Epilepsy in Southeast Asia, how much have we closed the management gap in past two decades?

@#The last review on epilepsy in Southeast Asian (SEA) countries was reported in 1997. This review aimed to update the understanding of epilepsy management in this region over the past 23 years. There has been significant increase in the epidemiological studies which reported a prevalence of 4.3-7.7 per 1,000 populations in this region. Reversible aetiologies of epilepsy such as head injury, birth trauma, cerebrovascular disease, and intracranial infections (neurocysticercosis or meningoencephalitis) are still prevalent, with a surge in autoimmune encephalitis. There was a surge in genetic studies which suggest ethnic variation. Treatment gap is still high especially in the rural and less developed areas, and the availability and affordability of newer anti-epileptic drugs (AEDs) is still a major challenge in SEA. Alternative medicine is a common practice but varies among different ethnic groups. AEDs hypersensitivity especially on the association between HLA-B*1502 and carbamazepine-related severe cutaneous reaction had been extensively studied and proven in nearly all SEA countries. However, HLA-B*1502 screening is not widely available in SEA and the cost-effectiveness of the screening is questionable. Stigma and its psychosocial consequences are still a major concern despite enormous efforts to study the public attitudes towards epilepsy and change of epilepsy naming in a few countries. The number and complexity of epilepsy surgery are progressing, but it is still under-utilized in many SEA countries, related to cost, cultural perception and lack of facilities. More resources should also be channelled in training adequate number of epileptologists who can spearhead epilepsy care around the region, as well as public education and research in epilepsy. In conclusion, there is an increase in epilepsy research in this region, gradual increase in trained neurologists and facilities, and efforts to reduce the knowledge and treatment gap, but the epilepsy management gap is still a battle to fight.

Delayed onset cerebral vasculitis from chronic Schistosoma mansoni infection in Myanmar: A case report

@#Neuroschistosomiasis is an infection of the central nervous system caused by Schistosoma species and constitute a severe manifestation of the disease. Schistosoma japonicum is well-known cause of cerebral schistosomiasis and Schistosoma mansoni for spinal schistosomiasis. Although neuroschistosomiasis is not rare, reports on cerebral vasculitis associated with Schistosoma mansoni infection is scarce. With regards to schistosomiasis in Asia, most of the published literature has been on Schistosoma japonicum and the prevalence of Schistosoma mansoni in Asia is not well established. We report here a 54-yearold Rakhine woman with history of diabetes mellitus for more than ten years presenting with three recurrent stroke occurring over 2 months, twelve months after returning to Yangon from Rakhine, an endemic area for Schistosoma mansoni infection. Cerebral MRA revealed beaded appearance along left ACA and segmental narrowing beyond terminal ICA both sides, and contrast enhancement was noted at left frontal lobe with restricted diffusion on MRI brain. Serum serology testing for Schistosoma mansoni infection was positive. With oral praziquantel and high dose corticosteroid, aphasia and swallowing improved. This is the first report of delayed onset cerebral vasculitis associated with chronic Schistosoma mansoni infection in Asia.

Complementary and alternative medicine for migraine and tension-type headache among the Malaysians

@#Background: The literature on complementary and alternative (CAM) therapies in South East Asia is limited. The objective of the study was to evaluate the frequencies of CAM therapies in the Malaysian patients with migraine and tension-type headache (TTH). We also assessed the reasons for CAM use. Methods: This was a cross-sectional study. The study was conducted in a tertiary hospital in Malaysia. Consecutive patients presenting with migraine and TTH to the neurology clinic were recruited. Demographic characteristics were documented. Data on CAM use, including frequency and the reasons was collected. Results: Six hundred and eighty five patients (365 TTH and 320 migraine) were recruited. They consisted of 305 (44.5%) Malay, 174 (25.4%) Chinese, 169 (24.7%) Indian and 37 (5.4%) patients from other ethnic groups. A total of 478 (69.8%) patients, comprising 266 (55.6%) patients with TTH and 212 (44.4%) patients with migraine used CAM therapies. The most commonly used CAM therapies were medicated oil (355 patients, 51.8%) and massage (246 patients, 35.9%). The most common reasons for CAM use were reduction of pain (47.7 %), stress reduction (34.9%), and “cooling” effect (27.4%). Thirteen (4.1%) patients with migraine practiced reflexology, whereas 5 (1.4%) patients with TTH practiced reflexology (p=0.032). Twenty three (7.2%) patients with migraine took vitamin supplements compared to 13 (3.6%) patients with TTH (p=0.039). On univariate analysis, CAM use was significantly associated with ethnic groups (p=0.014), gender (p<0.0001), age (p=0.004), salary (p=0.014), educational level (p=0.003), and headache subtypes (p= 0.067). On logistic regression, married women were more likely to use CAM (OR=1.864, 95% CI 1.216-2.858, p=0.004). Conclusion: A large number of Malaysian headache patients used CAM. The most common reasons were reduction of pain, stress and “heatiness”. Medicated oil was most commonly used, followed by massage. Married women were more likely to use CAM, and this was the only determinant in this study.

