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Background & Objective: A substantial proportion of patients were managed by general clinicians in resource-limited settings. Therefore, we aim to develop a simple and rapid focal seizure screening tool that can assist non-neurologists in seizure classification. Methods: We conducted a self-administered qualitative questionnaire study on seizure manifestation developed based on the validated comprehensive questionnaires by Reutens et al. for clinical diagnosis of seizures. Logistic regression analyses were conducted to determine the features of seizure which form the items of a focal seizure screening tool. A receiver operating characteristic (ROC) curve analysis was conducted to determine the optimal cut-off score. Results: Among the 199 subjects, 145 (73%) had focal seizures. Three categories of symptoms, i.e., (i) aura (fear, déjà vu, and epigastric aura), (ii) unilateral motor phenomena, and (iii) oral automatism, are significantly associated with the diagnosis of focal seizure. The logistic regression model containing these 3 items / features was statistically significant, χ2 (3, N=199) = 22.93, p

Background & Objective: Neurological manifestations were reported in dengue fever. We hypothesize that the diagnosis of DEN virus (DENV) encephalitis based on current clinical diagnostic criteria has been made too liberally. We conducted a systematic review of the literature to clarify this, and to characterize DENV encephalitis better. Methods: We systematically review the literature using MEDLINE and PubMed databases papers published from 1st January 1960 to 31st March 2020. We grouped the cases into definite and probable DENV encephalitis. Definite DENV encephalitis required demonstration of DENV (live virus, viral antigens, RNA) in the central nervous system or CSF whereas probable DENV encephalitis required positive anti-DENV IgM in the CSF and evidence of virus or anti-DENV IgM in the serum. Results: Of the 230 publications obtained from literature search, 121 case reports and series appeared relevant to DENV encephalitis. After applying our inclusion criteria, only 42 cases (34.7%) were acceptable as DENV encephalitis: 30 (24.8%) definite and 12 (9.9%) probable cases. Our findings suggest that DENV encephalitis is more uncommon than previously thought. Part of the reason for non-inclusion may be because many studies relied solely on DENV serology for diagnosis. Cross-reactivities of anti-DENV with anti-JE virus immunoglobulins in serum or CSF occur and this limits their usefulness to distinguish DENV encephalitis from JE. Conclusions: The majority of DENV encephalitis cases reported in the literature did not satisfy a more stringent inclusion criteria. Further investigations including autopsy studies are warranted to better characterize and to understand the pathology and pathogenesis of DENV encephalitis.

ImportanceSelection of antiseizure medications (ASMs) for epilepsy remains largely a trial-and-error approach. Under this approach, many patients have to endure sequential trials of ineffective treatments until the “right drugs” are prescribed.ObjectiveTo develop and validate a deep learning model using readily available clinical information to predict treatment success with the first ASM for individual patients.Design, Setting, and ParticipantsThis cohort study developed and validated a prognostic model. Patients were treated between 1982 and 2020. All patients were followed up for a minimum of 1 year or until failure of the first ASM. A total of 2404 adults with epilepsy newly treated at specialist clinics in Scotland, Malaysia, Australia, and China between 1982 and 2020 were considered for inclusion, of whom 606 (25.2%) were excluded from the final cohort because of missing information in 1 or more variables.ExposuresOne of 7 antiseizure medications.Main Outcomes and MeasuresWith the use of the transformer model architecture on 16 clinical factors and ASM information, this cohort study first pooled all cohorts for model training and testing. The model was trained again using the largest cohort and externally validated on the other 4 cohorts. The area under the receiver operating characteristic curve (AUROC), weighted balanced accuracy, sensitivity, and specificity of the model were all assessed for predicting treatment success based on the optimal probability cutoff. Treatment success was defined as complete seizure freedom for the first year of treatment while taking the first ASM. Performance of the transformer model was compared with other machine learning models.ResultsThe final pooled cohort included 1798 adults (54.5% female; median age, 34 years [IQR, 24-50 years]). The transformer model that was trained using the pooled cohort had an AUROC of 0.65 (95% CI, 0.63-0.67) and a weighted balanced accuracy of 0.62 (95% CI, 0.60-0.64) on the test set. The model that was trained using the largest cohort only had AUROCs ranging from 0.52 to 0.60 and a weighted balanced accuracy ranging from 0.51 to 0.62 in the external validation cohorts. Number of pretreatment seizures, presence of psychiatric disorders, electroencephalography, and brain imaging findings were the most important clinical variables for predicted outcomes in both models. The transformer model that was developed using the pooled cohort outperformed 2 of the 5 other models tested in terms of AUROC.Conclusions and RelevanceIn this cohort study, a deep learning model showed the feasibility of personalized prediction of response to ASMs based on clinical information. With improvement of performance, such as by incorporating genetic and imaging data, this model may potentially assist clinicians in selecting the right drug at the first trial.

