The Phramongkutklao Epilepsy Program (PMK CEP), established in 2000 at Phramongkutklao Hospital and College of Medicine, Bangkok, is one of Thailand’s premier comprehensive epilepsy centers. It provides advanced multidisciplinary care for patients with epilepsy, especially those with drug-resistant and complex cases, integrating clinical management, surgical treatment, research, and education.

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Historical Context and Development

Thailand has a population of approximately 67 million, with epilepsy prevalence estimated at about 7.2 per 1,000 people in rural areas, and nearly 30% of cases classified as refractory epilepsy. The country’s epilepsy surgery program is the oldest in Southeast Asia, with over 300 epilepsy surgeries performed in the decade from 2000 to 2010. The Phramongkutklao program evolved alongside other major centers such as Chulalongkorn University’s Comprehensive Epilepsy Program (established 1994) and has been pivotal in advancing epilepsy care in Thailand despite limited resources.

Early epilepsy surgeries in Thailand began in the late 1980s, initially focusing on temporal lobe epilepsy (TLE) with mesial temporal sclerosis, using basic tools like MRI and routine EEG. The Phramongkutklao program introduced advanced presurgical evaluations including 24-hour video EEG monitoring (since 1998), 1.5T MRI with epilepsy protocols, ictal SPECT (since 1998), Thai-language Wada testing (since 1999), and interictal PET imaging (since 2006). These tools have enabled precise localization of epileptogenic zones, critical for successful surgery.

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Clinical Services

1. Diagnostic Evaluation:
The program offers comprehensive presurgical workups involving:

• Long-term video-EEG monitoring to capture seizure onset and propagation.
• High-resolution MRI with epilepsy-specific protocols and 3D post-processing to detect subtle lesions.
• Functional neuroimaging including ictal and interictal SPECT, PET, fMRI, and EEG source imaging to supplement structural data.
• Neuropsychological and psychiatric assessments to evaluate cognitive and behavioral comorbidities.

2. Medical Management:
Optimized antiseizure medication regimens are tailored to individual patients, including newer agents and polytherapy for drug-resistant epilepsy.

3. Epilepsy Surgery:

• Over 300 surgeries have been performed, including temporal lobectomies, extratemporal resections, corpus callosotomies, and hemispherectomies.
• The program pioneered the use of intracranial EEG, including subdural grids and depth electrodes, and more recently stereotactic EEG (SEEG), for precise localization of epileptogenic foci, especially in non-lesional or deep brain epilepsy.
• Functional cortical mapping via cortical stimulation is routinely used to preserve eloquent brain areas during surgery.
• Pediatric epilepsy surgery has been a major focus, with studies showing good seizure control and minimal complications in children and adolescents.

4. Alternative and Adjunctive Therapies:

• Vagus nerve stimulation (VNS) has been available since 2006, with over 40 implantations performed.
• The ketogenic diet, modified to incorporate traditional Thai recipes, is used especially in pediatric patients with drug-resistant epilepsy.
• Gamma Knife radiosurgery has been applied in select refractory lesional epilepsy cases.

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Research and Innovation

The Phramongkutklao Epilepsy Program actively engages in clinical research and innovation:

• Development of a Thai-language mobile application, “Epilepsy Care,” designed to improve self-management and medication adherence in children and adolescents, showing promising improvements in seizure control and quality of life.
• Investigations into psychiatric and behavioral comorbidities in epilepsy patients have found relatively low prevalence of anxiety and depression but highlighted their impact on wellbeing, informing holistic care approaches.
• Clinical trials on newer antiseizure medications, including perampanel as adjunctive therapy in drug-resistant epilepsy, have been conducted in collaboration with other centers.

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Education and Training

The program is one of three epilepsy fellowship training centers in Thailand, accredited by the Royal College of Physicians of Thailand. It offers a two-year post-graduate fellowship for neurologists specializing in epilepsy, covering advanced diagnostics, medical management, surgical techniques, and research methodologies. This training has been instrumental in building national expertise and expanding epilepsy care capacity.

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