Complementary and alternative medicine for migraine and tension-type headache among the Malaysians

@#Background: The literature on complementary and alternative (CAM) therapies in South East Asia is limited. The objective of the study was to evaluate the frequencies of CAM therapies in the Malaysian patients with migraine and tension-type headache (TTH). We also assessed the reasons for CAM use. Methods: This was a cross-sectional study. The study was conducted in a tertiary hospital in Malaysia. Consecutive patients presenting with migraine and TTH to the neurology clinic were recruited. Demographic characteristics were documented. Data on CAM use, including frequency and the reasons was collected. Results: Six hundred and eighty five patients (365 TTH and 320 migraine) were recruited. They consisted of 305 (44.5%) Malay, 174 (25.4%) Chinese, 169 (24.7%) Indian and 37 (5.4%) patients from other ethnic groups. A total of 478 (69.8%) patients, comprising 266 (55.6%) patients with TTH and 212 (44.4%) patients with migraine used CAM therapies. The most commonly used CAM therapies were medicated oil (355 patients, 51.8%) and massage (246 patients, 35.9%). The most common reasons for CAM use were reduction of pain (47.7 %), stress reduction (34.9%), and “cooling” effect (27.4%). Thirteen (4.1%) patients with migraine practiced reflexology, whereas 5 (1.4%) patients with TTH practiced reflexology (p=0.032). Twenty three (7.2%) patients with migraine took vitamin supplements compared to 13 (3.6%) patients with TTH (p=0.039). On univariate analysis, CAM use was significantly associated with ethnic groups (p=0.014), gender (p<0.0001), age (p=0.004), salary (p=0.014), educational level (p=0.003), and headache subtypes (p= 0.067). On logistic regression, married women were more likely to use CAM (OR=1.864, 95% CI 1.216-2.858, p=0.004). Conclusion: A large number of Malaysian headache patients used CAM. The most common reasons were reduction of pain, stress and “heatiness”. Medicated oil was most commonly used, followed by massage. Married women were more likely to use CAM, and this was the only determinant in this study.

Cerebral venous thrombosis in multi-ethnic patients from Malaysia

@#Background & Objectives: The literature on cerebral venous thrombosis (CVT) in South East Asia is limited. The objectives were to evaluate the clinical profile, predisposing factors and clinical outcome of the CVT patients in Malaysia. Methods: We conducted a retrospective descriptive study of the CVT patients admitted to the neurology ward. The clinical presentation, predisposing factors, radiological findings, treatment and prognostic characteristics were evaluated from the charts. Clinical outcome on discharge and six months was measured by Modified Rankin Scale (mRS) scores. Poor outcome and good outcome was defined as Modified Rankin Scale (mRS) scores of 3-6 and 0-2 respectively. Results: Forty nine CVT patients who presented between 2007 and 2017 were recruited. The mean age was 43.51±16.52. The patients consisted of 39 Malaysians (13 Indians, 12 Malays, 12 Chinese, one Iban, one Eurasian descent), and ten non-Malaysians. Thirty (61.2%) patients were women. The most common presenting complaint was headache (75.5%). Six percent had multiple risk factors, whereas 51% had idiopathic CVT. The most common predisposing factors were oral contraceptive pill use (18.4%), followed by infection (12.2%), especially central nervous system (CNS) infection (6.1%); 11.8% had prothrombotic disorder. The most common location for CVT was superior sagittal sinus (83.7%). On neuroimaging, 77.6% had parenchymal lesions, 53.1% had venous infarcts and 38.8% had intracerebral haemorrhage, one patient had CVT complicated by rare venous collateral channels. Poor outcome on discharge and at six months was 38.8% and 33.3% respectively. On univariate analysis, female gender (p=0.002), seizures (p=0.037) and cerebral oedema (p=0.018) were associated with poor functional outcome. On binary logistic regression, female gender (OR=14.50, 95% CI 2.10-99.94,p=0.003) and seizures (OR=6.54, 95% CI 1.33-32.07, p=0.017) were associated with poor outcome. Conclusion: The CVT patients in this study had a higher proportion of CNS infections. Poor outcome was independently associated with female gender and seizures.

