Water usage behaviour: Case study in a southern state in Peninsular Malaysia

Generally, Malaysia’s per capita water consumption is high. Therefore, this study perform a thorough investigation on a water consumption that is related to a middle-class community in Malaysia, which accounts for the highest income group in the country. Specifically, we focused on three major categories, i.e. domestic water-usage activities, water habits of the community, and water-saving efforts that can be easily adopted. The main source of data was collected using structured interview method. The frequency of indoor water usage of more than four times a day was high, which suggested that most people did not control their water consumption, especially for cooking, bathing/showering, toilet usage, and dish washing. Community awareness in terms of water-saving efforts is low, as indicated by the respondents that uses dual-pump cisterns in their toilets and employs rainwater-harvesting system for non-potable use. Low water tariff in the study area may discouraged the residents to practice water-saving measures. The findings from this study are important, particularly in understanding the activities and habits associated with high water usage. Additionally, the relevant stakeholders can use these findings to formulate a pro-active action plan to achieve the water usage of 165 litres/capita/day recommended by the World Health Organization.

Rapid detection of Salmonella Typhi by loop-mediated isothermal amplification (LAMP) method

An in-house loop-mediated isothermal amplification (LAMP) reaction was established and evaluated for sensitivity and specificity in detecting the presence of Salmonella Typhi (S. Typhi) isolates from Kelantan, Malaysia. Three sets of primers consisting of two outer and 4 inner were designed based on locus STBHUCCB_38510 of chaperone PapD of S. Typhi genes. The reaction was optimised using genomic DNA of S. Typhi ATCC7251 as the template. The products were visualised directly by colour changes of the reaction. Positive results were indicated by green fluorescence and negative by orange colour. The test was further evaluated for specificity, sensitivity and application on field samples. The results were compared with those obtained by gold standard culture method and Polymerase Chain Reaction (PCR). This method was highly specific and -10 times more sensitive in detecting S. Typhi compared to the optimised conventional polymerase chain reaction (PCR) method.

Inhibitory effect of asiatic acid on acetylcholinesterase, excitatory post synaptic potential and locomotor activity

The asiatic acid, a triterpenoids isolated from Centella asiatica was used to delineate its inhibitory effect on acetylcholinesterase (AChE) properties, excitatory post synaptic potential (EPSP) and locomotor activity. This study is consistent with asiatic acid having an effect on AChE, a selective GABA(B) receptor agonist and no sedative effect on locomotor.

Effects of asiatic acid on passive and active avoidance task in male Spraque-Dawley rats

AIM OF THE STUDY

Centella asiatica has a reputation to restore declining cognitive function in traditional medicine. To date, only a few compounds that show enhancing learning and memory properties are available. Therefore, the present study investigates the effects of for acute administration of asiatic acid (A-A) isolated from Centella asiatica administration on memory and learning in male Spraque-Dawley rats.

MATERIALS AND METHODS

4-5 weeks Spraque-Dawley rats were administered with concentration 1, 3, 5, 10, 30 mg/kg of A-A, baclofen, scopolamine and saline intra peritoneally and were evaluated for passive avoidance (PA), active avoidance (AA) and changes in blood pressure (BP).

RESULTS

Treatment 30 mg/kg of A-A resulted in significantly dose-dependently improved memory, with increased retention latency to enter difference compartment in PA test compared to baclofen, saline and scopolamine. Furthermore, 30 mg/kg of A-A was significantly higher on learning abilities on 1st day but there was no significantly difference on avoidance memory ability after 7 days of retention. Low reading in blood pressure dose-dependent significantly difference was observed in the 30 mg/kg of A-A group compared to saline group.

CONCLUSIONS

Administration A-A facilitated PA and AA on memory and learning and but had no effect on active avoidance on memory. Hence, may serve useful memory and learning with less effect in blood pressure in promoting memory and learning increases.

Acute toxicity study of the standardized methanolic extract of Mitragyna speciosa Korth in rodent

ETHNOPHARMACOLOGICAL RELEVANCE

Mitragyna speciosa Korth (ketum) is widely used in Malaysia as a medicinal agent for treating diarrhea, worm infestations and also acts as an analgesic and antipyretic.

AIM

The aim of the study is to determine the acute toxicity of Mitragyna speciosa Korth standardized methanol extract in vivo in 4-weeks-old Sprague-Dawley rats.

METHODOLOGY

Rats were orally administrated single dose of 100, 500 and 1000 mg/kg Mitragyna speciosa Korth standardized methanol extract and the control group received 430 mg/kg of morphine orally. There were 10 rats in each group. All animals were sacrificed after 14 days of treatment. Eight parameters were tested: cage side observation, body weight measurement, food and water consumption, blood pressure, absolute and relative organ weight, hematology, biochemical analysis and histopathology, to look for evidence of toxicity.

