Hypertensive Retinopathy and the Risk of Hemorrhagic Stroke

Objective@#: Hemorrhagic stroke (HS) and hypertensive retinopathy are known end organ damage of the brain and eye respectively, with HS having deleterious consequence to the patients. This study is to correlate between hypertensive retinopathy and HS in hypertensive disease. @*Methods@#: A control group of hypertensive patients only, and an investigated group of hypertensive HS patients. Fundoscopic examination to determine the grade of retinopathy was performed and then divided into low or high severity hypertensive retinopathy. Clinical and radiological parameter included are demography, vital signs, Glasgow coma scale (GCS) on admission, clot volume, site of clot, Intracerebral hemorrhage (ICH) score and Glasgow outcome scale (GOS). Data were correlated with the severity of hypertensive retinopathy. @*Results@#: Fifty patient in the control group and 51 patients in the investigated group were recruited. In the hypertensive HS group, 21 had low severity retinopathy (no or mild retinopathy) accounting for 41.2% and 30 patients had high severity (moderate or severe retinopathy). In the hypertensive patients 49 had low severity and one had high severity (p-value of 0.001). In HS group low severity showed better GCS score of 9–15 on admission (p-value of 0.003), clot volume less than 30 mL (p-value 0.001), and also a better 30 days mortality rate by using the ICH score (p-value 0.006), GOS score of 4 and 5 the low severity retinopathy fair better than the high severity retinopathy (p-value of 0.001), and the relative risk to develop HS in low severity and high severity retinopathy was 0.42 and 29.4, respectively. @*Conclusion@#: Hypertensive retinopathy screening could be used as an indicator in hypertensive patient, to evaluate the risk of developing hypertensive HS in the future.

Hypertensive Retinopathy and the Risk of Hemorrhagic Stroke

Objective@#: Hemorrhagic stroke (HS) and hypertensive retinopathy are known end organ damage of the brain and eye respectively, with HS having deleterious consequence to the patients. This study is to correlate between hypertensive retinopathy and HS in hypertensive disease. @*Methods@#: A control group of hypertensive patients only, and an investigated group of hypertensive HS patients. Fundoscopic examination to determine the grade of retinopathy was performed and then divided into low or high severity hypertensive retinopathy. Clinical and radiological parameter included are demography, vital signs, Glasgow coma scale (GCS) on admission, clot volume, site of clot, Intracerebral hemorrhage (ICH) score and Glasgow outcome scale (GOS). Data were correlated with the severity of hypertensive retinopathy. @*Results@#: Fifty patient in the control group and 51 patients in the investigated group were recruited. In the hypertensive HS group, 21 had low severity retinopathy (no or mild retinopathy) accounting for 41.2% and 30 patients had high severity (moderate or severe retinopathy). In the hypertensive patients 49 had low severity and one had high severity (p-value of 0.001). In HS group low severity showed better GCS score of 9–15 on admission (p-value of 0.003), clot volume less than 30 mL (p-value 0.001), and also a better 30 days mortality rate by using the ICH score (p-value 0.006), GOS score of 4 and 5 the low severity retinopathy fair better than the high severity retinopathy (p-value of 0.001), and the relative risk to develop HS in low severity and high severity retinopathy was 0.42 and 29.4, respectively. @*Conclusion@#: Hypertensive retinopathy screening could be used as an indicator in hypertensive patient, to evaluate the risk of developing hypertensive HS in the future.

Brain Tumours and Their Metabolic Profiles by Magnetic Resonance Spectroscopy

@#Introduction: Intracranial brain tumour like meningiomas and glioblastomas are most prevalent tumour. The metastasis to the brain is one of the major issues in the tumours of the central nervous system. The diagnosis of metastatic and primary brain tumour is incomprehensible with standard magnetic resonance imaging (MRI). The magnetic resonance spectroscopy (MRS) is basically performed in standard clinical setting for diagnosing and tracking the brain tumour. Method: It is a retrospective study containing 53 patients with MRS. The patients with metastatic tumour (n=10), glioblastomas (n=8) and meningiomas (n=20) are included in the study. Single voxel technique is applied in the tumour core to determine the metabolites. The tumour N-acetyl aspartate (NAA), Choline (Cho), Creatine (Cr), Lactate, Alanine and lipids were analysed. The ratios of NAA/Cr, Cho/NAA and Cho/Cr were recorded and compared between the three tumours. The metabolites were detected between short echo time (TE) to long echo time (TE) during MRS. Results: There is a sharp fall of NAA peak in metastatic tumour. The resonance of creatine, lactate and alanine is higher in glioblastomas. A high lipid mean value of 3.13(0.17) is seen in metastatic tumour. The ROC curve shows a low NAA/Cr specificity of 46.7%, high sensitivity of 83.3% in Cho/NAA and Cho/Cr ratio. Conclusion: The metabolic profiles of metastatic brain tumour, glioblastomas and meningioma illustrate a divergence in their description that will assist in planning therapeutic and surgical intervention of these tumours.

