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.

Background & Objective: We knew that 63.6% of the epilepsy population can be seizure free with the use of anti-epileptic drugs (AED), but are unsure how many more with epilepsy surgeries. We aimed to determine the additional remission rate achieved with epilepsy surgeries in addition to AED. Methods: We analysed the seizure outcome among epilepsy patients seen retrospectively over oneyear period in University Malaya Medical Centre, Malaysia, which provides all levels (level 1-4) of epilepsy cares, in response to anti-epileptic drug (AED) and epilepsy surgeries. The seizure outcome was categorised into remission and drug-resistant, according to ILAE definition of drug resistance. Results: There were 909 patients seen during the study period, majority with focal epilepsy (63.3%), and Chinese (37.4%). Of those, 409 (45.0%) were in seizure remission, 238 (26.2%) had drug-resistant epilepsy and 262 (28.8%) uncertain. Only the remission and drug-resistant groups (N=647) were included in subsequent analysis. The mean age of onset in drug-resistant group was 14.8±12.3 years old, which was significantly younger than the remission group (20.8±16.8, p<0.05). There were 40 (54.8%) patients who underwent resective epilepsy surgeries (10 were lesion-negative cases). The seizure freedom rate with epilepsy surgery was 60.0% (n=24). Overall, a total of 59.5% of patients were in seizure remission with AED, with an additional 3.7% with epilepsy surgery. Conclusion: There were 3.7% of epilepsy patients achieved seizure remission with epilepsy surgeries in a general epilepsy cohort in addition to AEDs.

Takayasu arteritis is a rare granulomatous vasculitis that is commonly classified as a large vessel disease. Small and medium vessel involvement are extremely rare, with only a few case reports describing neurovascular, ocular and cutaneous involvement. We describe a 21 year old Malaysian woman with pre-existing Takayasu arteritis confined to the large vessels, presenting one year later to our centre with status epilepticus. Extensive radiologic studies revealed diffuse encephalopathic changes and multifocal neurovascular involvement, with the vasculitis progressing to encompass the large, medium and small vessels. The patient was treated with high dose steroid therapy and discharged well with long term steroid and immunosuppressive therapy. Follow up MRI with vessel wall imaging sequence (VW-MR) and arterial spin labelling (ASL) perfusion imaging demonstrated intra and extracranial vessel wall inflammation, with generalized reduction in left sided cerebral blood flow. This case demonstrates that Takayasu arteritis is not exclusively a large vessel vasculitis, and that small and medium vessel involvement does not preclude its diagnosis.

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.

Phenytoin is a widely prescribed antiepileptic agent for both focal and generalized seizure. We report a case of a 20-year-old man with focal epilepsy presented with acute bilateral visual loss, and delirium. His random phenytoin serum concentration on admission was 43.6 mg/L, well above the recommended therapeutic range of 10-20 mg/L. Extensive investigations have ruled out other vascular or demyelinating causes. His visual symptoms completely resolved after discontinuing phenytoin for 84 hours. This case shows that acute phenytoin toxicity can result in reversible visual failure.

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.

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.

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

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
Transcranial Magnetic Stimulation ; Epilepsy

Objective: To determine the validity and reliability of the Chinese parent proxy and child self-report health related quality of life measure for children with epilepsy (CHEQOL-25) in Malaysia. Methods: Face and content validity of the Chinese parent proxy and child self-report CHEQOL-25 was verified by an expert panel, and piloted in five children with epilepsy (CWE). The Chinese CHEQOL-25 was then administered to 40 parent proxies and their CWE (aged 8-18 years), from two tertiary hospitals, at baseline and 2 weeks later. Results: Forty parents and their CWE were recruited. Cronbach’s alpha for each subscale ranged from 0.56-0.83. At test-retest, the interclass correlation for all items ranged from 0.68-0.97. Items 8 and 25 were removed as their corrected item-total correlation values were <0.3. Epilepsy severity, the number of anti-epileptic drugs taken daily, number of close friends and number of time spent with friends were found to be associated with the parent proxy CHEQOL-25 score. Duration of epilepsy, child’s cognitive ability, number of close friends and number of time spent with friends were associated with child self-report CHEQOL-25. The parent proxy and the child selfreport showed high to fair agreement on the “interpersonal/social” [Intraclass correlation coefficient (ICC)=0.670, p<0.001] and “epilepsy secrecy” subscale (ICC=0.417, p=0.048). Conclusions: Our small study found that the Chinese CHEQOL-25 was a valid and reliable questionnaire to assess the quality of life of children with epilepsy from the parent prospective and child self-report when items 8 and 25 were removed.
Epilepsy