RESULT

No mortality was noted after 14 days of treatment. In general, behavior, food and water consumption, hematological studies and organ weights showed no significant changes. The standardized methanol extraction of Mitragyna speciosa Korth increased rat blood pressure (systolic: 147.4+/-1.01, 131.64+/-4.94 and 137.8+/-4.46) after an hour of 100, 500 and 1000 mg/kg doses, respectively. Biochemical studies showed significant elevation of ALT, AST, albumin, triglycerides, cholesterol and albumin (p>0.05), at all levels of doses. But, nephrotoxicity evidenced by elevated creatinine was seen only at a dose of 1000 mg/kg. Histological examination showed congestion of sinusoids, hemorrhage hepatocytes, fatty change, centrilobular necrosis and increased number of Kuppfer cells in the liver of all Mitragyna speciosa Korth standardized methanol extract treated groups.

CONCLUSION

Oral administration of standardized methanolic extraction of Mitragyna speciosa Korth resulted in increasing rat blood pressure after an hour of drug administration. The highest dose of extract also induced acute severe hepatotoxicity and mild nephrotoxicity. However, Mitragyna speciosa Korth shows no effects on body weight, food and water consumption, absolute and relative organ weight and also hematology parameters.

Severe traumatic brain injury: outcome in patients with diffuse axonal injury managed conservatively in Hospital Sultanah Aminah, Johor Bahru--an observational study

Patients with isolated severe head injury with diffuse axonal injury and without any surgical lesion may be treated safely without cerebral resuscitation and intracranial pressure (ICP) monitoring. Seventy two patients were divided into three groups of patients receiving treatment based on ICP-CPP-targeted, or conservative methods either with or without ventilation support. The characteristics of these three groups were compared based on age, gender, Glasgow Coma Scale (GCS), pupillary reaction to light, computerized tomography scanning according to the Marshall classification, duration of intensive care unit (ICU) stays, Glasgow Outcome Score (GOS) and possible complications. There were higher risk of mortality (p < 0.001), worse GCS improvement upon discharge (p < 0.001) and longer ICU stays (p = 0.016) in ICP group compared to Intubation group. There were no significant statistical differences of GOS at 3rd and 6th months between all three groups.

Structure of SO2946 orphan from Shewanella oneidensis shows "jelly-roll" fold with carbohydrate-binding module

The crystal structure of the uncharacterized protein SO2946 from Shewanella oneidensis MR-1 was determined with single-wavelength anomalous diffraction (SAD) and refined to 2.0 A resolution. The SO2946 protein consists of a short helical N-terminal domain and a large C-terminal domain with the "jelly-roll" topology. The protein assembles into a propeller consisting of three C-terminal blades arranged around a central core formed by the N-terminal domains. The function of SO2946 could not be inferred from the sequence since the protein represents an orphan with no sequence homologs, but the protein's structure bears a fold similar to that of proteins containing carbohydrate-binding modules. Features such as fold conservation, the presence of a conserved groove and a metal binding region are indicative that SO2946 may be an enzyme and could be involved in binding carbohydrate molecules.

CT scan in minor head injury: a guide for rural doctors

Minor head injury in a developing country like Malaysia is managed by primary care physicians and/or medical assistants in district hospitals. These patients are seen initially in their local hospitals, which have at least an X-ray machine for the purpose of screening. This study aimed to guide these physicians to manage these patients at a primary care level. A cross-sectional study was conducted and the study revealed significant predictors of significant computed tomographic (CT) findings. The presence of a Glasgow coma scale (GCS) score of 14 or 13 was associated with the risk of developing significant CT findings compared to patients with a GCS of 15 (p<0.001). Thirty-seven out of 50 patients with GCS of 14 or 13 developed clinically significant brain injury on CT scan. Similarly, the presence of skull fracture was associated with the risk of developing CT abnormalities (p<0.001). Forty-two out of 51 patients with skull fracture developed clinically significant CT findings. Vomiting was associated with developing CT abnormalities (p=0.017). Twenty-seven out of 40 patients with vomiting showed significant CT findings. Soft tissue injury was also found to be associated with developing CT abnormalities (p=0.007). Therefore, we propose reclassifying minor head injury based on the GCS score. Patients with a GCS score of 15 were classified as having mild head injury, while patients with a GCS score of 13 or 14 were at higher risk of developing brain injury and therefore categorized as high risk mild head injury. This group requires emergency CT scan examination, especially when associated with non-motor vehicle accidents, abnormal central nervous system (CNS) examination, craniofacial injuries or skull fractures. They should be referred to a general surgical unit which can treat head injuries or a neurosurgical tertiary centre.

The use of an In House Scoring System Scale versus Glasgow Coma Scale in non-traumatic altered states of consciousness patients: can it be used for triaging patients in Southeast Asian developing countries?