PurposeSeizures are a common presenting symptom among patients with low- and high-grade glioma. However, the impact and inter-relationship between the presence of seizures, anti-seizure medication and survival are unclear. We retrospectively analyzed the incidence of seizures and identified the pattern and relationship of anti-seizure medication on survival in our cohort of patients with glioma.MethodsWe evaluated all glioma patients who underwent treatment at the University of Malaya Medical Centre (UMMC) between 2008 to 2020. Demographic and clinical data of seizures and pattern of ASM administration in comparison to overall survival were analyzed.ResultsA total of 239 patients were studied, with a minimum of one year clinical follow-up post-treatment. The mean survival for low-grade glioma was 122 months whereas high-grade glioma was 47 months. One-third of our glioma patients (n=72) presented with seizures. All patients with seizures and a further 49.2% of patients without seizures were started on anti-seizure medication preoperatively. Seizure and Levetiracetam (LEV) were significantly associated with OS on univariate analysis. However, only LEV (p=0.019; HR 0.53;95%CI: 0.31-0.90) was significantly associated with OS on multivariate analysis. Once ASM was adjusted for relevant factors and each other, LEV was found to be protective in all grade gliomas (p=0.012; HR 0.50; 95% CI: 0.30-0.86) and specifically high-grade gliomas (p=0.00; HR 0.44; 95% CI: 0.25-0.77). ConclusionsPre-operative seizures among patients with glioma indicated a better overall prognosis. The administration of ASM, specifically LEV demonstrated a significant survival advantage in our retrospective cohort of patients.

Allopurinol is known to cause severe cutaneous adverse drug reactions (SCAR) in Malaysia. However, the incidence of allopurinol-induced SCAR is unknown. Therefore, we aimed to determine the incidence of allopurinol-induced SCAR in Malaysia over 5 years from 2015 to 2019.This retrospective analysis was done in collaboration with the National Pharmaceutical Regulatory Agency (NPRA). All allopurinol-induced adverse drug reaction cases reported to NPRA from 2015 to 2019 were extracted. Allopurinol-induced SCAR cases were identified and the incidence over the 5 years was calculated.Incidence of allopurinol-induced SCAR averaged at 2.5 cases per 1000 new users over the 5-year period, with a reducing trend from 3.2 per 1000 new users in 2015 to 2.25 per 1000 in 2019; despite the increasing number of adverse drug reaction cases being reported over the years. Stevens-Johnson syndrome was the commonest form of allopurinol-induced SCAR reported, at 143 cases (46.8% of total SCAR reported). Among Malaysia's 3 main ethnicities, the Chinese had the highest percentages of allopurinol-induced SCAR when compared to the Bumiputera and Indians (3.18 × 10The estimated incidence of allopurinol-induced SCAR in Malaysia from 2015 to 2019 was 2.5 cases per 1000 new users. This figure is consistent with the incidence reported in other Asian countries, namely Taiwan and Thailand.

