating and upsetting. People have often been treated for a diagnosis of epilepsy, sometimes for many years.  Patients with NES may feel confused, angry, or think that their doctor does not believe them because the spells feel outside of their control.  Patients worry that others do not believe their seizures are "real."  However, although the seizures are not epilepsy they are not voluntary.

Additionally, the diagnosis can be hard to understand because it can be difficult to find the psychological links that trigger the episodes.  Besides, the realization that the mind can produce physical symptoms is a hurdle obstacle that many patients have difficulty dealing with creating a barrier to treatment.

What if other doctors thought I had epilepsy?
It is fairly common that persons with NES have been given a diagnosis of epilepsy by physicians based on their reports of their spells.  Many doctors do not have access to an Epilepsy Monitoring Unit (EMU) with a team of specialists and have to diagnose patients based on the possibility of the most dangerous cause, such as epilepsy.  However, when the medications fail to control seizures, a complete evaluation by an epilepsy specialist is often needed.  Continuing medications for epileptic seizures are not likely to be helpful and can create additional problems including long-term side effects and unnecessary costs.   Sometimes minor abnormalities on a routine EEG are seen and can mislead the diagnosis.  The gold standard for diagnosis is to be admitted to an Epilepsy Monitoring Unit (EMU) for video EEG monitoring.

What can be done?
Often it is helpful just to understand why the seizures are occurring.  An honest discussion with a physician may identify stresses or conflicts which have created the conditions for non-epileptic seizures.  Understanding this connection can help reduce the frequency of these attacks.  Reassurance with formal testing to ensure that a patient does not have epilepsy is often times helpful in itself.  The successful treatment of most patients depends on a trusting and honest relationship with an experienced and compassionate professional.

If the seizures continue, you will be referred to a professional who can help provide you with skills to understand and change those conditions which lead to the non-epileptic seizures.  This will often be a mental health professional who is familiar with NES, in your area.   They can provide you with guidance and skills to identify emotional and life triggers, early indicators that a seizure is coming on, and skills to manage the stress so that a full seizure does not need to occur.  Fortunately, a recent well-designed research study found that some treatment programs can be effective for many patients.   

Pain diagnostics

Baylor Scott & White Neurology – Dallas is a multi-disciplinary neurology clinic that specializes in diagnostic of pain.

Stroke

A stroke, or brain attack, happens when blood flow to your brain is stopped. It is an emergency situation.

The brain needs a constant supply of oxygen and nutrients in order to work well. If blood supply is stopped even for a short time, this can cause problems. Brain cells begin to die after just a few minutes without blood or oxygen.

When brain cells die, brain function is lost. You may not be able to do things that are controlled by that part of the brain. For example, a stroke may affect your ability to:

• Move
• Speak
• Eat
• Think and remember
• Control your bowel and bladder
• Control your emotions
• Control other vital body functions

Testing and procedures

• EEGs, EMGs, MRIs, CT Scan
• Imaging goes through Touchstone, Preferred Imaging or Envision Imaging
• Physical Therapy with our own Baylor Scott & White Institute of Rehabilitation
• Injections such as Nerve Blocks and BOTOX® is available in office to treat headaches
• Skin biopsies and DBS for Parkinsons, other movement disorders, and other neurological conditions
• BOTOX® for chronic migraines, dystonia, spasms, and other movement disorders

Tremors

Tremor is an involuntary shaking movement that is repeated over and over. Tremors can be caused by conditions or medicines that affect the nervous system, including Parkinson's disease, liver failure, alcoholism, mercury or arsenic poisoning, lithium, and certain antidepressants. Side effects from other medicines can also cause tremors. There are some differences between essential tremor and tremor caused by Parkinson's disease. If a cause is discovered, the disease will be treated rather than the tremor.

Parkinson’s disease
Parkinson’s disease is a condition that affects control over your movements. It’s caused by a lack of dopamine, a chemical that helps the nerve cells in your brain communicate with each other. When dopamine is missing from certain areas of the brain, the messages that tell your body how to move are lost or distorted. This can lead to symptoms such as shaking, stiffness, and slow movement. There’s no cure for Parkinson’s disease. But proper treatment can help ease symptoms and allow you to live a full, active life.

Changes in the brain
Dopamine is produced in a small area of the brain called the substantia nigra. For reasons that aren’t yet clear, the nerve cells in this region that make dopamine begin to die. This means less dopamine is available to help control your movements. When healthy, the substantia nigra makes enough dopamine to help control your body’s movements.

Symptoms of Parkinson’s disease
Parkinson’s symptoms often appear gradually. Some may take years to develop. Others you may not have at all. Below are the most common:

• Shaking (resting tremor) can affect the hands, arms, and legs. Most often, the shaking is worse on one side of the body. It usually lessens when the limb is used.
• Slow movement (bradykinesia) can affect the whole body. People may walk with short, shuffling steps. They can also feel “frozen” and unable to move.
• Stiffness (rigidity) occurs when muscles don’t relax. It can cause muscle aches and stooped posture.
• Other symptoms include balance problems, small handwriting, soft voice volume, constipation, reduced or “flat” facial expression, and sleep problems. Memory loss or other problems with thinking may also occur later in the progression of the disease.

How is Parkinson’s diagnosed?
There is no single test for Parkinson’s disease. The diagnosis is based on your symptoms, medical history, and a physical exam. You may also have tests to help rule out other problems. These may include blood tests to look for diseases that cause similar symptoms. They can also include brain-imaging tests, such as an MRI of the brain