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.

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.

COVID-19 Pandemic and Its Impact on Neurosurgery Practice in Malaysia: Academic Insights, Clinical Experience and Protocols from March till August 2020.

The newly discovered coronavirus disease 2019 (COVID-19) is an infectious disease introduced to humans for the first time. Following the pandemic of COVID-19, there is a major shift of practices among surgical departments in response to an unprecedented surge in reducing the transmission of disease. With pooling and outsourcing of more health care workers to emergency rooms, public health care services and medical services, further in-hospital resources are prioritised to those in need. It is imperative to balance the requirements of caring for COVID-19 patients with imminent risk of delay to others who need care. As Malaysia now approaches the recovery phase following the pandemic, the crisis impacted significantly on neurosurgical services throughout the country. Various emergency measures taken at the height of the crisis may remain as the new normal in the provision of neurosurgical services and practices in Malaysia. The crisis has certainly put a strain on the effective delivery of services and as we approach the recovery era, what may have been a strain may prove to be a silver lining in neurosurgical services in Malaysia. The following details are various measures put in place as the new operational protocols for neurosurgical services in Malaysia.

Review of CHESS Score in SAH Patients in Local Malaysian Population.

Background Chronic hydrocephalus caused by subarachnoid hemorrhage is a reversible and treatable condition. To date, existing clinical scores for predicting the development of posthemorrhagic hydrocephalus are few and difficult to apply in the clinical settings. Chronic hydrocephalus ensuing subarachnoid hemorrhage score (CHESS) was first published in 2016. Although it showed promising results, no external validation has been done outside Europe. We designed this study to validate the accuracy and reliability of CHESS score and to also look for other factors that may cause posthemorrhagic shunt dependent hydrocephalus. Objectives This study is to determine the reliability of CHESS score and to look for other parameters with predictive value in patients with shunt-dependent posthemorrhagic hydrocephalus. Results Thirty-one percent of the studied population developed shunt-dependent hydrocephalus ( n = 41). CHESS score showed an odds ratio (OR) of 2.184 with p -value < 0.001 and two other risk factors were found to be strongly related to develop shunt-dependent hydrocephalus, that is, early infarct in computed tomography (CT) brain (OR = 0.182; p -value = 0.004) and Fisher's grade > 3 (OR = 1.986; p -value = 0.047). The sensitivity and specificity for CHESS score in this cohort population showed a sensitivity of 73.2% and specificity of 93.3%. The area under the curve for CHESS score in our cohort is 0.922. Conclusion CHESS score is a reliable tool in early prediction of shunt-dependent hydrocephalus post subarachnoid hemorrhage.

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.

History of Neurosurgery in Malaysia.

The development of neurosurgical services and training in Malaysia began in 1963, with the first centre established in its capital city at Hospital Kuala Lumpur, aimed to provide much needed neurosurgical services and training in the field of neurology and neurosurgery. This center subsequently expanded in 1975 with the establishment of the Tunku Abdul Rahman Neuroscience Institute (IKTAR); which integrated the three allied interdependent disciplines of neurosurgery, neurology and psychiatry. The establishment of this institute catalysed the rapid expansion of neurosurgical services in Malaysia and paved the way for development of comprehensive training for doctors, nurses, and paramedics. This culminated in the establishments of a local comprehensive neurosurgery training program for doctors in 2001; followed by a training program for nurses and paramedics in 2006. To date, there are more than 60 neurosurgeons providing expert care in 11 centers across Malaysia, along with trained personnel in the field of neurosciences.