Non-traumatic Altered States of Consciousness (ASC) are a non-specific consequence of various etiologies, and are normally monitored by Glasgow Coma Scale (GCS). The GCS gives varriable results among untrained emergency medicine personel in developing countries where English is not the first language. An In House Scoring System (IHSS) scale was made by the first author for the purpose of triaging so as to quickly asses patients when seen by medical personel. This IHSS scale was compared to the GCS to determine it's specificity and sensitivity in the accident and emergency department (ED) of Hospital University Sains Malaysia (HUSM). All patients with non-traumatic ASC were selected by purposive sampling according to pre-determined criteria. Patients were evaluated by the two systems, IHSS and GCS, by emergency physicians who were on call. Patient demographics, clinical features, investigations, treatment given and outcomes were collected and followed for a period of 14 days. A total of 221 patients with non-traumatic ASC were studied, 54.3% were males. The mean age of the patients was 56 years old. The mean overall GCS score on presentation to the ED was 10.3. The mean duration of ASC was 11.6 hours. One hundred thirty patients (58.8%) experienced ASC secondary to general or focal cerebral disorders. The mortality rate was 40.3% 2 weeks after the ED visit. Fifty-four point three percent of the patients were awake and considered to have good outcomes while 45.7% of the patients had poor outcomes (comatose or dead) 2 weeks after the ED visit. The mean overall GCS score, verbal and motor subscores as well as the IHSS had significantly decreased (worsened) after treatment in the ED. A poor IHSS scale, hypertension, current smoking, abnormal pupillary reflexes and acidosis were associated with a worse 2-week outcome. The mean age and WBC count was lower and the mean overall GCS score and eye, verbal and motor subscores were higher as well as those having a lower IHSS scale for the good outcome category. Multivariate analysis revealed that smokers and hypertensives were at higher risk for a poor outcome. Higher eye scores on the GCS were associated fewer poor outcomes. There was significant agreement between the IHSS scale and GCS scores in the assessment of non-traumatic ASC. The sensitivity and specificity of the IHSS score versus GCS were 71.9% and 100.0%, respectively.

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.

Intra-cranial metastatic lacrimal gland tumour

We report a case of an adult who presented with progressive swelling in the right eye with suggestive of intracranial lesion on imaging. Histopathological revealed a lacrimal gland malignant mixed tumour.

Referral of epileptic patients in North East Coast of West Malaysia an area with poor MRI coverage: an analysis

Advances in neuroimaging techniques, particularly Magnetic Resonance Imaging (MRI), have proved invaluable in detecting structural brain lesions in patients with epilepsy in developed countries. In Malaysia, a few electroencephalography facilities available in rural district hospitals run by trained physician assistants have Internet connections to a government neurological center in Kuala Lumpur. These facilities are more commonly available than MRI machines, which require radiological expertise and helium replacement, which may problematic in Southeast Asian countries where radiologists are found in mainly big cities or towns. We conducted a cross-sectional study over a two year period begining January 2001 on rural patients, correlating EEG reports and MRI images with a clinical diagnosis of epilepsy to set guidelines for which rural patients need to be referred to a hospital with MRI facilities. The patients referred by different hospitals without neurological services were classified as having generalized, partial or unclassified seizures based on the International Classification of Epileptic Seizures proposed by the International League Against Epilepsy (ILAE). The clinical parameters studied were seizure type, seizure frequency, status epilepticus and duration of seizure. EEG reports were reviewed for localized and generalized abnormalities and epileptiform changes. Statistical analysis was performed using logistic regression and area under the curve. The association between clinical and radiological abnormalities was evaluated for sensitivity and specificity. Twenty-six males and 18 females were evaluated. The mean age was 20.7 +/- 13.3 years. Nineteen (43.2%) had generalized seizures, 22 (50.0%) had partial seizures and 3 (6.8%) presented with unclassified seizures. The EEG was abnormal in 30 patients (20 with generalized abnormalities and 10 localized abnormalities). The MRI was abnormal in 17 patients (38.6%); the abnormalities observed were cerebral atrophy (5), hippocampal sclerosis (4), infarct/gliosis (3), cortical dysgenesis (2) and tumors (2). One patient had an arachnoid cyst in the right occipital region. Of the 17 patients with an abnormal MRI, 14 had an abnormal EEG, this difference was not statistically significant. There was no significant associaton between epileptographic changes and MRI findings (p = 0.078). EEG findings were associated with MRI findings (p = 0.004). The association between an abnormal EEG and an abnormal MRI had a specificity of 82.4%, while epileptogenic changes had a specificity of 64.7% in relation to abnormal MRI findings. This meants that those patients in rural hospitals with abnormal EEGs should be referred to a neurology center for further workup and an MRI to detect causes with an epileptic focus.

The prognostic value of early follow-up computerized tomography of the brain in adult traumatic brain injury

A total of 31 adult patients with moderate and severe head injury were assessed clinically on admission for Glasgow Coma Scale (GCS) and short test of mental status (STMS) on follow-up and compared to their initial and follow up CT scan. Good predictors were admission GCS, midline shift, volume of subdural haemorrhage in the initial CT scan of the brain as well as the presence of post-traumatic hydrocephalus, gliosis and site of gliosis in the follow-up CT scan. There was no direct correlation between the significant predictors on the first CT scan and the follow-up CT scan of the brain.

