P. Joseph Cherian and Kurupath Radhakrishnan
"Careful history taking and interpreting, and minute and repeated clinical examinations are time consuming. It is particularly the busy physician who is inclined to delegate the diagnosis to the laboratory in the vain hope of saving time. Laboratory procedures often seem necessary because the clinical examination has not been adequate. They are all too often superfluous, and a thorough clinical examination would have provided grounds for correct management of the patient. The more clinical neurology we know, the less need there is for laboratory procedures and more valuable these procedures become when they are necessary."
Robert Wartenberg, 1953
Epilepsy is a major health problem worldwide with a prevalence rate of ~5 per 1000.1 Developing countries carry more than 90% of epilepsy burden.2 Most studies from developing countries have reported high prevalence rates.3,4 However, some of the recent community-based surveys from India have shown prevalence rates similar to that of developed countries.5,6 The high prevalence of epilepsy in developing countries is attributed to some of the geographically specific etiological factors such as neurocysticercosis,7 other infections of central nervous system (CNS), and hot water epilepsy.8
With better understanding of the etiopathogenesis and natural history of various epilepsies and epilepsy syndromes, there is an increasing need for specialized care of people with epilepsy. A wide variety of electrophysiological, and structural and functional neuroimaging modalities and also molecular genetic investigations are now available for the clinician to provide an accurate diagnosis and he is also has different treatment options like antiepileptic drug (AED) therapy, epilepsy surgery, and nonpharmacological interventions for optimal care of people with epilepsy. Often considerable expertise is required to make a judicious choice from this bewildering array of investigations. Data regarding the sensitivity, specificity, predictive power and cost-effectiveness of various investigative modalities are limited.
Resource constraints are universal, but more so in developing countries. The developed world is slowly getting used to the limits set by managed care and the availability or not of the medical insurance for a patient. The problems in developing countries are different. Investigations considered very basic like an electroencephalogram (EEG) are not available in many regions or may not be affordable to a large segment of patient population. Even in the few centers where EEG equipment is available, the technical expertise required for recording and interpreting EEGs may be lacking. Computerized tomography scan (CT) facility is available in most of the big towns in developing countries. But magnetic resonance imaging (MRI) is available only in a few regional centers or metropolitan cities. The number of centers where single photon emission computed tomography (SPECT) and positron emission tomography (PET) are performed in India are very few. Long-term video-EEG monitoring and epilepsy surgery programs are restricted to few selected centers.9-11 Absence of statutory bodies enforcing quality control and lack of trained personnel lead to overuse as well as abuse of the available investigative facilities.
Diagnosis of epilepsy is fundamentally a clinical judgment based on history. The accuracy of diagnosis of epilepsy depends on the skill and experience of the physician and the quality and reliability of the witness information available. The diagnostic questions that a physician, caring people with suspected seizure disorder, encounter would include: (1) Is it an epileptic seizure? (2) What is or are the seizure types? (3) What is the syndrome or type of epilepsy? (4) What is the cause? The diagnostic approach to a patient with epilepsy depends on the clinical setting, availability and access to investigative facilities and economic factors. When compared to well-structured health care and reimbursement systems in developed countries, in developing countries, a majority of people with epilepsy pays for investigations from their own pocket. In this chapter, we describe the investigative facilities available for patients with epilepsy in tropical countries and critically examine how these facilities can be utilized in a cost-effective way.
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