The use of magnetic resonance phase-contrast cine in Chiari malformation with syringomyelia

@#mesodermal origin and is commonly associated withsyringomyelia. Foramen magnum decompression is thefirst-line of standard treatment in symptomatic patients witha confirmed radiographic diagnosis. Magnetic resonance(MR) cine allows accurate evaluation of cerebrospinal fluid(CSF) physiology at the craniovertebral junction but oftenthis is under-utilised in Malaysia. Methods: In this series, we looked into nine cases of CM withsyringomyelia from clinical and radiological perspectivebefore and after surgery. The radiological parameters wereherniated tonsillar length, syrinx: cord ratio, syrinx lengthand diameter. Flow velocity and morphologic changes inChiari were illustrated. Results: Seven patients showed either reduction in syrinxlength, syrinx: cord ratio or both postoperatively. Clinicalrecovery somewhat varied in motor and sensory symptoms.Four patients gained better functional grade in modifiedRankin scale (MRS) while the rest remained similar. Thestudy highlighted the advantage of CSF flow dynamicsinformation over MR anatomical radiographic improvementin addressing the neurologic and functional recovery. Wealso discussed the practicality of cine sequence inpreoperative patient selection, syrinx analysis andpostoperative flow evaluation in anticipation of clinicaloutcome. Conclusion: Phase-contrast cine MRI is a useful tooldictated by resource availability. We recommend its routineuse in preoperative analysis and subsequent observationalfollow-up after surgery.

Deep Vein Thrombosis and the Neurosurgical Patient

@#Background: Neurosurgical patients are varied, encompassing cranial and spinal diseases and trauma, and are admitted under both elective and emergency settings. In all settings, neurosurgery patients are at risk of deep vein thrombosis. D-dimer and ultrasound Doppler have long been good screening and confirmatory tools for the diagnosis of deep vein thrombosis (DVT). We conducted a study to identify the factors associated with DVT among neurosurgical patients, and the overall rate of occurrence at our centre. We aimed to also compare our results to the incidence in similar studies elsewhere in which more judicious use of pharmacological prophylaxis was undertaken. We also included the Well’s score to validate its usefulness in screening for DVT in our local setting. Methods: All patients admitted into our centre were screened for eligibility and those who underwent surgery from September 2016 to September 2017 had a D-dimer screening after surgery, followed by an ultrasound Doppler if the former was positive. The choice of anticoagulant therapy was not influenced by this study, and observation of the use was in keeping with usual practices in our centre was done. Results: A total number of 331 patients were recruited in this study, however, after the inclusion and exclusion criteria had been met, 320 patients remained eligible, i.e. suitable for analysis. The mean age of our patients was 46 years, with 66% being male patients. A majority of the cases in this study were cranial related, with only 5% being spine surgeries. On the multivariate analysis, the Well’s score and the number of days in bed remained statistically significant, after adjusting for age group, gender, ethnicity, type of central venous access and type of DVT prophylaxis with an adjusted odd’s ratio, and a confidence interval of 95%, and P < 0.05 for each. Conclusion: Well’s scoring and number of days in bed were independent factors affecting the rate of DVT in patients undergoing neurosurgical procedures in our centre.

The First Awake Clipping of a Brain Aneurysm in Malaysia and in ASEAN: Achieving International Standards

World-renowned neurosurgeon, Professor Saleem Abdulrauf, has been featured in several medical journals for his successful “Awake Brain Aneurysm Surgery”. Regarded as a “world first”, this surgery, involves clipping un-ruptured brain aneurysms while patients are awake. Only one or two neurosurgery centres worldwide are capable of this. Performing the surgery while the patient is awake lowers risks of brain ischemia with neurological deficits and ventilator associated morbidities. The technique has been viewed as the start of a new era in brain surgery. Physicians from the Universiti Sains Malaysia (USM) School of Medical Sciences, at the Health Campus in Kelantan, headed by Professor Dr Zamzuri Idris (neurosurgeon) and Dr Wan Mohd Nazaruddin Wan Hassan (neuroanaesthetist), recently performed a similar procedure, the first such surgery in Malaysia and Southeast Asia. The USM team can therefore be considered to be among the first few to have done this brain surgery and achieved successful patient outcomes.

