Depiction of Cerebral Aneurysm Wall by Computational Fluid Dynamics (CFD) and Preoperative Illustration.

Introduction Preoperative illustration is a part of an important exercise to study the configuration, direction, and presence of any perforations, and is the weakest point in the wall of the cerebral aneurysm. The same illustration is used to study the surrounding brain structures to decide the best and safe surgical approach prior to any surgical procedure. With the evolution of the aneurysm wall study and study of flow dynamic within the involved artery and its aneurysm wall using computational fluid dynamics (CFD), a better surgical plan can be formulated to improve the flow dynamics. As one of the clinical applications of CFD, we propose a study using a composite image that combines preoperative illustration and CFD, which is traditionally widely used in neurosurgery. Methods and Materials We study the use of illustrations of the unruptured cerebral aneurysm of internal carotid-posterior communicating (ICPC) artery and anterior communicating artery (AcomA) treated at our hospital. The combinations of both preoperative illustrations and CFD images by using "ipad Pro" were used. Result and Conclusion Medical illustration in the preoperative study of unruptured cerebral aneurysm with combinations of CFD and surrounding brain structures is helpful to decide the surgical approaches and successful surgical treatments.

Preoperative 3D Image Evaluation of EC-IC Bypass by 3D Visualization Analysis Software Amira®.

Background: Careful evaluation of the preoperative imaging for extracranial-intracranial bypass performed for conditions like intracranial stenosis and Moya disease is important. The traditional use of 2D imaging has a significant limitation for neurosurgeons, primarily to determine the optimal location of the recipient artery for performing the surgical bypass. Therefore, many neurosurgeons use 3D angiograms more frequently to overcome these shortcomings. Materials And Methods: We performed the preoperative evaluation of the possibility of performing an anastomosis between the superficial temporal artery and the middle cerebral artery (STA-MCA) bypass by synthesizing images of computerized tomography (CT), magnetic resonance imaging (MRI), and digital subtraction angiography (DSA) using Amira® of 3D visualization analysis software (Thermo Scientific Co.). Results: The 3D images prepared before surgery using this software showed good agreement with the intraoperative findings. Conclusion: Preoperative image processing using tools like Amira provide optimal information for good planning and communication for performing STA-MCA bypass and may become a helpful tool.

Malaysia’s third COVID-19 wave – a paradigm shift required

@#The first case of COVID-19 was reported in Malaysia on the 25 January 2020. By the 20 January 2021, the cumulative numbers reported confirmed cases of COVID-19 had reached 169,379 including 630 deaths. Malaysia has been hit by three waves of COVID-19. This article reports on the three waves, the current situation and some of the possible factors associated. It outlines the need to reassess the overall situation, re-strategize the approach in order to contain the spread. The first COVID-19 wave lasted from 25 January to 16 February 2020, the second wave occurred between the 27 February 2020 and the 30 June 2020. The current third wave began on 8th September 2020.The sudden surge of cases in the third wave was mainly due to the two largest contributors, namely the Benteng Lahad Datu cluster in Sabah state and Kedah's Tembok cluster. The current situation is critical. The daily confirmed cases of COVID-19 continue to soar. The challengers faced by healthcare workers and other front liners is tremendous. Non-communicable diseases such as cardiovascular diseases, diabetes and cancer are the leading cause of death in Malaysia. A paradigm shift in the approach is required to ensure the sustainability of the normal healthcare services provided by the government especially for the lower income groups. There is also a need to expedite the tabling of Tobacco Control Bill in coming parliament session which is long overdue. H.E. the King of Malaysia has called on all Malaysians to put aside political, racial and religious differences and show the spirit of loyalty, humanitarianism and steadfastness in fighting the COVID-19 pandemic.

Acute Spontaneous Cervical Spinal Epidural Haematoma a Very Rare Presentation Mimicking of Carotid Dissection during Sleep.

