Disruption of white matter integrity and its relationship with cognitive function in non-severe traumatic brain injury.

Background: Impairment in cognitive function is a recognized outcome of traumatic brain injury (TBI). However, the degree of impairment has variable relationship with TBI severity and time post injury. The underlying pathology is often due to diffuse axonal injury that has been found even in mild TBI. In this study, we examine the state of white matter putative connectivity in patients with non-severe TBI in the subacute phase, i.e., within 10 weeks of injury and determine its relationship with neuropsychological scores. Methods: We conducted a case-control prospective study involving 11 male adult patients with non-severe TBI and an age-matched control group of 11 adult male volunteers. Diffusion MRI scanning and neuropsychological tests were administered within 10 weeks post injury. The difference in fractional anisotropy (FA) values between the patient and control groups was examined using tract-based spatial statistics. The FA values that were significantly different between patients and controls were then correlated with neuropsychological tests in the patient group. Results: Several clusters with peak voxels of significant FA reductions (p < 0.05) in the white matter skeleton were seen in patients compared to the control group. These clusters were located in the superior fronto-occipital fasciculus, superior longitudinal fasciculus, uncinate fasciculus, and cingulum, as well as white matter fibers in the area of genu of corpus callosum, anterior corona radiata, superior corona radiata, anterior thalamic radiation and part of inferior frontal gyrus. Mean global FA magnitude correlated significantly with MAVLT immediate recall scores while matrix reasoning scores correlated positively with FA values in the area of right superior fronto-occipital fasciculus and left anterior corona radiata. Conclusion: The non-severe TBI patients had abnormally reduced FA values in multiple regions compared to controls that correlated with several measures of executive function during the sub-acute phase of TBI.

Risk Prediction of Cerebral Infarction after Anterior Circulation Aneurysm Rupture in an Under-Equipped Centre.

Background: Morbidity and mortality is high among aneurysm rupture patients. Despite surviving the initial rupture, morbidity is high as they suffer from vasospasm and cerebral infarction (CI). Most prediction tools for CI after aneurysmal subarachnoid haemorrhage (SAH) are complex and are not routinely available in all neurosurgical centres. Current therapies for prevention of CI are still debatable and selective usage among high-risk patients is advised. These factors necessitate a simple prediction model for identifying patients in the high risk group to initiate early preventive treatment of CI. Methods: Patients with anterior circulation aneurysm rupture who underwent surgical clipping were included. Demographic data and factors related to CI were collected to determine significance and were used to develop VINODH score (VS). Results: Two hundred patients were included with a median age of 51 years old. Multivariate analysis proved only four predictors were significant (P < 0.01) for developing CI. These predictors were used for the development of VS which was named after the main author and the model's sensitivity was 79.0% and specificity was 83.0%. This highly predictive score (receiver operating characteristic [ROC]: 0.902) was internally validated. Conclusion: VS is a reliable tool for early identification of patients at risk of CI after aneurysmal SAH.

Alteration in the Functional Organization of the Default Mode Network Following Closed Non-severe Traumatic Brain Injury.

The debilitating effect of traumatic brain injury (TBI) extends years after the initial injury and hampers the recovery process and quality of life. In this study, we explore the functional reorganization of the default mode network (DMN) of those affected with non-severe TBI. Traumatic brain injury (TBI) is a wide-spectrum disease that has heterogeneous effects on its victims and impacts everyday functioning. The functional disruption of the default mode network (DMN) after TBI has been established, but its link to causal effective connectivity remains to be explored. This study investigated the differences in the DMN between healthy participants and mild and moderate TBI, in terms of functional and effective connectivity using resting-state functional magnetic resonance imaging (fMRI). Nineteen non-severe TBI (mean age 30.84 ± 14.56) and twenty-two healthy (HC; mean age 27.23 ± 6.32) participants were recruited for this study. Resting-state fMRI data were obtained at the subacute phase (mean days 40.63 ± 10.14) and analyzed for functional activation and connectivity, independent component analysis, and effective connectivity within and between the DMN. Neuropsychological tests were also performed to assess the cognitive and memory domains. Compared to the HC, the TBI group exhibited lower activation in the thalamus, as well as significant functional hypoconnectivity between DMN and LN. Within the DMN nodes, decreased activations were detected in the left inferior parietal lobule, precuneus, and right superior frontal gyrus. Altered effective connectivities were also observed in the TBI group and were linked to the diminished activation in the left parietal region and precuneus. With regard to intra-DMN connectivity within the TBI group, positive correlations were found in verbal and visual memory with the language network, while a negative correlation was found in the cognitive domain with the visual network. Our results suggested that aberrant activities and functional connectivities within the DMN and with other RSNs were accompanied by the altered effective connectivities in the TBI group. These alterations were associated with impaired cognitive and memory domains in the TBI group, in particular within the language domain. These findings may provide insight for future TBI observational and interventional research.

