Abstracts

Rationale: Epilepsy surgery is an important treatment option for drug-resistant epilepsy that has been proven to reduce seizures and improve patients’ quality of life, but is often underutilized in clinical settings. Jette et al. (2012) identified substantial knowledge gaps regarding epilepsy surgery referrals through a national survey of Canadian neurologists and developed the Canadian Appropriateness of Epilepsy Surgery (CASES) online tool to combat this barrier to epilepsy surgery. Our objective was to apply the CASES tool to a cohort in the lower middle-income Himalayan country of Bhutan where there are no neurologists. We quantify the potential impact of the surgical treatment gap in a lower income setting and suggest ways to refine the algorithm for the resource-dependent challenges prominent in such settings. Methods: Study participants ages 12 years and above who had epilepsy for ≥1 year were identified through the Jigme Dorji Wangchuck National Referral Hospital’s registry. Data were collected on seizure characteristics, medical history, and use of antiepileptic drugs. Each participant underwent at least one 30-minute xltek EEG by a U.S.-certified technician and a 1.5 Tesla brain MRI. EEGs and MRIs were interpreted by North American-based neurologists.Each patient’s data was entered into the online appropriateness tool for epilepsy surgery (toolsforepilepsy.com). The eight variables required by the CASES algorithm were operationalized using carefully-chosen survey questions. Results: There were 179 eligible patients after excluding 48 children <12 years old, 10 adults for having epilepsy <1 year, and 31 adults with incomplete brain MRI data. The 179 patients were stratified into two groups: those who tried more than 1 AED and those who tried 1 or none. This division was chosen as the CASES algorithm overwhelmingly designates patients who have taken ≤1 AED as low surgery priorities regardless of other variables. From the >1 AED cohort (n=68), 64.7% (n=44) were designated by the tool as definite surgery referrals, 13.2% (n=9) were strongly recommended for referral, and 22.1% (n=15) were deemed inappropriate for referral. For the ≤1 AED cohort (n=111), 0.9% (n=1) were definite referrals, 6.3% (n=7) were strong recommendations, and 92.8% (n=103) were deemed inappropriate. In total, combining both groups revealed 25.1% (n=45) definite referrals, 8.9% (n=16) strong recommendations, and 65.9% (n=118) inappropriate for referral. Of all participants classified as definite referrals, 77.8% (n=35) would be considered “very high” priority and 22.2% (n=10) were “high” priorities, with no “moderate” priorities. Conclusions: A significant proportion of Bhutanese people with epilepsy experience missed opportunities for epilepsy surgery referrals. Initiatives to improve pathways and tools for epilepsy surgery referrals for non-neurologist specialists could be valuable, potentially through collaboration with international partners. Presently a referral pattern to India exists but is infrequent and no surgeries have been performed. We also identify modifications to the CASES algorithm that could improve its validity in lower income settings. The tool should account for AED availability and price barriers by providing informative projections simulating the patient’s ability to use multiple AEDs. We demonstrate the utility of CASES in this neurocysticercosis-endemic setting and suggest active implementation of a modified CASES tool and initiatives to improve epilepsy surgery access in other similar lower income countries.Jette N, Quan H, Tellez-Zenteno JF, et al. Development of an online tool to determine appropriateness for an epilepsy surgery evaluation. Neurology. 2012 Sep 11; 79(11): 1084-93. Funding: No funding