There is a great challenge to establish a level 4 epilepsy care offering complete 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 the outcome of epilepsy surgery over the past 4 years. It provides a concrete example of how higher level of epilepsy care can be established in a middle-income Asian country.

The 4 levels of epilepsy care was proposed by the Board of the National Association of Epilepsy Centers and revised in 2010. First level of epilepsy care occurs at emergency department or primary care clinic. It then proceeds to the second level of epilepsy care, which is a consultation with a general neurologist or possibly an epileptologist in a specialized epilepsy center. Level 3 and 4 centers provide interdisciplinary and comprehensive approach to the diagnosis and treatment of patients especially with intractable epilepsy. A level 3 center offers noninvasive evaluation for epilepsy surgery, whereas a level 4 center offers complete evaluation for epilepsy surgery including invasive monitoring and provides a broad range of surgical procedures for epilepsy.

In Malaysia, a middle-income Asian county with a GDP per capita of USD 10,538, there are three key challenges in setting up a level 4 epilepsy care service in a middle-income county. Level 4 care requires specific investigation modalities, e.g. single-photon emission computed tomography (SPECT) and positron emission tomography (PET). In addition, personnel specialized in implanting invasive EEG electrodes and interpreting the results are lacking. The last challenge is the high cost of performing these advanced investigations and procedures.

These challenges can be overcome with joint effort and perseverance. With advancements in neuroimaging and the presence of a multidisciplinary team, a total of 16 surgeries were performed after stage 2 evaluation, with a 50% Engel class I outcome and 20% achieved worthwhile improvement.

In conclusion, level 4 epilepsy care has an important role and is possible with joint multidisciplinary effort in a middle-income country like Malaysia despite resource limitation. The more expensive and invasive monitoring, though available and useful, should be limited to patients who definitely require it. This patient selection can be achieved by careful assessment and joint discussion in the MDT.

 

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