1.Sports and safety in epilepsy
Neurology Asia 2010;15(Supplement 1):25-27
Sport is important not only in normal healthy populations, but also in persons with medical illness,
physical or mental disabilities. Active participation in sports is benefi cial physically and psychologically.
The main concern in sports for persons with epilepsy is safety. This results in sedentary lifestyles, overprotective
attitudes of caregivers and friends. Despite the benefi ts of sports, with the various reassuring
studies showing non-signifi cant impact of sports in seizures frequency, physiological changes, EEG,
and physical injury, people with epilepsy continue to be less active in sports. This is related to various
barriers in sports include epilepsy-specifi c fear, personal barriers, social barrier. Understanding and
overcoming these barriers is the key in promoting sports among people with epilepsy.
2.Epilepsy stigma in Asia: the meaning and impact of stigma
Kheng-Seang Lim ; Chong-Tin Tan
Neurology Asia 2014;19(1):1-10
Stigma is conceptually broad and culturally variable. Understanding stigma from the conceptual
theories, culturally application based on the word stigma in other languages, the definition of stigma
and its synonyms, as well as the medical implications in other stigmatized disease such as AIDS,
will help us to understand the complexity of stigma in epilepsy. This review investigated the meaning
and types of stigma from different perspectives, leading to staging stigma into 5 levels, i.e. social
identity, stereotype, prejudice, discrimination and social disability. In addition to the conventional
categorization of stigma into social, felt, self-perceived or internalized stigma, new categories of
stigma i.e. personal and general attitudes towards epilepsy based on a newly developed Public
Attitudes Toward Epilepsy (PATE) scale was introduced. Courtesy stigma was further elaborated in
related to Asian culture. Based on well-established and recently developed theories, the causation and
impact of epilepsy stigma was discussed in an Asian context, especially from the aspects of language
and society values which are culturally specific. Integrating these theories of causation, illness and
stereotype perceptions were proposed to be the mediating mechanism of stigma, which led to the
development of a practical and multi-dimensional stigmatization model, aiming to guide, widen and
deepen the scope of future stigma research in epilepsy. Using the established model, together with
review of related studies, research priorities in epilepsy stigma research especially in Asia focusing on
five aspects, i.e. expanding population studies especially on significant others, understanding stigma
from personal attitude perspective, investigating the cultural and social causation of stigma, and the
impacts of stigma on patients as well as the family members, were proposed.
3.Attitudes toward epilepsy, a systematic review
Kheng Seang Lim ; Chin Hwan Lim ; Chong Tin Tan
Neurology Asia 2011;16(4):269-280
Surveys about attitudes towards those with epilepsy have been performed since 1949, in order to
understand the social stigma toward epilepsy. This review aims to demonstrate the variation in public
attitudes towards epilepsy and its associated factors, with a critical review of the methodology used
to examine attitudes towards epilepsy. There was marked variation of attitudes between Western and
non-Western populations, and these attitudes were positively correlated with the standard of living.
Besides the general public, studies were also performed within specifi c groups, particularly teachers
and students. However absence of a standardized questionnaire makes direct comparison diffi cult. A
few quantitative methods were developed but these were limited by cultural variations and thus lack
of global acceptance. Short-term intervention studies demonstrate an improvement of attitude with
knowledge. Nonetheless, the cultural and social reasons underlying the attitudes, and how this affects
the life of people with epilepsy, are understudied. Therefore, surveys on attitudes should continue to be
carried out, particularly in populations prone to have negative attitudes with emphasis on underlying
reasons, and such progress should be monitored longitudinally. Attitudes of people such as parents,
teachers, school counselors, health care professionals, and employers, which have a direct impact on
people with epilepsy, should be more extensively studied.
4.Variability of plantar response in normal population
Ri An Lee ; Li Lian Tay ; Kheng Seang Lim ; CT Tan
Neurology Asia 2011;16(2):143-147
Background: There is lack of normality data in the literature on the plantar response. Objective: To
determine the variability of plantar response in normal population and factors that might contribute to
the variability. Methods: We conducted a study of plantar response in healthy subjects aged 19-21 in
two phases. First phase was plantar examination with hard strike. Subjects with big toe extension in
the fi rst phase were re-examined with light and hard strike in the second phase. Results: 100 subjects
recruited in fi rst phase, 19 subjects in second phase. Out of 600 attempts (3 attempts for each foot) with
hard strike, responses of the big toe were fl exion (48.3%), extension (11.3%), no movement (39.8%);
other toes were fl exion (55.0%), extension (13.0%), no movement (32.0%); ankle was dorsifl exion
(30.8%), no movement (59.3%); knee were fl exion (15.7%), no movement (84.3%); hip were fl exion
(15.2%), no movement (84.8%). Of those with big toe extension, signifi cantly less had persistent big
toe extension with light strike. More (41%) among those with extensor big toe has withdrawal response
(with fl exion of the hip and knee) as compared to those with fl exor big toe (18.5%, p<0.05). Interfoot
asymmetry was seen in 27% (kappa 0.54). Plantar responses of sequential strikes were mostly
consistent, with only 3.5% inter-attempt variability.