Acute spontaneous spinal epidural hematoma without any identified etiology is a rare phenomenon and an uncommon cause of acute spinal cord compression. We report a case of acute spontaneous cervical spinal epidural hematoma, with sudden onset of acute neck pain and left-side body weakness during sleep which resembling of cervicle carotid dissection. The pain commenced suddenly, early in the morning while the patient was asleep. He had no previous history of any relevant medical disorder. Cervical Spine MRI revealed a cervical epidural haematoma at C3/C4, mainly on the left side, with spinal cord compression. Therefore, an emergent C3/C6 hemilaminectomy and evacuation of hematoma were carried out within 24 h of presentation. The patient's neck pain resolved after surgery and he was able to walk, though he required bladder catheterization on discharge after 1 week. He has nearly intact motor neurological examination in the second month of the operation.

Women in Neurosurgery (WIN): Barriers to Progress, World WIN Directory and the Way Forward.

Women in Neurosurgery (WIN) have come a long way and are making inroads in every neurosurgical subspecialty. There has been a worldwide increase in the number of female neurosurgeons both in the training and practice. Although this is a welcome trend, gender equality at work in terms of opportunities, promotions, and pay scales are yet to be attained. This is more apparent in the developing and underdeveloped nations. Barriers for a female neurosurgeon exist in every phase before entering residency, during training, and at workplace. In the neurosurgical specialty, only a few women are in chief academic and leadership positions, and this situation needs to improve. WIN should be motivated to pursue fellowships, sub-specialty training, research, and academic activities. Furthermore, men should come forward to mentor women, only then the gender debates will disappear and true excellence in neurosurgery can be attained. This article reviews the issues that are relevant in the present era focusing on the barriers faced by female neurosurgeons in the developing and underdeveloped countries and the possible solutions to achieve gender equality in neurosurgery. The authors also present the data from the World WIN Directory collected as a part of Asian Congress of Neurological Surgeons-WINS project 2019. These numbers are expected to grow as the WIN progress and add value to the neurosurgical community at large.

High-Flow Bypass with Radial Artery Graft for Cavernous Carotid Aneurysms: A Case Series.

BACKGROUND: The incidence of cavernous carotid aneurysms (CCAs) of intracranial aneurysms is low. Majority of cases presented as incidental findings with benign natural progression. The most common presenting symptoms are multiple cranial neuropathies among symptomatic patients. The treatment modalities for symptomatic patients include direct surgical clipping, endovascular coil embolization, or placement of flow diverter, or indirect procedures such as occlusion of parent artery with and without revascularization techniques. The advancement in the microsurgical treatments and endovascular devices have enable a high success rate in the treatment of patients with CCAs with low morbidity and mortality rates. OBJECTIVE: To study the surgical outcomes of patients with cavernous aneurysm who underwent high-flow bypass between 2015 and 2020 in our institution. MATERIALS AND METHODS: A total of six patients in a single institution presented with CCAs who were treated with high-flow bypass surgery were included in this case-series. A single-case illustration was presented focusing on the details of surgical case management of CCA. The intraoperative middle cerebral artery (MCA) pressure monitoring during bypass surgery was also described. RESULTS: All five female patients and one male patient who were diagnosed with cavernous carotid aneurysms were studied. The mean age was 68.8 years old (range: 24-84 years old) and the mean size of the aneurysm was 19.6mm (range: 9.7 - 30mm). There were successfully treated with high flow bypasses using radial artery graft without any neurological sequelae. CONCLUSION: The surgical treatments of cavernous carotid aneurysms should be limited to experienced neurosurgeons in view of significant risk of morbidity and mortality. Endovascular procedures may be the main stay of treatments. The success shown in this case series with parent artery occlusion and bypass surgery may provide an safe alternative to the endovascular treatment.

Battling COVID-19 pandemic waves in six South-East Asian countries: A real-time consensus review