Epilepsy surgery on dysembryoplastic neuroepithelial tumours

Two rare cases of intractable epilepsy caused by Dysembryoplastic Neuroepithelial Tumours (DNET) are reported and their different management discussed. The first case required vagal nerve stimulation and radiosurgery while the later was operated with the help of neuronavigation. Both had good outcome according to Engel classification after a one year follow up.

A study of the factors related to intima-media thickness of the common carotid artery amongst rural middle age individuals in Hospital Universiti Sains Malaysia

There is very little data regarding the factors related to intima-media thickness (IMT) of the common carotid artery in normal individuals in those with non-insulin diabetes mellitus and perimenopausal women in Southeast Asian countries. Ultrasound imaging evaluating the carotid artery IMT in those with diabetes and those on hormone replacement therapy (HRT) was performed beginning in August 2000 for a period of nearly two years at the Department of Radiology, Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia. A total of 153 participants were included. Significant differences between the women on HRT and not on HRT were IMT and systolic blood pressure. When comparing those with non-insulin dependent diabetes mellitus (NIDDM) and normal individuals, the significant differences were IMT, total cholesterol level, systolic blood pressure and diastolic blood pressure. IMT was high in those with NIDDM but not in those on HRT. Both those with NIDDM and those on HRT had associated dyslipidemia and systolic hypertension.

COBB syndrome treated by staged intravascular embolisation and surgery

A 28-year old Malay man with evidence of an upper motor neuron cord lesion was diagnosed to have a C7 to T2 spinal arterio-venous malformation and associated cutaneous vascular lesion. He finally agreed for treatment after 5 years of progressive spastic right lower limb weakness leading to inability to mobilize. A two staged intravascular procedure was done followed by surgery with recovery of ASIA impairment scale grade B.

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.

Extradural spinal cord and intraabdominal ganglioneuroblastoma

We report a rare case of a giant extradural and intraabdominal ganglioneuroblastoma in a young Malay girl who presented to a paediatrician initially at 5 days of life with a palpable abdominal mass. Unfortunately, the parents refused any form of surgical intervention until the child was 3 years old. She subsequently underwent vascular embolisation followed by the removal of this large tumour both via the abdomen and through a laminectomy approach and subsequently refused chemotherapy. The c-myc amplication in this patient was absent and there were no chromosomal aberrations, During the 2 year folow-up the patient remained well, and ambulatory with no tumour recurrence.

Molecular genetic analysis of a supratentorial haemangioblastoma in a non-Von Hippel Lindau patient

We describe a rare tumor site in a 46 year old man who presented with a two week history of headache. Physical examination revealed bilateral papilloedema with no other localizing signs. Computed Tomographic Scan as well as Magnetic Resonance Imaging of the brain revealed a lesion with a dura tail located adjacent to the falx cerebri of the right frontal lobe. This lesion was not invading the inner table of the skull base. A tumor blush was seen on angiogram. There were no abnormalities on CT scan of the abdomen and fundoscopy was normal. Intraoperatively a vascular tumor not attached to the dura was noted and removed totally. Histopathological examination was typical of a hemangioblastoma. Analysis revealed no mutations of the VHL gene in 5 regions, exon 5-8 of the p53 gene, exon 1-2 of the p16 gene and exon 5,6 and 8 of the PTEN gene. This is the first case report of a supratentorial hemangioblastoma in a non-Von Hippel Lindau patient with genetic evidence.

Which mild head injured patients should have follow-up after discharge from an accident and emergency ward? A study in a university hospital setting in Kelantan, Malaysia

Mild head injury (MHI) is a common presentation to many hospitals in both rural and urban settings in Southeast Asia, but it is not well studied. We studied 330 patients that presented to Hospital Universiti Sains Malaysia Emergency Department with possible MHI, with the intentions to identify prognostic factors that may improve the diagnosis of MHI in the emergency setting as well as to determine which patients would need follow-up. Patients' one-year outcomes were classified as discharged well (DW) for patients without post-traumatic signs and symptoms and discharged with long term follow-up (DFU) for patients with such signs and symptoms. Four patients died and 82 were DFU. An abnormal skull X ray was associated with mode of accident and type of transportation, older age, presence of vomiting, confusion, bleeding from ear, nose or throat, abnormal pupil size on the right side associated with orbital trauma, unequal pupillary reflexes, absence of loss of consciousness (LOC), a lower Glasgow Coma Scale (GCS) score, multiple clinical presentations, and DFU. An abnormal CT scan was associated with older age, multiple clinical presentation, skull X-ray findings, and DFU. A similar analysis on outcomes revealed that mode of accident, older age, vomiting, confusion, headache, bleeding from ear, nose and throat, neurological deficits, absence of LOC, pupil size, multiple presentation, abnormal skull X ray, CT scan of the brain, and a GCS of 13 was associated with DFU. In conclusion, all patients involved in motor vehicle accidents (MVAs), especially motorcycles, aged over 30 years of age, with multiple clinical presentations, including a lower GCS, and with abnormal radiological findings should have a longer follow-up due to persistent post-traumatic symptomatology.