Conclusion: Plantar response with extensor great toe is seen in about 10% of normal adults, less with
lighter strike. Withdrawal response can be a partial explanation to the big toe extensor response in
normal adults.
5.Association of HLA-B*1502 allele and carbamazepine induced severe adverse cutaneous drug reaction among Asians, a review
Kheng Seang Lim ; Patrick Kwan ; Chong Tin Tan
Neurology Asia 2008;13(1):15-21
Strong association between HLA B*1502 and carbamazepine-induced Steven-Johnson syndrome (SJS)
and toxic epidermal necrolysis (TEN) was demonstrated among Han Chinese in 2004. Studies from
Europe showed that the HLA B*1502 is not a universal marker for SJS/TEN, but is ethnicity specific
for Asians. Reports across Asia has shown that the prevalence of HLA B*1502 is high among Han
Chinese (5-15%), Malays (12-15%), and Thais (8-27%), but low among Japan, Korea, Sri Lanka,
and most ethnic groups in India. Other than Han Chinese, the association between HLA B*1502 and
carbamazepine-induced SJS-TEN is also seen among the Thais and Malay. There is urgent need for
further studies to determine the prevalence of SJS/TEN, and HLA B*1502 in the various ethnic groups
in Asia, and its association with carbamazepine-induced SJS-TEN in each of these ethnic groups. In
view of the significant morbidity and mortality in SJS-TEN, facilities should be developed to allow
for screening of HLA B*1502 before carbamazepine is prescribed to the Hans Chinese, Malays and
Thais. For those who experience no adverse cutaneous reaction after 3 months use of carbamazepine,
the risk of SJS/TEN is low, and the drugs can be continued.
6.Traumatic vertebral artery dissection mimicking central pontine myelinolysis: A case report
Jaishree Sharmini ; Kheng-Seang Lim ; Norlisah Ramli ; Chong-Tin Tan
Neurology Asia 2010;15(2):167-171
A 27 year-old Chinese man, involved in a motor vehicle accident, presented with rapidly progressive
pseudobulbar palsy and spastic tetraplegia. Magnetic resonance imaging (MRI) of the brain showed central
pontine T2 hyperintensity with an unaffected outer rim, consistent with central pontine myelinolysis.
There was no hyponatraemia before MRI and he was neither an alcoholic nor malnourished. Cerebral
angiogram confi rmed the diagnosis of right vertebral artery dissection. Vertebral artery dissection
should be considered in a case with imaging suggestive of central pontine myelinolysis.
7.Anti N-Methyl-D-Aspartate receptor encephalitis: An under-recognised cause of encephalitis
Giri Shan Rajahram ; Reena Nadarajah ; Lim Kheng Seang ; Jayaram Menon
The Medical Journal of Malaysia 2015;70(6):363-364
Anti-N-Methyl-D-Aspartate receptor (NMDAR) encephalitis is
an immune mediated condition with characteristic clinical
presentation. We report the first case from Borneo, Sabah
and the use of electroconvulsive therapy (ECT) in treating
recalcitrant psychiatrist symptoms associated with this
condition.
8.Spontaneous remission without progression to limbic encephalitis in a patient with LGi1 seropositive faciobrachial dystonic seizure
Sherrini Bazir Ahmad ; Suhailah Abdullah ; Chong Tin Tan ; Kheng Seang Lim ; Khean Jin Goh
Neurology Asia 2016;21(2):191-193
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.
Limbic Encephalitis
9.EEG is sensitive in early diagnosis of anti NMDAR encephalitis and useful in monitoring disease progress
Suhailah Abdullah ; Kheng Seang Lim ; Won Fen Wong ; Hui Jan Tan ; Chong Tin Tan
Neurology Asia 2015;20(2):167-175
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.
Electroencephalography
10.Only certain aspects of knowledge have impact on attitudes toward epilepsy
Kheng Seang Lim ; Monica Chen Mun Wo ; Sherrini Ahmad Bazir Ahmad ; Chong Tin Tan
Neurology Asia 2013;18(4):361-368
Introduction: None of the identified studies employed quantitative scales correlating the knowledge and
attitudes toward epilepsy. Method: This study aimed to study the relationship between the knowledge
and attitudes toward epilepsy, using the Epilepsy Knowledge Questionnaire (EKQ) and the Public
Attitudes Toward Epilepsy (PATE) scale. Results: A total of 279 publics with a mean age of 36.6±14.7
years (ranged from 15-77 years), 50.8% female with majority (63.0%) Chinese, and 49.5% with
tertiary education level, were recruited. The mean score of epilepsy knowledge questionnaire (EKQ)
was 21.05±3.92 (95% CI: 20.57-21.48). Higher score in EKQ was associated with higher education
level (p<0.01). The total score in the EKQ correlated negatively with the mean scores in the PATE
scale, as well as the mean scores in both the personal domain and general domains in the PATE scale
(p<0.05). Only 8 out of 34 items in EKQ were associated significantly with the mean scores in the
personal domain, and 4 other items were with the general domain of the PATE scale.
Conclusion: This study showed that although the overall knowledge in epilepsy is significantly associated
with better attitudes toward epilepsy, only certain aspects of knowledge in the scale contributed to
this association.