The Public TV has highlighted the adoption of a less invasive surgical method for diagnosing and treating children with epilepsy at the "Arabkir" medical center. This advancement in modern medicine, stereotactic electroencephalography, enables precise identification and removal of epileptogenic foci, leading to significant improvements in patients’ quality of life.    Niko Arzumanyan, the head of the Neurosurgery service at the “Arabkir” MC-ICAH, explains, “Through the sequential recording of brain electrical activity from each microelectrode of the implanted electrodes, relevant specialists identify the foci responsible for epileptic seizures in the patient during the study.” Stereo-EEG was performed for the first time on a child with epilepsy in Armenia. This method is considered one of the most modern and complex approaches to treating this condition. It involves a minimally invasive intervention, allowing for the precise identification of the epileptic focus by gathering information about the activity of brain cells.   Niko Arzumanyan explains, “When a specific epileptogenic zone is identified, we immediately conduct radiofrequency ablation of the indicated areas without any incision or damage to the skull. This procedure targets the identified foci, offering patients the opportunity to alleviate their epileptic seizures. For most patients, stereo-EEG provides crucial information, enabling us to identify the epileptogenic zone accurately. Subsequently, we perform open surgery to achieve optimal results.”   Biayna Sukhudyan explains, “Following the intervention, the patient, who previously experienced seizures monthly, remained seizure-free for a month. This outcome indicated the correctness of our decision, and we recognized that complete cessation of seizures was not achievable after the ablation. Another month elapsed before we performed surgery on the patient and surgically removed the identified focus.”   Armenian doctors, in collaboration with Bulgarian colleagues, conducted a stereo-EEG procedure on a 14-year-old child. The doctor elaborates that the intervention is facilitated through the use of a stereotactic system. Neurosurgeon Niko Arzumanyan further explains and demonstrates, “The device features numerous coordinates and angles, aiding us in pinpointing the exact location for electrode insertion into the brain. A 1.5mm incision is made in the skin, followed by a 2mm diameter incision in the skull, through which electrodes are carefully placed deep into the corresponding brain regions.” An epileptology dispensary operates within the "Arabkir" medical center, where approximately 3,800 patients under the age of 18 are registered.   Biayna Gagikovna explains, “It's important to note that surgery is not suitable for all epilepsy patients. Approximately 70% of patients can be effectively treated with medication, while around 30% have drug-resistant forms of the condition. Hence, only about 50% of patients are eligible candidates for epilepsy surgery. Epilepsy, being a chronic disease, can manifest in various ways, from motor to emotional seizures.”   Doctor Sukhudyan elaborates, “In childhood, we primarily encounter hereditary forms of epilepsy, although there are several acquired causes as well. These include infantile cerebral palsy, fetal asphyxiation at a young age, various infectious diseases affecting the brain, tumor diseases, and immune disorders. In other words, there can be numerous underlying reasons.”   If a person is having seizures in a public place, citizens often take the wrong steps when providing first aid, according to the doctor.   Doctor Sukhudyan advises, “It's crucial to avoid taking incorrect actions when providing assistance. Refrain from intervening, attempting to open the patient's mouth, pulling their tongue out, or trying to revive them forcibly, as such actions can be harmful. Instead, the first step is to gently turn the person onto their side and promptly call for emergency assistance.”  

