Awake Craniotomy: A Case Series of Anaesthetic Management using a Combination of Scalp Block, Dexmedetomidine and Remifentanil in Hospital Universiti Sains Malaysia.

Awake craniotomy is a brain surgery in patients who are kept awake when it is indicated for certain intracranial pathologies. The anaesthetic management strategy is very important to achieve the goals of the surgery. We describe a series of our first four cases performed under a combination of scalp block and conscious sedation. Scalp block was performed using a mixture of ropivacaine 0.7% and adrenaline 5 5µg/ ml administered to the nerves that innervate the scalp. Conscious sedation was achieved with a combination of two recently available drugs in our country, dexmedetomidine (selective α 2-agonist) and remifentanil (ultra-short acting opioid). Remifentanil was delivered in a target controlled infusion (TCI) mode.

Polymodal therapy for high grade gliomas: a case report of favourable outcomes following intraoperative radiation therapy.

High grade gliomas, frequently with their infiltrative nature, often make the outcome from neurosurgical intervention alone unsatisfactory. It is recognized that adjuvant radiochemotherapy approaches offer an improved prognosis. For these reasons, we opted for surgical debulking, intraoperative radiation therapy (IORT) in combination with whole brain irradiation therapy and chemotherapy (temozolamide cycles) in the management of a 42 year-old lady with Glioblastoma Multiforme (GBM). Her troublesome symptoms improved after 3 months of this polymodal therapy and remained independently functional for more than two years.

LINAC based radiosurgery and radiotherapy for neurosurgical diseases: what have we learnt so far.

BACKGROUND: Stereotactic radiosurgery uses a single fraction high dose radiation while stereotactic radiotherapy uses multifractionated lower dose focused radiation. MATERIALS AND METHODS: Radiosurgery used rigid CRW head frame while stereotactic radiotherapy utilized GTC or HNL relocatable frames. Stereotactic planning and radiation involved Radionics X-plan and LINAC system. RESULTS: Since December 2001, we have treated 83 lesions from 77 patients using either radiosurgery or fractionated stereotactic radiotherapy. Eighty six percent (86%) of our treated lesions showed favourable outcomes with median follow-up of 32 months (0-7 years). CONCLUSIONS: Our lessons from LINAC precision radiation therapy uphold its value as a promising and effective tool in treating a range of nervous system pathologies.

Effects of asiatic acid on passive and active avoidance task in male Spraque-Dawley rats.

AIM OF THE STUDY: Centella asiatica has a reputation to restore declining cognitive function in traditional medicine. To date, only a few compounds that show enhancing learning and memory properties are available. Therefore, the present study investigates the effects of for acute administration of asiatic acid (A-A) isolated from Centella asiatica administration on memory and learning in male Spraque-Dawley rats. MATERIALS AND METHODS: 4-5 weeks Spraque-Dawley rats were administered with concentration 1, 3, 5, 10, 30 mg/kg of A-A, baclofen, scopolamine and saline intra peritoneally and were evaluated for passive avoidance (PA), active avoidance (AA) and changes in blood pressure (BP). RESULTS: Treatment 30 mg/kg of A-A resulted in significantly dose-dependently improved memory, with increased retention latency to enter difference compartment in PA test compared to baclofen, saline and scopolamine. Furthermore, 30 mg/kg of A-A was significantly higher on learning abilities on 1st day but there was no significantly difference on avoidance memory ability after 7 days of retention. Low reading in blood pressure dose-dependent significantly difference was observed in the 30 mg/kg of A-A group compared to saline group. CONCLUSIONS: Administration A-A facilitated PA and AA on memory and learning and but had no effect on active avoidance on memory. Hence, may serve useful memory and learning with less effect in blood pressure in promoting memory and learning increases.

Post traumatic cerebral oedema in severe head injury is related to intracranial pressure and cerebral perfusion pressure but not to cerebral compliance.

This was a prospective cohort study, carried out in the Neuro Intensive Care Unit, Department of Neurosciences, Hospital Universiti Sains Malaysia, Kubang Kerian Kelantan. The study was approved by the local ethics committee and was conducted between November 2005 and September 2007 with a total of 30 patients included in the study. In our study, univariate analysis showed a statistically significant relationship between mean intracranial pressure (ICP) as well as cerebral perfusion pressure (CPP) with both states of basal cistern and the degree of diffuse injury and oedema based on the Marshall classification system. The ICP was higher while CPP and compliance were lower whenever the basal cisterns were effaced in cases of cerebral oedema with Marshall III and IV. In comparison, the study revealed lower ICP, higher mean CPP and better mean cerebral compliance if the basal cisterns were opened or the post operative CT brain scan showed Marshall I and II. These findings suggested the surgical evacuation of clots to reduce the mass volume and restoration of brain anatomy may reduce vascular engorgement and cerebral oedema, therefore preventing intracranial hypertension, and improving cerebral perfusion pressure and cerebral compliance. Nevertheless the study did not find any significant relationship between midline shifts and mean ICP, CPP or cerebral compliance even though lower ICP, higher CPP and compliance were frequently observed when the midline shift was less than 0.5 cm. As the majority of our patients had multiple and diffuse brain injuries, the absence of midline shift did not necessarily mean lower ICP as the pathology was bilateral and even when after excluding the multiple lesions, the result remained insignificant. We assumed that the CT brain scan obtained after evacuation of the mass lesion to assess the state basal cistern and classify the diffuse oedema may prognosticate the intracranial pressure and cerebral perfusion pressure thus assisting in the acute post operative management of severely head injured patients. Hence post operative CT brain scans may be done to verify the ICP and CPP readings postoperatively. Subsequently, withdrawal of sedation for neurological assessment after surgery could be done if the CT brain scan showed an opened basal cistern and Marshall I and II coupled with ICP of less than 20 mmHg.