Risk Factors Associated with Outcome of Spontaneous Intracerebral Haemorrhage: Hospital Kuala Lumpur Experience.

Background: Stroke is the third leading cause of death in Malaysia. This study aims to evaluate the mortality risk factors of spontaneous intracerebral haemorrhage (ICH) in Hospital Kuala Lumpur, Malaysia. Methods: A single centre prospective cohort study was performed between 1 May 2017 and 30 April 2018 for patients above 18 years old with spontaneous ICH. Patients exhibiting haemorrhage due to tumours and ruptured arteriovenous malformations were excluded. The demographics, clinical parameters, radiology findings, surgical intervention, mortality at 30 days and outcome based on modified Rankin score (MRS) grading were recorded. Selected variables were incorporated into a binary logistic regression to determine the outcome predictors of mortality. Results: A total of 292 patients were recruited into the study. The findings showed that the mean age of ICH patients was 48.9 years old. Most of the lesions were located in the putamen (45.9%). More than half (61.0%) of the patients presented with a good outcome whereas 39.0% of the patients presented with a poor outcome. The mortality rate at 30 days was 29.1%. The important predictors for mortality were male (odds ratio [OR] = 0.343; P = 0.043), concomitant use of warfarin and aspirin (OR = 14.696; P = 0.007), ischaemic heart disease [IHD] (OR = 0.007; P = 0.003), brainstem bleed (OR = 0.001; P = 0.001), the presence of intraventricular haemorrhage [IVH] (OR = 0.198; P = 0.049) and surgery. Conclusion: Most diagnosed ICH patients in Malaysia were at a younger age (mean of 48.9 years old) with the significant mortality predictors were IVH, IHD, surgery and brainstem bleed.

Neural alterations in working memory of mild-moderate TBI: An fMRI study in Malaysia.

Working memory (WM) encompasses crucial cognitive processes or abilities to retain and manipulate temporary information for immediate execution of complex cognitive tasks in daily functioning such as reasoning and decision-making. The WM of individuals sustaining traumatic brain injury (TBI) was commonly compromised, especially in the domain of WM. The current study investigated the brain responses of WM in a group of participants with mild-moderate TBI compared to their healthy counterparts employing functional magnetic resonance imaging. All consented participants (healthy: n = 26 and TBI: n = 15) performed two variations of the n-back WM task with four load conditions (0-, 1-, 2-, and 3-back). The respective within-group effects showed a right hemisphere-dominance activation and slower reaction in performance for the TBI group. Random-effects analysis revealed activation difference between the two groups in the right occipital lobe in the guided n-back with cues, and in the bilateral occipital lobe, superior parietal region, and cingulate cortices in the n-back without cues. The left middle frontal gyrus was implicated in the load-dependent processing of WM in both groups. Further group analysis identified that the notable activation changes in the frontal gyri and anterior cingulate cortex are according to low and high loads. Though relatively smaller in scale, this study was eminent as it clarified the neural alterations in WM in the mild-moderate TBI group compared to healthy controls. It confirmed the robustness of the phenomenon in TBI with the reproducibility of the results in a heterogeneous non-Western sample.

Vacuum Drains versus Passive Drains versus No Drains in Decompressive Craniectomies-A Randomized Controlled Trial on Subgaleal Drain Complication Rates (VADER Trial).

OBJECTIVE: Subgaleal drains are generally deemed necessary for cranial surgeries including decompressive craniectomies (DCs) to avoid excessive postoperative subgaleal hematoma (SGH) formation. Many surgeries have moved away from routine prophylactic drainage but the role of subgaleal drainage in cranial surgeries has not been addressed. METHODS: This was a randomized controlled trial at 2 centers. A total of 78 patients requiring DC were randomized in a 1:1:1 ratio into 3 groups: vacuum drains (VD), passive drains (PD), and no drains (ND). Complications studied were need for surgical revision, SGH amount, new remote hematomas, postcraniectomy hydrocephalus (PCH), functional outcomes, and mortality. RESULTS: Only 1 VD patient required surgical revision to evacuate SGH. There was no difference in SGH thickness and volume among the 3 drain types (P = 0.171 and P = 0.320, respectively). Rate of new remote hematoma and PCH was not significantly different (P = 0.647 and P = 0.083, respectively), but the ND group did not have any patient with PCH. In the subgroup analysis of 49 patients with traumatic brain injury, the SGH amount of the PD and ND group was significantly higher than that of the VD group. However, these higher amounts did not translate as a significant risk factor for poor functional outcome or mortality. VD may have better functional outcome and mortality. CONCLUSIONS: In terms of complication rates, VD, PD, and ND may be used safely in DC. A higher amount of SGH was not associated with poorer outcomes. Further studies are needed to clarify the advantage of VD regarding functional outcome and mortality, and if ND reduces PCH rates.