Incidence, Clinico-Radiological Features and Outcome of Skull Base versus Non-Skull Base Meningiomas Treated in Kuala Lumpur General Hospital: A Five-Year Experience

Background: Meningiomas are the most common intracranial tumours; they accountfor 13%–26% of all the primary intracranial tumours. Skull base meningiomas make up 25% of allmeningiomas and are one of the most difficult intracranial tumours to be managed surgically. Thisis due to the fact that it is difficult to approach the lesions which are also close to vital structuressuch as cranial nerves and major blood vessels. Despite the abundance of these cases in Malaysia,local data on meningiomas is scarce.Methods: This is a retrospective study consisting of 199 patients with meningiomaswho have been operated at the Kuala Lumpur General Hospital from January 2010–December2014. They were categorised into skull base and non-skull base groups. Demography, tumourcharacteristics, and patient outcomes were analysed. Kaplan-Meier survival curves as well asCox hazard univariable and multivariable regressions for the possible predictors of survival wereanalysed.Results: 97.5% of the patients (n = 194) had WHO grade I meningioma and only fivepatients had WHO grade II meningioma. There was a female predominance (n = 134; 67.3%), witha male-to-female ratio of 1:2. Some 27.1 % patients had skull base meningiomas. Patients with skullbase meningiomas had poorer outcomes and discharge conditions (n = 23; 42.6% P < 0.01), inaddition to higher risk of incomplete resections (n = 34; 63% P < 0.01). Multivariate cox hazardregressions showed that the skull base meningioma group had four times the risk of death of thenon-skull base group.Conclusions: Symptomatic meningiomas can be curative if the tumour is completelyremoved. Our study has revealed that skull base meningiomas which were operated locallyhad higher rates of incomplete resection and poorer surgical outcomes as compared to the nonskullbase group. Patients with skull base meningiomas had four times the risk of death vis-à-visnon-skull base ones. More local studies are needed to look into skull base meningiomas for theimprovement of its surgical outcomes.

Inflammatory Biomarkers and Their Value in Predicting Survival and Outcome among Patients with Spontaneous Intracerebral Haemorrhage

Background: Spontaneous intracerebral haemorrhage (SICH) has emerged as one of the most devastating forms of stroke in recent decades. This disease is noted to carry a 30-day mortality rate of approximately 45%. An increasing number of studies have implicated a complex immune-mediated and inflammation-mediated cascade of responses in the pathophysiology of SICH and the resultant neurologic outcome. Several clinical studies have demonstrated an association between inflammatory markers and outcome in patients with SICH. However, the exact relationship between serum biomarkers and functional outcomes amongst survivors has not been clearly elucidated. This study aimed to evaluate the changes in peripheral leukocyte count (WBC count) and C-reactive protein (CRP) levels in patients with SICH and to correlate these findings with survival and functional outcome. Methodology: A prospective, descriptive and correlational study was conducted at Sarawak General Hospital (SGH) over the span of two years (April 2013–April 2015). Patients aged between 30 years and 75 years with supratentorial intracerebral bleed secondary to uncontrolled hypertension were recruited in this study. Data pertaining to the demography, clinical and radiological parameters, peripheral WBC count and CRP levels were obtained. Mortality and functional outcomes were determined at 6 months post ictus. Patients were recruited following the fulfilment of exclusion and inclusion criteria, and all obtained data were analysed with the Statistical Package for Social Sciences (SPSS) for Windows version 21.0. Results: A total of 60 patients with a mean age of 56 years were recruited in this study. We found that approximately 16 patients were less than or equal to 50 years old (26.7%) and that 44 patients belonged to the older age group of above 50 years (73.3%). The Glasgow Coma Scale (GCS) score on admission ranged from 9 to 14/15 with a median value of 11/15. The mean clot volume was 20.1 cm3. The GCS score on admission and clot volume were significantly associated with the Glasgow Outcome Scale (GOS) at 6 months and overall survival (P < 0.05). The elevated WBC count and CRP level on admission and at 72 hours post admission were significantly associated with GOS at 6 months and overall survival (P < 0.05). Thus, the GCS score, clot volume, WBC count and CRP levels on admission and at 72 hours post admission can be used to predict functional outcome at 6 months and overall survival in patients with SICH. Conclusion: We could conclude via this study that for patients with SICH, the main determinants or predictors of functional outcome at 6 months and overall survival were noted to be the GCS score on admission, clot size, WBC count and CRP levels on admission and at 72 hours post admission.