Disseminated Takayasu arteritis with neurovascular small and medium vessel involvement

@#Takayasu arteritis is a rare granulomatous vasculitis that is commonly classified as a large vessel disease. Small and medium vessel involvement are extremely rare, with only a few case reports describing neurovascular, ocular and cutaneous involvement. We describe a 21 year old Malaysian woman with pre-existing Takayasu arteritis confined to the large vessels, presenting one year later to our centre with status epilepticus. Extensive radiologic studies revealed diffuse encephalopathic changes and multifocal neurovascular involvement, with the vasculitis progressing to encompass the large, medium and small vessels. The patient was treated with high dose steroid therapy and discharged well with long term steroid and immunosuppressive therapy. Follow up MRI with vessel wall imaging sequence (VW-MR) and arterial spin labelling (ASL) perfusion imaging demonstrated intra and extracranial vessel wall inflammation, with generalized reduction in left sided cerebral blood flow. This case demonstrates that Takayasu arteritis is not exclusively a large vessel vasculitis, and that small and medium vessel involvement does not preclude its diagnosis.

Predictors of functional outcome in patients with stroke thrombolysis in a tertiary hospital in Malaysia

INTRODUCTION@#Intravenous (IV) thrombolysis with alteplase (rt-PA) is effective in ischaemic stroke. The primary objective was to evaluate predictors of functional outcome in acute ischaemic stroke (AIS) patients treated with IV rt-PA. The secondary objective was to assess the outcome with the modified Rankin scale (mRS). We also examined the predictive value of the Totaled Health Risks in Vascular Events (THRIVE) score.@*METHODS@#AIS patients treated with IV rt-PA from February 2012 to August 2016 were recruited. Demographic data, National Institutes of Health Stroke Scale (NIHSS) scores, timing and neuroradiological findings were recorded. Patients received a dose of 0.9 mg/kg IV rt-PA within 4.5 hours of symptom onset. mRS score was evaluated at discharge and three months, and good and poor clinical outcomes were defined as scores of 0-2 and 3-6, respectively. Baseline THRIVE scores were assessed.@*RESULTS@#36 patients received IV rt-PA. 20 (55.6%) patients had an mRS score of 0-2 at three months. Based on THRIVE score, 86.1% had a good or moderately good prognosis. On univariate analysis, poor outcome was associated with NIHSS score before rt-PA (p = 0.03), THRIVE score (p = 0.02), stroke subtype (p = 0.049) and diabetes mellitus (DM; p = 0.06). Multiple logistic regression showed that outcome was significantly associated with NIHSS score before rt-PA (p = 0.032) and DM (p = 0.010).@*CONCLUSION@#Our newly developed Malaysian IV rt-PA service is safe, with similar outcomes to the published literature. Functional outcome after thrombolysis was associated with baseline NIHSS score and DM.

Moyamoya disease in a young woman with intraand extracranial vessels involvement on vessel wall imaging

@#Moyamoya disease (MMD) was first described in 1957 as “bilateral hypoplasia of internal carotid arteries (ICAs)”.1 Aside from involving the intracranial arteries, MMD can also affect extracranial ICAs and external carotid arteries (ECAs).2-4 High resolution magnetic resonance (MR) vessel wall imaging (VWI) is increasingly being used to help with the diagnosis and characterization of the condition focusing mainly on intracranial vessels and extracranial ICAs.5-9 We present a case of a young woman with MMD, demonstrating vessel wall enhancement of nonstenotic maxillary branches of bilateral ECAs.