Antiseizure medication can potentially cause severe cutaneous adverse reactions, and certain antiseizure medication-induced severe cutaneous adverse reactions are associated with specific human leukocyte antigen alleles. This caused a change in antiseizure medication prescribing patterns, which may influence the incidence of antiseizure medication-induced severe cutaneous adverse reactions. Thus, we aimed to determine the incidence of antiseizure medication-induced severe cutaneous adverse reactions and its change over 15 years (2006-2019) in Malaysia. This retrospective analysis combined antiseizure medication-induced SCAR cases from the national adverse drug reaction database in the National Pharmaceutical Regulatory Agency, antiseizure medication usage data from the Malaysian Statistics of Medicine, and prescribing data from University Malaya Medical Centre, a national-level tertiary hospital to calculate antiseizure medication-induced SCAR incidence in Malaysia. We observed an upward trend in reported antiseizure medication-induced SCAR cases from 28 cases in 2006 to 92 in 2016. The incidence of carbamazepine (CBZ)-induced severe cutaneous adverse reactions increased from 7.5 per 1000 person-years (2006) to 17.8 per 1000 person-years (2016) but dropped to 7.2 per 1000 person-years subsequently (2019). Concurrently, there was an increase in the incidence of severe cutaneous adverse reactions secondary to phenytoin and lamotrigine. The prevalent users of CBZ had reduced from 22.8% (2006) to 14.1% (2016), whereas the levetiracetam and sodium valproate users increased by 5.5% and 4.8%, respectively. The incidence of CBZ-induced severe cutaneous adverse reactions had reduced since 2016, probably related to the implementation of human leukocyte antigen-B*1502 screening in Malaysia or substitution of CBZ with other antiseizure medications. However, this was accompanied by an increase in SCAR incidence related to phenytoin and lamotrigine.

Background: Up to 73.0% of patients with bilateral temporal lobe epilepsy (BTLE) on scalp electroencephalogram (EEG) were found to have unilateral temporal seizure onset via invasive EEG monitoring (iEEG) and 58% of them achieved good surgical outcome. However, iEEG in resource- limited countries is limited by cost. We aimed to present the surgical outcome of a simplified and cost- effective 2-electrode bilateral hippocampal depth implantation strategy in 7 cases with bilateral temporal lobe epilepsy based on scalp EEG and unilateral mesial temporal sclerosis (MTS). Methods: Total 7 cases who underwent epilepsy surgery were reviewed. All patients underwent 2-stage evaluation of video-EEG monitoring followed by intracranial monitoring. A simplified 2-depth electrode implantation strategy was used, targeting the bilateral anterior hippocampus. Results: All 7 patients had interictal bilateral independent temporal epileptiform discharges. Four had bilateral temporal ictal onset on scalp EEG and 3 with ictal onset contralateral to the MTS. With iEEG, 4 patients (57.1%) were confirmed to be unilateral TLE, concordant with the MTS, and 3 patients (42.9%) had true BTLE. All 7 patients underwent anterior temporal lobectomy, ipsilateral to the side of MTS. Four patients (57.1%) achieved Engel I surgical outcome, of which 3/4 (75.0%) were patients with unilateral TLE. For those with true BTLE, 2/3 (66.7%) achieved favourable surgical outcome (Engel I and II). Conclusions: This simplified two-electrode implantation strategy is effective in lateralization of TLE in patients with BTLE and more affordable to those in resource-limited countries.

The standardized mortality ratio (SMR) of epilepsy in Asia ranges from 2.5 to 5.1. However, there are no such published data in Malaysia to date. Understanding the mortality rate and related factors will allow us to better assess and monitor the health status of PWE, thereby, preventing premature deaths among PWE. Hence, this study aimed to determine the mortality rate of adults with epilepsy (PWE) at the University Malaya Medical Centre (UMMC), a tertiary hospital in Malaysia.A total of 2218 PWE were recruited retrospectively into this study. Deceased cases from 2009-2018 were identified from the National Registry Department of Malaysia. Age-, gender-, and ethnic-specific SMR were calculated.There was a total of 163 deaths, of which 111 (68.1%) were male. The overall case-fatality rate (CFR) was 7.3%. Male PWE had higher CFR (9.2%) compared to females (5.1%, p0.001). The annual death rate of PWE was 867 per 100, 000 persons. The overall all-cause SMR was 1.6 (CI 95% 1.3-1.8). The SMR for younger age groups (15-19 and 20-29 years) were higher (5.4-5.5) compared to other age groups (0.4-2.5). Overall SMR for male PWE (1.8, 95% CI 1.5-2.1) was higher than females (1.2, 95% CI 0.9-1.6). However, the SMR for female PWE in the younger age groups (15-19, 20-29 and 30-39 years) was higher. SMR among the Indian PWE was the highest (1.6, 95% CI 1.2-2.0) compared to the Chinese (1.5, 95% CI 1.2-1.9) and the Malays (1.4, 95% 1.0-1.9). The CFR was higher in those with focal epilepsy (8.5% vs. 2.5-3.7% in genetic and other generalized epilepsies, p=0.003), epilepsy with structural cause (9.5% vs. 5.9% in others, p=0.005) and uncontrolled seizures (7.9% vs. 5.2% in seizure-free group, p0.001).The mortality rate of PWE in Malaysia is higher than that of the general population but lower compared to other Asian countries. Specifically, the rates are higher in the younger age group, male gender, and Indian ethnicity. Those with focal epilepsy, structural causes and uncontrolled seizures have higher mortality rates.