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.

Ratio of Nitric Oxide Metabolite Levels in Cerebrospinal Fluid and Serum, and Their Correlation with Severity and Outcome in Patients with Subarachnoid Haemorrhage.

BACKGROUND: Nitric oxide (NO) is involved in a multitude of physiological processes in the central nervous system (CNS). Given the ubiquitous nature of NO and its involvement in various vital processes, nitric oxide metabolite (NOx) has been investigated as a biomarker in CNS diseases. This study aims to investigate the ratio of NOx levels and serum in cerebrospinal fluid (CSF) in patients with spontaneous subarachnoid haemorrhage (SAH). The associations among these markers with clinical outcomes were also studied. METHODS: A prospective cohort study was conducted over a 2-year period (May 2013-May 2015) to investigate the levels of NOx in the CSF and serum of patients with radiologically confirmed aneurysmal SAH. NOx samples and all relevant data were collected from the patients on admission and serially over 5 days. On admission, NOx levels were compared between the groups of patients, who were divided as per the World Federation Neurosurgeons Score (WFNS) grading scale, Fisher scale, occurrence of vasospasm on transcranial doppler (TCD), and Glasgow outcome scale (GOS) upon discharge and at 6 months follow-up. The ratios of CSF-to-serum were calculated and correlated with SAH severity and the outcome parameters listed above. RESULTS: The patients (N = 40) had a mean (SD) age of 58.2 (11.8) years old. The majority (65%) had a higher severity of SAH (WFNS score 3-5). On evaluation of the CT scan findings, 74% had outcomes equivalent to 4 on the Fisher scale. Vasospasm was detected via TCD in nearly half (45%) of the cohort during the study period; 80% were noted to have a poor outcome (GOS 1-3) at discharge; this persisted at 6 months follow-up. Comparison of NOx levels in the CSF/serum ratio was based on the incidence of vasospasm and severity of outcome (GOS) for day-1 and day-4. Statistically significant results were evident for patients with better outcomes, high severity grading, and the presence of vasospasm (P-values: 0.031, 0.034 and 0.043, respectively). CONCLUSION: Elevated NOx levels in CSF and serum and reductions in the ratio of NOx in CSF/serum were found to be associated with severity, occurrence of vasospasm and clinical outcome in aneurysmal SAH patients. This indicates the possible role of NOx as a biomarker to assess severity and prognosis in patients with SAH.

History of Neurosurgery in Malaysia: The Past, Present and Future.

The history of neurosurgery in Malaysia traces back to 1962 and is filled with stories of vibrant and humble neurosurgeons who have dedicated their life to patients and professions. The early development of neurological and neurosurgical services begins from the establishment of the neurosurgery unit at Hospital Kuala Lumpur (HKL), followed by the foundation of the Tunku Abdul Rahman Neuroscience Institute (IKTAR). Due to the exponentially increased demand for the care of neurosurgical patients, many universities and government hospitals have opened their neurosurgical units. In 2001, the formal residency training programme (USM Masters in Neurosurgery) started and since then has produced qualified neurosurgeons that empowered and shaped the present generation. The formation of the Neurosurgical Association of Malaysia (NAM) is another turning point towards bidirectional collaboration with the World Federation of Neurosurgical Societies (WFNS). Many opportunities were created for educational activities and the expansion of subspecialties in neurosurgery. This article describes the impact of the past neurosurgeons and the endeavors that they had gone through; the present neurosurgeons who pioneered the current neurosurgical services in Malaysia, and the future neurosurgeons that will continue the legacy and bring neurosurgery further ahead in this country.

Clinical Outcome of Tuberculous Meningitis with Hydrocephalus - A Retrospective Study.