Tuberculous optochiasmatic arachnoiditis and optochiasmatic tuberculoma in Malaysia

@#Background & Objectives: Arachnoiditis which involves the optic chiasm and optic nervecan rarely occurs in the patients with tuberculous meningitis (TBM). The primary objective of this study was to determine the incidence, assess the clinical and neuroimaging findings, and associations, understand its pathogenesis of these patients, and determine its prognosis. Methods: The patients admitted with TBM in the neurology wards of two tertiary care hospitals from 2009 to 2017 in Kuala Lumpur, Malaysia were screened. The patients with OCA and optochiasmatic tuberculoma were included in this study. We assessed the clinical, cerebrospinal fluid (CSF), imaging findings of the study subjects and compared with other patients without OCA or optochiasmatic tuberculoma. Results: Eighty-eight patients with TBM were seen during the study period. Seven (8.0%) had OCA and one (1.1%) had optochiasmatic tuberculoma. Five out of seven (71.4%) patients with OCA were newly diagnosed cases of TBM. The other two (28.6%) had involvement while on treatment with antituberculous treatment (paradoxical manifestation). The mean age of the patients with OCA was 27.3 ± 11.7. All the OCA patients had leptomeningeal enhancement at other sites. All had hydrocephalus and cerebral infarcts on brain neuroimaging. Three (42.9%) patients had cerebral tuberculoma at sites other than suprasellar and optic chiasm areas. On univariate analysis, the presence of OCA and optochiasmatic tuberculoma was associated with raised CSF opening pressure (p=0.014), younger age (p=0.024), cerebral infarcts (p=0.018) and hydrocephalus (p= 0.046). There was no statistically significant association on logistic regression. Only one (14.3%) patient had visual impairment. Conclusion: OCA and optochiasmatic tuberculoma were seen in 9% of a cohort of Malaysian TBM patients. They were more likely to be younger, have raised CSF opening pressure, cerebral infarcts and hydrocephalus, suggesting the association with a more severe exudative disease.

Role of cytokines in the assessment of clinical outcome and neuroimaging findings in patients with tuberculous meningitis

Background: Tuberculous meningitis is a life-threatening manifestation resulting from infection by Mycobacterium tuberculosis, especially in the developing countries. The molecular aspects of pathogenesis of tuberculous meningitis remain poorly understood. We evaluated the correlation of cerebrospinal fluid (CSF) and serum cytokine levels with the clinical outcome of 15 HIV-negative patients with tuberculous meningitis. We also assessed the association of CSF and serum cytokines with neuroimaging of brain findings in the patients. Methods: The prospective longitudinal study was conducted at the University Malaya Medical Centre between 2012 and 2014. Neuroimaging of the brain was performed and the findings of leptomeningeal enhancement, hydrocephalus, tuberculoma, infarcts and vasculopathy were recorded. The CSF and serum specimens were analyzed for IL-1ß, IL-8, IL-10, IL-18, IP-10, IFN-γ, MCP-1, TGF-ß, VEGF, TNF- α, IL-18BPa and MMP-9. The clinical outcome was graded at 3 months based on Modified Rankin scale (mRS). Results: On admission and at one month of anti-tuberculosis treatment, the CSF levels of IL-8, IL-1β, IP-10, IFN-γ and VEGF were elevated in all of the patients. Serum IP-10, MCP-1, IL-1β and IL-8 levels were increased on admission and at one month of anti-tuberculosis treatment. There were statistically significant differences between good and poor outcome (mRS at 3 months) for CSF IFN-γ (p=0.033), CSF IL-10 (p=0.033) and serum VEGF (p=0.033) at one month of treatment. None of the patients showed any association between CSF and serum cytokines on admission and at one month of anti-tuberculosis treatment with neuro-radiological findings. Conclusion: The CSF cytokine levels were not related to TBM disease severity on admission, and changes on MRI/CT scans. CSF levels of IFN-γ and IL-10 at one month of anti-tuberculosis treatment were associated with clinical outcome at 3 months. CSF cytokine levels on admission were not associated with the clinical outcome.