Prevalence of seizures in brain tumors vary substantially between studies even with similar histopathological types. We aimed to identify the seizure prevalence of the commonest types of brain tumors.Systematic computerized search of PubMed, Embase, and Web of Science were performed. The meta-analysis of pooled prevalence and 95 % confidence interval (CI) for tumor-related seizures were calculated by using a random effect model. Based on the 2014 epilepsy definition, a mean seizure prevalence of 60 % is used to indicate high seizure prevalence in this study.74 studies that reported seizure prevalence with 23,116 patients were included in this meta-analysis. These tumors has higher seizure incidence rate (at least 60 %) with pooled prevalence of 63 % for adult with low-grade astrocytoma (95 % CI: 57-68 %), 65 % for oligodendroglioma (95% CI: 57-72 %), 72 % for oligoastrocytoma (95 % CI: 67-77 %), 81 % for ganglioglioma (95 % CI: 66-97 %) and 94 % for DNET (94 % CI: 83-100 %).This study highlights the type of brain tumors that carry a high seizure prevalence. Screening for subtle seizures and early management of seizures may be beneficial in patients with low-grade astrocytoma (adult), oligodendroglioma, oligoastrocytoma, ganglioglioma or DNET brain tumor.

Seizure remission rates of 60% with antiseizure medications were reported in developed countries, but might be lower in resource-limited countries. The challenges in epilepsy care in resource-limited regions were highlighted 10 years ago, and still remain an ongoing issue. This study aimed to determine the seizure freedom rates in level-2 epilepsy care centres (centres with general neurologists) compared to level-3/4 centres (centres with epileptologists providing epilepsy surgery evaluation) in Malaysia. This is a retrospective study of 1,347 adult epilepsy patients from two level-2 (n = 290) and two level-3/4 epilepsy care centres (n = 1,057). The seizure remission rates were significantly lower in level-2 centres (42.5%) compared to the level 3/4 centres (61.9%, p 0.05). Level-2 centres had significantly more patients with undetermined seizure types compared to level-3/4 centres (6.6% vs 3.1%, p 0.05). Level-3/4 centres had significantly more patients with epilepsy of structural and genetic origins, whereas more patients in level-2 centres had unknown aetiology (46.2% vs. 34.0% in level-3/4, p 0.05). Level-2 centres had a lower neurologist-to-patient ratio (1:97 vs. 1:50 in level-3/4 centres, p 0.05). Level-2 centres also had fewer patients, who underwent investigations such as EEG (74.1% vs. 89.6%) and brain MRI (54.1% vs. 72.4%, p 0.05) in comparison with level-3/4 centres. Our study emphasized the existing challenges in epilepsy care in a resource-limited country to achieve the ideal 60% seizure remission rate.

Background Telehealth use is limited in developing countries. Therefore, a modified approach with early physical consultation was designed and applied in our hospital. This study aimed to determine the efficacy of this early physical consultation in reducing the clinical and psychological impacts of coronavirus disease-19 (COVID-19), which enabled insight into its global feasibility. Method Participants were contacted and offered early physical consultation with a neurologist. Patients who participated in the Phase 1 study on the impacts of the COVID-19 pandemic on people with epilepsy and treated in our hospital were recruited. Clinical and psychological outcomes of COVID-19 were assessed with the Hospital Anxiety Depression Scale (HADS) and Quality of Life in Epilepsy Inventory (QOLIE-31). Result A total of 312 patients completed this study with a mean age of 39.13 ± 16.13 years, majority female (51.0%), and experienced seizures at least once yearly (64.7%). There was 12.6% who experienced seizure worsening related to the COVID-19 pandemic. After receiving early clinical intervention, 30.8% achieved better seizure control with another 51.1% had no seizure occurrence. The mean HADS anxiety score improved immediately post-intervention (5.27 ± 4.32 vs. 4.79 ± 4.26, p

