Epilepsy – like a thunderstorm in the brain

We have arrived well in Siem Reap and have already experienced a lot in our first few weeks. The care is great, and our interests are taken into account, for example neurology. Dr. Bunthong, the head of the neonatal ward, was able to organize a visit to the EEG ward for us. An EEG - an electroencephalography - is used to diagnose epilepsy and records brain waves.

On our first day in the neurology department, we were warmly welcomed by Dr. Raksmey and given an introduction. Children with suspected epilepsy are referred to ward C1. This means that seizures have been observed in the child. Depending on the case, an MRI is also carried out in addition to the EEG to rule out other causes.

There is a separate room on the ward for the EEG measurements. The air here is pleasantly cooled so that the children can fall asleep better (for us it was also a welcome cool-down). The night before the EEG, patients have to be awake from 2 a.m. so that they are sleep-deprived at the time of the measurement. Patients have to wash their hair before the examination.

The examination begins with the application of the 21 electrodes. To do this, the skull must first be measured using the so-called 10-20 system (see photo). The individual electrodes are then attached to the marked points and wired to the machine. Now the patient is ready and lies down carefully on the couch. The actual examination is usually divided into four sections:

1. opening/closing the eyes

2. intermittent photic stimulation (flickering light)

3. hyperventilation

4. sleep

Opening and closing the eyes is intended to relax the brain. The high-frequency light and hyperventilation are trigger factors for epileptic activity. It is easiest to recognize signs of epileptic changes during sleep.

Meanwhile, the electrical currents are observed on the screen and signs of epileptic activity are searched for. These signs can be seen by means of special waves/spikes in the EEG. They do not mean that the patient is having a seizure at the same time. Combined with the patient's medical history, a diagnosis can be made and treatment planned.

The next day, we were able to attend and help with an EEG examination. Patient Sokneam is a 14-year-old monk from a remote district. He has been suffering from three to five seizures a month for a year, during which his body tenses up. His seizures last three to five minutes. He was here a month ago but couldn't stay long enough for the examination.

When we enter the room, Sokneam seems a little tired and reserved. Our presence does not worry him. Srey Pun and Derich, the EEG assistants, measure his head and instruct us on how to attach the electrodes. Then Sokneam lies down comfortably and we start the measurements. He cooperates well with the first three steps, and it doesn't take long before we hear a slight snoring sound. Not all children manage to fall asleep so easily - we then help them with a sedative.

After about 20 minutes of sleep, the examination is over, and we can look at the results with Dr. Raksmey. His EEG shows epileptic activity in the form of “sharp waves” and “spike waves” (see photo). This allows us to make his diagnosis: generalized tonic epilepsy. He can now start drug therapy. In his case, this is carbamazepine 5 mg/kg/day.

Sokneam will attend his first follow-up appointment in a month's time. If he has no more seizures, he can maintain the dose, otherwise it will be increased. As soon as he is well controlled with the medication, the interval between follow-up appointments will be extended to six months. If he remains seizure-free for a longer period of time (usually three to four years), a control EEG is performed to determine the remaining epileptic activity. If there is no more activity, the medication can be slowly discontinued in order to end the treatment.

During our stay, we also came into contact with the Cambodian population's perception of epilepsy. It is a difficult and controversial subject. The doctors did their best to explain it to us. The word epilepsy has two different translations in Khmer. On the one hand, there is the translation in the medical sense. On the other hand, it also means “foolish pig”. The word in Khmer taints the whole family of the patient and has a strong negative connotation. It is mainly used in the older generations and rural areas and is due to the lack of understanding of the cause of epilepsy. This is why Dr. Raksmey and her team also need to raise awareness.

The EEG system has been available at the hospital since April 2019; a total of 926 examinations have already been carried out. Dr. Raksmey completed her training for this at the hospital in Phnom Penh, where the system has been in operation for some time. She visits the hospital for annual training and can contact her mentor if she has any questions.

The EEGs performed diagnose epilepsy in around 90 percent of cases, most frequently generalized tonic-clonic epilepsy. Most cases are treated with medication and only a few require surgical intervention. Dr. Raksmey estimates the average age of the children to be between five and ten years. There are currently over 600 children undergoing treatment (see table). Last year, around 100 children dropped out of treatment, reflecting the difficulty of long-term treatment.

Best regards from Siem Reap

Sophie and Samuel