Original Paper

Neuroepidemiology 2023;57:78–89 Received: November 28, 2021

Accepted: January 26, 2022
DOI: 10.1159/000522442 Published online: October 7, 2022

The Prevalence of Active Epilepsy in the

Kingdom of Saudi Arabia:
A Cross-Sectional Study

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Ahmed Al Rumayyan a, b, c Ashraf Alharthi b Mohammad Al-Rowaili a, b
Sameer Al-Mehmadi b Waleed Altwaijri a, b Talal Alrifai a, b Motasim Badri a, c, d
aCollege of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; bDepartment of
Pediatrics, King Abdullah Medical City, Riyadh, Saudi Arabia; cKing Abdullah International Medical Research Centre,
Riyadh, Saudi Arabia; dCollege of Public Health and Health Informatics, King Saud Bin Abdulaziz University for
Health Sciences, Riyadh, Saudi Arabia

Keywords analyzed. Results: Among the 13,873 participants, active

Epilepsy · Door-to-door survey · Epidemiology · Prevalence · epilepsy was evidenced in 55 patients (3.96; 95% CI: [2.99–
Saudi Arabia 5.16]/1,000 persons). No significant variation in the preva-
lence rate was detected between male and female patients
(3.99 vs. 3.94/1,000 persons). The age-specific prevalence
Abstract was the highest among the infants (1–12 months) (14.78/
Introduction: The global prevalence of active epilepsy is 1,000 persons). Of the various seizure types, complex par-
around 6.38/1,000 persons. In the Arabian region, the me- tial seizures were the most common (33%), followed by
dian prevalence of active epilepsy is 4.4/1,000 persons. In the generalized seizures (29.1%). Concerning etiology, epilep-
Kingdom of Saudi Arabia (KSA), the last prevalence study for sies with idiopathic and cryptogenic etiologies were the
active epilepsy cases was conducted in 2001 and showed an most common in 18 (36.3%) cases. Structural, vascular,
estimate of 6.5/1,000 persons. Objectives: The aim of the and focal abnormalities were the most commonly diag-
study was to investigate the prevalence of active epilepsy nosed abnormalities (18.2%, 14.5%, and 39.2%, respec-
and etiological factors among Saudi individuals of all ages tively). Conclusion: The prevalence of active epilepsy in KSA
resident in the Riyadh area, the central province, and the has dramatically decreased during the last decades to a rate
capital of KSA. Method: This is a door-to-door cross-section- lower than those reported in most developing countries.
al epidemiological study that was conducted between 2012 © 2022 S. Karger AG, Basel
and 2016. Patients were initially screened at their homes us-
ing a questionnaire, and then suspected individuals were in-
terviewed in the clinic by neurologists and epileptologists. Introduction
Data related to age, age at seizure onset, gender, probable
etiology, treatment, family history, duration of epilepsy, and Epilepsy is a common neurologic disorder that is charac-
seizure control, as well as images for electroencephalo- terized by recurrent unprovoked seizures which develop due
gram and magnetic resonant imaging, were collected and to abnormal hypersynchronous activity of the neurons in the

[email protected] © 2022 S. Karger AG, Basel Correspondence to:

www.karger.com/ned Ahmad Al Rymayyan, rumayyana @ ksau-hs.edu.sa
brain [1]. Active epilepsy is identified as the most recent ep- those authors suggest that a total of 204,777 new cases of
isodes of seizure that have occurred during the last 5 years epilepsy develop in the Arabic region every year. How-
or treatment with anti-epileptic drugs [2]. In general, epi- ever, no epidemiological data were found from 10 Arabic
lepsy affects both male and female individuals of all ages and countries. Hence, more awareness should be given to the
is associated with an increased risk of psychiatric comor- prevalence of epilepsy in the Arabian league.
bidities, health problems, high economic burden, and stigma The Kingdom of Saudi Arabia (KSA) is one of the larg-
[3, 4]. At the clinical level, epilepsy is classified into two ma- est countries in the Arabic region with a total population
jor types being either partial (focal), affecting one hemi- of around 34 million (0.41% of the world’s total popula-
sphere, or generalized that originates in both hemispheres tion), occupying 5 regions (i.e., eastern, western, central,
simultaneously (i.e., diffused cortical activation) [3, 5]. How- southern, and northern) (https://tradingeconomics.com/
ever, seizures associated with dyscognitive features and im- saudi-arabia/population). People with mixed nationalities