Cerebral venous thrombosis in multi-ethnic patients from Malaysia

@#Background & Objectives: The literature on cerebral venous thrombosis (CVT) in South East Asia is limited. The objectives were to evaluate the clinical profile, predisposing factors and clinical outcome of the CVT patients in Malaysia. Methods: We conducted a retrospective descriptive study of the CVT patients admitted to the neurology ward. The clinical presentation, predisposing factors, radiological findings, treatment and prognostic characteristics were evaluated from the charts. Clinical outcome on discharge and six months was measured by Modified Rankin Scale (mRS) scores. Poor outcome and good outcome was defined as Modified Rankin Scale (mRS) scores of 3-6 and 0-2 respectively. Results: Forty nine CVT patients who presented between 2007 and 2017 were recruited. The mean age was 43.51±16.52. The patients consisted of 39 Malaysians (13 Indians, 12 Malays, 12 Chinese, one Iban, one Eurasian descent), and ten non-Malaysians. Thirty (61.2%) patients were women. The most common presenting complaint was headache (75.5%). Six percent had multiple risk factors, whereas 51% had idiopathic CVT. The most common predisposing factors were oral contraceptive pill use (18.4%), followed by infection (12.2%), especially central nervous system (CNS) infection (6.1%); 11.8% had prothrombotic disorder. The most common location for CVT was superior sagittal sinus (83.7%). On neuroimaging, 77.6% had parenchymal lesions, 53.1% had venous infarcts and 38.8% had intracerebral haemorrhage, one patient had CVT complicated by rare venous collateral channels. Poor outcome on discharge and at six months was 38.8% and 33.3% respectively. On univariate analysis, female gender (p=0.002), seizures (p=0.037) and cerebral oedema (p=0.018) were associated with poor functional outcome. On binary logistic regression, female gender (OR=14.50, 95% CI 2.10-99.94,p=0.003) and seizures (OR=6.54, 95% CI 1.33-32.07, p=0.017) were associated with poor outcome. Conclusion: The CVT patients in this study had a higher proportion of CNS infections. Poor outcome was independently associated with female gender and seizures.

Epilepsy research output in Southeast Asian countries: A systematic review

@#Objective: Epilepsy is understudied in Southeast Asian (SEA) countries. This systematic review aimed to determine the number of epilepsy publications performed in SEA and identify factors associated with research output in this region. Methods: Existing academic journal article searches were performed using PubMed, Scopus, Medline and Web of Science till 1st March 2018. Openness is determined by the use of English in medical school and overseas epilepsy fellowship. Results: A total of 702 epilepsy articles have been published in the last 50 years in the SEA region, with an exponential increase of publications after the year 1997, with the cumulative number doubled every 5 years. Only half (54%) were published in the journals with impact factor (IF) ≥1. Majority of the publications (48.2%) employed cross sectional design, followed by animal or laboratory studies (21.1%), with few randomized controlled trials and systematic review/meta-analysis studies (1.7% and 2.3%, respectively). Half (52.9%) of the publications were clinical studies. The number of papers with IF≥1 correlated positively with openness to international standard (R=0.720, p<0.05), and knowledge-based economy (p=0.01). Conclusion: Epilepsy research output in SEA is low in quantity and quality. The output is mainly related to the type of economy (knowledge-based or non-knowledge-based) and openness to international ideas and standard.

