Radiation effects on the intima-media thickness of the common carotid artery in post-radiotherapy patients with head and neck malignancy.

BACKGROUND: Post-radiation large vessel injury has not received as much attention as microvascular irradiation injury. A few studies have shown that common carotid intima-media thickness (IMT) is increased after radiotherapy to the head and neck. However, in most of these studies, the irradiated subjects also had other major risk factors for atherosclerosis. In this study, irradiated subjects with major risk factors such as hypertension, diabetes, history of previous cerebrovascular accident and connective tissue disorder were excluded. OBJECTIVE: To show in a cross-sectional study if radiotherapy to the carotid area has any effect on the IMT of the common carotid artery. SUBJECTS AND METHODS: 13 patients with head and neck malignancies who had completed radiotherapy to the carotid region at least 1 year previously underwent ultrasound of the carotid artery. IMT measurements were compared with those of 13 healthy controls, matched for age, sex and race, with no history of radiotherapy. RESULTS: The irradiated subjects had significantly larger IMT measurements (mean 0.74 mm) than the non-irradiated subjects (mean 0.46 mm). The difference was significant (p<0.001) with a confidence interval of 95%. CONCLUSIONS: This study shows that there is a measurable, significant (p<0.001) increase in IMT of the common carotid artery after radiotherapy for head and neck malignancy compared with non-irradiated matched controls. This knowledge is important for risk-benefit assessment of prophylactic or therapeutic neck irradiation. Increased awareness of this complication should provide an opportunity to intervene and prevent future cerebrovascular accidents in the majority of such patients.

A study of the factors related to intima-media thickness of the common carotid artery amongst rural middle age individuals in Hospital Universiti Sains Malaysia.

There is very little data regarding the factors related to intima-media thickness (IMT) of the common carotid artery in normal individuals in those with non-insulin diabetes mellitus and perimenopausal women in Southeast Asian countries. Ultrasound imaging evaluating the carotid artery IMT in those with diabetes and those on hormone replacement therapy (HRT) was performed beginning in August 2000 for a period of nearly two years at the Department of Radiology, Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia. A total of 153 participants were included. Significant differences between the women on HRT and not on HRT were IMT and systolic blood pressure. When comparing those with non-insulin dependent diabetes mellitus (NIDDM) and normal individuals, the significant differences were IMT, total cholesterol level, systolic blood pressure and diastolic blood pressure. IMT was high in those with NIDDM but not in those on HRT. Both those with NIDDM and those on HRT had associated dyslipidemia and systolic hypertension.

Computed tomography perfusion of ischaemic stroke patients in a rural Malaysian tertiary referral centre.

INTRODUCTION: Computed tomography (CT) perfusion is a new method to diagnose ischaemic stroke especially in developing countries. It identifies the area and is useful to predict the size of final infarction. The aim of this study was to assess cerebral ischaemia with CT perfusion (CTP) among patients with acute ischaemic stroke in Hospital Universiti Sains Malaysia, a tertiary referral centre in a rural setting. METHODS: 42 consecutive unenhanced CT and CTP examinations of the brain in adult patients were evaluated prospectively. Unenhanced CT images were divided into normal, suspicious or frank infarction. CTP images was classified as normal or ischaemic. Subgroup analysis was carried out with a limit of six hours from time of ictus. RESULTS: Out of 42 patients, 20 had frank infarction on unenhanced CT, 15 had suspicious CT studies, while seven were normal. There was no significant association of demographical, clinical and radiological parameters to CTP in the whole group among acute stroke patients without frank infarction. Among the subgroup of patients without frank infarction, there was no significant association between unenhanced CT and CTP in patients who were studied less than six hours after stroke (p-value is 0.063) as well as those after six hours (p-value is 0.317). The prevalence of a normal unenhanced CT and positive CTP for ischaemia was 22.7 percent (95 percent confidence interval 7.8, 45.4). CONCLUSION: CTP may be a useful imaging tool for determining cerebral infarction in a rural-based community population, especially in cases where the unenhanced CT is normal. Thrombolysis is a therapeutic option, even when the history of onset of stroke is unclear.

The prognostic value of early follow-up computerized tomography of the brain in adult traumatic brain injury.