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.

Preliminary report on spiegelberg pre and post-operative monitoring of severe head-injured patients who received decompressive craniectomy

The monitoring of craniospinal compliance is uncommonly used clinically despite it's value. The Spiegelberg compliance monitor calculates intracranial compliance (C = deltaV/deltaP) from a moving average of small ICP perturbations (deltaP) resulting from a sequence of up to 200 pulses of added volume (deltaV = 0.1 ml, total V = 0.2 ml) made into a double lumen intraventricular balloon catheter. The objective of this study was thus to determine the effectiveness of the decompressive craniectomy done on the worst brain site with regard to compliance (Cl), pressure volume index (PVI), jugular oximetry (SjVo2), autoregulation abnormalties, brain tissue oxygen (TiO2) and cerebral blood flow (CBF). This is a prospective cohort study of 17 patients who were enrolled after consent and approval of the ethics committee between the beginning of the year 2001 and end of the year 2002. For pre and post assessment on compliance and PVI, all 12 patients who survived were reported to become normal after decompressive craniectomy. There is no significant association between pre and post craniectomy assessment in jugular oxymetry (p > 0.05), autoregulation (p > 0.05), intracranial brain oxymetry (p = 0.125) and cerebral blood flow (p = 0.375). Compliance and PVI improved dramatically in all alive patients who received decompressive craniectomy. Compliance and PVI monitoring may be crucial in improving the outcome of severe head injured patients after decompressive craniectomy.

Association of p53 tumor suppressor gene with paraclinical and clinical modalities of gliomas patients in Malaysia

BACKGROUND

Alteration of the tumor suppressor gene p53 is considered to be a critical step in the development of human cancer. Changes in this gene have been detected in a wide range of human tumours, including gliomas. In glioma, the presence of p53 gene alterations has been associated with worse prognosis.

METHODS

Forty-seven Malaysian adult glioma patients of the Malay race were prospectively studied over a period of 3 years where the presence of p53 mutation using cold-SSCP method and their clinical and paraclinical response were correlated.

FINDINGS

Among these glioma patients, p53 mutations were detected in 12 tumors, an incidence rate of 25.5%. Mutations were found in 2 patients of grade II, and 5 patients both in grade III and grade IV. The sequencing results revealed the presence of base-substitutions (7) (58.3%) and frameshifts mutations (5) (41.7%). Of the base-substitutions, 57.1% were transversions and 42.9% were transitions.

INTERPRETATION

Our analysis shows that 3 factors were associated with p53 mutations i.e. grade, site and consistency of tumour using univariate analysis although multivariate analysis revealed no positive on predictors of mutation. In conclusion, although p53 genetic alterations are involved in glioma patients in Malaysia, it has no impact on prognosis.

Spontaneous intracerebral hemorrhage in northeast Malaysian patients: a four-year study

The aim of this study was to compare nonsurgical versus stereotactic aspiration of intracerebral hematomas in relation to clinical aspects, computed tomographic imaging features of the brain, laboratory parameters and specific risk factors that may influence the outcome in southeast Asian Malay patients. Fifty-five of the patients with intracerebral hemorrhage (ICH) underwent stereotactic aspiration and 57 did not. Analysis was done on risk factors, locations and treatments of ICH, and the final outcomes measured by the Glasgow Outcome Scale. A total of 112 patients were evaluated. Mean age was 52 years with ages ranging from 12 to 80 years. Hypertension was seen in 60.7% of patients with ICH. The mortality rate was 25% by 3 months. 58.9% had a poor final outcome, while 41.1% had a good outcome. The selected variables were incorporated into models generated by multiple logistic regression method analysis to define the significant predictors of outcome. Significant predictors of outcome were the Glasgow Coma Scale score on admission, the duration of surgery and the total volume of the hematoma. Significant predictors of mortality were high total white blood cell differential count, low plasma protein, and high plasma lactate dehydrogenase and brain edema. The study suggests that stereotactic aspiration of patients with ICH does not offer any definite advantage over conservative treatment.

Two-stage management of mega occipito-encephalocele

We report three cases of large occipito-encephaloceles that were managed in the Neurosciences Unit, Hospital Universiti Sains Malaysia over the last 5 years. All patients had pre-operative MRI (magnetic resonance imaging) evolution and mapping of the sagittal sinus tract. The cerebrospinal fluid (CSF) of all three patients were initially diverted by means of ventricular shunt two weeks prior to shunt removal. The slow drainage of CSF prevented electrolyte and volume disturbances due to sudden decompression during their definitive occipital encephalocele operations. After 3 years follow-up, all these patients are progressing well.