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paired awareness and consciousness are known as complex and ethnicity, diverse religious beliefs and practices (i.e.,
partial seizures [6]. However, during the last decades, the related to food and marriage habits), social relations, and
number of epidemiological studies investigating the preva- income are living in these varied areas of KSA. Up to date,
lence and incidence of epilepsy has rapidly increased world- only a single estimate for the prevalence of active epilepsy
wide and in developed countries, in particular [4]. Up to in KSA exists [10, 11]. In 2001, the median prevalence rate
date, the national and global prevalence estimates of active of epilepsy was 6.54/1,000 persons, which was restricted to
epilepsy are largely heterogenic and varied among countries 23,700 Saudis living only in the eastern province of the
due to variations in several factors including ages, study pop- Kingdom. Beyond this date, no further estimates were
ulation, sampling methods, diagnosis, analysis, income, case done at the level of the provinces or the Kingdom, and data
ascertainment, etc. [4, 7]. In the most recent meta-analysis are still deficient. Such addition will provide more infor-
published in 2017 that utilized 222 published international mation that helps in the diagnosis, treatment, and preven-
studies (48 for incidence & 197 for prevalence) [7], it was tion of epilepsy. Of note, and during the last 2 decades,
shown that the overall global prevalence of active epilepsy much investments and improvement in the educational,
was 6.38/1,000 persons (95% CI 5.57–7.30) compared to health (tools and training), and research systems, as well
7.60/1,000 persons (95% CI 6.17–9.38) for that of the lifetime as the increased people awareness of many disorders have
prevalence, where epilepsy of unknown etiology and the substantially increased in all areas within KSA. Such im-
generalized type was the most common. Besides, the same provements are expected to reduce the prevalence and in-
authors have shown that the prevalence of active epilepsy cidence of many disorders including active epilepsy.
cases was higher in countries with low to moderate-income. Therefore, in this door-to-door study, conducted be-
Nevertheless, concerning Arabic countries, which tween 2012 and 2016, we have evaluated the prevalence of
stretched over Asia and Africa, limited data on the epide- active epilepsy in 13,873 male and female Saudi individuals
miology of epilepsy exist [8, 9]. Besides, the majority of of all ages in the Riyadh area, the capital of KSA which locates
the published systematic reviews that have evaluated the in the central area of the Kingdom. Besides, we have evalu-
epidemiology of active epilepsy cases in Asia and Africa ated the common types and associated etiological factors.
have excluded the Arabic countries, despite their large
number (22 countries), huge population (approximately
Materials and Methods
315 million), and similarities in the language, culture, re-
ligion, and almost ethnicity [8, 9]. In 2009, a previous Study Population
analysis, based on 5 published studies, evaluated the prev- By 2016, the city of Riyadh had a total population of about 7
alence of active epilepsy in the 4 countries of the Arabic million. This study was conducted as a population-based survey
region (Saudi Arabia, Tunisia, Sudan, and Libya) and among randomly selected families (every third house) in residen-
tial compounds in Riyadh with a wide spectrum of sociodemograph-
showed an average rate of 2.3/1,000 persons [8]. On the ic characteristics. The inclusion criteria were to be Saudi families,
other hand, in the most recent analysis published in 2016, currently living in the Riyadh area with household registration for
from data of 9 prevalence studies in 6 Arabic countries at least the last 10 years, and non-married to an ethnic minority
(Egypt, Saudi Arabia, Libya, Algeria, the UAE, and Tuni- (non-Saudi). Each third house was selected from the overall sam-
sia) have shown a median active prevalence rate of pling frame. A total of 2,312 households were screened with an
average family member of 5–8 individuals (7 ± 1.8). A total of
4.4/1,000 persons (95% CI 2.1–9.3, range 2.1–9.3), where- 13,873 citizens were recruited in this study. Written informed con-
as the lifetime prevalence of 7.5 per 1,000 persons (95% sent forms were obtained from all participants or their informants
CI 2.6–12.3, range 1.9–12.9) [9]. Based on their findings, or guardians to participate in this study.

Prevalence of Epilepsy in KSA Neuroepidemiology 2023;57:78–89 79

DOI: 10.1159/000522442
 Color version available online

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Fig. 1. Study flowchart.

Ethical Approval types and symptoms of seizures and epilepsy, conducted a door-
This study was approved by the Institutional Review Board of to-door screening and survey of all target residents. All partici-
human research at the King Abdullah International Medical Re- pants received special training in the survey protocols and attended
search Center (KIMRC) at King Saud Bin Abdulaziz University for a special seminar on seizures and epilepsy (1 h sessions) by epide-
Health Sciences (KSAU-HS), Riyadh, KSA (IBB #IRBC/030/13 miologists from the College of Medicine at KSAU-HS, as well as
and in accordance with the guidelines established by the World by neurologist and epileptologist from King Abdulaziz Medical
Medical Association Declaration of Helsinki. City in Riyadh, KSA. Besides, all the people who conducted this
part of the study showed videos about epileptic seizures in real
Study Design (Epidemiological Survey) patients by an epileptologist. All these sessions were set out to
This study was conducted in 3 phases, namely, (1) door-to- achieve the objective of the study and make sure that all the par-
door screening, (2) neuroimaging and electroencephalographic ticipants fill out the form correctly. Patients were considered to
evaluation, (3) and diagnosis as previously described by others [2, have active epilepsy if they had any seizures during the last 5 years
12–14]. During the 1st phase, 10 well-trained students, general and inactive if they have more than 5 years had elapsed since the
practitioners, and public health specialists who are aware of the last seizure.

