Pre-surgical Evaluation Pathways and Their Limitations for Epilepsy in Africa: A Scoping Review Protocol

Review Title: Pre-surgical Evaluation Pathways and Their Limitations for Epilepsy in Africa: A Scoping Review Protocol Anticipated start date: July 1, 2025 Anticipated completion date: December 30, 2025 1. Review Question This scoping review aims to answer the question: What are the current pre-surgical evaluation pathways for epilepsy in Africa, and what limitations or barriers hinder their effective implementation? 2. Background Epilepsy is one of the most common neurological disorders globally, affecting over 50 million people, with nearly 80 percent of these individuals living in low- and middle-income countries (World Health Organization [WHO], 2023). Within Africa, epilepsy represents a particularly pressing public health issue, as the continent faces a higher prevalence of the disease compared to high-income regions. This increased burden is driven by a combination of factors, including limited access to diagnostic services, delays in treatment initiation, and significant sociocultural stigma (Ba-Diop et al., 2014; Newton & Garcia, 2012). The high incidence of epilepsy in Africa is further exacerbated by preventable causes such as perinatal injury, central nervous system infections, and head trauma, many of which remain inadequately addressed. While pharmacological treatment is the first-line management for most individuals with epilepsy, a significant proportion of patients, particularly those with drug-resistant epilepsy (DRE), require surgical intervention for seizure control. Epilepsy surgery has demonstrated favorable long-term outcomes in appropriately selected patients, offering the potential for seizure freedom or significant reduction in seizure frequency (Engel et al., 2012). A more recent advancement in surgical care, Laser Interstitial Thermal Therapy (LITT), has emerged as a minimally invasive technique that offers promising results in select DRE cases. LITT has a favorable safety profile and is associated with shorter hospital stays and lower perioperative morbidity (Tovar-Spinoza et al., 2013). Before undergoing epilepsy surgery, patients must complete a thorough pre-surgical evaluation. This typically includes high-resolution magnetic resonance imaging (MRI), long-term video electroencephalography (EEG) monitoring, neuropsychological testing, and review by a multidisciplinary team composed of neurologists, neurosurgeons, radiologists, and psychologists (Wiebe & Jette, 2012). In high-income countries, these evaluations are systematically integrated into clinical pathways. However, in Africa, the implementation of pre-surgical evaluation remains inconsistent due to significant barriers. These include limited access to advanced neuroimaging and EEG equipment, a shortage of trained epilepsy specialists, and insufficient integration of surgical evaluation into national healthcare systems (Otte et al., 2016). Although countries such as Morocco, Kenya, Nigeria, and South Africa have taken steps to establish epilepsy surgery programs, a consolidated understanding of how pre-surgical evaluations are currently being implemented across African nations is lacking. This gap in knowledge limits the ability to optimize patient care, allocate resources effectively, and inform health policy and system strengthening efforts (Mbuba et al., 2020). 2.1 Problem Statement Despite increasing recognition of epilepsy surgery as an effective treatment for drug-resistant epilepsy, pre-surgical evaluation remains underdeveloped across many African countries. Limited access to MRI, EEG, and neuropsychological services, along with a shortage of trained professionals and poor health system integration, significantly hinder the identification of suitable surgical candidates (Ngugi et al., 2019; Mbuba & Newton, 2012). Financial constraints, geographic barriers, and stigma further restrict access to comprehensive evaluation. The first documented epilepsy surgery in Africa was performed in Morocco in 2005 at the Hopital des Spécialités in Rabat, marking a key milestone in the region’s neurosurgical history (El Ouazzani et al., 2013; El Khamlichi et al., 2024). Since then, countries such as Morocco, Kenya, Nigeria, and South Africa have initiated epilepsy surgery programs. However, a consolidated understanding of how pre-surgical evaluations are implemented across the continent is lacking, which limits the ability to improve clinical outcomes, guide resource allocation, and inform health policy (Mbuba et al., 2020). A scoping review is essential to synthesize current practices and identify gaps in access, infrastructure, and clinical capacity. 3. Objectives Primary Objective: • To map existing evidence on the pre-surgical evaluation pathways for epilepsy in Africa. Secondary Objectives: 1. To identify the components and modalities used in pre-surgical evaluation across epilepsy centers in Africa. 2. To describe barriers and limitations impeding effective pre-surgical evaluation. 3. To highlight research, policy, and capacity gaps relevant to surgical readiness in epilepsy care. 4. Methodology This review will be conducted using the Joanna Briggs Institute (JBI) framework for scoping reviews and reported by the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. 4.1 Eligibility Criteria (PCC Framework) • Population: Individuals with epilepsy, specifically those evaluated or considered for epilepsy surgery. • Concept: Pre-surgical evaluation pathways, including neuroimaging, EEG monitoring, neuropsychological assessments, MDT decision-making, and related protocols. • Context: Healthcare systems in African countries, including tertiary hospitals, epilepsy centers, and national-level strategies. Inclusion Criteria: • Articles reporting on pre-surgical evaluation or readiness for drug-resistant epilepsy surgery conducted in African countries. • Peer-reviewed articles, reviews, qualitative studies, program evaluations, and grey literature. Exclusion Criteria: • Articles unrelated to drug-resistant epilepsy surgery or pre-surgical evaluation. Language: English or French. Time Frame: studies published between January 2005 and June 2025 will be conducted to mark two decades since the first documented epilepsy surgery in Africa, which was performed in Morocco (El Ouazzani et al., 2013). 