Suitability of Parkinson's patients for surgery in the north East coast of peninsular malaysia: a prospective analysis

There is no report in the English literature on the criteria for neuroablation or neuroaugmentation for the treatment of Parkinson's disease in a developing country like Malaysia. A prospective study of patients with Parkinson's disease from the north-eastern peninsular Malaysia was done to assess their suitability of surgery. Age, race, duration of illness and dementia were considered important factors towards the success of such surgical procedures. A mathematical model is suggested for future cases deemed to be suitable for neuroaugmentative or ablative surgery.

Unilateral exophthalmos caused by an extramedullary plasmacytoma: a case report

Solitary plasmacytoma of the head and neck is a rare disease entity. Its description in the literature consist of some case reports. Solitary plasmacytoma presenting with exophthalmos are rare. We report a case of intracranial solitary plasmacytoma in an elderly lady with involvement of the right orbitocranial region presenting with severe exophthalmos. The tumour was debulked and radiotherapy was given.

Stereotactic neuroendoscopic management of hydrocephalus: a three-year follow-up and analysis of Malaysian children with aqueduct stenosis

The beneficial effects of stereotactic third ventriculostomy versus ventriculoperitoneal shunt were evaluated in 62 paediatric patients and analysed in relation to age, sex, clinical history, presence of meningomyelocele, magnetic resonance imaging measurements of hydrocephalus and third ventricle floor size. The third ventriculostomy were done on 50 patients using the Richard-Wolf Caemaert Endoscope and the Leksell Stereotactic Frame Model G. These patients were operated using the 4-French Fogarty catheter to open the base of the third ventricle. During the same period of study 12 paediatric patients with aqueduct stenosis who were managed by ventriculoperitoneal shunt were included. Both surgical procedures were compared. Statistically univariate analysis revealed that those patient with an age group of more than six months undergoing ventriculostomy had good outcome. Multivariate analysis revealed that past history of haemorrhage and/or meningitis were predictors of poor outcome. Sex, size of lumbar meningocele at birth, abnormal ventricular anatomy or narrow third ventricular floor size were non predictors of bad outcome in these patients. There was no difference in outcome in both the shunt or ventriculostomy group.

Bovine pericardium for dural graft: clinical results in 22 patients

BACKGROUND

Bovine pericardium has widely been used for grafts in cardiac surgery and seems to have suitable properties for use as a dural graft. We report our experience of using locally processed bovine pericardium for dural grafts in 22 patients undergoing cranial operations.

METHODS

22 patients were analysed prospectively and followed-up for a maximum 3 years. All available records and information regarding the indication for grafting, graft size, complications and outcome were collected and analysed.

RESULTS

Indications for grafting included neurosurgical, tumour, congenital and trauma patients. Outcomes were classified as good or excellent in 20 patients, whereas in two patients death was not related to surgical closure but more to malignant intracranial hypertension. In no patient was the dural graft a significant factor in the outcome. Bovine pericardium was found to be easily sutured and watertight using standard 4-0 silk suture. This material is relatively inexpensive compared to other non-synthetic grafts.

CONCLUSION

In this clinical assessment, our bovine pericardium better known as Lyolemb was found to be an excellent dural graft material for local and eventual international consumption.

Outcome of children with traumatic brain injury in rural Malaysia

Malaysia had the second highest crude accident rate in the world until 1998. Most children who were involved in these road traffic accidents required intensive neurosurgical care management. We report a prospective study on 36 paediatric neurotrauma patients in rural North East West Malaysia who underwent uniform intensive therapy and were subsequently followed up over a period of 2 years. The modified paediatric Glasgow Coma Scale with support of the revised Wechlser Intelligence Scale for children was used to test the outcome of these children over a period of two years. All patients were managed aggressively in our intensive care as well as our high dependency units. Our results indicate that improvement in outcome is seen after a six month period. Midline shift, duration of coma and duration of transport were found to be significant variables associated with bad outcome. Other variables i.e. age, sex, Glasgow Coma Scale on admission and on site, and lesions of the dominant lobe were not found to be associated with good outcome in these patients.

A rare case of bleeding in a cerebellopontine angle epidermoid cyst

Epidermoid cysts of the central nervous system are described as rare, benign, slow growing lesions with a history of high rate of recurrence even after surgical removal. This lesion is rarely located at the cerebellopontine angle and is found to be composed of solid and cystic components with close adherence to vital neurovascular structures that might complicate its removal. We present a rare case of a twenty-five year old housewife with signs and symptoms of increased intracranial pressure due to the above pathology after multiple episodes of intra-tumoral bleeding. Microneurosurgical techniques were used for tumour dissection and excision. The patient recovered well after a three-year follow-up. This is the fourth example in the index medicus of bleeding seen in a histopathologically proven cerebellopontine angle intraepidermoid cyst.