80 Neuroepidemiology 2023;57:78–89 Al Rumayyan/Alharthi/Al-Rowaili/

DOI: 10.1159/000522442 Al-Mehmadi/Altwaijri/Alrifai/Badri
 Table 1. Overall prevalence of epilepsy and its prevalence according to age groups and sex

N = 13,873 (%) of epilepsy Prevalence (/1,000) 95% CI

Patients with active epilepsy 55 100 3.96 (2.99–5.16)

p value
Age group
Infants (1 month–1 year old) (n = 203) 3 5.5 14.78 0.066
Children (>1–12 years old) (n = 4,881) 13 23.6 2.66
Adolescents (>12–18 years old) (n = 2,573) 15 27.2 5.83
Young adults (>18–45 years old) (n = 4,407) 16 29.1 3.63
Adults (>45–60 years old) (n = 930) 4 7.2 4.30
Aged (> 60 years old) (n = 879) 4 7.2 4.55

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Sex
Males (n = 6,770) 27 49.0 3.99 0.963
Females (n = 7,103) 28 51.0 3.94

Table 2. Prevalence of epilepsy stratified by age groups and sex (/1,000)

Age group Male (n = 6,770) Female (n = 7,103) Total (n = 13,873)

Infants (1 month–1 year old) (n = 203) 20.2 (2.46–71.08) 9.62 (0.24–52.41) 14.78 (3.06–42.58)
Children (> 1–12 years old) (n = 4,881) 3.36 (1.45–6.61) 2.00 (0.65–4.66) 2.66 (1.42–4.55)
Adolescents (> 12–18 years old) (n = 2,573) 5.57 (2.24–11.45) 6.07 (2.63–11.93) 5.83 (3.27–9.6)
Young adults (> 18–45 years old) (n = 4,407) 3.25 (1.31–6.69) 3.99 (1.83–7.56) 3.63 (2.08–5.89)
Adults (> 45–60 years old) (n = 930) 4.41 (0.53–15.82) 4.2 (0.51–15.09) 4.30 (1.17–10.98)
Aged (> 60 years old) (n = 879) 2.34 (0.06–12.95) 6.65 (1.37–19.32) 4.55 (1.24–11.61)
Overall 3.99 (2.63–5.8) 3.94 (2.62–5.69) 3.96 (2.99–5.16)

Data expressed as prevalence (per 1,000 population) and the 95% confidence interval for the prevalence in
parentheses.

During the initial screening, initial 4 screening questions were During the 2nd stage, all suspected individuals (n = 80) were
directed toward each member of the household and were filled out invited to the neurology clinic at King Abdulaziz Medical City
by adults, either individuals or guardians. These were as follows: (i) (KAMC), a university hospital, and all were present (no missing
has someone at home lost consciousness or fallen unconscious? (ii) cases). Information related to age, age at seizure onset, gender,
has someone ever been disconnected from their surroundings or probable etiology, family history, duration of epilepsy, and seizure
stared without movement? (iii) has someone exhibited involuntary control were collected from each invited subject. Data on treat-
movement or experienced strange sensations in their limbs or any ment, abuse, and household census components (i.e., income,
part of the body? and (iv) has someone ever experienced convul- educational levels, nutritional pattern, diet, electricity supply, liv-
sions, seizures, or epilepsy? Any subject who answered at least one ing conditions, etc.) were missed. To validate the cases, the pa-
of these 4 questions (or his/her guardian if a child) was asked to tients were then exposed to neurological examination: electroen-
fill out the major questionnaire that is composed of 9 questions cephalogram (EEG), magnetic resonant imaging (MRI), and an
(online suppl. Appendix I; for all online suppl. material, see www. interview with an expert neurologist and epileptologist who eval-
karger.com/doi/10.1159/000522442). Such a questionnaire was ad- uated their images, classified the type of epilepsy, identified the
opted from the standard questionnaire issued by the WHO (World etiology, and suggested treatment and follow-up plan. These have
Health Organization) for the validation of large-scale clinical-epide- been performed on various weeks. Among these 80 patients, 10
miological studies and described in more detail by Placencia et al. cases did not attend the MRI examination but underwent EEG
[15]. This questionnaire considers the geographical, social, religious, and the interview. The standards of the clinical diagnosis of active
and structural characteristics of the local population and provides a epilepsy were based on the Commission on Classification and
good compromise between high specificity and sensitivity both for Terminology of the International League (ILAE) against epilepsy
partial and generalized seizures (sensitivity of 79.3%, specificity of report, 2005–2009 issued in 2010. Standardized treatment was
92.9%, positive predictive value of 18.3%, negative predictive value given to each patient based on the diagnosis issued. A graphical
of 99.6%, and a Youden’s index of 0.79). All the questions of the flowchart explaining the experimental design of this study is
questionnaire were translated to Arabic and explained. shown in Figure 1.