A total of 31 adult patients with moderate and severe head injury were assessed clinically on admission for Glasgow Coma Scale (GCS) and short test of mental status (STMS) on follow-up and compared to their initial and follow up CT scan. Good predictors were admission GCS, midline shift, volume of subdural haemorrhage in the initial CT scan of the brain as well as the presence of post-traumatic hydrocephalus, gliosis and site of gliosis in the follow-up CT scan. There was no direct correlation between the significant predictors on the first CT scan and the follow-up CT scan of the brain.

CT scan in minor head injury: a guide for rural doctors.

Minor head injury in a developing country like Malaysia is managed by primary care physicians and/or medical assistants in district hospitals. These patients are seen initially in their local hospitals, which have at least an X-ray machine for the purpose of screening. This study aimed to guide these physicians to manage these patients at a primary care level. A cross-sectional study was conducted and the study revealed significant predictors of significant computed tomographic (CT) findings. The presence of a Glasgow coma scale (GCS) score of 14 or 13 was associated with the risk of developing significant CT findings compared to patients with a GCS of 15 (p<0.001). Thirty-seven out of 50 patients with GCS of 14 or 13 developed clinically significant brain injury on CT scan. Similarly, the presence of skull fracture was associated with the risk of developing CT abnormalities (p<0.001). Forty-two out of 51 patients with skull fracture developed clinically significant CT findings. Vomiting was associated with developing CT abnormalities (p=0.017). Twenty-seven out of 40 patients with vomiting showed significant CT findings. Soft tissue injury was also found to be associated with developing CT abnormalities (p=0.007). Therefore, we propose reclassifying minor head injury based on the GCS score. Patients with a GCS score of 15 were classified as having mild head injury, while patients with a GCS score of 13 or 14 were at higher risk of developing brain injury and therefore categorized as high risk mild head injury. This group requires emergency CT scan examination, especially when associated with non-motor vehicle accidents, abnormal central nervous system (CNS) examination, craniofacial injuries or skull fractures. They should be referred to a general surgical unit which can treat head injuries or a neurosurgical tertiary centre.

Red flags in patients presenting with headache: clinical indications for neuroimaging.

Headache is a very common patient complaint but secondary causes for headache are unusual. Neuroimaging is both expensive and has a low yield in this group. Most patients with intracranial pathology have clinical features that would raise a "red flag". Appropriate selection of patients with headache for neuroimaging to look for secondary causes is very important. Red flags act as screening tools to help in identifying those patients presenting with headache who would benefit from prompt neuroimaging, and may increase the yield. The aim of this study is to evaluate clinical features in patients with headache using neuroimaging as a screening tool for intracranial pathology. 20 red flags were defined. A retrospective study of 111 patients was performed and the outcomes were divided into positive and negative. Abnormal neuroimaging was present in 39 patients. Results were analysed using the Logistic Regression model. Sensitivity and specificity of red flags were analysed to establish the cut-off point to predict abnormal neuroimaging and a receiver operating characteristic (ROC) curve plotted to show the sensitivity of the diagnostic test. Three red flag features proved to be statistically significant with the p-value of less than 0.05 on both univariate and multivariate analysis. These were: paralysis; papilloedema; and "drowsiness, confusion, memory impairment and loss of consciousness". In addition, if three or more red flags from the list were present, this showed strong indication of abnormal neuroimaging, from cut-off point of ROC curve (area under the curve =0.76).

Multifocal mucus secreting papillary adenocarcinoma of the bile duct causing obstructive jaundice.

We present a 64-year-old Malay lady who had undergone a choledochoduodenostomy (CDD) two years ago for obstructive jaundice. She was admitted with jaundice and underwent ultrasonography, percutaneous transhepatic cholangiography (PTC), endoscopic retrograde cholangio pancreatography (ERCP) and computed tomographic (CT) scanning of the liver and biliary tree. All the investigations confirmed a type IVa choledochal cyst. At operation, the grossly dilated biliary system was packed with a thick mucoid material and the mucosa of the bile ducts was visibly abnormal with scattered nodules. This mucoid material had caused occlusion of the entire biliary tree resulting in obstructive jaundice. To the best of our knowledge, this is probably the first report of obstructive jaundice caused by thick mucus. The peculiar management problems of this case and the risk of malignant change in choledochal cysts are discussed.