Moyamoya disease in a young woman with intraand extracranial vessels involvement on vessel wall imaging

@#Moyamoya disease (MMD) was first described in 1957 as “bilateral hypoplasia of internal carotid arteries (ICAs)”.1 Aside from involving the intracranial arteries, MMD can also affect extracranial ICAs and external carotid arteries (ECAs).2-4 High resolution magnetic resonance (MR) vessel wall imaging (VWI) is increasingly being used to help with the diagnosis and characterization of the condition focusing mainly on intracranial vessels and extracranial ICAs.5-9 We present a case of a young woman with MMD, demonstrating vessel wall enhancement of nonstenotic maxillary branches of bilateral ECAs.

Epilepsy care: Work, upbringing, leisure, and Chinese culture

@#Stigma in epilepsy arises from the misconceptions and prejudices rooted in the patient’s culture and traditions. Upbringing also has an important impact on the quality of life of epilepsy patients. In Chinese tradition, the main purpose of life is to be a “gentleman” 君子, to fully express the true human nature. The essence of being a gentleman is “benevolence” and “virtue”. According to Zhuangzi’s concept of “virtue overcoming deformity” 德充符, virtue can prevail over physical deficiencies. Consistent with such a principle, a person with epilepsy should receive high honour if he can demonstrate the character of a “gentleman”. In - traditional Chinese culture, the sense of shame is the foundation of morality; “feeling shame” 知耻 and “being shameless” 无耻 are important moral concepts. A gentleman has a sense of shame, whereas a “petty person” 小人 is shameless. However, the ability to resist feeling inappropriate shame - “not feeling ashamed” 不耻 is also a trait of the gentleman. Thus, based on traditional Chinese philosophy, one should resist feeling ashamed for having epilepsy. Chinese culture emphasizes the importance of exerting vitality in the presence of adversity; people with epilepsy who do not feel ashamed of their deficiency is manifesting such a vitality. Traditional Chinese culture takes a positive attitude towards hardship and adversity, that it is essential for developing character and skills. Overcoming adversity requires responsibilities, the pre-requisite is personal freedom. Thus, allowing freedom and nurturing independence is consistent with traditional Chinese attitude to upbringing.

Non-bacterial thrombotic endocarditis: A rare manifestation of cervical adenocarcinoma

@#Non-bacterial thrombotic endocarditis (NBTE) denotes the presence of sterile non-infective vegetation on structurally normal, or subtly degenerate cardiac valves and is often associated with advanced malignancies. In gynaecological cancer in particular, NBTE has been most commonly associated with ovarian cancer.1,2 Here we report a rare but interesting case of NBTE in a patient with locally advanced cervical adenocarcinoma.

Tuberculous optochiasmatic arachnoiditis and optochiasmatic tuberculoma in Malaysia

@#Background & Objectives: Arachnoiditis which involves the optic chiasm and optic nervecan rarely occurs in the patients with tuberculous meningitis (TBM). The primary objective of this study was to determine the incidence, assess the clinical and neuroimaging findings, and associations, understand its pathogenesis of these patients, and determine its prognosis. Methods: The patients admitted with TBM in the neurology wards of two tertiary care hospitals from 2009 to 2017 in Kuala Lumpur, Malaysia were screened. The patients with OCA and optochiasmatic tuberculoma were included in this study. We assessed the clinical, cerebrospinal fluid (CSF), imaging findings of the study subjects and compared with other patients without OCA or optochiasmatic tuberculoma. Results: Eighty-eight patients with TBM were seen during the study period. Seven (8.0%) had OCA and one (1.1%) had optochiasmatic tuberculoma. Five out of seven (71.4%) patients with OCA were newly diagnosed cases of TBM. The other two (28.6%) had involvement while on treatment with antituberculous treatment (paradoxical manifestation). The mean age of the patients with OCA was 27.3 ± 11.7. All the OCA patients had leptomeningeal enhancement at other sites. All had hydrocephalus and cerebral infarcts on brain neuroimaging. Three (42.9%) patients had cerebral tuberculoma at sites other than suprasellar and optic chiasm areas. On univariate analysis, the presence of OCA and optochiasmatic tuberculoma was associated with raised CSF opening pressure (p=0.014), younger age (p=0.024), cerebral infarcts (p=0.018) and hydrocephalus (p= 0.046). There was no statistically significant association on logistic regression. Only one (14.3%) patient had visual impairment. Conclusion: OCA and optochiasmatic tuberculoma were seen in 9% of a cohort of Malaysian TBM patients. They were more likely to be younger, have raised CSF opening pressure, cerebral infarcts and hydrocephalus, suggesting the association with a more severe exudative disease.

