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.

Cavernomatosis múltiple y aneurisma cerebral trombosado: una asociación inusual / Cavernous haemangioma multiple and brain aneurysm thrombosed: an unusual association

Los cavernomas son malformaciones angiográficamente ocultas, pueden ser únicos o múltiples y esporádica o familiar.Suelen asociarse a otras malformaciones vasculares como las anomalías de drenaje venoso, sin embargo no es habitual su asociación con aneurismas cerebrales. Los aneurismas son malformaciones evidenciables en angiografía, sin embargo cuando se encuentran trombosados puede dificultarse su diagnostico, observándose en algunos casos como lesiones pseudotumorales. Nuestro objetivo es exponer una rara asociación entre cavernomatosis múltiple y aneurisma cerebral trombosado en un paciente pediátrico. Presentamos una paciente de 2 años de edad con diagnóstico de cavernomatosis múltiple y aneurisma cerebral trombosado. Se realiza una revisión de la literatura de ambas entidades y su rara asociación, medianteuna búsqueda exhaustiva en la base de datos de PUBMED Y COCHRANE utilizando las siguientes palabras claves: Cavernous angioma. Familial cavernomatosis. Hemorrhagic stroke. Multiple cavernomatosis. Cerebral aneurysm. Thrombosed aneurysm. Se discute la epidemiologia, diagnóstico y manejo quirúrgico de la cavernomatosis múltiple y sus asociaciones, preconizando fundamentalmente la evaluación pre quirúrgica de estos pacientes. No encontramos ningún caso de asociación entre cavernomatosis múltiple y aneurismas en nuestra revisión bibliográfica. Dado que se pueden presentar como lesiones pseudotumorales, la tomografía computada, resonancia magnética y la angiografía cerebral son métodos fundamentales para llegar a un diagnostico prequirúrgico certero. La indicación quirúrgica debe ser evaluada individualmente en cada paciente, y se debe realizar un seguimiento clínico-imagenologico.

Cavernomas are angiographically occult malformations may be single or multiple and sporadic or familial. Usually associated with other vascular malformations such as venous drainage anomalies, however it is not common its association with brain aneurysms. Aneurysms are into evidence malformations in angiography, however when they meet their diagnosis can be difficult thrombosed observed in some cases as pseudotumoral injuries. Our goal is to present a rare association between multiple cavernous haemangioma and thrombosed cerebral aneurysm in a pediatric patient. We present a patient 2 years old diagnosed with multiple cavernous haemangioma and thrombosed cerebral aneurysm. A review of the literature of both entities and its rare association is done through an exhaustive search in the database PUBMED and COCHRANE using the following keywords: Cavernous angioma. Familial cavernous haemangioma. Hemorrhagic stroke. Multiple cavernous haemangioma. Brain aneurysm. Thrombosed aneurysm. The epidemiology, diagnosis and surgical management of multiple cavernous haemangioma and their associations is discussedessentially advocating the presurgical evaluation of these patients. No case of association between multiple cavernous haemangioma and aneurysms in our literature review. Because can be presented as pseudotumoral lesions, computed tomography, magnetic resonance imaging and cerebral angiography are fundamental methods to reach an certain diagnosis preoperatively. The surgical indication should be evaluated individually for each patient, and should be performed a clinical-imaging follow-up.

Efficacy Observation of Dexmedetomidine for Cerebral Protection in Brain Aneurysm Surgery / 中国药房

OBJECTIVE:To observe the cerebral protective effects of dexmedetomidine in brain aneurysm surgery. METH-ODS:48 patients with intracranial aneurysm were randomly divided into observation group and control group,with 24 cases in each group. Observation group was given dexmedetomidine 1 μg/kg,pump time 10 min,at rate of 0.5 μg/kg;control group re-ceived constant volume of normal saline. Hemodynamic changes,the levels of S100β protein and neuron specific enolase (NSE) were compared between 2 groups. RESULTS:The heart rate and mean arterial blood pressure were more stable in the observation group after medication,with statistical significance(P<0.05). The serum level of S100β protein at the end of operation(T5),6 h after operation(T6),12 h after operation(T7),24 h after operation(T8)were(1.52±0.35)μg/L,(1.69±0.33)μg/L,(1.72±0.42)μg/L,(2.08±0.57)μg/L;the serum level of NSE were(10.9±1.2)ng/L,(13.5±1.5)ng/L,(16.8±2.8)ng/L and(19.7±4.3)ng/L in observation group;those were all lower than in control group,with statistical significance(P<0.05). CONCLUSIONS:Dexme-detomidine for cerebral aneurysm operation is helpful for hemodynamics stability,and result in lower S100β protein and NSE. So it is important for cerebral protection.

