Risk Prediction of Cerebral Infarction after Anterior Circulation Aneurysm Rupture in an Under-Equipped Centre.

Background: Morbidity and mortality is high among aneurysm rupture patients. Despite surviving the initial rupture, morbidity is high as they suffer from vasospasm and cerebral infarction (CI). Most prediction tools for CI after aneurysmal subarachnoid haemorrhage (SAH) are complex and are not routinely available in all neurosurgical centres. Current therapies for prevention of CI are still debatable and selective usage among high-risk patients is advised. These factors necessitate a simple prediction model for identifying patients in the high risk group to initiate early preventive treatment of CI. Methods: Patients with anterior circulation aneurysm rupture who underwent surgical clipping were included. Demographic data and factors related to CI were collected to determine significance and were used to develop VINODH score (VS). Results: Two hundred patients were included with a median age of 51 years old. Multivariate analysis proved only four predictors were significant (P < 0.01) for developing CI. These predictors were used for the development of VS which was named after the main author and the model's sensitivity was 79.0% and specificity was 83.0%. This highly predictive score (receiver operating characteristic [ROC]: 0.902) was internally validated. Conclusion: VS is a reliable tool for early identification of patients at risk of CI after aneurysmal SAH.

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.

Hypertensive Retinopathy and the Risk of Hemorrhagic Stroke.

OBJECTIVE: Hemorrhagic stroke (HS) and hypertensive retinopathy are known end organ damage of the brain and eye respectively, with HS having deleterious consequence to the patients. This study is to correlate between hypertensive retinopathy and HS in hypertensive disease. METHODS: A control group of hypertensive patients only, and an investigated group of hypertensive HS patients. Fundoscopic examination to determine the grade of retinopathy was performed and then divided into low or high severity hypertensive retinopathy. Clinical and radiological parameter included are demography, vital signs, Glasgow coma scale (GCS) on admission, clot volume, site of clot, Intracerebral hemorrhage (ICH) score and Glasgow outcome scale (GOS). Data were correlated with the severity of hypertensive retinopathy. RESULTS: Fifty patient in the control group and 51 patients in the investigated group were recruited. In the hypertensive HS group, 21 had low severity retinopathy (no or mild retinopathy) accounting for 41.2% and 30 patients had high severity (moderate or severe retinopathy). In the hypertensive patients 49 had low severity and one had high severity (p-value of 0.001). In HS group low severity showed better GCS score of 9-15 on admission (p-value of 0.003), clot volume less than 30 mL (p-value 0.001), and also a better 30 days mortality rate by using the ICH score (p-value 0.006), GOS score of 4 and 5 the low severity retinopathy fair better than the high severity retinopathy (p-value of 0.001), and the relative risk to develop HS in low severity and high severity retinopathy was 0.42 and 29.4, respectively. CONCLUSION: Hypertensive retinopathy screening could be used as an indicator in hypertensive patient, to evaluate the risk of developing hypertensive HS in the future.

An Aggressive growth of cranial sarcoma.

Sarcomas are a group of rare malignant tumours of the connective tissues. They can occur in almost any location, but more frequently in the extremities. The occurrence of sarcomas in the head and neck region is less than 1%. We are presenting a case report of a very large cranial sarcoma. Gross total tumour excision was done with pedicle skin graft and titanium mesh cranioplasty. The excised tumour weighed approximately 1.1 kg. Histopathological examination showed primitive intermediate-sized tumour cells arranged in sheets, nests and cords with focal palisading. Postoperative MRI done 2 weeks post surgery showed no evidence of residual tumour.

White cord syndrome: A devastating complication of spinal decompression surgery.

BACKGROUND: Reperfusion injury of the spinal cord or "white cord syndrome" refers to the sudden onset of neurological deterioration after spinal decompressive surgery. Associated magnetic resonance (MR) findings only include focal hyperintensity on T2-weighted images without any other pathological changes. CASE DESCRIPTION: A patient with cervical stenosis secondary to metastatic tumor in the intradural and extradural compartments presented with lower limb paraparesis. She underwent an uneventful tumor excision accompanied by posterior cervical decompression and fusion. Postoperatively, she was quadriplegic and required ventilator support. The emergent postoperative MR scan revealed focal hyperintensity on the T2-weighted image consistent with spinal cord edema extending into the lower brain stem. CONCLUSION: Very few cases of reperfusion injury of the cervical spinal cord or "white cord syndrome" are described in the literature. Here we present a patient who, following cervical laminectomy and fusion for excision of metastatic tumor, developed quadriplegia. Notably, postoperative MR showed only findings of upper cervical cord and lower brain stem edema consistent with a "white cord syndrome" without other compressive pathology.

Backstabbing swordfish: a rare cause of traumatic hemiparesis.

Swordfish attacks on humans are uncommon, with only a few case reports available in the current literature. The authors report the first known case of a penetrating spinal injury from a swordfish, in which the patient presented with a small stab wound and hemiparesis. The presentation of a fisherman with hemiparesis and a harmless-looking stab wound must alert clinicians to the possibility of penetrating swordfish injuries to the spine.

Comparison between Ventriculosubgaleal Shunt and Extraventricular Drainage to Treat Acute Hydrocephalus in Adults.