Prevalence of Epilepsy in KSA Neuroepidemiology 2023;57:78–89 81

DOI: 10.1159/000522442
Table 3. Total prevalence of active
epilepsy according to the diagnosis N (%) of epilepsy Prevalence (/1,000)

Total recruited individuals 13,873

Patients with active epilepsy 55 100 3.96
Diagnosis
Idiopathic 13 23.60 0.94
HIE 7 12.70 0.504
Stroke 5 9.01 0.36
Cryptogenic 5 9.01 0.36
Benign rolandic epilepsy 4 7.20 0.288
Unknown 3 5.50 0.216
Congenital hydrocephalus 2 3.64 0.018
Absence seizure 2 3.64 0.018

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Tumors 2 3.64 0.018
Cerebral sinus thrombosis 1 1.81 0.072
Vasculitis 1 1.81 0.072
Small vessel disease 1 1.81 0.072
Cortical dysplasia 1 1.81 0.072
Porencephaly 1 1.81 0.072
Panayiotopoulos epilepsy 1 1.81 0.072
Juvenile myoclonic epilepsy 1 1.81 0.072
Lennox-Gastaut syndrome 1 1.81 0.072
Trauma 1 1.81 0.072
Metabolic disorders 1 1.81 0.072
Meningitis 1 1.81 0.072
Demyelinating disorders 1 1.81 0.072

Table 4. MRI findings, EEG abnormalities,

and seizure type for cases of epilepsy Patients with active epilepsy N Percent

MRI findings (N = 45) None 18 40.0%

Structural 10 22.2%
Vascular 8 17.8%
Atrophy 4 8.9%
HIE 2 4.4%
Nonspecific 3 6.7%
Seizure type (N = 55) Simple partial seizure 2 3.63%
Complex partial seizure 18 32.7%
Partial with secondary generalization 14 25.4%
Generalized 16 29.1%
Unknown 5 9.1%
EEG abnormalities (N = 55) None 17 33%
Focal abnormalities 20 39.2%
Generalized abnormalities 8 15.6%
Slowing abnormalities 6 11.7%

Data Collection Statistical Analysis

All patients’ data including age, gender, family history, diag- Data were entered and analyzed using IBM SPSS Statistics for
nosis, and treatment were collected and fed into an Excel sheet Windows, Version 20.0. Armonk, NY: IBM Corp. Prevalence was
on a computer. The total prevalence of active epilepsy was pre- expressed as cases/1,000 person with an exact 95% confidence in-
sented as the number of cases/1,000 person (55/13,873). The per- terval. Fisher’s exact test was used to compare the prevalence of
centage of any parameter was calculated as a ratio of the total epilepsy between groups such as sex and age groups. A test was
number of cases. considered significant if the p value <0.05.

82 Neuroepidemiology 2023;57:78–89 Al Rumayyan/Alharthi/Al-Rowaili/

DOI: 10.1159/000522442 Al-Mehmadi/Altwaijri/Alrifai/Badri
Table 5. Distribution of type of epilepsy across different age groups

Type of epilepsy Infants Children Adolescents Young adults Adults Aged

(1 month–1 year) (> 1–12 years) (> 12–18 years) (> 18–45 years) (> 45–60 years) (> 60 years)
(n = 3) (n = 13) (n = 15) (n = 16) (n = 4) (n = 4)

Partial epilepsies
Simple Partial 1 (33.3) 1 (7.7) 0 0 0 0
Complex Partial 2 (66.7) 7 (53.8) 3 (20.0) 4 (25.0) 1 (25.0) 1 (25.0)
Partial with secondary generalized 0 0 6 (40.0) 5 (31.3) 0 3 (75.0)
Generalized epilepsy 0 4 (30.8) 6 (40.0) 5 (31.3) 1 (25.0) 0
Unclassified seizures 0 1 (7.7) 0 2 (12.5) 2 (50.0) 0

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* Column percent is reported.

Results and sex. Overall, males and females had similar prevalence
across different age groups except for infants, where it
The Overall Prevalence Rate of Active Epilepsy was higher in males 20.2 versus 9.62/1,000, respectively.
In this study, 13,873 individuals of all ages and both Moreover, males had a lower prevalence in the aged group
sex were recruited. Eighty patients were suspected to have 2.34 versus 6.65/1,000, respectively.
active epilepsy. When these patients were called to the
clinic and filled out the questionnaire, they passed a neu- Prevalence of Epilepsy according to Seizure Type
rological examination to validate the cases. Among them, The major types of seizures among the 55 patients with
55 cases were identified to have active epilepsy and 25 active epilepsy were complex partial (32.7%), generalized
were considered false positives, giving a prevalence rate (29.1%), and focal with secondary generalization (25.4%)
of 2.99–5.16)/1,000 persons (3.96; 95% CI) (Table 1). (Table 3).

Prevalence of Epilepsy according to Age Prevalence of Epilepsy according to the Underlying

Among the 55 patients, active epilepsy was highly found Cause and Diagnosis
in infants (1–12 months old) (14.78/1,000 person). How- The most common diagnosis associated with active
ever, screening positivity for active epilepsy was found to epilepsy among the tested patients was idiopathic (13 cas-
be increased with age. Active epilepsy was less in children es/23.6%) followed by hypoxic-ischemic encephalopathy
(>1–12 years) (2.66/1,000 person). The active epilepsy (HIE) (7 cases/12.7%), stoke, and cryptogenic (each of 5
prevalence among young adults, adults, and aged groups cases (9.01%), and then benign rolandic epilepsy (BRE)
was 3.63, 4.30, and 4.55/1,000 persons, respectively (4 cases/7.2%) (Table 3). The prevalence rates of active
(Table 1). Of note, the highest rates of active epilepsy were epilepsy with idiopathic, HIE, stroke/cryptogenic, and
seen in infants (>12–18 years old) (14.78/1,000 person) and BRE diagnosis were 0.94, 0.504, 0.36, and 0.288/1,000
adolescents (>12–18 years old) (5.83/1,000 person). persons, respectively (Table 3).