BACKGROUND: To study the clinical outcome of tuberculous meningitis with hydrocephalus (TBMH) and the factors contributing to its poor clinical outcome. METHODS: Clinical data of 143 adult patients diagnosed with TBM over a 6-year period in two tertiary hospitals in Malaysia were retrospectively reviewed. Relevant clinical and radiological data were studied. Patients with TBMH were further analysed based on their clinical grade and rendered treatment to identify associated factors and outcome of this subgroup of patients. The functional outcome of patients was assessed at 12 months from treatment. RESULTS: The mean age of patients was 35.6 (12.4) years old, with a male gender predominance of 67.1%. Forty-four percent had TBMH, of which 42.9% had surgical intervention. In the good modified Vellore grade, 76.5% was managed medically with concurrent anti-tuberculosis treatment (ATT), steroids and osmotic agents. Four patients had surgery early in the disease as they did not respond to medical therapy and reported a good outcome subsequently. Poor outcome (65.2%) was seen in the poor modified Vellore grade despite medical and surgical intervention. Multivariate model multiple Cox regression showed significant results for seizure (adjusted hazard ratio [aHR]: 15.05; 95% CI: 3.73, 60.78), Glasgow coma scale (GCS) (aHR: 0.79; 95% CI: 0.70, 0.89) and cerebrospinal fluid (CSF) cell count (aHR: 1.11; 95% CI: 1.05, 1.17). CONCLUSION: Hydrocephalus was seen in 44% of patients in this study. GCS score, seizure and high CSF cell count were factors associated with a poor prognosis in TBM. Patients with TBMH treated medically (TBMHM) had better survival function compared to TBMH patients undergoing surgical intervention (TBMHS) (P-value < 0.001). This retrospective study emphasises that TBMH is still a serious illness as 47.6% of the patients had poor outcome despite adequate treatment.

Evaluation Study of Intraoperative Cytology Smear and Frozen Section of Glioma.

OBJECTIVE: Glioma is the commonest primary malignant brain tumour. Diagnosis is made based on cytology smear, frozen section and histopathological examination. Intraoperative pathological diagnosis using either cytology smear, frozen section or combination of both, plays a crucial role in patient's future management and prognosis. This study aims to determine the accuracy of cytology smear and frozen section in glioma, and to compare the difference between both techniques. METHODS: A cross-sectional study was conducted involving 22 cases of glioma diagnosed intraoperatively from January 2013 until August 2019 in Hospital Universiti Sains Malaysia. The selected tissues were processed for cytology smear and frozen section. The remaining tissues were proceeded for paraffin section. The diagnosis was categorized as either low-grade or high-grade glioma based on cellularity, nuclear pleomorphism, mitotic count, microvascular proliferation and necrosis. The sensitivity and specificity of frozen section and cytology smears were determined based on paraffin section being as the gold standard. The accuracy of both techniques was compared using statistical analysis. RESULTS: The overall sensitivity and specificity of cytology smear were 100% and 76.9%, respectively. Meanwhile, the sensitivity and specificity of frozen section were 100% and 84.6%. There was no significant difference in diagnostic accuracy between cytology smear and frozen section in glioma (p>0.05). CONCLUSION: Cytology smears provides an alternative method for frozen section due to good cellularity and morphology on smear. Cytology smear is rapid, inexpensive, small amount of tissue requirement and less technical demand. This finding may benefit to the hospital or treatment centres where frozen section facility is unavailable.

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.

Computed tomography perfusion in detecting malignant middle cerebral artery infarct.

BACKGROUND: Computed tomography perfusion (CTP) is an emerging modality which produces maps of time-to- peak (TTP), cerebral blood flow (CBF), and cerebral blood volume (CBV), with a computerized automated map of the infarct and penumbra. This modality provides a better evaluation of the extent of infarction, making it a potential method for assessing patients suffering from large middle cerebral artery (MCA) infarctions. METHODS: A prospective cohort study of all patients in Hospital Kuala Lumpur, Malaysia, who presented with the clinical diagnosis of a large MCA infarction within 48 h of onset were subjected to CT brain, and CTP scans on admission and were followed up to determine the development of malignant infarction requiring surgical decompression. RESULTS: CTP parameters were generally lower in patients with malignant brain infarct (MBI) group compared to the nonMBI group. The largest mean difference between the group was noted in the TTP values (P = 0.005). CTP parameters had a comparable positive predictive value (83%-90%) and high net present value (88-93). CBF with cutoff value of >32.85 of the hemisphere could accurately predict malignant infarctions in 81.4% of cases. The National Institutes of Health Stroke Scale score of more than 13.5 was also found to be able to accurately determine malignant infarct (97.6%). Functional outcome of patients based on Glasgow outcome scale was similar on discharge, however, showed improvement at 6 months during reviewed base on modified Rankin scale (P < 0.001). CONCLUSION: CTP parameters should be included in the initial evaluation of patients to predict malignant brain infarction and facilitate surgical treatment of large MCA infarctions. KEY MESSAGES: CT perfusion parameters have an important role in predicting malignant brain infarction and should be included in the initial evaluation of patients to facilitate the early identification and surgical treatment of large middle cerebral artery infarctions, to improve patient's prognosis.