@#health concerns, triggering an escalated burden to healthsystems worldwide. The pandemic has altered people’sliving norms, yet coherently escalating countries’ socio-economic instability. This real-time consensus review aimsto describe the epidemiological trends of COVID-19pandemic across six South-East Asian nations, and country-specific experiences on pandemic preparedness, responsesand interventions.Methods: Consensus-driven approach between authorsfrom the six selected countries was applied. Countryspecific policy documents, official government mediastatements, mainstream news portals, global statisticsdatabases and latest published literature available betweenJanuary-October 2020 were utilised for information retrieval.Situational and epidemiological trend analyses wereconducted. Country-specific interventions and challengeswere described. Based on evidence appraised, a descriptiveframework was considered through a consensus. Theauthors subsequently outlined the lessons learned,challenges ahead and interventions that needs to be in placeto control the pandemic. Results: The total number of people infected with COVID-19between 1 January and 16 November 2020 had reached48,520 in Malaysia, 58,124 in Singapore, 3,875 in Thailand,470,648 in Indonesia, 409,574 in Philippines and 70,161 inMyanmar. The total number of people infected with COVID-19 in the six countries from January to 31 October 2020 were936,866 cases and the mortality rate was 2.42%. Indonesiahad 410,088 cases with a mortality rate of 3.38%, Philippineshad 380,729 cases with a mortality rate of 1.90%, Myanmarhad 52,706 cases with a mortality rate of 2.34%, Thailand had3,780 cases with a mortality rate of 1.56%, Malaysia had31,548 cases with a mortality rate of 0.79%, and Singaporehad 58,015 cases with a mortality rate of 0.05% over the 10-month period. Each country response varied depending onits real-time situations based on the number of active casesand economic situation of the country. Conclusion: The number of COVID-19 cases in thesecountries waxed and waned over the 10-month period, thenumber of cases may be coming down in one country, andvice versa in another. Each country, if acting alone, will notbe able to control this pandemic. Sharing of information andresources across nations is the key to successful control ofthe pandemic. There is a need to reflect on how thepandemic affects individuals, families and the community asa whole. There are many people who cannot afford to beisolated from their families and daily wage workers whocannot afford to miss work. Are we as a medical community,only empathising with our patients or are we doing ourutmost to uphold them during this time of crisis? Are thereany other avenues which can curb the epidemic whilereducing its impact on the health and socio-economiccondition of the individual, community and the nation?

From the MJM Editors’ Desk: Common errors authors make in submission to the Medical Journal of Malaysia

@#Proper understanding the ‘Instructions to authors’ for a particular journal is the key towards successful submission of a manuscript which will lead to it being published. Common errors that are frequently made by authors in their submission to the Malaysia Journal of Malaysia (MJM) that lead to rejection of their submission or requiring major revisions or minor revisions are listed and discussed in this article. Outright rejection prior to even a peer review process may be made for an article due to: it is poorly written or when there is suspicion on the authenticity of the submission, which contains elements that are suspected to be plagiarised, it is a duplicate submission or not in the format required by the MJM. The editor in charge of the issue makes a recommendation to the Editor in Chief for the final decision.

Coronavirus disease (COVID-19) pandemic

@#The Coronavirus disease (COVID-19) pandemic (caused by the virus SARS-CoV-2) is the greatest threat not only to global health but also has far reaching socio economic impact on nearly all the countries in the world. The first 4 cases of COVID-19 was first reported on the 29th December 2019, all linked to Huanan (Southern China) seafood wholesale market. 1,2 On the 31st December 2019, the World Health Organization (WHO) China Country Office was informed of a pneumonia of unknown cause, detected in the city of Wuhan in the Hubei province, China

Current Updates on Idiopathic Normal Pressure Hydrocephalus.

Idiopathic normal pressure hydrocephalus (iNPH) is one of the neurodegenerative diseases which can be treated surgically with favorable outcome. The gait disturbance, cognitive, and urinary symptoms are known as the clinical triad of iNPH. In this review, we have addressed the comorbidities, differential diagnoses, clinical presentations, and pathology of iNPH. We have also summarized the imaging studies and clinical procedures used for the diagnosis of iNPH. The treatment modality, outcomes, and prognosis were also discussed.

Expert Consensus on the Management of Brain Arteriovenous Malformations.

Brain arteriovenous malformations (bAVMs) are complex, heterogeneous, and uncommon intracranial lesions. They can be treated by one or a combination of the following treatment modalities, namely embolization, radiosurgery, or microsurgical resection. In Spetzler-Martin Grade 4 and 5 arteriovenous malformations (AVMs), conservative management may be the best option. A group of experts in the management of AVMs of different disciplines gathered in January 2019 in Hanoi to compile the "Expert Consensus on the Management of Brain Arteriovenous Malformations".