Prevalence of Epilepsy according to Gender Abnormalities on the MRI and EEG in the Patients
The data of this study revealed that 49% (27 cases) of with the Active Epilepsy
the 55 patients diagnosed with active epilepsy were MRI was performed only for 45 patients. One-third
males, as compared to 51% (28 cases) females. Accord- (n = 18, 33%) of patients exhibited abnormal findings.
ingly, the calculated prevalence of epilepsy among males The abnormalities observed on MRI in those 45 patients
and females were 3.99 and 3.94/1,000 persons, respec- were structural (10 cases/22.2%), vascular (8 cases/17.8%),
tively (Table 1). atrophy (4 cases/8.9%), nonspecific (3 cases/6.7%), and
HIE (2 cases/4.4%). On the other hand, EEG was done
Prevalence of Epilepsy Stratified by Age Groups and Sex on 51 patients with active epilepsy where the analysis
Table 2 presents the prevalence of epilepsy and its as- revealed normal levels of activity in 17 patients (33.3%)
sociated 95% confidence interval stratified by age groups (Table 4). Focal abnormalities were observed in 20 patients

Prevalence of Epilepsy in KSA Neuroepidemiology 2023;57:78–89 83

DOI: 10.1159/000522442
Table 6. The recent global prevalence of active epilepsy

Country Authors Population Type of study Prevalence/1,000

Europe Turkey Velioglu et al., 2010 5,254 Door-to-door cross-sectional 5

Kocatürk et al., 2019 4,093 Door-to-door cross-sectional 5.1
Italy Giussani et al., 2014 912,458 Retrospective 7.9
Cossu et al., 2012 333,576 Retrospective 6.62
Finland Keränen et al., 1989 1,233 Retrospective 6.29
Denmark Christensen et al., 2007 6,543,341 Retrospective 6.8
North and Latin USA Helmers et al., 2015 23,000,000 Retrospective 8.5
Americas Thurman et al., 2015 61,714 Health interview survey 9.9
Kelvin et al., 2007 8,297 Health interview survey 5

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Argentina Melcon et al., 2005 17,049 Door-to-door cross-sectional 3.8
Brazil Sampaio et al., 2010 22,013 Door-to-door cross-sectional 8.7
Siqueira et al., 2016 30,132 Door-to-door cross-sectional 5.6
Ecuador Placencia et al., 1992 72,121 Retrospective 7.6–8
Africa Tanzania Hunter 103,026 Door-to-door cross-sectional 2.9
Nigeria Owolabi et al., 2018 Meta-analysis 8
Egypt Khedr et al., 2013 6,498 Door-to-door cross-sectional 9.3
Farghaly et al., 2018 36,195 Door-to-door survey 9.7
Tunisia Attia-Romdhane et al., 1994 35,370 Retrospective 4.04
Sudan Younis, 1,983 20,000 Retrospective 0.9
Libya Sridharan et al., 1986 568 Population-based study 2.3
Asia India Goel et al., 2009 14,086 Door-to-door cross-sectional 10
Das et al., 2006 52,377 Cross-sectional 5.9
Radhakrishnan et al., 2000 238,102 Door-to-door survey 4.7
Mani et al., 1997 64,963 Retrospective 4.6
Pakistan Aziz et al., 1994 24,130 Door-to-door cross-sectional 9.99
China Ding et al., 2018 54,976 Door-to-door cross-sectional 2.4
Pi et al., 2014 32,059 Door-to-door cross-sectional 2.8
Gu et al., 2013 7,695,961 Meta-analysis 2.89
Pi et al., 2012 32,059 Door-to-door cross-sectional 2.83
Fong et al., 2013 17,783 Population-based survey 3.94
Japan Tanaka et al., 2019 3,333 Door-to-door cross-sectional 6.9
Taiwan Chen et al., 2012 131,287 Retrospective 5.85
South Korea Lee et al., 2016 6,774 Retrospective 3.84
KSA Alrajeh et al., 2001 23,700 Door-to-door cross-sectional 6.54