  The team of neurosurgeons and neurologists at the “Arabkir” Medical Center is introducing modern methods for diagnosing and treating epilepsy in Armenia. Collaborating with colleagues from the University Hospital “St. Ivan Rilski” in Sofia, Bulgaria, our specialists recently performed stereo-EEG, a unique intervention that precisely identifies the source of epileptic seizure activity and facilitates coordination for subsequent surgical treatment. Further details can be found in the video on news.am. 14-year-old Eric, who has been dealing with drug-resistant epilepsy since childhood, now has an opportunity to overcome seizures. He underwent a modern examination at the “Arabkir” medical center, specifically stereo-EEG. This diagnostic and, in some cases, treatment method, accurately identifies epileptic seizure foci in the brain - a procedure performed for the first time in Armenia.   Unlike regular electroencephalography, stereo-EEG is a minimally invasive surgical procedure. Special electrodes are placed in deeper areas of the brain using a stereotactic system, recording epileptic activity.  “Firstly, stereo-EEG is primarily considered a diagnostic method. However, based on its results, a minimally invasive surgical treatment of epilepsy can be undertaken. After placing the electrodes, the neurological team examines all contacts. Upon identifying relevant epileptogenic foci, a discussion is held to determine whether to proceed with coagulation or the surgical removal of the area,” says Sevak Badalyan, a neurosurgeon from the “Arabkir” MC.   Eric’s case presented a unique challenge: despite undergoing various examinations, the epileptogenic focus could not be identified. To achieve accurate diagnosis, 12 electrodes have been placed in his brain, and specialists are monitoring the child’s brain electrical activity to decide the course of further treatment.  “The reason we opted for stereo-EEG in this patient was due to uncertainty about the origin of epileptic activity. While an epileptic focus was visible on the MRI, the description, videotape and EEG did not align. Clinicians entertained doubts that this identified focus was the one to be removed. Therefore, electrodes were placed not only in that focus but also in anterior areas that appeared more suspicious of causing the clinical picture of the seizure.By the second day after electrode placement, we were convinced that our hypothesis was correct. The identified area had no connection with Eric’s epilepsy, and seizures were originating from slightly anteriorly located areas on the same side. This allows us to plan the upcoming surgery accurately” says Biayna Sukhudyan, head of the Neurology and Epileptology service at the “Arabkir” MC.     The first stereo-EEG at the “Arabkir” Medical Center was conducted in collaboration with Bulgarian specialists. According to the pediatric neurologist Petia Dimova from Sofia, they have been working in partnership with Biayna Sukhudyan and the Neurosurgical team at the “Arabkir” MC for 15 years.   “It’s a wonderful team. Although this is the first case, they are already well-versed and capable of conducting similar procedures in the future, thereby assisting patients in Armenia. This hospital, under its management, is dedicated to making all modern diagnostics and treatment methods accessible to citizens, particularly children, in Armenia” says Petya Dimova, a pediatric neurologist from Bulgaria. The specialists are currently monitoring the child’s spontaneous seizures and conducting special stimulation to identify contacts for ablation. While small foci can be addressed with a temporary effect, the ultimate solution for treating the disease involves the surgical removal of the epileptogenic focus.

Another neurosurgical operation using the stereotactic system was performed in the "Arabkir" medical center. This system allows interventions that were previously considered impossible. The video produced by News.am showcases the drainage of a brain cyst in a 35-year-old patient using a stereotactic system. It is also used in the surgical treatment of Parkinson's disease, epilepsy, as well as during brain tumor ablation, radiosurgery and biopsy.   Neurosurgeon Sevak Badalyan and the head of the neurosurgical service, Niko Arzumanyan, provide detailed insights into the procedure.

