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.

Craniotomy Improves Traumatic Optic Neuropathy.

Traumatic optic neuropathy (TON) is a rare devastating complication of traumatic head injury and is an ophthalmic emergency. Herein, we report a rare case of a 46-year-old gentleman who experienced severe blurring of vision, binocular diplopia, and pain over his left eye following a fall from a tree about three meters in height. Examinations revealed the visual acuity was 6/60 with a marked relative afferent pupillary defect and generalized ophthalmoplegia over his left eye. Emergency computed tomography (CT) brain and orbit showed a left frontotemporoparietal extradural hemorrhage, comminuted frontotemporoparietal and greater wing of sphenoid fracture with a bony spur impinging the lateral rectus and indirectly on the optic nerve. A diagnosis of left frontotemporoparietal bone fracture with traumatic optic neuropathy was made. An emergency left craniotomy, elevation of depressed skull fracture, and evacuation of clot was done. Postoperatively, his visual acuity showed marked improvement with visual acuity of 6/6 and all optic nerve functions were normal.

Transfrontal Transaqueductal, Transtrigonal, and Suboccipital Infratentorial Supracerebellar Endoscopic Fenestration of Posterior Fossa Arachnoid Cysts: Three Surgical Cases.

Symptomatic intracranial arachnoid cysts are commonly treated using neuroendoscopy. Cysts located within the posterior fossa may present a greater surgical challenge to the neurosurgeon due to the numerous vital neurovascular structures located within this confined space. Adding neuronavigation during endoscopy helps a neurosurgeon to visualize and utilize both anterior and posterior corridors safely to access and manage these lesions. We present three symptomatic posterior fossa arachnoid cysts that were treated successfully using minimally invasive neuronavigation-guided endoscopic neurosurgery utilizing the anterior transfrontal transaqueductal, anterior transfrontal transtrigonal, and posterior suboccipital infratentorial supracerebellar approaches.

The Effects of Minocycline on Spinal Root Avulsion Injury in Rat Model

Background: The neuroprotective role of minocycline in the treatment of brachial plexus injury is controversial. Objective: To study the neuroprotective effect of minocycline via different routes in adult Sprague Dawley rats with brachial plexus injury. Methods: The C7 nerve roots of the animals were avulsed via an anterior extravertebral approach. Traction force was used to transect the ventral motor nerve roots at the preganglionic level. Intraperitoneal and intrathecal minocycline (50 mg/kg for the first week and 25 mg/kg for the second week) were administered to promote motor healing. The spinal cord was harvested six weeks after the injury, and structural changes following the avulsion injury and pharmacological intervention were analysed. Results: Motor neuron death and microglial proliferation were observed after the administration of minocycline via two different routes (intraperitoneal and intrathecal) following traumatic avulsion injury of the ventral nerve root. The administration of intraperitoneal minocycline reduced the microglia count but increased the motor neuron count. Intrathecal minocycline also reduced the microglial count, with a greater reduction than in the intraperitoneal group, but it decreased the motor neuron count. Conclusions: Intraperitoneal minocycline increased motor neuron survival by inhibiting microglial proliferation following traumatic avulsion injury of the nerve root. The inhibitory effect was augmented by the use of intrathecal minocycline, in which the targeted drug delivery method increased the bioavailability of the therapeutic agent. However, motor neuron survival was impaired at a higher concentration of minocycline via the intrathecal route due to the more efficient method of drug delivery. Microglial suppression via minocycline can have both beneficial and damaging effects, with a moderate dose being beneficial as regards motor neuron survival but a higher dose proving neurotoxic due to impairment of the glial response and Wallerian degeneration, which is a pre-requisite for regeneration.

Deep Brain Stimulation (DBS) for Movement Disorders: An Experience in Hospital Universiti Sains Malaysia (HUSM) Involving 12 Patients

Deep brain stimulation (DBS) was first introduced in 1987 to the developed world. As a developing country Malaysia begun its movement disorder program by doing ablation therapy using the Radionics system. Hospital Universiti Sains Malaysia a rural based teaching hospital had to take into consideration both health economics and outcomes in the area that it was providing neurosurgical care for when it initiated its Deep Brain Stimulation program. Most of the patients were from the low to medium social economic groups and could not afford payment for a DBS implant. We concentrated our DBS services to Parkinson's disease, Tourette's Syndrome and dystonia patients who had exhausted medical therapy. The case series of these patients and their follow-up are presented in this brief communication.

Paclitaxel Inhibits Expression of Neuronal Nitric Oxide Synthase and Prevents Mitochondrial Dysfunction in Spinal Ventral Horn in Rats After C7 Spinal Root Avulsion.