(39.2%). However, generalized and slowing abnormali- Discussion

ties were observed in 8 and 6 patients (15.6% and
11.7%, respectively) (Table 4). The prevalence rate of Currently, it is well accepted that door-to-door surveys
active epilepsy according to EEG and MRI findings was are the most accurate method to study the epidemiology
impossible to be calculated due to the lack of data of of active epilepsy in populations that excludes unrelated
some patients. types and detect undiagnosed cases [2, 13]. This approach
was also followed in this study and utilized different stag-
Types of Epilepsy across Different Age Groups es including an initial interview with the patient, family
Simple partial and complex partial were more com- members, and other witnesses by well-trained health pro-
mon in infants and children (33.3% and 66.7%), respec- fessionals, examining the patient at the clinical by an ex-
tively. However, partial with secondary generalized or perienced neurologist, and confirming the diagnosis by
generalized epilepsy were more common in adolescents other neurological examinations (MRI and EEG) and ep-
and young adults (Table 5) ileptologists. Besides, our study is still unique as it is the

84 Neuroepidemiology 2023;57:78–89 Al Rumayyan/Alharthi/Al-Rowaili/

DOI: 10.1159/000522442 Al-Mehmadi/Altwaijri/Alrifai/Badri
first one since 2001 (the last recent update) which pro- On the other hand, the prevalence of active epilepsy in
vides more updates about the prevalence of active epi- patients of all ages in this study was lower than those previ-
lepsy in the Saudi population of all ages. ously reported for the Saudi population in 2001 in the east-
In this study, the current overall prevalence of active ern region of the Kingdom [11]. Since the patients of both
epilepsy among the Saudi individuals who are residents in studies are of the same race, religion, ages, and ethnicity,
the central province of the KSA, Riyadh area, was shown and given that a similar survey protocol was followed, it
to be about 3.96/1,000 persons. We have compared this seems reasonable that the reduction in the number of pa-
prevalence rate with recent global rates, as well as with the tients between 2001 and our study (conducted in 2016)
most recent (or available) prevalence rates which have could be attributed to the significant improvement in the
previously studied the epidemiology of active epilepsy in education and health systems (diagnosis, treatment, food,
both developing and non-developing countries (Table 6). etc.). On the other hand, being diagnosed with epilepsy

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Our data suggest that the prevalence of active epilepsy represents a major stigma that adversely affects patient’s
cases in the Saudi’s population is less than those reported quality of life due to its associated negative psychological
globally (6.38/1,000 persons) [7], as well as than the those (fear, depression, anger, denial, rejection), economical (i.e.,
previously reported in the USA, some European countries loss of work or unemployed), and social (e.g., marriage)
(i.e., Italy, Denmark, Finland, and Turkey), and some Lat- influences [8, 33, 34]. These factors may also have contrib-
in American countries (Brazil and Ecuador) which had an uted significantly to the lower rates of epilepsy among our
average prevalence rate of 5–9.9/1,000 persons [15–21]. study population, especially those who have hidden their
Also, the prevalence of epilepsy in our study population condition during the initial screening phase. In support,
are less than those reported in some Arabic-African coun- Banerjee et al. [35] argued that lower estimates of epilepsy
tries (4.04/1,000 in Tunisia, and 7.9–9.3/1,000 persons in in Asia may be attributed to the high levels of stigmatization
Egypt) [13, 22, 23] as well as some Asian countries includ- experienced by the affected individuals. In the same line,
ing Pakistan, Japan, India, Korea, and Taiwan where the Obaid [33] has indicated that 88.6% of patients with diag-
prevalence of the active cases were 9.9, 6.9, 4.6–10, and nosed epilepsy disliked being reported to have epilepsy as
5.85/1,000 persons, respectively [24–27]. it is considered a mental or psychiatric illness in the Ara-
However, the prevalence rate of active epilepsy in our bian area and preferred to use alternative terms. Addition-
patients was higher than those reported in China (2.4– ally, observations from our clinical practice indicate that
3.8/persons) [2, 28–30], Sudan (0.9/1,000) [31], and Libya patients with epilepsy often consider alternative therapies
(2.3/1,000 persons) [32]. Such variation between our data (e.g., herbal therapy, acupuncture, spiritual/psychiatric
and those mentioned above could be explained by the therapy, etc.) rather than clinical consultation.
variations in the study population, age, sex, ethnicity, On the other hand, we could not find any difference in
country income, infections, sampling criteria, study de- the prevalence of active epilepsy between males and fe-
sign, reporting methods, and measurements [4, 7]. Be- males (3.99 vs. 3.94/1,000). This supports the conclusion
sides, other contributing factors which may affect the reported by Fiest et al. [7] who analyzed 197 epidemio-
prevalence of active epilepsy between countries included logical studies of epilepsy and showed no effect of gender
the variations in accuracy of diagnosis (i.e., active epilep- on the prevalence of the active cases of epilepsy, but it may
sy, including the cases with partial or complete remission affect the incidence rate. Other studies in the USA, Italy,
(lifetime prevalence), local distribution of risk factors, parts of Asia, and China have also shown no significant
and the number of seizures diagnosed [4]. However, se- difference in the prevalence of active epilepsy between
lection bias and poor methodology were reported in the males and females [30, 36–39]. However, some other
Sudanese and the Libyan studies which may explain their studies have shown more prevalence in males [11, 40–42],
unusually low prevalence. Indeed, the patients who are whereas another two studies reported the opposite [43,
younger than 5 years old and/or patients who presented 44]. One possible explanation for the similarity in the
a single seizure were excluded from the Libyan study [32]. prevalence between males and females is the reduced par-
Besides, patients who presented with seizures during only ticipation of females who preferred to conceal their con-
the last 3 years (not 5 years) were not included in the Su- dition for sociocultural reasons (i.e., marriage) [4, 33, 45].
danese study [31]. Also, some of the above worldwide- Nonetheless, during the last decades, the incidence and
mentioned studies were performed only in selected age prevalence of epilepsy have dramatically reduced in chil-
groups (e.g., children or adults) or were conducted in a dren and the youngest age group perhaps due to the im-
multiethnic community. provement in sanitation, control of infection, and increased