CONTEXT: Hydrocephalus, due to subarachnoid or intraventricular hemorrhage (IVH), meningitis, or tumor compression, is usually transient and may resolve after treatment. There are several temporary methods of cerebrospinal fluid (CSF) diversion, none of it is superior to the other, and the decision is based on its various etiologies and factors. Ventriculosubgaleal shunt (VSGS) is one of those temporary measures, which is a simple and rapid CSF decompression method without causing electrolyte and nutritional losses. AIMS: The aim is to study the efficacy of VSGS for temporary CSF diversion, compared to extraventricular drainage (EVD) in adult hydrocephalus patients; to evaluate the outcome in terms of avoiding a permanent shunt, and to look for incidences of their complications. SETTINGS AND DESIGN: This was a retrospective observational study. SUBJECTS AND METHODS: The data were acquired from case notes of fifty patients with acute hydrocephalus: 26 secondary to IVH, 10 from aneurysm rupture, 8 posttrauma, and 6 from infection. All these patients had undergone CSF diversion in Hospital Queen Elizabeth II, Sabah, Malaysia, between 2013 and 2015. The patients were followed up from the date of treatment until the resolution of hydrocephalus, where parameters such as shunt dependency and complications were documented. STATISTICAL ANALYSIS USED: All analyses were carried out using Statistical Packages for the Social Sciences Version 22.0. Chi-squared test or Fisher's exact test is used for univariate analysis of categorical variables. RESULTS: A total of 21 (42%) patients underwent EVD insertion and 29 (58%) underwent VSGS insertion. Thirty-seven (74%) patients did not require a permanent shunt; 24 (64.8%) of them were from the VSGS group (P = 0.097). EVD had more intracranial complications (44.1%) compared with VSGS (23.5%), with a statistically significant P = 0.026. CONCLUSIONS: VSGS is a safe and viable option for adult hydrocephalus patients, with the possibility of continuation of the treatment for such patients in nonneurosurgical centers, as opposed to patients with EVDs. Furthermore, even though this method had no statistical difference in avoiding a permanent ventriculoperitoneal shunt, VSGS has statistically significant less intracranial complications compared with EVD.

Primary Central Nervous System Fibrosarcoma.

We report a rare case of a young female with primary brain fibrosarcoma, and to the best of our knowledge, we believe that only <50 cases have been reported or described worldwide so far. Fibrosarcoma is a malignant neoplasm, in which histologically the predominant cells are fibroblasts that divide excessively without cellular control and they can invade local tissues or metastasize. Primary central nervous system fibrosarcomas are very aggressive neoplasms and generally have a poor prognosis. This tumor is either from sarcomatous transformation of a meningioma or arises de novo within the brain parenchyma. Our patient, a 48-year-old woman, who presented with progressive speech disorder over the period of 4 months, showed a left temporoparietal lesion with surrounding edema and local mass effect. Total surgical resection was achieved. Histopathology revealed classical fibrosarcoma features and secondary screening revealed no other distant lesion as diagnosis of primary brain fibrosarcoma was established. This case is deemed to be extremely rare because most reports claim that recurrence is within 6 months with poor prognosis; however, this patient is currently recurrence-free at 3 years. This would suggest of the possibility for a relook into this disease's course and recurrence rate when complete excision is achieved. Due to extreme rarity of these tumors, more comparative studies will be needed to improve the disease outcome.

Alveolar soft part sarcoma with brain metastases.

Metastatic tumors are the most common mass lesions in the brain. This case reports a rare form of sarcoma with metastasis to the brain. The appropriate management of a patient with metastatic alveolar soft part sarcoma to the brain is discussed. Author describes a 32-year-old gentleman diagnosed with primary tumor at gluteus and distant metastases at lower lobe of right lung and the brain. Histopathology proves diagnosis as alveolar soft part sarcoma. Craniotomy with excision of brain lesion was done. Repeated magnetic resonance imaging of the brain after 2 months showed rapidly growing new lesions. The next step of management was made by the oncology team as recurrence rate was high and due to multi-systemic involvement. Patient was planned for palliative chemotherapy and to be reassessed later. This case report discusses the appropriate approach to any form of brain metastases and the role of early follow-up especially after surgery for better outcome and choice of post operative management such as radiotherapy or chemotherapy or both for malignant tumors. Based on this report, it was concluded that every brain tumor patient should be frequently monitored even in the outpatient setting as most of them are metastatic and rapidly spreading. The patient should be considered for radiotherapy or chemotherapy or both after surgery if the histopathology result is suggestive of malignancy.

Smartphones in remote medicine and daily neurosurgery: The Sabah update.

INTRODUCTION: Healthcare costs continue to rise every day as the demand outgrows the supply of surgeons. The application of telephone consultation for immediate management is needed as most neurosurgeons are technology orientated. This enables a specialist at a remote mobile site to receive the necessary information and reduce transmission time, from the second the patient is seen till the management is obtained. MATERIALS AND METHODS: We conducted a survey on smartphone ownership among doctors and gathered cases that needed neurosurgical input from 1(st) November 2012 till 30(th) April 2013 from all 24 district hospitals in Sabah, Malaysia. RESULTS: The percentage of smartphone ownership among doctors surveyed and usage of it for remote and daily medicine at various departments at Queen Elizabeth Hospital, Kota Kinabalu, which shows at least 90% smartphone ownership and proves 100% ownership of cross-platform instant messaging applications and its usage for remote and daily medicine. It also proves to be a more popular mode of referral compared to "teleconsultation" (TC). DISCUSSION: In Sabah, the TC service is used for remote medical consultation and only available at four hospitals. The sender needs direct access to a computer with the TC software, and it causes delay whereas doctors using smartphones will just need to discuss the case on the spot and obtain the appropriate management within minutes. Smartphone usage is also important in daily neurosurgery especially at the department level to promote efficient communication, organization, and interaction between all the staff. As for the department's administrative sector, it is useful to notify if anyone is on leave, attending courses or even meetings as the shortage can be avoided, and redistribution easily done. It also allows us to transfer simple intra-departmental data at any time, and any place whenever required. CONCLUSION: With all the given fact, it is clear that a day without utilizing this service in our daily life will leave us handicapped and struggling with time and resources.