Zamzuri Idris

Intracerebral haematomas after deep brain stimulation surgery in a patient with Tourette syndrome and low factor XIIIA activity

A 24-year-old male patient with refractory Tourette syndrome was treated with deep brain stimulation (DBS) and developed subsequent bilateral subcortical haematomas. Additional blood tests revealed abnormalities of plasma factor XIIIA and tryptophan levels, which may be associated with Tourette syndrome. Neurosurgeons who perform DBS surgery on patients with Tourette syndrome must be aware of possible disastrous complications resulting from factor XIIIA disorders of blood haemostasis. Routine screening for this condition is not typically performed prior to surgery in these patients.

Cost Effectiveness Analysis of Using Multiple Neuromodalities in Treating Severe Traumatic Brain Injury in a Developing Country Like Malaysia

OBJECTIVE The aim of this study was to determine the cost-effectiveness of using baseline neuromonitoring (BNM) compared with multimodality monitoring (M3) for severe traumatic brain injury (TBI). METHODS Sixty-two patients with severe TBI underwent a prospective observational study where they were divided into two groups of patients receiving treatment with M3 (32 patients) and BNM (30 patients). The macro and micro costings were performed on each patient. The Barthel Index score after 1 year was used as an outcome measurement tool for both groups. The cost-effectiveness (CE) ratio was calculated using the Poisson regression model. RESULTS The costs of equipment and consumables between the groups was statistically significant (p < 0.001) after correcting for age and severity of injury. Other cost categories were not significantly different. The crude CE ratios were 168.66 (95% CI: 168.32, 169.03) and 144.16 (95% CI: 143.87, 144.45) for BNM and M3 respectively. The two crude CE ratios were significantly different (p < 0.001). It was calculated by controlling or adjusting age, gender, Glasgow Coma Score, Marshalls classification at admission and type of injury. The adjusted CE ratios were 171.32 (95% CI: 170.97, 171.68) and 141.50 (95% CI: 141.26, 141.79) for BNM and M3, respectively. The two adjusted CE ratios were significantly different ( p< 0.001). CONCLUSION The application of M3 for severe TBI was more cost-effective than BNM. All calculations were made at 3.8 Malaysian Ringgit (MYR) to the United States dollar (USD).

Better Glasgow outcome score, cerebral perfusion pressure and focal brain oxygenation in severely traumatized brain following direct regional brain hypothermia therapy: A prospective randomized study.

Background: Induced hypothermia for treatment of traumatic brain injury is controversial. Since many pathways involved in the pathophysiology of secondary brain injury are temperature dependent, regional brain hypothermia is thought capable to mitigate those processes. The objectives of this study are to assess the therapeutic effects and complications of regional brain cooling in severe head injury with Glasgow coma scale (GCS) 6-7. Materials and Methods: A prospective randomized controlled pilot study involving patients with severe traumatic brain injury with GCS 6 and 7 who required decompressive craniectomy. Patients were randomized into two groups: Cooling and no cooling. For the cooling group, analysis was made by dividing the group into mild and deep cooling. Brain was cooled by irrigating the brain continuously with cold Hartmann solution for 24-48 h. Main outcome assessments were a dichotomized Glasgow outcome score (GOS) at 6 months posttrauma. Results: A total of 32 patients were recruited. The cooling-treated patients did better than no cooling. There were 63.2% of patients in cooling group attained good GOS at 6 months compared to only 15.4% in noncooling group (P = 0.007). Interestingly, the analysis at 6 months post-trauma disclosed mild-cooling-treated patients did better than no cooling (70% vs. 15.4% attained good GOS, P = 0.013) and apparently, the deep-cooling-treated patients failed to be better than either no cooling (P = 0.074) or mild cooling group (P = 0.650). Conclusion: Data from this pilot study imply direct regional brain hypothermia appears safe, feasible and maybe beneficial in treating severely head-injured patients.

Prognostic Study of Using Different Monitoring Modalities in Treating Severe Traumatic Brain Injury

OBJECTIVE To determine whether or not multimodality monitoring technique would result in a better outcome score than single modality monitoring in severely head injured patients. METHODS This was a prospective randomized study that included all adults with traumatic severe head injury who had a Glasgow Coma Score < 9 and computed tomography scan features that did not reveal significant infratentorial pathology. Subjects were randomized into a multimodality group where they received multiple cerebral monitoring or into a standard single modality group where they received only intracranial pressure monitoring. The outcome was analysed 6 months post treatment using the Barthel Index. RESULTS The outcome at 6 months post treatment between the two groups was not statistically significant (p < 0.48). However, the percentage of subjects who were independent at 6 months was higher in the multimodality group (21.2%) compared with the single modality group (17.3%). CONCLUSION Multimodality monitoring for severely head-injured patients has no effect on outcome. However, study with a larger sample size and improvement in groups comparison are required to ascertain the above findings.

Functional outcome after intracerebral haemorrhage - a review of the potential role of antiapoptotic agents.

Abstract Intracerebral haemorrhage (ICH) is the second most common form of stroke and is associated with greater mortality and morbidity compared with ischaemic stroke. The current ICH management strategies, which mainly target primary injury mechanisms, have not been shown to improve patient’s functional outcome. Consequently, multimodality treatment approaches that will focus on both primary and secondary pathophysiology have been suggested. During the last decade, a proliferation of experimental studies has demonstrated the role of apoptosis in secondary neuronal loss at the periphery of the clot after ICH. Subsequently, the value of certain antiapoptotic agents in reducing neuronal death and improving functional outcome following ICH was evaluated in animal models. Preliminary evidence from those studies strongly supports the potential role of antiapoptotic agents in reducing neuronal death and improving functional outcome after intracerebral haemorrhage. Expectedly, the ongoing and subsequent clinical trials will substantiate these findings and provide clear information on the most potent and safe antiapoptotic agents, their appropriate dosage, and temporal window of action, thereby making them suitable for the multimodality treatment approach.