Computed tomography of the brain in predicting outcome of traumatic intracranial haemorrhage in Malaysian patients

Head injury is a significant economic, social and medical problem all over the world. Road accidents are the most frequent cause of head injury in Malaysia with highest risk in the young (15 to 24 years old). The associated outcomes include good recovery, possibility of death for the severely injured, which may cause disruption of the lives of their family members. It is important to predict the outcome as it will provide sound information to assist clinicians in Malaysia in providing prognostic information to patients and their families, to assess the effectiveness of different modes of treatment in promoting recovery and to document the significance of head injury as a public health problem.

RESULTS

A total of 103 cases with intracranial haemorrhage i.e. intracerebral haemorrhage, extradural haemorrhage, subdural haemorrhage, intraventricular haemorrhage, haemorrhagic contusion and subarachnoid haemorrhage, following motor vehicle accidents was undertaken to study factors contributing to either good or poor outcome according to the Glasgow Outcome Scale. Patients below 12 years of age were excluded. The end point of the study was taken at 24 months post injury. The selected variables were incorporated into models generated by logistic regression techniques of multivariate analysis to see the significant predictors of outcome as well as the correlation between the CT findings with GCS.

CONCLUSION

Significant predictors of outcome were GCS on arrival in the accident emergency department, pupillary reflex and the CT scan findings. The CT predictors of outcome include ICH, EDH, IVH, present of SAH, site of ICH, volumes of EDH and SDH as well as midline shift.

Clinical presentation and outcome of brain abscess over the last 6 years in community based neurological service

Sixty patients with brain abscess were treated at the Neurosurgical Unit of the Department of Surgery, Hospital Universiti Sains Malaysia between January 1990 and December 1996. A retrospective study was done and data were collected from the computerise d registry of the Record Unit of Hospital Universiti Sains Malaysia. Good results were achieved in patients who were both treated surgically and medically. There were only twelve deaths in this group. The main factor that influences morbidity and mortality of brain abscess is the clinical presentation on admission. The mortality was high in patients treated solely by medical means. Death was common in patients who presented with acute onset of symptoms of less than one week duration and those with poor mental status. Brain abscess is common in the East Coast population of peninsular Malaysia, probably due in part to lower socioeconomic status. Efforts should be directed towards prevention of infection and early recognition and management.

Hydrocephalic children presenting to a Malaysian community-based university hospital over an 8-year period

There are few local statistics on the incidence of hydrocephalus and the outcome of hydrocephalic shunts in the South East Asian region. We report a retrospective study on 285 hydrocephalic patients who underwent shunting procedures between 1990 and 1998 at the University Hospital Science Malaysia, a regional referral center. Multiple logistic regression analysis was applied to predict determinants of outcome in relation to the timing of diagnosis, other congenital abnormalities associated with the hydrocephalus, timing of surgery and cortical thickness from CT scan. The relationship of shunt infection was correlated to the age of the patient and surgical procedure. The predictors for developmental outcome reported by this study were age at diagnosis, type of brain abnormalities and gender. Time of operation and cortical thickness did not contribute to the outcome.

Analysis of brain tumours suitable for curability via gene therapy in North East Malaysia

Two hundred primary brain tumours in both adults and children from the year 1990 to 1998 presenting for treatment to the Neurosurgical Division of the Hospital of the University of Sciences Malaysia were studied retrospectively. Volumes of tumours were taken from CT scans with contrast using two formulas and divided into 4 groups: (1) less than 20 cm(3), (2) 20-50 cm(3), (3) 50-100 cm(3) (4) larger than 100 cm(3). The majority of the brain tumours were in the volume range of 50-100 cm(3), and are thus potentially curable with retroviral gene therapy.

Use of bovine xenograft in reconstruction of traumatic anterior cranial fossa bone defects involving the frontal sinus

Four patients underwent reconstruction of anterior cranial fossa of skull defects between November 1997 and January 1998. All of them had traumatic anterior cranial fossa defect and were reconstructed with lyophilised bovine cortical bone graft. There was no cerebrospinal fluid leakage, meningitis, extradural abscess or other infections. This study demonstrates that the use of bovine bone graft in the reconstruction of anterior base defects is safe.

Cerebellar hemangioblastoma in a patient with von hippel-lindau disease : a case report

A 23 year-old Chinese woman presented with symptoms of increased intracranial pressure due to obstructive hydrocephalus as a sequel to a mass effect from cerebellar haemangioblastoma. She underwent removal of the right cerebellar haemangioblastoma and ventriculo-peritoneal shunting. She also had bilateral retinal haemangioblastoma, left renal carcinoma, renal and pancreatic cysts without phaeochromocytoma. A left partial nephrectomy was performed for renal cell carcinoma followed by radiotherapy. She survived the initial episode only to succumb to another cerebellar haemorrhage 18 months later.