Hemorragia subaracnóidea aneurismática: análise da evolução dos pacientes internados em um hospital de Tubarão / Aneurysmal subarachnoid hemorrhage: analysis of the evolution of the patients hospitalized at a hospital of Tubarão

Introdução: Estima-se que 2 a 3% dos seres humanos sejam portadores de aneurismas intracranianos. A ruptura dessas lesões gera um quadro clínico grave, com hemorragia subaracnóidea, cuja taxa de mortalidade chega a 40%. Objetivo: Analisar a evolução dos pacientes com hemorragia subaracnóidea de origem aneurismática internados no Hospital Nossa Senhora da Conceição (HNSC). Métodos: Realizado um estudo de coorte histórica e coorte. A população foi composta por todos os pacientes portadores de hemorragia subaracnóidea aneurismática internados entre janeiro de 2005 e maio de 2007. Resultados: A população foi composta por 33 pacientes, com prevalência maior em mulheres (57.5%). Pacientes tabagistas totalizaram 63% e hipertensos 54.6%. História prévia de aneurismas foi duas vezes maior no grupo de mau prognóstico (RP=2.00; IC 95%: 1.32-2.92). Cefaléia ou meningismo foi a apresentação clínica mais comum (66.7%). Pacientes submetidos ao tratamento cirúrgico apresentaram uma prevalência quase 60% menor de vir a ter um desfecho ruim na alta hospitalar (RP=0.43; IC 95%: 0.26-0.70; pKruskal-Wallis =0.03). Após a hemorragia aguda, 42.3% dos integrantes puderam retomar suas atividades laborais. Conclusão: Os resultados encontrados foram compatíveis com os descritos na literatura, o que sustenta a manutenção da modalidade terapêutica atual do HNSC frente aos pacientes com hemorragia subaracnóidea aneurismática.

Introduction: It is estimated that 2 to 3% of humans have intracranial aneurysms. The rupture of this lesion develop a serious clinical situation, with subarachnoid hemorrhage, whose rate of mortality arrives to 40%. Objective: To analyze the evolution of the patients with subarachnoid hemorrhage originated from intracranial aneurysms hospitalized at Nossa Senhora da Conceição Hospital (HNSC). Methods: A study of historical cohort and cohort. The population was formed by aneurysmal subarachnoid hemorrhage diagnosis patients hospitalized from January 2005 though May of 2007. Results: The population was formed by 33, with a higher prevalence in women (57.5%). Patients who were smokers summed 63%, and those with hypertension 54.6%. Previous history of aneurism was two times higher in the group of bad prognosis (PR=2.00; CI 95%: 1.32-2.92). Headache or meningism was the most common clinical presentation (66.7%). Patients submitted to surgical treatment presented a prevalence almost 60% lower of coming to have a bad prognosis in the discharge (PR=0.43; CI 95%: 0.26-0.70; pKruskal-Wallis =0.03). After the sharp hemorrhage, 42.3% of the participants were able to return to their labor activities. Conclusions: The results found here were compatible with the literature, ones what sustains the maintenance of the current therapeutic modality of the HNSC front to the patients with aneurysmal subarachnoid hemorrhage.

Endovascular Treatment of Cerebral Aneurysm: Early Experience in a Malaysian Tertiary Centre

Universiti Kebangsaan Malaysia Medical Center (UKMMC) started neurointerventional service in August 2008. In this study, we aimed to evaluate the immediate and short term outcome of endovascular treatment (EVT) of cerebral aneurysm during early period of the services. A retrospective study for cerebral aneurysm treated by endovascular technique, from the Neurosurgical and Radiology Department from September 2008 till February 2010 was performed. Patient’s demographic data, initial clinical presentation and assessment of the aneurysm were performed. The immediate results and short term assessment post EVT were evaluated based on standard criteria. Recurrence and complications during and following EVT procedures, were recorded. Twenty one patients with total of 22 aneurysms were treated. The mean age was 54.52 years with 57% being males and 43% females. The majority (81%) had single aneurysm. The most common site was anterior communicating artery (28 %). Mean aneurysm sac size was 6.19 mm and 2.55 mm for aneurysm neck. At follow-up, 3 (27.2%) had a small residual neck. Four patients (37.2%) had residual aneurysm filling, but three of them were treated with stent aiming to achieve flow diversion effect instead of complete occlusion during initial treatment. There was no rebleed or rupture from the immediate to follow-up. Significant complications up to 30-days was observed in 4 patients (20%) whereby 2 patients showed improvement and 2 patients died (10 % mortality rate). Endovascular treatment of cerebral aneurysms performed in our centre had early outcome, morbidity and mortality compared to other higher volume centres. Longer term follow up is needed to evaluate the long term outcome/occlusion rate, morbidity and mortality.