4.2 Search Methods Systematic searches will be conducted in the following databases: • PubMed/MEDLINE • Scopus • Web of Science • EMBASE • African Journals Online (AJOL) • WHO Global Index Medicus (AFRO Library) Search terms will include: A systematic literature search will be undertaken employing the following search terms: (“epilepsy surgery” OR “epilepsy surgical evaluation” OR “pre-surgical workup” OR “presurgical assessment” OR “preoperative evaluation” OR “epileptogenic zone localization”) AND (“Africa”) AND (“barriers” OR “challenges” OR “limitations” OR “access”) AND (“drug-resistant epilepsy” OR “DRE”) AND (“SEEG” OR “stereo-electroencephalography” OR “VEEG” OR “video EEG” OR “video-electroencephalography”), to identify pertinent literature that explores the obstacles to epilepsy surgical services within the African context. Grey literature will be identified via Google Scholar, ProQuest Dissertations, WHO and NGO websites, and national ministry of health portals. 4.3 Study Selection All citations will be exported to reference software (e.g., EndNote or Zotero), and duplicates removed. Two reviewers will independently screen titles and abstracts, followed by full-text review for eligibility. Discrepancies will be resolved through consensus or third-party adjudication. 4.4 Data Charting A standardized data extraction form will be developed and piloted. Data items include: • Author(s), year, country • Study aims and design • Study setting and population • Components of pre-surgical evaluation • Barriers, facilitators, and limitations • Outcomes and key findings 4.5 Data Synthesis Data extracted from included studies will be summarized descriptively and synthesized narratively to provide an overview of existing evidence. A thematic analysis will be undertaken using qualitative analysis software to systematically code and identify key themes related to barriers, innovations, and gaps. Data will be securely stored, with independent dual coding employed to enhance reliability; any discrepancies will be resolved through discussion. Additionally, geographical mapping will be performed to visualize the distribution of studies across Africa. This methodology aims to ensure transparency, rigor, and reproducibility consistent with scoping review standards. 4.6 Quality Assurance Formal risk of bias assessment will not be performed, consistent with scoping review methodology. However, methodological rigor and relevance will be discussed. Inter-reviewer agreement (e.g., kappa statistic) may be reported. 5. Risk of Bias Assessment As this is a scoping review, formal risk of bias will not be conducted, but limitations will be discussed. 6. Strategy for Data Synthesis Data synthesis will include descriptive statistics, narrative synthesis, thematic analysis, and geographical mapping. 7. Dissemination Plans Results will be published in peer-reviewed journals, presented at regional/international conferences, and disseminated via policy briefs to stakeholders and Ministries of Health in Africa. 8. Ethical Considerations No ethical approval is required since publicly available secondary data will be used. 9. References World Health Organization (WHO). (2023). Epilepsy. Retrieved from who.int Ba-Diop, A., Marin, B., Druet-Cabanac, M., Ngoungou, E. B., Newton, C. R., & Preux, P. M. (2014). Epidemiology, causes, and treatment of epilepsy in sub-Saharan Africa. The Lancet Neurology, 13(10), 1029–1044. doi.org)70114-0 Newton, C. R., & Garcia, H. H. (2012). Epilepsy in poor regions of the world. The Lancet, 380(9848), 1193–1201. doi.org)61381-6 Engel, J. Jr., McDermott, M. P., Wiebe, S., Langfitt, J. T., Stern, J. M., Dewar, S., ... & Early Randomized Surgical Epilepsy Trial (ERSET) Study Group. (2012). Early surgical therapy for drug-resistant temporal lobe epilepsy: A randomized trial. JAMA, 307(9), 922–930. doi.org Tovar-Spinoza, Z. A., Carter, D., Ferrone, D., Eksioglu, Y. Z., & Huckins, S. C. (2013). The use of MRI-guided laser-induced thermal ablation for epilepsy. Child’s Nervous System, 29(11), 2089–2094. doi.org Wiebe, S., & Jette, N. (2012). Epilepsy surgery utilization: Who, when, where, and why? Current Opinion in Neurology, 25(2), 187–193. doi.org Otte, W. M., Dossou-Yovo, M., Fereydooni, A., & de Boer, H. M. (2016). Barriers to surgical epilepsy care in low- and middle-income countries: A global survey. Neurology, 87(2), 142–148. doi.org Mbuba, C. K., Ngugi, A. K., Newton, C. R., & Carter, J. A. (2008). The epilepsy treatment gap in developing countries: A systematic review of the magnitude, causes, and intervention strategies. Epilepsia, 49(9), 1491–1503. doi.org Ngugi, A. K., Bottomley, C., Kleinschmidt, I., Sander, J. W., & Newton, C. R. (2019). Estimation of the burden of active and life-time epilepsy: A meta-analytic approach. Epilepsia, 60(5), 874–883. doi.org Mbuba, C. K., & Newton, C. R. (2012). Treatment of epilepsy in sub-Saharan Africa: Closing the gap. The Lancet Neurology, 11(8), 792–793. doi.org)70133-3 El Khamlichi, A., El Ouazzani, R., Melhaoui, A., Arkha, Y., Adeniran Bankole, N. D., Rifi, L., Lahjouji, F., Amor, M., & Jiddane, M. (2024). Advocacy for epilepsy surgery in Africa: Moroccan experience of 132 cases. World Neurosurgery, 183, e421–e431. doi.org Mbuba, C. K., Ndyanabangi, S., Sander, J. W., & Newton, C. R. (2020). Epilepsy surgery for drug-resistant epilepsy in Africa: A systematic review. Epilepsia Open, 5(1), 5–15. doi.org Ouazzani, R., Lahjouji, F., Belaidi, H., El Khamlichi, A., Jiddane, M., Birouk, N., Errguig, L., & Kably, B. (2013). La chirurgie de l’épilepsie au Maroc, étude et suivi à long terme de 51 patients. 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