Prevalence of Epilepsy in KSA Neuroepidemiology 2023;57:78–89 85

DOI: 10.1159/000522442
perinatal care [4, 46]. On the contrary, they increased in the 136 (28%) of Saudi’s patients with active epilepsy have par-
elderly probably due to increased age-related epileptogenic tial seizures (21 cases of complex partial vs. 17 cases of sim-
disorders such as neurodegenerative disorders, tumors, ple partial simple). Besides, they also showed that 21% of
stroke, as well as the increase in the life expectancy [4, 46]. the total population had generalized seizures.
Indeed, several lines of evidence have shown an increased Concerning etiology, it has been also shown that focal
prevalence of epilepsy in old patients who are more than 60 epilepsies of unknown etiology are the most common
years old [35] [17, 41, 47, 48]. Our data contradict this and type seen in people newly diagnosed with epilepsy [4, 53,
showed that active epilepsy was more common in patients 54]. In an old USA population-based study, it has been
of lower ages. Accordingly, about 85% of our patients de- demonstrated that epilepsy with unknown etiology was
veloped epileptic seizures before the age of 40, of which al- the most common in patients with active epilepsy and has
most 60% are diagnosed with active epilepsy before the age a prevalence rate is about 1.75/1,000 per person [53].

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of 20. However, the highest prevalence of active epilepsy However, symptomatic partial epilepsies due to metabol-
was seen among young adults (19–40 years old/29.1%) and ic or structural epilepsies occupied second place (1.72)
the least in elderly people (more than 60). These follow and were followed by symptomatic cryptogenic epilepsies
many other studies which were conducted in Egypt, Swe- (0.4%) [53]. According to GBD (2016), the prevalence of
den, and Italy [13, 19, 39, 49]. Such low prevalence rates of idiopathic epilepsy was 3.29/1,000 persons. The global
active epilepsy in elderly people could be attributed to the prevalence of epilepsy due to idiopathic causes is 60–91%
presence of other cofactors or disorders that leads to impair [35]. In Egypt, 59.6% of the epileptic patients had idio-
the consciousness of the patients and hence interfere with pathic epilepsy where the main etiology was perinatal
the diagnosis. Besides, another possible explanation could complications, mainly, in infants, followed by CNS infec-
be the absence of elderly patients during the first site visit tions in children, and post-traumatic epilepsy in adoles-
due to staying with other family members outside the Ri- cence [23]. In the Asser region, the southern province of
yadh area, traveling outside the country for treatment, or KSA, the major etiological factors in children aged be-
staying at nursing homes. tween 6 and 18 years were cerebral trauma and febrile
On the other hand, according to the recent update and convulsions [55]. In a meta-analysis for the prevalence of
meta-analysis studies, the most common seizure type seen active epilepsy in the Arabic region in 5 countries, most
in both children and adults is the focal (partial) seizure [4, of the cases were of idiopathic causes (73.5–82.6%) where
50, 51]. On the other hand, other studies have shown that early childhood brain damage associated with mental re-
generalized tonic/clonic seizure is more common in coun- tardation and cerebral palsy were the major causes for
tries with low to medium income and was attributed to un- symptomatic epilepsy [8]. However, in Sudan, infection
derestimation of the other types of seizure, mainly due to was the leading cause of symptomatic epilepsy [31]. In a
lack of proper diagnostic tools [4, 52]. Accordingly, it has Turkish study, epilepsy due to idiopathic causes was 46%
been demonstrated that the prevalence of complex partial where developmental brain malformation and cranial
seizures in developing countries is less than 6% [11, 24, 45]. brain trauma were the most identifiable etiology [42].
In support, in Egypt, generalized tonic/clonic seizure was In the present study, the epilepsy cases with idiopathic
the most prevalent type of seizure [23]. In this study, the and cryptogenic etiology of seizures account for 21/55 of
authors also show that partial seizures were more common the cases (38%, 1.3/1,000 persons). This percentage is low-
during infancy, whereas generalized seizures were more er than that reported in the above-mentioned studies as
common in children and adolescence [23]. However, Saudi well as those previously reposted in KSA [10]. However,
Arabia is a country that is relatively characterized by high HIE was the most common etiology for the symptomatic
income with well-developed diagnostic tools and hospitals cases with a ratio of 12.7% of the total cases and 20.5% of
and well-trained physicians. In this study and using the symptomatic epilepsy. This percentage is lower than that
EEG and MRI imaging, 20 patients of the total 55 patients reported in the above-mentioned studies as well as those
diagnosed with active epilepsy had a partial seizure (2 sim- previously reposted in KSA. Indeed, the prevalence of id-
ple and 18 complex partial), thus presenting a total ratio of iopathic epilepsy among Saudi patients was 63% in 1990
35.6%. However, 16 patients had generalized seizures [10]. Also, the same authors have shown that perinatal en-
(29.1%), 14 patients had focal with secondary generaliza- cephalopathy and cerebral trauma are the major identified
tion (25.4%), and 5 patients remained unknown (9.1%). etiologic factors [10]. This reduction could be explained by
These data are almost in the same line as those previously the smaller sample size in our study, as well as the lack of
reported by Alrajeh et al. [11] who have shown that 38 of EEG and MRI data for some diagnosed patients.