Background This study aimed to determine the relationship among the clinical, logistic, and psychological impacts of COVID-19 on people with epilepsy (PWE), and the impact of COVID-19 on the quality of life. Method This is a cross-sectional anonymized web-based study on PWE, using an online questionnaire to assess the clinical, logistic, and psychological impacts of COVID-19, including Hospital Anxiety Depression Scale (HADS) and Quality of Life in Epilepsy Inventory (QOLIE-31). Result 461 patients were recruited, with a mean age of 39.21 ± 15.88 years, majority female (50.1%), with focal epilepsy (54.0%), and experienced seizures at least once yearly (62.5%). There were 13.0% experienced seizure worsening during COVID-19 period, which were associated with baseline seizures frequency ≥ 1 per month (32.0% vs. 6.2%, p 1 per month (OR, 14.10) followed by anxiety (OR, 3.90), inadequate sleep (OR, 0.37), and treated in UMMC (OR, 0.31) as the predictors for seizure worsening during COVID-19 period. Poorer total QOLIE-31 score was noted in those with seizure worsening (48.01 ± 13.040 vs. 62.15 ± 15.222, p

Introduction The lifetime prevalence of epilepsy varies greatly from 1.5–14.0 per 1000 persons among the Asian countries. We aim to study the prevalence of epilepsy in Malaysia to have a better insight into the burden of disease in the country. Methods A population-based door-to-door survey was carried out throughout the country, using questionnaire for brief screening in ascertainment of epilepsy, using a questionnaire and its validated multilingual versions. Respondents who were screened positive underwent second-stage diagnostic phone interview by neurologists/ research assistants. Results A total 16, 686 respondents participated in the survey and 646 (3.8 %) respondents were screened positive during the first stage interview. A total of 185 consented for second stage diagnostic interview and 118 (63.8 %) respondents were contacted successfully for the second stage diagnostic phone interview, of which 17 (14.4 %) respondents were diagnosed to have epilepsy. An additional 68 (57.6 %) respondents had febrile seizures only. After applying a weighting factor to each respondent to adjust for non-response and for the varying probabilities of selection, the adjusted lifetime epilepsy prevalence was 7.8 in 1000 population, and the adjusted prevalence for active epilepsy was 4.2 in 1000 population in Malaysia. Conclusion The prevalence of lifetime epilepsy in Malaysia is 7.8 per 1000 persons.

Introduction. Guillain-Barre syndrome (GBS) is the commonest cause of acute flaccid paralysis. However, clinicians should not miss the other causes of acute flaccid paralysis which may mimic GBS. Results. We present 3 cases of flaccid areflexic paralysis which presented acute/subacutely resembling GBS. Case 1: A 29-year-old lady presented with 2-week history of bilateral lower limb weakness with left hip pain for 3 years. Investigations revealed hypercalcaemia, hypophosphataemia, elevated ALP, vitamin D deficiency, hyperparathyroidism with right parathyroid adenoma from parathyroid ultrasonography and scintigraphy. She had plasma exchange for presumed GBS, but her lower limb weakness worsened and progressed to involve upper limbs and facial muscles. Her weakness improved after parathyroidectomy and the diagnosis was revised to hyperparathyroidism-related polyneuropathy. Case 2: A 28-year- old lady with underlying epilepsy and intellectual disability presented with progressive weakness of extremities over 3 weeks after prolonged fasting. Her weakness did not improve after treatment with immunoglobulin for GBS. Investigations showed positive urine porphobilinogen and raised urine delta-aminolaevulinic acid. A diagnosis of acute intermittent porphyria was considered most likely and her weakness improved after continuous glucose loading. Case 3: A 52-year-old lady who had bariatric surgery presented with bilateral lower limb weakness over 4 weeks after recurrent bouts of vomiting and excessive weight loss. Investigations revealed vitamin D deficiency, hypoalbuminaemia, hyperhomocysteinemia, low folate and low normal serum thiamine. As her weakness continued to progress, a diagnosis of acute nutritional neuropathy was considered more likely. Her weakness improved following multivitamins replacement. All 3 patients had normal CSF analysis except Case 1 who showed cyto-albuminologic dissociation. Sensorimotor axonal polyneuropathy was the electrodiagnosis demonstrated in all the cases. Conclusion. Clinicians should have high index of suspicion when treating acute flaccid paralysis with progressive disease and null response to immunotherapy as the neurology is reversible with treatment of the underlying cause.