Level 4 comprehensive epilepsy program in Malaysia, a resource-limited country

Background and Objective: There is a great challenge to establish a level 4 epilepsy care offeringcomplete evaluation for epilepsy surgery including invasive monitoring in a resource-limited country.This study aimed to report the setup of a level 4 comprehensive epilepsy program in Malaysia and theoutcome of epilepsy surgery over the past 4 years. Methods: This is a retrospective study analyzingcases with intractable epilepsy in a comprehensive epilepsy program in University Malaya MedicalCenter (UMMC), Kuala Lumpur, from January 2012 to August 2016. Results: A total of 92 caseshad comprehensive epilepsy evaluation from January 2012 till August 2016. The mean age was 35.57years old (range 15-59) and 54 (58.7%) were male. There were 17 cases having epilepsy surgeryafter stage-1 evaluation. Eleven cases had mesial temporal sclerosis and 81% achieved Engel classI surgical outcome. Six cases had lesionectomy and 60% had Engel class I outcome. A total of 16surgeries were performed after stage-2 evaluation, including invasive EEG monitoring in 9 cases.Among those with surgery performed more than 12 months from the time of data collection, 5/10(50%) achieved Engel I outcome, whereas 2 (20%) had worthwhile improvement (Engel class III)with 75% and 90% seizure reduction.Conclusion: Level 4 epilepsy care has an important role and is possible with joint multidisciplinaryeffort in a middle-income country like Malaysia despite resource limitation.

Spinal tuberculous disease is common in tuberculous meningitis

Background: Tuberculous disease of spine (spinal TB) is under-recognized in tuberculous (TB) meningitis.The objective of the study was to evaluate the frequency, clinical and neuroimaging changes, andoutcome in the patients with spinal TB. Methods: All the patients with spinal TB admitted in the twolargest tertiary hospitals in Kuala Lumpur from 2009 to 2017 were recruited, the clinical features weredocumented, the magnetic resonance imaging (MRI) of the spine was performed. Clinical outcome wasassessed with Modified Rankin scale (MRS). Results: Twenty two patients were recruited. This wasout of 70 TB meningitis patients (31.4%) seen over the same period. Eighteen (81.8%) patients hadconcomitant TB meningitis. The clinical features consisted of systemic symptoms with fever (63.6%),meningitis symptoms with altered sensorium (45.5%), myelopathy with paraparesis (36.4%). Thefindings on spinal MRI were discitis (36.4%), spinal meningeal enhancement (31.8%), spinal cordcompression (31.8%), psoas abscess (27.3%), osteomyelitis (22.7%), and cord oedema (22.7%). Allexcept two patients (90.9%) had involvement in psoas muscle, bone or leptomeningeal enhancement,features that can be used to differentiate from myelopathy that affect the parenchyma only, such asdemyelination. Unusual manifestations were syringomyelia and paradoxical manifestations seen in 3patients each. The outcome were overall poor, with 68% having MRS 3 or more.Conclusion: Spinal TB is common in TB meningitis. The outcome is overall poor. A heightenedawareness is crucial to enable early diagnosis and treatment.