Stroke in pregnancy

@#Stroke is uncommon among young adults. However, the incidence of stroke among young women increases with pregnancy during peripartum and postpartum periods. The relative risk of suffering from haemorrhagic stroke was three times higher than ischemic stroke during these periods when compared with antenatal period. Neuroimaging should be prioritized in order to establish diagnosis and to facilitate treatment in a patient with suspected acute stroke. Prophylaxic anticoagulants should be used in high risk patients. Treatments of acute stroke in pregnant women include anti-platelet and thrombolytic agents. Further studies should be carried as there is lack of high level of evidences to formulate clear guideline for the management of stroke during pregnancy.

Fluorescence-Guided versus Conventional Surgical Resection of High Grade Glioma: A Single-Centre, 7-Year, Comparative Effectiveness Study.

BACKGROUND: High grade gliomas (HGGs) are locally invasive brain tumours that carry a dismal prognosis. Although complete resection increases median survival, the difficulty in reliably demonstrating the tumour border intraoperatively is a norm. The Department of Neurosurgery, Hospital Sungai Buloh is the first public hospital in Malaysia to overcome this problem by adopting fluorescence-guided (FG) surgery using 5-aminolevulinic acid (5-ALA). METHODS: A total of 74 patients with histologically proven HGGs treated between January 2008 and December 2014, who fulfilled the inclusion criteria, were enrolled. Kaplan-Meier survival estimates and Cox proportional hazard regression were used. RESULTS: Significant longer survival time (months) was observed in the FG group compared with the conventional group (12 months versus 8 months, P < 0.020). Even without adjuvant therapy, HGG patients from FG group survived longer than those from the conventional group (8 months versus 3 months, P = 0.006). No significant differences were seen in postoperative Karnofsky performance scale (KPS) between the groups at 6 weeks and 6 months after surgery compared to pre-operative KPS. Cox proportional hazard regression identified four independent predictors of survival: KPS > 80 (P = 0.010), histology (P < 0.001), surgical method (P < 0.001) and adjuvant therapy (P < 0.001). CONCLUSION: This study showed a significant clinical benefit for HGG patients in terms of overall survival using FG surgery as it did not result in worsening of post-operative function outcome when compared with the conventional surgical method. We advocate a further multicentered, randomised controlled trial to support these findings before FG surgery can be implemented as a standard surgical adjunct in local practice for the benefit of HGG patients.

A randomized, multicenter, open-label trial to establish therapeutic equivalence between the Carex and ultra disconnect systems in patients on continuous ambulatory peritoneal dialysis.

OBJECTIVE: In the present study, we undertook to establish therapeutic equivalence with respect to peritonitis and technique failure between the Carex disconnect system (B. Braun Carex, Mirandola, Italy) and the standard Ultra system (Baxter Healthcare, Tokyo, Japan) in patients on continuous ambulatory peritoneal dialysis (CAPD). DESIGN: This multicenter, parallel group, randomized controlled trial involved 363 prevalent CAPD patients from 8 centers. The primary endpoint was peritonitis rate; secondary endpoints were technique failure and technical problems encountered. The duration of the evaluation was 1 year. RESULTS: The risk of peritonitis on Carex varied between the centers. We found a significant treatment-center interaction effect (likelihood ratio test: p = 0.03). The incidence rate ratio (IRR) of peritonitis on Carex as compared with Ultra ranged from 0.4 to 7.2. In two centers, Carex was inferior to Ultra with regard to peritonitis; but, in five centers, the results were inconclusive. Equivalence was not demonstrated in any center. The overall rate of peritonitis in the Carex group was twice that in the Ultra group [IRR: 2.18; 95% confidence interval (CI): 1.51 to 3.14]. Technique failure and technical problems were more common with the Carex system. Technique failure rate at 1 year was 44% in the Carex group and 22% in the Ultra group. CONCLUSIONS: Equivalence between the Carex disconnect system and the Ultra disconnect system could not be demonstrated. The risk of peritonitis on Carex varied significantly between centers.