This is a follow-up study on mortality in adult patients in Malaysia. This study aimed to determine the cause of death and the factors associated with epilepsy-related death in PWE in Malaysia.Deceased PWE from 2005 to 2020 were identified from the National Registry Department of Malaysia. The details of the cause of death and predictors for epilepsy-related deaths was ascertained from medical records and phone interviews.There were a total of 227 deaths, 144 (63.4%) were male, two (0.9%) underwent autopsy and 46.3% passed away in the community. The majority of deaths (55.5%) were due to causes unrelated to epilepsy. Forty-five (19.8%) death were related to epilepsy, of which, 22 (9.7%) were due to death directly related to epilepsy including probable SUDEP (5.3%) and status epilepticus (4.4%). The cause of death was unknown in 56 (24.7%) cases. Binary logistic regression analysis identified 3 predictors for epilepsy-related deaths, i.e., structural causes (OR 3.09, 95% CI 1.100-8.691, p = 0.032), younger age of death (OR 2.35, 95% CI 1.039-5.333, p = 0.040) and history of brain surgery (OR 8.09, 95% CI 2.014-32.510, p = 0.003). Twelve (5.3%) had probable SUDEP. The incidence rate of probable SUDEP was 0.42 per 1000 person-years. The majority of them had intellectual disability (9/12), generalized tonic-clonic seizures (9/12), and 2 or more ASMs (9/12).Epilepsy-related deaths accounted for 20% of the deaths in PWE, associated with structural cause, younger age of death, and previous brain surgery. Probable SUDEP is not uncommon in Malaysia and could be under-diagnosed.

Complementary and alternative medicine (CAM) usage were reported in Europe, the United States of America and monoethnic Asian countries such as Korea and Taiwan. However, limited literature is available on the variability of CAM usage patterns among people with epilepsy (PWE) in a multi-racial country in particular Malaysia. This cross-sectional study assessed the prevalence, types, predictors and impact of CAM use among adult PWE and their adherence to anti-epileptic drugs (AEDs) treatment.140 patients were recruited, with a median age of 37.5 (IQR,28.0-51.5) years, majority female, had secondary or lower education level, earn

Epilepsy stigma is an important issue affecting people with epilepsy (PWE) in various social aspects of life. Most studies on stigma were among the metropolitan population but rarely on indigenous people. Hence, this study aimed to understand the attitudes toward epilepsy of the East Malaysians, comparing with the West Malaysians previously reported.This study was performed among the indigenous people in Kuching and Sibu (Sarawak) and Kota Kinabalu (Sabah) using the Public Attitudes Toward Epilepsy (PATE) scale. A higher score indicates poorer attitude.A total of 360 respondents (41.7% Kadazan-Dusun, 30.6% Bidayuh, and 24.7% Iban) aged 34.6 ± 12.6 years completed the questionnaire. They were predominantly females and had lower education level and income compared with the West Malaysians. The Sabah population had significantly lower mean scores (better attitudes) than those in Sarawak, in both personal and general domains (p .001). As compared with West Malaysia, the mean score in the personal domain was significantly lower in Sabah, while Sarawak had significantly higher scores in general domain (p .001). Subanalysis showed that the Sabah population had better attitudes toward marriage and employment in PWE than the West Malaysians, whereas Sarawak had poorer attitudes toward education and social contact in PWE.The attitudes toward epilepsy were different among the indigenous populations in Sabah and Sarawak, and from the West Malaysians, which could be attributable to their sociocultural differences.