Role of cytokines in the assessment of clinical outcome and neuroimaging findings in patients with tuberculous meningitis

Background: Tuberculous meningitis is a life-threatening manifestation resulting from infection by Mycobacterium tuberculosis, especially in the developing countries. The molecular aspects of pathogenesis of tuberculous meningitis remain poorly understood. We evaluated the correlation of cerebrospinal fluid (CSF) and serum cytokine levels with the clinical outcome of 15 HIV-negative patients with tuberculous meningitis. We also assessed the association of CSF and serum cytokines with neuroimaging of brain findings in the patients. Methods: The prospective longitudinal study was conducted at the University Malaya Medical Centre between 2012 and 2014. Neuroimaging of the brain was performed and the findings of leptomeningeal enhancement, hydrocephalus, tuberculoma, infarcts and vasculopathy were recorded. The CSF and serum specimens were analyzed for IL-1ß, IL-8, IL-10, IL-18, IP-10, IFN-γ, MCP-1, TGF-ß, VEGF, TNF- α, IL-18BPa and MMP-9. The clinical outcome was graded at 3 months based on Modified Rankin scale (mRS). Results: On admission and at one month of anti-tuberculosis treatment, the CSF levels of IL-8, IL-1β, IP-10, IFN-γ and VEGF were elevated in all of the patients. Serum IP-10, MCP-1, IL-1β and IL-8 levels were increased on admission and at one month of anti-tuberculosis treatment. There were statistically significant differences between good and poor outcome (mRS at 3 months) for CSF IFN-γ (p=0.033), CSF IL-10 (p=0.033) and serum VEGF (p=0.033) at one month of treatment. None of the patients showed any association between CSF and serum cytokines on admission and at one month of anti-tuberculosis treatment with neuro-radiological findings. Conclusion: The CSF cytokine levels were not related to TBM disease severity on admission, and changes on MRI/CT scans. CSF levels of IFN-γ and IL-10 at one month of anti-tuberculosis treatment were associated with clinical outcome at 3 months. CSF cytokine levels on admission were not associated with the clinical outcome.

HLA-B*1502 and carbamazepine induced StevensJohnson syndrome/toxic epidermal necrolysis in Indonesia

Background & Objective: Association between HLA-B*1502 and carbamazepine-induced StevenJohnson syndrome/toxic epidermal necrolysis (CBZ-SJS/TEN) was reported in many Southeast Asian populations but not in Indonesian. The purpose of this study was to evaluate the association between HLA-B*1502 andCBZ-SJS/TEN in an Indonesian population. Methods: Patients with history of CBZ-SJS/TEN are recruited as cases and those who tolerated CBZ as controls. HLA-B typing was performed. Results: We recruited 14 cases with CBZ-SJS/TEN and 53 controls. Positive HLA-B*1502 was found in 8 (57.1%) cases and 14 (26.4%) controls (OR 3.7, 95% CI 1.09-12.61, p=0.035). Conclusion: HLA-B*1502 is associated with CBZ-SJS/TEN patients in Indonesian.

Neurological melioidosis in East Malaysia: Case series and review of the literature

Melioidosis is an infectious disease caused by an aerobic, non-spore forming gram negative bacillus, Burkholderia pseudomallei. It is known to be of high incidence in parts of rural South East Asia, and in Northern Australia. Pneumonia is the commonest manifestation. We report here three cases of neurological melioidosis from the registry of 169 cases of melioidosis in Bintulu Hospital, Sarawak, East Malaysia, with a review of neurological melioidosis in the literature. The annual incidence of melioidosis is estimated to be 8 per 100,000 populations in the Bintulu district. Neurological melioidosis accounts for 1.8% of our melioidosis cases. A review of 76 cases of neurological melioidosis reported in the literature inclusive of our 3 cases shows that localized brain or spinal inflammation or abscess is the most common manifestation occurring in 80% of patients. Close to half (53%) have intra axial abscess (brain or spinal cord), a quarter (27%) have extra axial lesions only (epidural or subdural collection, osteomyelitis or scalp abscess), and another quarter (27%) have both intra and extra axial lesions. Thus, B. pseudomallei appears to be unique among the bacterial central nervous system infection to be able to affect the brain and its contiguous tissues, crossing the tissue plane particularly resulting in osteomyelitis, scalp abscess and vice versa. Two thirds of the neurologicalmelioidosis patients have only neurological disease with no evidence of disease elsewhere. Key words: Burkholderia pseudomallei; neurological melioidosis; Bintulu; Sarawak; Malaysia