Deep Brain Stimulation (DBS) for Movement Disorders: An Experience in Hospital Universiti Sains Malaysia (HUSM) Involving 12 Patients

Deep brain stimulation (DBS) was first introduced in 1987 to the developed world. As a developing country Malaysia begun its movement disorder program by doing ablation therapy using the Radionics system. Hospital Universiti Sains Malaysia a rural based teaching hospital had to take into consideration both health economics and outcomes in the area that it was providing neurosurgical care for when it initiated its Deep Brain Stimulation program. Most of the patients were from the low to medium social economic groups and could not afford payment for a DBS implant. We concentrated our DBS services to Parkinson's disease, Tourette's Syndrome and dystonia patients who had exhausted medical therapy. The case series of these patients and their follow-up are presented in this brief communication.

uncommon Elizabethkingia meningoseptica septicemia in hemorrhagic stroke with septic shock patient during prolonged neuro-intensive care management

Elizabethkingia meningoseptica septicemia is an uncommon nosocomial infection but has gradually emerged as the potential threat in intensive care setting. This organism is a multi-drug resistant, non-fermentative gram negative bacillus that is equipped with the ability to adapt to a spectrum of different environmental conditions. We report our first experience of managing E. meningoseptica septicemia in our ventilated hemorrhagic stroke patient with septic shock during prolonged neuro-intensive care management. The aim of this report is to highlight the update of this uncommon infection on incidence, risk factors, strategy of management and mortality related to it

Characteristics and Outcomes of Patients with Anterior Circulation Intracranial Aneurysm Managed with Clipping in Hospital Sungai Buloh

Introduction: The annual incidence of intracranial aneurysm in Malaysia is estimated to be 1.1–1.7 per 100,000 population based on a study done conducted in 1988. Since then, little epidemiological research has been conducted in Malaysia, and the real incidence is therefore probably unreported despite advancements in the diagnosis and treatment of this disorder. Intracranial aneurysm may be treated by microsurgical clipping or embolisation depending on its location and the surgeon’s preference. This study aims to report the characteristics and outcomes of patients with a clipped anterior circulation aneurysm in Hospital Sungai Buloh. Methods: We retrospectively collected the data of patients with anterior circulation aneurysms who underwent clipping from 1 January 2013 until 30 June 2014 in Hospital Sungai Buloh. Results: The mean age of the patients was 48.9 years old, and 56.7% of the study population were male and 63.3% were Malay. There were almost equal numbers of patients with (46.7%) and without (53.3%) co-morbidities such as hypertension and ischaemic heart disease. Half of the study population fell under Fisher grade 3 (50.0%), whereas 46.7% were Fisher grade 4. With respect to the Navarro score, 20% of patients scored 10, 16.7% scored 5 or 7, 13.3% scored 11, 10% scored 9, 6.7% scored 1 and 3.3% scored 2, 3 or 8. Most of the patients fell under grade I (33.3%) of the World Federation of Neurological Societies grading (WFNS), and the fewest number of patients were grade III (3.3%). Most (56.7%) patients had an intracranial aneurysm located at the anterior communicating artery (ACOM), followed by the anterior cerebral artery (ACA) and the middle cerebral artery (MCA) (16.7% each), the posterior communicating artery (PCOM) (6.7%) and, finally, the internal carotid artery (ICA) (3.3%). Neurological outcomes at three and six months were assessed using the Modified Rankin Scale (mRS). At three months follow-up, the majority of the participants (33.3%) scored 0 or 6, whereas at six months follow-up, the majority scored 0 (43.3%). Conclusion: The main characteristics of patients in Hospital Sungai Buloh were that they were in their 40s and mostly Malays without any known comorbidities. Although the majority of patients had high Fisher grades, their outcomes post intervention were promising. However,as data collected from Hospital Sungai Buloh may not be representative of the whole country, a larger-scale data collection is necessary to create our own database and to identify the risks factors that are exclusive to our country, if present.