AIM: This study evaluated the neuroprotective effect of intrathecally infused paclitaxel in the prevention of motoneuron death and mitochondrial dysfunction following brachial plexus avulsion injury. MATERIAL AND METHODS: Brachial root avulsion injury was induced in Sprague-Dawley rats. The Paclitaxel treatment group (n = 32) received a 5-d intrathecal infusion of paclitaxel (256 ng/d) via a micro infusion pump, whereas the Control group (n = 32) received normal saline. The cervical cord was harvested at survival times of 1, 2, 4, and 6 wk (n = 8 each). The number of surviving and nNOS-positive motoneurons at the injury level in the ventral horn was determined with NADPH-d histochemistry. Mitochondrial function at this location was measured with CcO histochemistry and densitometry. An independent t-test was applied to detect differences between the study groups at specific survival times. RESULTS: The Paclitaxel treatment group showed a significant relative reduction in nNOS expression at 2, 4, and 6 wk, and significantly improved mitochondrial function at 4 and 6 wk. Motoneuron survival was significantly increased at 2, 4, and 6 wk. CONCLUSION: Paclitaxel has a significant neuroprotective effect against spinal motoneuron degeneration following brachial plexus avulsion injury, which involves inhibition of nNOS expression and prevention of mitochondrial dysfunction.

A preliminary study of using active vision guided robotic arm for bone drilling in a developing country.

BACKGROUND: The study assesses the capability and accuracy of a robotic arm to perform burr holes. MATERIAL AND METHODS: The robotic systems are instructed to recognize targets on artificial skull models placed in different positions and to make burr holes. RESULTS: The accuracy ranged from 0.1 to 1.0 mm. CONCLUSION: Robotic arms are capable to perform basic surgical tasks. However, further improvement needs to be done to refine its accuracy and capability.

A case report of atypical teratoid/rhabdoid tumour in a 9-year-old girl.

Primary central nervous system atypical rhabdoid/teratoid tumour (ATRT) is a rare and highly malignant tumour that tends to occur in infancy and early childhood. The majority of tumours (approximately two-third) arise in the posterior fossa. The optimal treatment for ATRT remains unclear. Options of treatment include surgery, radiotherapy, and chemotherapy. Each of their role is still not clearly defined until now. The prognosis of the disease is generally unfavourable. This is a case report of ATRT in an atypical site in a 9-year-old girl.

Risk Factors and Phenytoin Prophylaxis for Early Post-Traumatic Seizures among Patients with Traumatic Brain Injury.

BACKGROUND: Post-traumatic seizure is a well-known and serious complication of traumatic brain injury (TBI). The incidence and risk factors vary among study populations. Very little data have been published concerning this in the Malaysian population. The aim of this study was to ascertain the risk factors for the development of early post-traumatic seizures among patients with TBI. METHODS: This was a prospective observational study, carried out in Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan, under the Department of Neurosciences. A total of 157 patients, from all age groups, who were diagnosed with TBI were enrolled from June 2007 to December 2007. They were followed-up for 12 months until death or their first post-traumatic seizure. Survival analysis with Kaplan-Meier curves and Cox proportional hazards regression was performed. RESULTS: A total of 11 (7.0%) of the patients developed early post-traumatic seizures. The risk factors for early post-traumatic seizures were young age (P = 0.021, 95% CI 0.806 to 0.982) and intubated patients (P = 0.029, 95% CI 1.194 to 25.913). The incidence of early post-traumatic seizures in the local population was 7.0%. CONCLUSION: The incidence of early post-traumatic seizures in the local population of Kelantan and Terengganu is comparable to the incidences reported elsewhere. Younger as well as intubated patients were at a higher risk of developing this condition. It may be necessary to give antiepileptic prophylaxis because any seizure could adversely affect morbidity and mortality. However, the study showed that antiepileptic drug was not beneficial in preventing late post-traumatic seizures, but may have a role in preventing early seizures.

Risk Factors and Phenytoin Prophylaxis for Early Post-Traumatic Seizures among Patients with Traumatic Brain Injury

Background: Post-traumatic seizure is a well-known and serious complication of traumatic brain injury (TBI). The incidence and risk factors vary among study populations. Very little data have been published concerning this in the Malaysian population. The aim of this study was to ascertain the risk factors for the development of early post-traumatic seizures among patients with TBI. Methods: This was a prospective observational study, carried out in Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan, under the Department of Neurosciences. A total of 157 patients, from all age groups, who were diagnosed with TBI were enrolled from June 2007 to December 2007. They were followed-up for 12 months until death or their first post-traumatic seizure. Survival analysis with Kaplan–Meier curves and Cox proportional hazards regression was performed. Results: A total of 11 (7.0%) of the patients developed early post-traumatic seizures. The risk factors for early post-traumatic seizures were young age (P = 0.021, 95% CI 0.806 to 0.982) and intubated patients (P = 0.029, 95% CI 1.194 to 25.913). The incidence of early post-traumatic seizures in the local population was 7.0%. Conclusion: The incidence of early post-traumatic seizures in the local population of Kelantan and Terengganu is comparable to the incidences reported elsewhere. Younger as well as intubated patients were at a higher risk of developing this condition. It may be necessary to give antiepileptic prophylaxis because any seizure could adversely affect morbidity and mortality. However, the study showed that antiepileptic drug was not beneficial in preventing late post-traumatic seizures, but may have a role in preventing early seizures.