Neuroimaging findings are sensitive and specific in diagnosis of tuberculous meningitis

Objective: The primary objective of this study was to describe the neuroimaging changes of tuberculous meningitis (TBM), and to determine the role of neuroimaging in the diagnosis of TBM. Methods: Between January 2009 and July 2015, we prospectively recruited TBM patients in two hospitals in Malaysia. Neuroimaging was performed and findings were recorded. The control consists of other types of meningo-encephalitis seen over the same period. Results: Fifty four TBM patients were recruited. Leptomeningeal enhancement was seen in 39 (72.2%) patients, commonly at prepontine cistern and interpeduncular fossa. Hydrocephalus was observed in 38 (70.4%) patients, 25 (46.3%) patients had moderate and severe hydrocephalus. Thirty four patients (63.0%) had cerebral infarction. Tuberculoma were seen in 29 (53.7%) patients; 27 (50.0%) patients had classical tuberculoma, 2 (3.7%) patients had “other” type of tuberculoma, 18 (33.3%) patients had ≥5 tuberculoma, and 11 (20.4%) patients had < 5 tuberculoma. Fifteen (37.2%) patients had vasculitis, 6 (11.1%) patients had vasospasm. Close to nine tenth (88.9%) of the patients had ≥1 classical neuroimaging features, 77.8% had ≥ 2 classical imaging features of TBM (basal enhancement, hydrocephalus, basal ganglia / thalamic infarct, classical tuberculoma, and vasculitis/vasospasm). Only 4% with other types of meningitis/encephalitis had ≥1 feature, and 1% had two or more classical TBM neuroimaging features. The sensitivity of the imaging features of the imaging features for diagnosis of TBM was 88.9% and the specificity was 95.6%. Conclusion: The classic imaging features of basal enhancement, hydrocephalus, basal ganglia/thalamic infarct, classic tuberculoma, and vasculitis are sensitive and specific to diagnosis of TBM.

Bilateral thalamic internal medullary lamina involvement in a case of dengue encephalitis

There are 50-100 million dengue infections each year, but dengue encephalitis is relatively uncommon. The aetiology of neuronal injury is proposed to be due to direct viral neurotropism or host immune response-mediated inflammation causing neuronal damage. We report a case of severe dengue encephalitis, presenting during the acute viraemic phase of the disease. This was associated with inflammation and haemorrhage of the internal medullary lamina of both thalami which, to our knowledge, has not yet been reported in other infections of the central nervous system.

Sarcocystis nesbitti related autoimmune diffuse alopecia

Background & Objective: Symptomatic sarcocystosis has been said to be rare until recent years, when there were reports of outbreaks of febrile myositis for travellers returning from the Malaysian island resorts. In 2012, an outbreak of Sarcocystis nesbitti infection involving 92 college students and staff occurred after returning from Pangkor Island, Malaysia. A few months after recovering from the febrile illness, some patients complained of hair loss. This study aimed to determine the prevalence, clinical features and outcome of this disorder. Methods: All patients who became sick in the outbreak were asked whether they had the hair loss. For those who had, they were interviewed with standard questionnaires, examined and investigated. Patients were followed-up via an online survey 2 years later. Results: Out of 89 patients who were ill, 19 patients (21.4%) complained of alopecia. The mean peak onset was 4 months after the initial illness. Eleven patients (57.9%) reported the hair fall of more than 100 per day. The other symptoms were itch 10 (52.6%), scaling 10 (52.6%), erythema 4 (21.1%), none had scarring. Eleven patients (57.8%) had positive antinuclear factor with high titre (speckled or nucleolar pattern). Two years after the event, 10 had complete or near complete spontaneous recovery, 1 had partial response and 1 had no improvement. Conclusions: A delayed transient diffuse alopecia is seen in close to half of patients with Sarcocystis nesbittiinfection. This high frequency of positive ANF suggested an immune-mediated mechanism.

