Yield of Brain MRI in Clinically Diagnosed Epilepsy in the Kingdom of Bhutan: A Prospective Study.

BACKGROUND: People with epilepsy (PWE) in low- and middle-income countries may not access the health resources that are considered optimal for epilepsy diagnosis. The diagnostic yield of magnetic resonance imaging (MRI) has not been well studied in these settings. OBJECTIVES: To report the diagnostic yield of brain MRI and identify clinical associations of abnormal MRI findings among PWE in a neurocysticercosis-endemic, resource-limited setting and to identify the proportion and putative structural brain causes of drug-resistant epilepsy. METHODS: PWE were prospectively enrolled at the Jigme Dorji Wangchuck National Referral Hospital in Bhutan (2014-2015). Each participant completed clinical questionnaires and a 1.5-Tesla brain MRI. Each MRI was reviewed by at least 1 radiologist and neurologist in Bhutan and the United States. A working definition of drug-resistant epilepsy for resource-limited settings was given as (a) seizures for >1 year, (b) at least 1 seizure in the prior year, and (c) presently taking 2 or more antiepileptic drugs (AEDs). Logistic regression models were constructed to test the cross-sectional association of an abnormal brain MRI with clinical variables. FINDINGS: A total of 217 participants (125 [57%] female; 54 [25%] < 18 years old; 199 [92%] taking AEDs; 154 [71%] with a seizure in the prior year) were enrolled. There was a high prevalence of abnormal brain MRIs (176/217, 81%). Mesial temporal sclerosis was the most common finding (n = 115, 53%, including 24 children), exceeding the number of PWE with neurocysticercosis (n = 26, 12%, including 1 child) and congenital/perinatal abnormalities (n = 29, 14%, including 14 children). The number of AEDs (odds ratio = .59, P = .03) and duration of epilepsy (odds ratio = 1.11, P = .02) were significantly associated with an abnormal MRI. Seizure in the prior month was associated with the presence of mesial temporal sclerosis (odds ratio = .47, P = .01). A total of 25 (12%) participants met our definition of drug-resistant epilepsy, with mesial temporal sclerosis (n = 10), congenital malformations (n = 5), and neurocysticercosis (n = 4) being the more common findings. CONCLUSIONS: The prevalence of abnormalities on brain MRI for PWE in resource-limited settings is high as a result of a diffuse range of etiologies, most commonly mesial temporal sclerosis. Drug-resistant epilepsy accounted for 12% of the referral population in a conservative estimation.

Neurocysticercosis in Bhutan: a cross-sectional study in people with epilepsy.

BACKGROUND: We sought to provide an assessment of the burden of neurocysticercosis among people with epilepsy (PWE) in Bhutan and evaluate the yield of various tests for Taenia solium. METHODS: PWE were enrolled at the National Referral Hospital in Thimphu (2014-2015). Serum was tested for anti-Taenia solium IgG using ELISA (Ab-ELISA), enzyme-linked immunoelectrotransfer blot (EITB), and parasite antigen. Results were compared to brain MRI. Participants were categorized as definite neurocysticercosis (MRI and EITB positive), probable neurocysticercosis (MRI or EITB positive), or without neurocysticercosis. Logistic regression models were constructed to explore clinicodemographic associations. RESULTS: There were 12/205 (6%, 95% CI 2%, 9%) definite and 40/205 (20%, 95% CI 14%, 25%) probable neurocysticercosis cases. 25/205 (12%) with positive EITB did not have neurocysticercosis on MRI, and 15/205 (7%) participants with positive MRI had negative EITB. Participants with neurocysticercosis-suggestive lesions on MRI had an average of 1.2 cysts (parenchymal 26/27; nodular/calcified stage 21/27). In a multivariable analysis, present age (OR 1.05, 95% CI 1.01,1.09, p=0.025) was positively associated with (combined probable or definite) neurocysticercosis while mesial temporal sclerosis on MRI (OR 0.294, 95% CI 0.144, 0.598, p=0.001) was negatively associated. CONCLUSIONS: Neurocysticercosis was associated with 6-25% of epilepsy in a Bhutanese cohort. Combining EITB and MRI would aid the diagnosis of neurocysticercosis among PWE since no test identified all cases.

PACS for Bhutan: a cost effective open source architecture for emerging countries.

This paper reports the design and implementation of an innovative and cost-effective imaging management infrastructure suitable for radiology centres in emerging countries. It was implemented in the main referring hospital of Bhutan equipped with a CT, an MRI, digital radiology, and a suite of several ultrasound units. They lacked the necessary informatics infrastructure for image archiving and interpretation and needed a system for distribution of images to clinical wards. The solution developed for this project combines several open source software platforms in a robust and versatile archiving and communication system connected to analysis workstations equipped with a FDA-certified version of the highly popular Open-Source software. The whole system was implemented on standard off-the-shelf hardware. The system was installed in three days, and training of the radiologists as well as the technical and IT staff was provided onsite to ensure full ownership of the system by the local team. Radiologists were rapidly capable of reading and interpreting studies on the diagnostic workstations, which had a significant benefit on their workflow and ability to perform diagnostic tasks more efficiently. Furthermore, images were also made available to several clinical units on standard desktop computers through a web-based viewer. MESSAGES/TEACHING POINTS: • Open source imaging informatics platforms can provide cost-effective alternatives for PACS • Robust and cost-effective open architecture can provide adequate solutions for emerging countries • Imaging informatics is often lacking in hospitals equipped with digital modalities.