Biventricular central neurocytoma

A case of biventricular neurocytoma is reported. A 36 year old Malay lady presented with headache of 8 months duration. Physical examination revealed signs of increase intracranial pressure. CT-scan and MRI showed tumour in both lateral ventricles. Patient underwent tumour debulking followed by adjuvant radiotherapy. The radiological appearances of central neurocytoma are discussed.

Incidence of tumours suitable for radiosurgery in a developing country like Malaysia: retrospective study done before the decision to start a radiosurgery programme

This is a descriptive epidemiologic study that was done retrospectively for the years 1990-1996. The objective was to determine whether tumours less than 4 cm in diameter are common and thereafter suitable for radiosurgical treatment. The results showed that the incidence of brain tumours less than 4 cm in diameter was 73.3% and about 20% were situated in the eloquent area.

Endoscopic neurosurgery: report of the first five cases done in Malaysia using the Caemaert-Abdullah method

The first endoscopic procedure done in Malaysia using the Caemaert-Abdullah method is reported and the followup results showed an excellent neurosurgical outcome. A 16-year-old girl with an aqueduct stenosis was operated on using a free-hand, computer-assisted endoscopic method where a third ventriculostomy was done. This was the first case being carried out in the Hospital Universiti Sains Malaysia. The next two cases were a suprasellar pituitary cyst in an elderly man and a child with an obstructive hydrocephalus who was previously shunted which became infected. Both endoscopic procedures, extirpation of the cyst using a Nd:Yag laser and a third ventriculostomy, respectively, were done under general anaesthesia in the supine position. Follow-up revealed a transient diabetes insipidus in all three cases up to 48 hours after the operation which resolved spontaneously. The fourth case involved an endoscopic removal of retained ventricular catheter after rectal migration of a shunt in an eight-year-old girl with congenital hydrocephalus. The fifth was a free-hand endoscopy with perforation of multiple brain septae in a ten-month-old baby with hydrocephalus secondary to meningitis. The final outcomes for all the cases were favourable hence we conclude that endoscopic neurosurgery is a safe procedure and hope that more neurosurgeons will continue to use this method, especially for the management of intraventricular cyst and hydrocephalus and especially in South East Asia.

Endoscopic management of craniopharyngiomas: a review of 3 cases

The authors describe the endoscopic management of cystic craniopharyngiomas in 3 cases. This method has been attempted in cystic craniopharyngiomas using a rigid endoscope. The instrument has been described earlier (7-9). All these operations were done under general anaesthesia. Criteria for endoscopic extirpation and removal included type D, E, F classification according to Yasargil (17). All 3 cases fitted in the F category. There were one female and two male patients. In the female patient an aspiration of cyst contents was performed as a first attempt to relieve her hydrocephalus. Two months later recurrent symptomology necessitated a larger intervention. All cysts were opened using the laser, drained by a Fogarthy balloon-catheter, and the capsule removed by forceps. This technique is safe and provides a reasonable alternative to open microsurgery, radioactive isotope instillation, or radiotherapy. In our series we achieved total removal in one case after the second intervention and partial removal in two cases. There was no mortality directly associated with this procedure and the female patient developed severe electrolyte disturbances after macroscopic total removal. Our results suggest that endoscopic of management of cystic craniopharyngiomas is a safe and effective procedure which could be considered as the initial management for cystic craniopharyngiomas of the intraventricular type.

Pseudo-dissection in percutaneous transluminal coronary angioplasty

Percutaneous transluminal coronary angioplasty (PTCA) is a well-established and effective treatment modality for significant coronary artery disease. Because it enlarges the arterial lumen by plaque disruption, minor wall dissection is not infrequent. Complex dissections are, however, uncommon but may lead to acute vessel closure with its attendant major clinical morbidity and mortality. We describe here a case of pseudo-dissection and its potential for misinterpretation and subsequent inappropriate management.

A double-blind study of neurotropin in patients with acute ischemic stroke

Neurotropin was found to reduce brain oedema in an experimental model of brain infarction in the guinea-pig. A randomized double-blind controlled trial with Neurotropin was performed in 220 patients admitted within 24 h after an acute ischemic stroke. 35 of the neurotropin and 41 of the placebo-randomized patients had to be excluded. 10 included patients in the neurotropin and 13 in the placebo-treated group died within the study period of 15 days. A better clinical outcome was observed in the 65 included surviving neurotropin compared with the 56 placebo-treated patients. The size of the infarct and of the oedema zones was significantly more decreased on CT scans from Day 11 compared with Day 3 after stroke in the neurotropin than in the placebo treated group. Neurotropin is helpful in treating brain oedema, related to acute ischemic stroke.

A multipurpose cerebral endoscope and reflections on technique and instrumentation in endoscopic neurosurgery

We discuss our experiences concerning our cerebral endoscope with reflections on various techniques used since 1986. During this time we have had experience with four prototypes. This minimal invasive procedure has been successful to a certain extent both in paediatric and adult patients, stereotactically and by freehand method or both. Further modification for flexibility and manipulation of the optic element is under development.