In Vitro Whole Blood Clot Lysis for Fibrinolytic Activity Study Using D-Dimer and Confocal Microscopy

This study aimed to evaluate in vitro whole blood (WB) clot lysis method for the assessment of fibrinolytic activity. Standardized unresected (uncut) retracted WB clot was incubated in pool platelet poor plasma (PPP) for varying incubation times and in streptokinase (SK) at different concentrations. The fibrinolytic activity was assessed by D-dimer (DD), confocal microscopy, and clot weight. DD was measured photometrically by immunoturbidimetric method. There was a significant difference in mean DD levels according to SK concentrations (P = 0.007). The mean DD ± SD according to the SK concentrations of 5, 30, 50, and 100 IU/mL was: 0.69 ± 0.12, 0.78 ± 0.14, 1.04 ± 0.14 and 2.40 ± 1.09 μg/mL. There were no significant changes of clot weight at different SK concentrations. Gradual loss and increased branching of fibrin in both PPP and SK were observed. Quantitation of DD and morphology of fibrin loss as observed by the imaging features are in keeping with fibrinolytic activity. Combination of DD levels and confocal microscopic features was successfully applied to evaluate the in vitro WB clot lysis method described here.

Intraventricular squamous papillary craniopharyngioma: report of a case with intraoperative imprint cytology.

BACKGROUND Squamous papillary craniopharyngioma is a distinct entity, and its cytologic features may be misleading. Because of the rarity of this tumor, this case is being reported with a note on the cytologic features. CASE A 56-year-old Malay man who had 1-month history of generalized lethargy was admitted for altered sensorium. On examination, he was found to have neck stiffness, bilateral papilledema and generalized atrophy of muscles, with reduced power in all limbs. Magnetic resonance imaging of the brain showed a solid mass in the third ventricle causing obstructive hydrocephalus. Intraoperative cytology of the mass diagnosed intraventricular meningioma. However, the final histopathologic examination revealed squamous papillary craniopharyngioma. CONCLUSION Craniopharyngioma, squamous papillary type, is a rare entity and usually occurs in adults as an intraventricular solid tumor. Awareness of this entity will aid in arriving at the correct cytologic diagnosis.

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 Fishers 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.

The use of event-related potential (P300) and neuropsychological testing to evaluate cognitive impairment in mild traumatic brain injury patients

Background: The aim of the study is to compare the amplitude and latency of the P300 event-related potential (ERP) component between a control group and patients after mild traumatic brain injury (mTBI) during 1–7 days (short duration) and 2–3 months (long duration), and to compare the outcome of neuropsychological tests between the long duration postinjury and control study groups. Materials and Methods: We studied responses to auditory stimulation in two main and one subgroups, namely the control healthy group (19 patients, both ERP and neuropsychology test done), the mTBI 1 group (17 patients, only ERP done within 7 days after injury), and the mTBI 2 subgroup (the 17 mTBI 1 patients in whom a repeated ERP together with neuropsychological testing was done at 2–3 months postinjury). Auditory evoked responses were studied with two different stimuli (standard and target stimuli), where the P300 amplitude and latency were recorded from three midline sites and results were compared between the groups, as were the neuropsychological test results. Results: There was a significant prolongation of the target P300 latency values shown by the MBI 1 group measured at the central electrode when compared to the control group, which was also seen when the mTBI 1 and mTBI 2 groups were compared. The results of the P300 amplitude values measured at the frontal electrode showed the control group to have higher readings during the presentation of standard tones when compared to the mTBI 1 group. The mTBI 2 group performed better on some neuropsychological tests. Conclusion: The latency of P300 was significantly prolonged in early mTBI patients who improved over time, and the neuropsychological testing on mTBI 2 patients showed them to be comparable to the control group. The study indicates that ERP should be used as an additional modality of investigation in mTBI patients.

Expression Profile of Genes Modulated by Aloe emodin in Human U87 Glioblastoma Cells

Glioblastoma, the most aggressive and malignant form of glioma, appears to be resistant to various chemotherapeutic agents. Hence, approaches have been intensively investigated to targeti specific molecular pathways involved in glioblastoma development and progression. Aloe emodin is believed to modulate the expression of several genes in cancer cells. We aimed to understand the molecular mechanisms underlying the therapeutic effect of Aloe emodin on gene expression profiles in the human U87 glioblastoma cell line utilizing microarray technology. The gene expression analysis revealed that a total of 8,226 gene alterations out of 28,869 genes were detected after treatment with 58.6 μg/ml for 24 hours. Out of this total, 34 genes demonstrated statistically significant change (p<0.05) ranging from 1.07 to 1.87 fold. The results revealed that 22 genes were up-regulated and 12 genes were down-regulated in response to Aloe emodin treatment. These genes were then grouped into several clusters based on their biological functions, revealing induction of expression of genes involved in apoptosis (programmed cell death) and tissue remodelling in U87 cells (p<0.01). Several genes with significant changes of the expression level e.g. SHARPIN, BCAP31, FIS1, RAC1 and TGM2 from the apoptotic cluster were confirmed by quantitative real-time PCR (qRT-PCR). These results could serve as guidance for further studies in order to discover molecular targets for the cancer therapy based on Aloe emodin treatment.