Spinal tuberculous disease is common in tuberculous meningitis

Background: Tuberculous disease of spine (spinal TB) is under-recognized in tuberculous (TB) meningitis.The objective of the study was to evaluate the frequency, clinical and neuroimaging changes, andoutcome in the patients with spinal TB. Methods: All the patients with spinal TB admitted in the twolargest tertiary hospitals in Kuala Lumpur from 2009 to 2017 were recruited, the clinical features weredocumented, the magnetic resonance imaging (MRI) of the spine was performed. Clinical outcome wasassessed with Modified Rankin scale (MRS). Results: Twenty two patients were recruited. This wasout of 70 TB meningitis patients (31.4%) seen over the same period. Eighteen (81.8%) patients hadconcomitant TB meningitis. The clinical features consisted of systemic symptoms with fever (63.6%),meningitis symptoms with altered sensorium (45.5%), myelopathy with paraparesis (36.4%). Thefindings on spinal MRI were discitis (36.4%), spinal meningeal enhancement (31.8%), spinal cordcompression (31.8%), psoas abscess (27.3%), osteomyelitis (22.7%), and cord oedema (22.7%). Allexcept two patients (90.9%) had involvement in psoas muscle, bone or leptomeningeal enhancement,features that can be used to differentiate from myelopathy that affect the parenchyma only, such asdemyelination. Unusual manifestations were syringomyelia and paradoxical manifestations seen in 3patients each. The outcome were overall poor, with 68% having MRS 3 or more.Conclusion: Spinal TB is common in TB meningitis. The outcome is overall poor. A heightenedawareness is crucial to enable early diagnosis and treatment.

Neuroimaging findings are sensitive and specific in diagnosis of tuberculous meningitis

Objective: The primary objective of this study was to describe the neuroimaging changes of tuberculous meningitis (TBM), and to determine the role of neuroimaging in the diagnosis of TBM. Methods: Between January 2009 and July 2015, we prospectively recruited TBM patients in two hospitals in Malaysia. Neuroimaging was performed and findings were recorded. The control consists of other types of meningo-encephalitis seen over the same period. Results: Fifty four TBM patients were recruited. Leptomeningeal enhancement was seen in 39 (72.2%) patients, commonly at prepontine cistern and interpeduncular fossa. Hydrocephalus was observed in 38 (70.4%) patients, 25 (46.3%) patients had moderate and severe hydrocephalus. Thirty four patients (63.0%) had cerebral infarction. Tuberculoma were seen in 29 (53.7%) patients; 27 (50.0%) patients had classical tuberculoma, 2 (3.7%) patients had “other” type of tuberculoma, 18 (33.3%) patients had ≥5 tuberculoma, and 11 (20.4%) patients had < 5 tuberculoma. Fifteen (37.2%) patients had vasculitis, 6 (11.1%) patients had vasospasm. Close to nine tenth (88.9%) of the patients had ≥1 classical neuroimaging features, 77.8% had ≥ 2 classical imaging features of TBM (basal enhancement, hydrocephalus, basal ganglia / thalamic infarct, classical tuberculoma, and vasculitis/vasospasm). Only 4% with other types of meningitis/encephalitis had ≥1 feature, and 1% had two or more classical TBM neuroimaging features. The sensitivity of the imaging features of the imaging features for diagnosis of TBM was 88.9% and the specificity was 95.6%. Conclusion: The classic imaging features of basal enhancement, hydrocephalus, basal ganglia/thalamic infarct, classic tuberculoma, and vasculitis are sensitive and specific to diagnosis of TBM.

Primary angiitis of the central nervous system with myelopathy as initial clinical presentation

Primary angiitis of the central nervous system (PACNS) is a rare vasculitis restricted to the central nervous system without systemic involvement. Delay in diagnosis and treatment is common due to its non-specific symptoms and lack of non-invasive diagnostic tests. Myelopathy can occur in PACNS, during the clinical course of the illness, with or without cerebral symptoms. We describe here a 51 year-old ethnic Chinese woman who presented initially with paraparesis without cerebral symptoms. The diagnosis of PACNS was eventually made from brain biopsy when she subsequently developed cerebral involvement. Despite aggressive treatment, the patient developed progressive neurological deterioration and died. This patient demonstrates the rare occurrence of myelopathy as the sole initial presentation of PACNS.

Leptomeningeal glioblastoma multiforme presenting as cauda equina syndrome

Glioblastoma multiforme (GBM) is the commonest primary cerebral malignancy consisting of 12- 20% of intracranial brain tumours.1 We report here a patient with GBM with very unusual marked and widespread leptomeningeal GBM.