Epilepsy stigma has been associated with poor quality of life among people with epilepsy (PWE). It is important to understand the variation and degree of epilepsy stigma in one of the most populous and culturally diverse nations in the world, Indonesia. Hence, this study aimed to test the validity and reliability of the Indonesian version of the Public Attitudes Toward Epilepsy (PATE) scale.The translation was performed according to standard principles and tested in 200 native Indonesian speakers who were aged above 18-year-old for psychometric validation.The items in each domain had similar means and standard deviations (equal item variance), means ranging from 2.17 to 2.86 in general domain and 2.75 to 3.56 in personal domain and, standard deviations ranging from 0.87 to 1.05 and 0.88 to 1.01 in general and personal domain, respectively. Item-domain correlations were more than 0.5 for all items, and they correlate higher within their own domain compare with the other domain (convergent and divergent validity). Multitrait analysis showed similar variance, floor, and ceiling patterns to a great extent compared with the initial study. The Indonesian PATE scale also showed mostly similar correlation with demographic characteristics except monthly income. Principle axis analysis revealed strong factor loading (0.3) in their hypothesized domain, except item 14. The Cronbach's α values for general and personal domains were 0.836 and 0.765, which were within the accepted range of 0.7 to 0.9.The Indonesian PATE scale is a validated and reliable translation for measuring public attitudes toward epilepsy.

Epilepsy surgery is an important treatment modality for medically refractory focal epilepsy. The outcome of surgery usually depends on the localization accuracy of the epileptogenic zone (EZ) during pre-surgical evaluation. Good localization can be achieved with various electrophysiological and neuroimaging approaches. However, each approach has its own merits and limitations. Electroencephalography (EEG) Source Imaging (ESI) is an emerging model-based computational technique to localize cortical sources of electrical activity within the brain volume, three-dimensionally. ESI based pre-surgical evaluation gives an overall clinical yield of 73–91%, depending on choice of head model, inverse solution and EEG electrode density. It is a cost effective, non-invasive method which provides valuable additional information in presurgical evaluation due to its high localizing value specifically in MRI-negative cases, extra or basal temporal lobe epilepsy, multifocal lesions such as tuberous sclerosis or cases with multiple hypotheses. Unfortunately, less than 1% of surgical centers in developing countries use this method as a part of pre-surgical evaluation. This review promotes ESI as a useful clinical tool especially for patients with lesion-negative MRI to determine EZ cost-effectively with high accuracy under the optimized conditions.

Introduction. The reported mortality rate of epilepsy in Asia ranged from 2.5-5.1, but there was no published data in Malaysia. This study aimed to find out the mortality rate of patient with epilepsy in University Malaya Medical Centre (UMMC), a tertiary hospital in Malaysia. Methods. There were 2389 patients with epilepsy recruited retrospectively from 2009-2018 in this study. Fatal cases were identified from National Registry Department Malaysia. Age- specific and gender-specific Standardized Mortality Ratio (SMR) were calculated. Results. There were 175 deaths (7.33%). The all-cause overall SMR is 1.6 (CI 95% 1.4-1.8). The SMR in the younger age groups (15- 19, 20-29, 30-39 and 40-49) were higher than the older age groups. Overall SMR for male patients (1.8, CI 95% 1.5-2.2) was higher than female (1.3, CI 95% 1.0-1.6). However, in specific age groups (15-19, 20-29 and 30-39), the SMR in female was higher. Conclusion. The mortality rate of epilepsy in Malaysia is higher than the general population in Malaysia but lower than other Asian countries. Specifically, the rate is higher among the males and younger age group.

