Summary:Purpose: To study propagation properties of focally originating frontal lobe seizures: principally direction and promptness of ictal spread.Method: Forty-eight scalp EEG-recorded and 17 subdurally recorded seizures in two separate groups of patients were visually scrutinized.Results: Initial propagation was directed more commonly to contiguous frontal cortex than to the opposite hemisphere in both studies: 58% and 86% for scalp and subdural recordings, respectively. Eighteen (38%) of scalp EEG seizures propagated within 5-10 s of apparent onset, whereas 16 (33%) did so after 11-20 s; no evidence of propagation could be discerned in the remaining 14 (29%). Of subdurally recorded attacks, only four (24%) propagated in the first 4 s; six (35%) did so after a delay of 5-10 s; six (35%) either failed to propagate or did so after Ն20-s latency. Latency to initial propagation was between 5 and 20 s in 41 (63%) of the 65 seizures in both studies. Ictal activity remained within the frontal lobe of origin for Ն10 s in 39 (81%) of scalp-recorded seizures and 11 (65%) of subdural seizures. It remained so confined for Ն15 s in 26 (54%) and nine (53%), respectively. Twenty-four (50%) of scalp-recorded seizures displayed evidence of opposite hemisphere (bisynchronous or other contralateral) involvement, occurring 5-10 s after onset in eight (17%) seizures and 10-20 s after onset in 16 (33%). Similarly, the subdural study documented spread to the opposite hemisphere in 11 (65%) of seizures with a latency ranging from 1 to 45 s.Conclusions: Frontal lobe seizures in this study propagated less promptly than reputed, and initial spread occurred more commonly to the frontal lobe of origin than to the opposite hemisphere. Such properties underlie the good lateralizing value of clinical semiology of frontal lobe seizures.

Aim. Clinicians trained to interpret EEG in Africa are scarce. The region is challenged by inadequate access to healthcare professionals and a significant burden of disease, with the result that trained neurophysiologists and epileptologists may not be viewed as an immediate priority. However, approaches, specific to the African context, could be adopted to enable safe practice of basic EEG interpretation. Educational guidelines for the interpretation of paediatric studies, relevant to the region, are lacking. As a result, a handbook targeting this training need was developed and a pilot study undertaken to assess the efficacy of this tool to improve EEGreporting skills for clinicians at a basic level. Methods. Eleven health practitioners, who manage children with epilepsy, from various African countries, were recruited. The group analysed selected EEGs before and after reading a training manual (the handbook). A survey was conducted on how useful the participants found the handbook.Results. There was a trend (p<0.06) supporting improvement in the ability to analyse EEGs following reading of the handbook. The doctors who had one-on-one tutoring, in addition to access to the handbook, did significantly better in most EEG-reporting variables (p<0.01). Conclusions. The handbook was found to be a viable tool to promote EEG interpretation in the African setting, where foundation skills are needed. However, optimal outcomes were evident with additional individual tutoring, as well as on-going support to maintain skills. This curriculum will be adapted into a post-graduate qualification intended to generate clinicians with key basic EEG skills, but not fully trained electrophysiologists. Currently, in the African setting, for maximum impact on patient care, this approach is considered the most likely to have the furthest reach.

There are few dedicated pediatric neurophysiology services in Africa. Optimizing the efficiency of these units is essential for the large populations they serve. Two hundred eighty-seven electroencephalogram (EEG) studies, performed in a sub-Saharan neurophysiology unit, were analyzed for referral sources, appropriateness of referral, reporting consistency, and use in confirming epilepsy or a neurologic process. Pediatric neurologists requested 24% of the electroencephalogram studies and pediatricians 45%. Pediatric neurologists requested more appropriate referrals than pediatricians or nonspecialists. The electroencephalogram studies assisted management in 40% of cases. Electroencephalogram studies for nonepileptic indications, such as syncope, were highly predictable and typically normal. Education and training in the management of children with epilepsy could improve requesting practice and the subsequent usefulness of electroencephalograms in the diagnosis of epilepsy syndromes. This is especially important in the context of a resource-poor country.

Objective. Neurologists and epileptologists are scarce in sub-Saharan Africa (SSA). Whilst electroencephalograms (EEGs) are becoming more available in the region, interpretation is typically undertaken by non-specialist clinicians with limited or no training. This is a systematic review of the peer-reviewed literature on EEG training of non-specialist clinicians worldwide, assessing the efficacy of the training methodology and the curricula content. Methods. The published literature was searched for papers relating to EEG training of non-specialist clinicians worldwide (1/01/1989-30/06/2020). All regions of the world were included and assessed for content on efficacy of curricula and potential adaptability or applicability to resource-poor settings. The grey literature was searched using ProQuest and Primo databases and references from review articles. The websites of the International League Against Epilepsy, International Federation of Clinical Neurophysiologist, American Academy of Neurology and World Federation of Neurology were reviewed for reports (non-peer reviewed) which described roll-out and impact of novel EEG training curricula. Results. There was limited data. From 2,613 articles, 15 complied with the study question. Ten studies were performed on cross-speciality clinicians, four on neurology registrars and one on a combination of healthcare workers. There was diversity of curricula models used. The studies themselves lacked consistency and directness. A few training programs were trialled in low-middle-income countries (LMICs) and paediatric training was included in only two. An ideal training curriculum was not evident nor evaluated for resource-poor settings. However, diverse teaching models were reported and set the foundations for further development of EEG training curricula for non-specialist clinicians. Significance. There is a lack of access to education in EEG training and interpretation for non-specialist clinicians in LMICs. Existing models need to be expanded or adapted and evaluated for this population group.