April 11th is highlighted in medical calendar as Parkinson’s Disease Awareness Day:  an occasion to talk about parkinsonism, its diagnosis and modern methods of treatment.   The video from news.am refers to neurosurgical treatment of parkinsonism at "Arabkir" Medical Center emphasizing how effective deep brain stimulation with neuromonitoring can be and how important it is for improving the quality of human life.  The 60-year-old man has had Parkinson's disease for over 10 years. He had been receiving drug treatment for many years, but the medications are no longer helpful, and even cause some complications. According to neurologist Zaruhi Tavadyan in a conversation with NEWS.am Medicine, the man had problems with work, social activities, and quality of life. The doctors at “Arabkir” Medical Center suggested a surgical treatment method - deep brain stimulation, which will allow him to return to his active life. “Parkinson’s disease is a chronic progressive neurological disorder of the central nervous system. Its classic symptoms are mainly motor: slowness in motion, tremor, impaired gait, coordination problems, muscle stiffness, and many non-motor symptoms like depression, sleep disorders, pain, etc. All of these symptoms together have a significant impact on the quality of life. During this disorder and drug treatment, patients may experience complications related to the treatment, irregular response to medications, irregular movements. At a certain point, it becomes difficult for patients to continue their treatment with conventional medications alone” says Zaruhi Tavadyan. She also mentions that deep brain stimulation has been used as a treatment method for over two decades. It allows for continuous adjustments in the patient’s mobility over time and helps them to remain active. Deep brain stimulation is a surgery, during which electrodes are placed in specific areas of the brain, which are then connected to a stimulation device implanted under the skin in the chest cavity. The device generates electrical impulses that inhibit abnormal brain activity. This is a complex operation, and surgeons need to find the correct position of electrodes without damaging the motor area of the brain. In the past, the surgery was performed with local anesthesia as the patient had to perform some tasks during the operation in order to evaluate the method's effectiveness and safety. For example, violinist Roger Frisch is known to have played the violin during this type of operation. Today, in “Arabkir” Medical Center, deep brain stimulation is performed with modern technology, neuromonitoring, and there is no longer a need to keep the patient awake, says neurosurgeon Sevak Badalyan. “In our center, deep brain stimulation is performed under general anesthesia and under the control of neuromonitoring, which has many advantages. Firstly, the patient is in a more comfortable state under general anesthesia, and neuromonitoring allows us to adjust the electrode's position and avoid possible side effects of stimulation. Neuromonitoring is a widely used method nowadays. It involves closing an electrical circuit, i.e . a stimulation of the corresponding area is done and the stimulus is recorded from the peripheral muscles. In other words, it can be facial muscle, upper or lower limbs, therefore, it will be facial  nerve or hypoglossal nerve, depending on the specifics of the operated region. The goal is to avoid the damage to relevant areas and pathways” he says. Before the operation, doctors carefully study the patient's brain MRI image, find target nuclei and insert electrodes virtually. Then, right before the operation, contrast CT-scan is performed, the results of which are then combined with MRI. To determine the precise place of where electrodes should be placed, a special coordinate system called stereoscopic circle, is used, Niko Arzumanyan, the head of the Neurosurgery Service has noted. “The intervention consists of several stages. In the first stage of the operation, a special metal device is attached to the patient’s head, which helps us to create a virtual coordinate system, and by combining the results of the computed tomography and MRI imaging through the appropriate program, we are able to get coordinates we need, and with the corresponding coordinates, insert the electrodes in the right place with an accuracy of up to 0.6mm” he says.  Niko Arzumanyan mentions that deep brain stimulation has been used in “Arabkir” Medical Center for over a year now, and all the operated patients are satisfied with the results. All of this became possible thanks to the latest equipment and digital technologies acquired by the center.  Deep brain stimulation is used not only to treat parkinsonism, but for other neurological and even psychiatric disorders as well, says Zaruhi Tavadyan. “Deep brain stimulation is used primarily for Parkinson’s disease, as well as for genetic or essential tremor, and in pediatrics for some types of dystonia. By now, the indications for deep brain stimulation are increasing, the field is expanding, and in the future this method will be used for movement disorders as well, and not only. For example, it can be used in psychiatry, but for now it is used for movement disorders such as classical parkinsonism, essential tremor and dystonia”, she says. 3-4 weeks after the surgery, when the patient’s wounds have healed, the doctors will run the stimulator and make the adjustments. As a result, the patient's slowness of movement, tremor, gait and speech will be corrected, the use of medication will be reduced, which will significantly improve his quality of life.  