Background In epilepsy stigma, certain perceptions are culturally dependent and greatly influence a person’s attitudes. Hence, we aimed to explore the perceptions associated with attitudes toward epilepsy in various urban subpopulations. Method This is a mixed-method study employing the Public Attitude Toward Epilepsy (PATE) scale as the quantitative measure, followed by a semi-structured interview. The qualitative data were then counted and analyzed concurrently with the quantitative data. Result A total of 410 respondents (104 people with epilepsy [PWE]; 104 family members [FM]; 100 medical students [MS]; 102 public [Pb]) aged 37 years (IQR 23–55) were recruited. They were mostly female (57.3%), Chinese (52.0%), and highly educated (63.7%). The attitudes toward epilepsy among medical students are the best, followed by the PWE and their family members, and the worst among the public. The qualitative results revealed 4 main themes, which were “general social values”, “epilepsy severity and control”, “PWE’s abilities”, and “harms and burdens to the respondents and others”. A two-dimensional perception model was constructed based on these themes, which consisted of general-personal and universal-specific dimensions. Generally, the PWE/FM subgroup focused more on PWE’s abilities, whereas the MS/Pb subgroup more on general social values, and harms and burden. In the education aspect, most attitudes were related to the epilepsy severity and PWE’s abilities, whereas in employment, the main consideration was the PWE’s abilities. Burden to life and concern about inheritance were major considerations in the marital relationship. Those with positive attitudes tend to highlight the importance of general social values, while negative attitudes associated more with epilepsy severity. In general domain, general social values were the main considering factor but in personal domain, most participants will consider epilepsy severity and control, harms and burden to themselves. Conclusion The perceptions underlying attitudes toward epilepsy were complex and varied between subpopulations, attitude levels, domains, and aspects of life. (304 words)

Introduction Prevalence studies of epilepsy in Asia revealed a prevalence ranging from 1.5 to 14.0 per 1000 among Asian populations. However, the prevalence of epilepsy in Malaysia is not available for comparison with other countries. This study aimed to translate and validate a Malay brief screening instruments for ascertainment of epilepsy. Method We translated into Malay a brief screening instrument for ascertainment of epilepsy designed and validated by Ottman et al., using the three-stage cross-cultural adaptation process developed by the International Quality of Life Assessment (IQOLA) project. We then administered the translated questionnaire via online survey to 162 cases (patients with epilepsy under follow-up care at the neurology clinic in University of Malaya Medical Centre, Kuala Lumpur) and 146 controls with no known history of epilepsy for validation. Results Applying the most liberal definition for a positive screen, we obtained a sensitivity of 96.3% (95% confidence interval [CI]: 91.8–98.5%), with a specificity of 66.4% (95% CI: 58.1–73.0%) and positive predictive value (PPV) of 2.0%. The most stringent definition for a positive screen (only epilepsy) resulted in a sensitivity of 97.4% (95% CI: 62.0–72.6%), specificity of 98.6% (95% CI: 94.6–99.7%), and PPV of 26.6%. Narrowing the definition of a positive screen decreased sensitivity but improved PPVs. When compared to the original English questionnaire, the sensitivities were similar for all four definitions of a positive screen. Conclusion This is the first validated epilepsy screening questionnaire in the Malay language and represents a useful tool for the ascertainment of epilepsy in population-based studies.

Introduction Video-EEG monitoring is one of the key investigations in epilepsy pre-surgical evaluation but limited by cost. This study aimed to determine the efficacy and safety of a 48-hour (3-day) video EEG monitoring, with rapid pre-monitoring antiepileptic drugs withdrawal. Material and methods This is a retrospective study of epilepsy cases with VEM performed in University Malaya Medical Center (UMMC), Kuala Lumpur, from January 2012 till August 2016. Results A total of 137 cases were included. The mean age was 34.5 years old (range 15–62) and 76 (55.8 %) were male. On the first 24 -h of recording (D1), 81 cases (59.1 %) had seizure occurrence, and 109 (79.6 %) by day 2 (D2). One-hundred and nine VEMs (79.6 %) were diagnostic, in guiding surgical decision or further investigations. Of these, 21 had less than 2 seizures recorded in the first 48 h but were considered as diagnostic because of concordant interictal ± ictal activities, or a diagnosis such as psychogenic non-epileptic seizure was made. Twenty-eight patients had extension of VEM for another 24−48 h, and 11 developed seizures during the extension period. Extra-temporal lobe epilepsy and seizure frequency were significant predictors for diagnostic 48 -h VEM. Three patients developed complications, including status epilepticus required anaesthetic agents (1), seizure clusters (2) with postictal psychosis or dysphasia, and all recovered subsequently. Conclusions 48-h video EEG monitoring is cost-effective in resource limited setting.