Outcomes of traumatic brain injury in the patient of 60 years and above: a single centre retrospective study.

INTRODUCTION: The elderly is at risk for traumatic brain injury (TBI), but local data on their morbidity and mortality outcomes was lacking. This study aims to assess the outcome in mortality and functional outcome, Glasgow Outcome Scale (GOS) and factors associated with poor outcomes in patients with TBI more than 60 years old. MATERIALS AND METHODS: This single centre retrospective cohort study was carried out involving patients age 60 years old and above with TBI between June 2018 to May 2021. The mortality and GOS at hospital discharge, 30th day, and 90th day of trauma were analysed. The simple logistic regression (SLR) and multiple logistic regression (MLR) were performed to determine factors associated with poor outcomes and mortality. RESULTS: A total of 248 patients were analysed. The mean age was 67.5 ± 6.31 years. 156 (62.9%), 26 (10.5%), and 66 (26.6%) had mild, moderate, and severe TBI, respectively. The overall mortality rate was 9.7% and the median(IQR) GOS score were 4(2); p<0.001 at hospital discharge, 30th day and 90th day. There was significant difference in GOS outcomes after 90 days χ2(2) = 136.76 p<0.001. Upon MLR, there was a significant association of polytrauma, Adj. OR 11.04 (2.503-48.711); p < 0.002 and TBI severity: moderate TBI, Adj. OR 71.44(13.028-391.782); p < 0.001 and severe TBI, Adj OR 2533.51 (213.050-30127.644); p<0.001 towards poor outcome. However, only severity of TBI: moderate TBI, Adj. OR 19.48 (1.899-199.094); p=0.012 and severe TBI, Adj OR 26.42 (2.864-243.722); p=0.004 is associated with mortality. CONCLUSION: Polytrauma and moderate-severe head injury are associated with poor outcomes and moderate-severe head injury is associated with high mortality.

The use of magnetic resonance phase-contrast cine in Chiari malformation with syringomyelia.

INTRODUCTION: Chiari malformation (CM) is a disorder of mesodermal origin and is commonly associated with syringomyelia. Foramen magnum decompression is the first-line of standard treatment in symptomatic patients with a confirmed radiographic diagnosis. Magnetic resonance (MR) cine allows accurate evaluation of cerebrospinal fluid (CSF) physiology at the craniovertebral junction but often this is under-utilised in Malaysia. METHODS: In this series, we looked into nine cases of CM with syringomyelia from clinical and radiological perspective before and after surgery. The radiological parameters were herniated tonsillar length, syrinx: cord ratio, syrinx length and diameter. Flow velocity and morphologic changes in Chiari were illustrated. RESULTS: Seven patients showed either reduction in syrinx length, syrinx: cord ratio or both postoperatively. Clinical recovery somewhat varied in motor and sensory symptoms. Four patients gained better functional grade in modified Rankin scale (MRS) while the rest remained similar. The study highlighted the advantage of CSF flow dynamics information over MR anatomical radiographic improvement in addressing the neurologic and functional recovery. We also discussed the practicality of cine sequence in preoperative patient selection, syrinx analysis and postoperative flow evaluation in anticipation of clinical outcome. CONCLUSION: Phase-contrast cine MRI is a useful tool dictated by resource availability. We recommend its routine use in preoperative analysis and subsequent observational follow-up after surgery.

Cerebral venous sinus thrombosis: review of cases in a single centre in Malaysia.

INTRODUCTION: Cerebral venous sinus thrombosis (CVST) is a potentially fatal neurological condition. However, due to the non-specific clinical and radiological features of CVST, it can sometimes result in a delay in the diagnosis and subsequent management. The aim of this study was to evaluate the demography, risk factors and one-year outcome of CVST patients treated in Hospital Universiti Sains Malaysia. METHODS: In this retrospective study, we reviewed the cases diagnosed with CVST admitted to our centre from January 2011 until November 2015. RESULTS: A total of 15 patients were included in this review. The patterns of imaging findings as well as risk factors for CVST is discussed with a review of the literature and current management practices. One year followed-up showed full recovery (Glasgow Outcome Scale (GOS) of 5) in 10 cases (66.7%), whereas 4 cases (26.7%) with GOS of 4 (three cases with neurological deficits, and 1 case with mild symptom. There was one case of mortality in this study secondary to sepsis during hospitalisation. The presenting symptoms were mainly headache, focal neurology deficits, seizure and altered sensorium. Risk factors identified were oral contraceptive pills usage, chronic sinuses or ear infections, and obesity. Initial computed tomography (CT) scan showed various findings and haemorrhagic infarct was one of the common findings. Magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) revealed majority of the patients had occlusion at two or more venous sinus sites. No patients had new or recurrent intracranial haemorrhage following initiation of anticoagulation therapy. CONCLUSION: Thus it is considerable safe to start anticoagulation therapy in CVST patients including those with intracranial haemorrhage. We propose further neuroimaging to avoid missed diagnosis of CVST in patient presented with recent onset headache and CT evidence of unusual cerebral infarction.

Neuronavigation-guided endoscopic management of a pineal region tumour with obscured floor of the third ventricle: case report.

BACKGROUND: Shunt surgery is frequently chosen to manage periventricular metastasis of pineal region tumours which obscured the floor of the third ventricle. However, this procedure falls short due to distant metastasis. Neuronavigation-guided endoscopic surgery offers a viable alternative. PATIENT: A 17-year-old man became symptomatic from widespread periventricular metastasis of a pineal region tumour which completely obscured the floor of the third ventricle. RESULTS: Endoscopic tumour biopsy followed by neuronavigation-guided endoscopic third ventriculotomy was performed successfully. CONCLUSION: This case report emphasizes the value of neuronavigation-guided endoscopic third ventriculostomy as a feasible surgical alternative for pineal region tumours with widespread periventricular metastasis that obscure the third ventricular floor.

Recurrent paediatric supratentorial extraventricular ependymoma associated with genetic mutation at exon 4 of p53 gene.

Recurrent supratentorial extraventricular ependymoma in a four-year-old Malay boy treated twice surgically in combination with cranial radiotherapy is reported. He presented with symptoms of raised intracranial pressure and a history of focal seizure. Computed tomography of the brain showed a left supratentorial extraventricular cystic lesion causing a mass effect. The tumour histology was ependymoma (WHO grade II). The clinical course, radiological characteristics and management of this tumour are discussed. Molecular genetic analysis of p53 and p27 genes revealed substitution of nucleotide G to C at location nucleotide 12139, exon 4 of gene p53. No alteration was detected at exon 5-6 and 8 of p53 gene and exon 1 and 2 of p27 gene.

Intraventricular angiolipoma.

We report a case of 50-year-old man who was presented with recurrent episodes of left sided hemiparesis. CT scan and MRI brain revealed a large intraventricular fatty lesion. Histopathological examination showed a picture of angiolipoma.

Neonatal posterior fossa haemorrhage associated with vacuum extractor.

We report one case of posterior fossa intracranial haemorrhage in a full-term Malay baby boy following vacuum assisted delivery. The patient, a term baby boy was delivered by a vacuum extraction and later developed signs of increased intracranial pressure 72 hours after birth. Computed tomography (CT) of the brain showed a posterior fossa intracranial haemorrhage with acute obstructive hydrocephalus. He was initially treated with isolated ventricular shunting which later caused an upward cerebellar herniation. An immediate suboccipital craniectomy for evacuation of cerebellar haematoma was performed which resulted in a gradual recovery.

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.