News.am's reference to the recently performed complex surgery in the neurosurgical service of the “Arabkir” Medical Center intended to remove a child’s brain tumor and thus prevent epileptic episodes.   The head of the Neurology and Epileptology service Biayna Sukhudyan, and the head of the Neurosurgery service Niko Arzumanyan provided details about the case, the surgery and, as a whole, about this problem and its modern solutions.    In “Arabkir” Medical Center, a surgical treatment of epilepsy was performed on an 8-year old girl, using modern technologies. Studies have shown that the cause of the child’s epileptic seizures over several years was a large tumor, which compressed nearby areas of the brain. During the tumor removal, neuromonitoring was used to bypass the motor nerve fibers and avoid damage to the child’s motor functions. According to Niko Arzumanyan, the head of the Neurosurgery service who spoke with NEWS.am Medicine, the issue in this patient’s case was not the tumor itself, but the compression of nearby areas of the brain by the tumor, resulting in epilepsy.  What is neuromonitoring?  "Neuromonitoring was very important for this surgery, because the tumor was directly adjacent to the motor areas of the brain and cerebral cortex, as well as corresponding pathways. During the removal of every millimeter of the tumor, we use a special tool to stimulate the brain tissue.    Depending on amount of electric current used to stimulate the brain and elicit a response, we estimate how far we are from the corresponding motor nerve fibers. The main goal of this is so that during the surgery and post-operative care we will not have any deficit and will not damage the motor ability of the body," he said.  According to Niko Arzumanyan, surgical treatment of epilepsy with simultaneous monitoring is one of the new directions that is being developed in “Arabkir” Medical Center. Until now such operations were performed here with the participation of foreign partners, but now the doctors of “Arabkir” MC work independently. The surgery lasted almost 10 hours, because the tumor was quite large and solid. It took the doctors multiple efforts and hours to remove it without damaging the vessels and nerves of the brain.    Biayna Sukhudyan, the head of the Neurology and Epileptology service of “Arabkir” Medical Center mentioned, that the child had been under the of doctors at “Arabkir” MC for several years, her illness appeared with seizures. Various examinations such as MRI and video-EEG monitoring were performed and right parietal tumor with epileptic activity were diagnosed.  “For the first time in Armenia, tractography was performed, which allowed us to understand that the tumor does not include important nerve fibers, however, our neurosurgeons chose to use neuromonitoring during surgery to be safer,” she said.    Video EEG Electroencephalography remains as one of the most important diagnostic tests for epilepsy. Video-EEG or video electroencephalography is one of the newest methods used in “Arabkir” MC. It is a study that records the electrical activity of the brain over a long period of time, which significantly increases the chances of accurate diagnosis of epileptic foci.  “Electrodes are attached with special paste to the heads of our children and adults, and the patients remain in the hospital for 24, 48 or 72 hours. Then the doctor deciphers the results and tries to determine where that electrical activity comes from. If a number of studies confirm and coincide, all showing the same epileptogenic focus, then the patient's chances of overcoming the disease with surgical intervention in the future are quite high,” she explained.  The operated child will undergo EEG monitoring again in a few months to check the effectiveness of the surgery. She will take her medicine for several years, after which, the doctors are sure that she will finally get rid of epilepsy and will live a full and healthy life.   Epilepsy Statistics  The head of the service, Biayna Sukhudyan stated that 70% of the epilepsy cases can be managed through medical treatment, while 30% are difficult to control, and 15% require surgical treatment.  All children in Armenia with epilepsy are under the supervision of "Arabkir" Medical Center. Not only children, but many adults with epilepsy and other neurological disorders receive treatment in the hospital, according to Biayna Sukhudyan. “Currently over 3600 children aged 0-18 are under our care, all of whom have some form of epilepsy, whether genetic or acquired.  Today we have adults and children under our control, and the state program includes people up to the age of 40 who may potentially be candidates for surgery. We also receive adults with drug-resistant epilepsy” she explained.

Neurosurgeons Krasimir Minki (general surgeon, Associate Professor), Kaloian Gabrovski (Assistant) and epileptologist Petia Dimova (Associate Professor) from the University Hospital of Saint Ivan Rilski were at "Arabkir" MC. A team of Bulgarian and Armenian neurosurgeons operated on a group of patients with severe, drug-resistant epilepsy whose problems appeared for various reasons: congenital brain defects, strokes in early childhood, inflammatory diseases, hippocampal sclerosis etc.    Before the surgery, they underwent long-term video-EEG monitoring, MRI and PET scans, computerized comparison and post-processing of the past examinations were performed.  In many of the patients, it was also possible to perform seizure EEG, which further clarified the location of the epileptogenic zone.    Performed surgeries, including unique and rare operations in Armenia, such as hemispherotomy, "everything but motor" operation, have so far shown 95 percent effectiveness and can free most of the patients from chronic administration of anticonvulsant drugs.    The operations were performed under awake and asleep intraoperative neurophysiological monitoring.