Efficacy of repetitive transcranial magnetic stimulation on refractory epilepsy in Malaysia

Background & Objective: Modulation of cortical excitability by low frequency repetitive transcranial magnetic stimulation (rTMS) has demonstrated therapeutic use in epilepsy. This study aimed to evaluate the efficacy of low-frequency rTMS on refractory epilepsy in a group of Malaysian subjects. Methods: Nine patients with refractory epilepsy completed the study. All patients received 10 sessions of 1Hz rTMS (1000 pulses per session) at 90% of resting motor threshold. Outcome measures included seizure frequency, Symptom Checklist-90 (SCL-90), Beck Depression Inventory II (BDI II) and Quality of Life in Epilepsy-31 (QOLIE-31). Responders were defined as having ≥ 50% seizure reduction. Results: The mean age was 33.8 years (SD 11.7), with 4 male. Three patients had mesial temporal sclerosis (MTS); 4 with focal cortical dysplasia (FCD) and two lesion-negative. Three patients achieved >50% seizure reduction at 8 weeks post-treatment, with 2 of them had improvement in the number of IED. All of the responders had FCD. The responders were younger (mean 24.7 vs. 38.3 years old), had shorter duration of illness (mean 15.7 vs. 30.5 years) and had less frequent seizure frequency prior to treatment (mean 5.5 vs. 10.8 attacks per week), as compared to the non-responders. Six patients had improvement in BDI-II scores, two in QOLIE-31 and four in SCL-90 post treatment, irrespective of seizure control. The mean scores in BDI-II improved significantly with treatment (p<0.01). Conclusion: rTMS is a potentially promising treatment for epilepsy, esp

Spontaneous remission without progression to limbic encephalitis in a patient with LGi1 seropositive faciobrachial dystonic seizure

Faciobrachial dystonic seizures are pathognomonic of leucine-rich glioma inactivated-1 (LGi1) antibody, non-paraneoplastic limbic encephalitis. Faciobrachial dystonic seizures usually precede limbic encephalitis by about a month. It is unknown whether, if untreated, faciobrachial dystonic seizures inevitably progress to limbic encephalitis. We present an LGi1 seropositive patient with a year’s history of faciobrachial dystonic seizures, who achieved remission spontaneously without immunotherapy or antiepileptic drug treatment, and did not develop evidence of limbic encephalitis over a three-year follow-up.

EEG is sensitive in early diagnosis of anti NMDAR encephalitis and useful in monitoring disease progress

Background& Objective: Investigation modalities, such as MRI and CSF examination, are neither sensitive nor specific in the early phase of anti-NMDAR encephalitis. Nuclear imaging may be useful to monitor the response to treatment but limited by the availability.We aimed to determine the role of EEG as a tool for early diagnosis as well as a tool to assess disease progression and response to treatment. Methods: A total of 99 EEGsdone in 16 patients diagnosed with anti-NMDAR encephalitis throughout the course of illness, were reviewed retrospectively. The EEG changes were correlated with the clinical presentations and response to treatment. Sixteen EEGs of patients with schizophrenia and mood disorder, and 10 EEGs of patients with infective encephalitis were included as control. Results: EEGs performed during the psychiatric and cognitive dysfunctionphase in patient with anti-NMDAR encephalitis, showed diffuse background slowing in the delta-theta range in all the patients. Serial EEGs showed that the dominant background frequency improved with improvement in cognitive status. Nine patients had complete recovery with normalisation of the EEG abnormalities. Eight patients had their typical clinical seizure recorded during EEG monitoring, but only 2 (25.0%) with EEG correlation. Ten patients had status epilepticus (62.5%), 5 had EEG recorded during their status epilepticus, of which only one with EEG correlation (20.0%). Eleven patients had asymmetric background (68.8%), but only 1 has correlation with focal changes in the MRI brain (9.1%). Even though the EEGs of patients with infective encephalitis also showed background slowing, their CSF analysis was supportive of an infective cause. EEGs of patients with established psychiatric disorder were within normal limits. Conclusion: EEG abnormality has a good correlation with the degree of psychiatric and cognitive dysfunction in patient with anti-NMDAR encephalitis, and is useful in early diagnosis, monitoring the progress and the response to treatment. However, it has poor correlation with clinical seizures.