Giant Occipital Encephalocele with Chiari Malformation Type 3.

Encephaloceles are rare embryological mesenchymal developmental anomalies resulting from inappropriate ossification in the skull through which herniate the intracranial contents of the sac. Occipital encephaloceles are described as giant when they are larger than the head from which they arise, and they pose a great surgical challenge. Herein, we present a case of a giant occipital encephalocele in a neonate with Chiari malformation Type 3 to highlight the problems encountered in its management and the outcome of the surgery.

White cord syndrome: A devastating complication of spinal decompression surgery.

BACKGROUND: Reperfusion injury of the spinal cord or "white cord syndrome" refers to the sudden onset of neurological deterioration after spinal decompressive surgery. Associated magnetic resonance (MR) findings only include focal hyperintensity on T2-weighted images without any other pathological changes. CASE DESCRIPTION: A patient with cervical stenosis secondary to metastatic tumor in the intradural and extradural compartments presented with lower limb paraparesis. She underwent an uneventful tumor excision accompanied by posterior cervical decompression and fusion. Postoperatively, she was quadriplegic and required ventilator support. The emergent postoperative MR scan revealed focal hyperintensity on the T2-weighted image consistent with spinal cord edema extending into the lower brain stem. CONCLUSION: Very few cases of reperfusion injury of the cervical spinal cord or "white cord syndrome" are described in the literature. Here we present a patient who, following cervical laminectomy and fusion for excision of metastatic tumor, developed quadriplegia. Notably, postoperative MR showed only findings of upper cervical cord and lower brain stem edema consistent with a "white cord syndrome" without other compressive pathology.

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 account for 13%-26% of all the primary intracranial tumours. Skull base meningiomas make up 25% of all meningiomas and are one of the most difficult intracranial tumours to be managed surgically. This is due to the fact that it is difficult to approach the lesions which are also close to vital structures such 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 meningiomas who have been operated at the Kuala Lumpur General Hospital from January 2010-December 2014. They were categorised into skull base and non-skull base groups. Demography, tumour characteristics, and patient outcomes were analysed. Kaplan-Meier survival curves as well as Cox hazard univariable and multivariable regressions for the possible predictors of survival were analysed. RESULTS: 97.5% of the patients (n = 194) had WHO grade I meningioma and only five patients had WHO grade II meningioma. There was a female predominance (n = 134; 67.3%), with a male-to-female ratio of 1:2. Some 27.1 % patients had skull base meningiomas. Patients with skull base meningiomas had poorer outcomes and discharge conditions (n = 23; 42.6% P < 0.01), in addition to higher risk of incomplete resections (n = 34; 63% P < 0.01). Multivariate cox hazard regressions showed that the skull base meningioma group had four times the risk of death of the non-skull base group. CONCLUSIONS: Symptomatic meningiomas can be curative if the tumour is completely removed. Our study has revealed that skull base meningiomas which were operated locally had higher rates of incomplete resection and poorer surgical outcomes as compared to the non-skull base group. Patients with skull base meningiomas had four times the risk of death vis-à-vis non-skull base ones. More local studies are needed to look into skull base meningiomas for the improvement of its surgical outcomes.

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.

Primary Central Nervous System Fibrosarcoma.

We report a rare case of a young female with primary brain fibrosarcoma, and to the best of our knowledge, we believe that only <50 cases have been reported or described worldwide so far. Fibrosarcoma is a malignant neoplasm, in which histologically the predominant cells are fibroblasts that divide excessively without cellular control and they can invade local tissues or metastasize. Primary central nervous system fibrosarcomas are very aggressive neoplasms and generally have a poor prognosis. This tumor is either from sarcomatous transformation of a meningioma or arises de novo within the brain parenchyma. Our patient, a 48-year-old woman, who presented with progressive speech disorder over the period of 4 months, showed a left temporoparietal lesion with surrounding edema and local mass effect. Total surgical resection was achieved. Histopathology revealed classical fibrosarcoma features and secondary screening revealed no other distant lesion as diagnosis of primary brain fibrosarcoma was established. This case is deemed to be extremely rare because most reports claim that recurrence is within 6 months with poor prognosis; however, this patient is currently recurrence-free at 3 years. This would suggest of the possibility for a relook into this disease's course and recurrence rate when complete excision is achieved. Due to extreme rarity of these tumors, more comparative studies will be needed to improve the disease outcome.