Early Malaysian experience on the use of head and neck localizers in the precision radiotherapy of intra and extra cranial sites for first 28 cases.

Precision Radiotherapy at high doses require a fixed, referable target point. The frame system fulfills the required criteria by making the target point relocatable and fixed within a stereotactic space. Since December 2001, we have treated 28 central and peripheral nervous system lesions using either radiosurgery as a single high dose fraction or fractionated 3-dimensional conformal radiotherapy using a lower dose and a multi-leaf collimator. Various pathological lesions either benign or malignant were treated. Eighty six percent of our treated lesions showed growth restraint, preventing them from causing new symptoms with a median follow-up duration of 20.5 months. However, the true benefit from this technique would require a long-term follow-up to document the progress.

Molecular genetic analysis of a supratentorial haemangioblastoma in a non-Von Hippel Lindau patient.

We describe a rare tumor site in a 46 year old man who presented with a two week history of headache. Physical examination revealed bilateral papilloedema with no other localizing signs. Computed Tomographic Scan as well as Magnetic Resonance Imaging of the brain revealed a lesion with a dura tail located adjacent to the falx cerebri of the right frontal lobe. This lesion was not invading the inner table of the skull base. A tumor blush was seen on angiogram. There were no abnormalities on CT scan of the abdomen and fundoscopy was normal. Intraoperatively a vascular tumor not attached to the dura was noted and removed totally. Histopathological examination was typical of a hemangioblastoma. Analysis revealed no mutations of the VHL gene in 5 regions, exon 5-8 of the p53 gene, exon 1-2 of the p16 gene and exon 5,6 and 8 of the PTEN gene. This is the first case report of a supratentorial hemangioblastoma in a non-Von Hippel Lindau patient with genetic evidence.

Giant nerve sheath tumour: report of six cases.

Giant nerve sheath tumour is a rare tumour originating from the nerve sheath. It differs from the conventional nerve sheath tumour only by the size these tumours can reach. There are two main type of tumours that occur in the nerve sheath which include neurofibroma and schwannoma. The current views are that schwannomas arise from the progenitor of the schwann cell. Whereas the neurofibroma series probably arise from a mesenchymal origin closer to a fibroblast. We report on six cases of nerve sheath tumour that occur in the spinal and paraspinal region that presented to us over a 5 year period.

Preliminary report on spiegelberg pre and post-operative monitoring of severe head-injured patients who received decompressive craniectomy.

The monitoring of craniospinal compliance is uncommonly used clinically despite it's value. The Spiegelberg compliance monitor calculates intracranial compliance (C = deltaV/deltaP) from a moving average of small ICP perturbations (deltaP) resulting from a sequence of up to 200 pulses of added volume (deltaV = 0.1 ml, total V = 0.2 ml) made into a double lumen intraventricular balloon catheter. The objective of this study was thus to determine the effectiveness of the decompressive craniectomy done on the worst brain site with regard to compliance (Cl), pressure volume index (PVI), jugular oximetry (SjVo2), autoregulation abnormalties, brain tissue oxygen (TiO2) and cerebral blood flow (CBF). This is a prospective cohort study of 17 patients who were enrolled after consent and approval of the ethics committee between the beginning of the year 2001 and end of the year 2002. For pre and post assessment on compliance and PVI, all 12 patients who survived were reported to become normal after decompressive craniectomy. There is no significant association between pre and post craniectomy assessment in jugular oxymetry (p > 0.05), autoregulation (p > 0.05), intracranial brain oxymetry (p = 0.125) and cerebral blood flow (p = 0.375). Compliance and PVI improved dramatically in all alive patients who received decompressive craniectomy. Compliance and PVI monitoring may be crucial in improving the outcome of severe head injured patients after decompressive craniectomy.

Extradural spinal cord and intraabdominal ganglioneuroblastoma.

We report a rare case of a giant extradural and intraabdominal ganglioneuroblastoma in a young Malay girl who presented to a paediatrician initially at 5 days of life with a palpable abdominal mass. Unfortunately, the parents refused any form of surgical intervention until the child was 3 years old. She subsequently underwent vascular embolisation followed by the removal of this large tumour both via the abdomen and through a laminectomy approach and subsequently refused chemotherapy. The c-myc amplication in this patient was absent and there were no chromosomal aberrations, During the 2 year folow-up the patient remained well, and ambulatory with no tumour recurrence.

Congenital nasal encephalocele--a review of surgical techniques.

We report a case of a 6 month old baby boy who had congenital nasal encephalocele, repaired via the traditional staging procedure. The surgical techniques and procedures are described and discussed.

A rare case of bleeding in a cerebellopontine angle epidermoid cyst.

Epidermoid cysts of the central nervous system are described as rare, benign, slow growing lesions with a history of high rate of recurrence even after surgical removal. This lesion is rarely located at the cerebellopontine angle and is found to be composed of solid and cystic components with close adherence to vital neurovascular structures that might complicate its removal. We present a rare case of a twenty-five year old housewife with signs and symptoms of increased intracranial pressure due to the above pathology after multiple episodes of intra-tumoral bleeding. Microneurosurgical techniques were used for tumour dissection and excision. The patient recovered well after a three-year follow-up. This is the fourth example in the index medicus of bleeding seen in a histopathologically proven cerebellopontine angle intraepidermoid cyst.