Improving EEG education: Asian Epilepsy Academy raises the bar

Electroencephalography (EEG) is a key part of epilepsy diagnosis and treatment.  Seizures cause changes in the brain’s activity, which show on an EEG. Even when seizures are not occurring, EEG can assist in diagnosis and care of people with epilepsy.

Many Asian countries have limited access to EEG and a lack of experienced technologists and readers.  At the most recent congress of the International League Against Epilepsy’s Asia & Oceania region, held in Bali in June 2018, experts reviewed the progress and challenges to using EEG in Asia, as well as the contributions of the region’s Asian Epilepsy Academy (ASEPA) in improving EEG education.

Throughout much of Asia, EEG technology often is limited to large cities. At the Bali congress, Kheng-Seang Lim, MD, professor at the University of Malaya, presented survey data indicating that outside the capital or major cities, 12 of 22 Asian countries have limited availability of EEG. Some countries—such as Bhutan, Laos, Cambodia and East Timor—have either extremely limited EEG services or no services at all.

According to a survey by The World Health Organization (WHO), about 78% of countries in Southeast Asia have EEG. However, only 22% of low-income countries in Asia have video EEG, compared with about 77% of high-income countries. Video EEG is considered a gold standard for capturing seizure activity.

Because EEG is available mostly in large cities and at private facilities, cost also comes into play. According to Lim, 36% of Asians have no national insurance coverage. In countries where health insurance is offered through formal employment, those who have informal employment lack access to coverage. A recent report estimated that 1.3 billion people work informally in Asia. Informal employment is common in rural areas, encompassing nearly all agricultural work. Other common types of informal employment include street vendors, rickshaw drivers and waste pickers.

Competency also is an issue, said Lim. Many of the surveyed countries reported that fewer than half of their EEG centers were competent. Only Singapore was rated as having >70% competency.

Asia also has a dearth of trained neurologists—those completing a fellowship in epilepsy or EEG—to interpret the results. Of the 22 countries in the survey, half had fewer than 10 neurologists who had completed such a fellowship. Three of these countries—Brunei, East Timor and Cambodia—have no trained neurologists.

Administration and interpretation are further challenges, as most countries do not have structured training or certification for EEG technicians. Malaysia, Singapore, China, Japan, India and Pakistan are the only countries in the region that have both EEG training and EEG certification.

Even in higher-income countries in the Asia & Oceania region, such as Australia, there is a need for EEG skills, said John Dunne, MD, professor at the University of Western Australia and chair of the ILAE-Asia & Oceania ASEPA Task Force. “There’s an unstable pyramid of expertise, with neurologists with no training at the bottom and EEG experts at the top, and not many people in the middle,” he said. The result is that many neurologists interpret EEGs with no training.

Research shows that EEG interpretation by inexperienced or untrained readers can lead to overinterpretation and misdiagnosis of epilepsy, particularly in pediatric patients. These errors can lead to years of unnecessary treatment, or to the withholding of medication.

In 2000, ASEPA—the educational arm of ILAE-Asia & Oceania—established an EEG course that is now given throughout Asia.

Led by Shih Hui Lim, professor and senior associate dean at Duke-NUS Medical School, Singapore, ASEPA also has established EEG certification exams across the region.

The exam consists of written (part 1) and oral (part 2) sections, and is offered during regional epilepsy conferences, ASEPA teaching courses or workshops, ILAE chapter conferences and other appropriate venues.

Part 1 consists of 150 questions. It is meant for:

• Practicing neurologists or psychiatrists
• Neurology, epilepsy or EEG trainees (with proof of adequate training in EEG interpretation)
• Experienced EEG technologists

As of June 2018, part 1 has been given 42 times in 11 countries, with 741 people sitting for the exam and 482 passing (65%).

After passing part 1, candidates are eligible to take part 2, which consists of two 30-minute sections. First, the candidate reviews and discusses two EEG records brought from his or her routine EEG laboratory. Second, the candidate reviews short segments of 20 EEG samples and must identify various patterns and describe their clinical significance.

Part 2 has been offered 33 times, with 431 taking the exam and 311 (72.2%) passing.

Those who pass both parts become certified electroencephalographers.

ASEPA currently offers an introductory EEG teaching course, as well as the certification exam and a supervisor accreditation. The introductory teaching course generally runs for two days. Recent locations include Guanzhou, China; Karachi, Pakistan; and Dhaka, Bangladesh.

“The ASEPA course offers an important opportunity to obtain at least a basic training in the clinical application and interpretation of EEG to a large audience of East Asian neurologists and some pediatricians, working in countries with mostly still substandard or even missing EEG resources,” said Walter Van Emde Boas, chair of ILAE’s Distance Education Task Force. “The course seems to be an important resource for epilepsy education and care in the region.”

Efforts continue to increase the number of EEG technicians and interpreters across Asia, said Dunne. “We still do not have a solid core of people reading EEGs who are competent to do so,” he said. “Why is that? Because EEG is invisible. People don’t appreciate that it takes time to learn.”

What is EEG?

An electroencephalogram (EEG) records the electrical activity of the brain. When neurons fire, they create an electric current that can be detected using electrodes placed on the scalp. EEG does not pick up all brain activity; some electrical pulses are too deep or subtle to reach the electrodes.

EEG will record most seizure activity. The physician uses this information to understand where seizures start, how and where they spread and how long they last. This information aids in diagnosing the type of epilepsy and prescribing treatment.

A regular EEG records for 20 to 40 minutes, so it does not always record a seizure. If someone with epilepsy is not having a seizure, their brain activity is generally normal. However, an EEG can still pick up seizure-related patterns, which could help in diagnosis or management.

Recording seizure activity often requires an ambulatory EEG, during which the EEG equipment is worn for 1 to 3 days at home. In other cases, the person is admitted to a hospital or outpatient clinic for a video EEG, which couples an EEG recorder with a video camera. This set-up records behavior during a seizure and matches it with EEG output.