86 Neuroepidemiology 2023;57:78–89 Al Rumayyan/Alharthi/Al-Rowaili/

DOI: 10.1159/000522442 Al-Mehmadi/Altwaijri/Alrifai/Badri
 However, trauma (secondary to motor vehicle acci- regarding the household census components such as the
dents) was reported in only one case. Though we expect- monthly income, educational levels, nutritional pattern,
ed this rate to be higher, the relatively low rate of trauma diet, electricity supply, living conditions, etc., which are vital
may be because no active conflict has occurred in Saudi components of the majority of the epidemiological studies.
Arabia for more than two decades. Moreover, rates of traf- The deficiency of these data could affect the findings of this
fic accidents in the area are considered among the highest study. In addition, we have already used a questionnaire
in the region, though trauma alone did not account for with pre-established sensitivity and specificity. One major
higher numbers of cases, especially in comparison to rates limitation validating our data is that we did not calculate
observed in Asian countries (which have the highest pro- these parameters from the questionnaire of this study to
portion of global road fatalities), where post-traumatic validate it. This could help in the future for better assess-
epilepsy accounts for 20% of all symptomatic epilepsy. ment of some types of seizures, especially focal dyscognitive

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In conclusion, the findings of this study represent the seizures. Finally, prevalence surveys also ascertain whether
most recent update on active epilepsy in Saudi’s popula- or not individuals are receiving adequate treatment. These
tion. Our study suggests a reduced prevalence of epilepsy data would be useful and maybe correlated with other de-
among all ages to levels lower than those reported in mographic factors. Another important limitation in this
many developing and developed countries. However, our study is that we have no information about the previous or
recommendation is to extend these types of surveys all current treatment of the tested individuals. The availability
through the Kingdom to have true values of the preva- of these data will enable the calculation of a treatment gap.
lence which will improve the diagnosis and treatment of
epilepsy among our population.
Acknowledgments
Limitations of the Study
The authors express their heartfelt gratitude to those who, in one
The major limitation of this study is the small sample way or another, helped in the completion of this research study in-
size. A lower sample size may reduce the power of the epi- cluding Dr. Mahmoud AlKhateeb, Dr. Emad Masuadi, and Dr. Aamir
demiological studies. Such small size in our study could be Omair from the College of Medicine at KSAU-HS, Riyadh, KSA.
explained by several social and economic causes. The pres-
ent study was conducted in a single residential area and
might not reflect the overall epidemiology of seizure and Conflict of Interest Statement
epilepsy in the Saudi population. In addition, and due to
All the authors declare no conflict of interest.
restricted regulations, feeling of shame (stigma), and reli-
gious beliefs in the KSA population, many families refused
to meet the team and refused to participate in this study.
Funding Sources
Indeed, we have found a big hesitation of some examined
patients to give more information about their disease during This study is a student research project that was funded by the
the interview for some economic and social reasons. Be- King Abdullah International Medical Research Center (KIMRC)
sides, even though ethically approved, this study received no at King Saud Bin Abdulaziz University for Health Sciences (KSAU-
funding to cover the fees of the participants, physicians, and HS), Riyadh KSA.
subjects, as well as their transportation which limited ex-
panding the survey. In addition, as discussed in the materi-
Author Contributions
als and methods, we have targeted families living in Riyadh
for the last 10 years. In general, Riyadh is a very big and All the authors contributed to the conception or design of the
highly dynamic city where people keep coming and leaving. work and analysis and interpretation of the data, as well as drafting
In addition, part of this study was conducted during week- the manuscript or revising it critically for content and providing
end days where many families leave to travel to their home the final approval of the version to be published.
cities or other locations, either for relative visits or vacations.
Furthermore, trying to get additional information through
a follow-up interview from household members of some Data Availability Statement
families or getting in touch with that person with epilepsy The data that support the findings of this study are available
was unsuccessful and was a major cause for the missing data. from the corresponding author, Ahmed Al Rumayyan, upon rea-
Another limitation in this study is the lack of information sonable request.

Prevalence of Epilepsy in KSA Neuroepidemiology 2023;57:78–89 87

DOI: 10.1159/000522442
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Prevalence of Epilepsy in KSA Neuroepidemiology 2023;57:78–89 89

DOI: 10.1159/000522442