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Fulltext Limited Evaluation of Image Quality Produced by a Portable Head CT Scanner (CereTom) in a Neurosurgery Centre

Abdullah AC, Adnan JS, Rahman NA, Palur R

Malays J Med Sci, 2017 Mar;24(1):104-112.
PMID: 28381933 DOI: 10.21315/mjms2017.24.1.11

INTRODUCTION: Computed tomography (CT) is the preferred diagnostic toolkit for head and brain imaging of head injury. A recent development is the invention of a portable CT scanner that can be beneficial from a clinical point of view.
AIM: To compare the quality of CT brain images produced by a fixed CT scanner and a portable CT scanner (CereTom).
METHODS: This work was a single-centre retrospective study of CT brain images from 112 neurosurgical patients. Hounsfield units (HUs) of the images from CereTom were measured for air, water and bone. Three assessors independently evaluated the images from the fixed CT scanner and CereTom. Streak artefacts, visualisation of lesions and grey-white matter differentiation were evaluated at three different levels (centrum semiovale, basal ganglia and middle cerebellar peduncles). Each evaluation was scored 1 (poor), 2 (average) or 3 (good) and summed up to form an ordinal reading of 3 to 9.
RESULTS: HUs for air, water and bone from CereTom were within the recommended value by the American College of Radiology (ACR). Streak artefact evaluation scores for the fixed CT scanner was 8.54 versus 7.46 (Z = -5.67) for CereTom at the centrum semiovale, 8.38 (SD = 1.12) versus 7.32 (SD = 1.63) at the basal ganglia and 8.21 (SD = 1.30) versus 6.97 (SD = 2.77) at the middle cerebellar peduncles. Grey-white matter differentiation showed scores of 8.27 (SD = 1.04) versus 7.21 (SD = 1.41) at the centrum semiovale, 8.26 (SD = 1.07) versus 7.00 (SD = 1.47) at the basal ganglia and 8.38 (SD = 1.11) versus 6.74 (SD = 1.55) at the middle cerebellar peduncles. Visualisation of lesions showed scores of 8.86 versus 8.21 (Z = -4.24) at the centrum semiovale, 8.93 versus 8.18 (Z = -5.32) at the basal ganglia and 8.79 versus 8.06 (Z = -4.93) at the middle cerebellar peduncles. All results were significant with P-value < 0.01.
CONCLUSIONS: Results of the study showed a significant difference in image quality produced by the fixed CT scanner and CereTom, with the latter being more inferior than the former. However, HUs of the images produced by CereTom do fulfil the recommendation of the ACR.

Matched MeSH terms: Neuroimaging
Fulltext The brain in pain

Ahmad AH, Abdul Aziz CB

Malays J Med Sci, 2014 Dec;21(Spec Issue):46-54.
PMID: 25941463 MyJurnal

Pain, while salient, is highly subjective. A sensation perceived as painful by one person may be perceived as uncomfortable, not painful or even pleasant to others. Within the same person, pain may also be modulated according to its threat value and the context in which it is presented. Imaging techniques, such as functional magnetic resonance imaging and positron emission tomography, have identified a distributed network in the brain, the pain-relevant brain regions, that encode the sensory-discriminative aspect of pain, as well as its cognitive and affective/emotional factors. Current knowledge also implicates the prefrontal cortex as the modulatory area for pain, with its subdivisions forming the cortico-cortical pathway, an alternative pain modulatory pathway distinct from the descending modulatory pathway of pain. These findings from neuroimaging in human subjects have paved the way for the molecular mechanisms of pain modulation to be explored in animal studies.

Matched MeSH terms: Neuroimaging
Visual brain activity patterns classification with simultaneous EEG-fMRI: A multimodal approach

Ahmad RF, Malik AS, Kamel N, Reza F, Amin HU, Hussain M

Technol Health Care, 2017;25(3):471-485.
PMID: 27935575 DOI: 10.3233/THC-161286

BACKGROUND: Classification of the visual information from the brain activity data is a challenging task. Many studies reported in the literature are based on the brain activity patterns using either fMRI or EEG/MEG only. EEG and fMRI considered as two complementary neuroimaging modalities in terms of their temporal and spatial resolution to map the brain activity. For getting a high spatial and temporal resolution of the brain at the same time, simultaneous EEG-fMRI seems to be fruitful.
METHODS: In this article, we propose a new method based on simultaneous EEG-fMRI data and machine learning approach to classify the visual brain activity patterns. We acquired EEG-fMRI data simultaneously on the ten healthy human participants by showing them visual stimuli. Data fusion approach is used to merge EEG and fMRI data. Machine learning classifier is used for the classification purposes.
RESULTS: Results showed that superior classification performance has been achieved with simultaneous EEG-fMRI data as compared to the EEG and fMRI data standalone. This shows that multimodal approach improved the classification accuracy results as compared with other approaches reported in the literature.
CONCLUSIONS: The proposed simultaneous EEG-fMRI approach for classifying the brain activity patterns can be helpful to predict or fully decode the brain activity patterns.

Matched MeSH terms: Functional Neuroimaging/methods*
Fulltext The Spetzler-Martin Grading System and management of patients with intracranial arteriovenous malformation in a tertiary referral hospital

Al-Edrus, S. A., Suhaimi, S. N., Noor Azman, A. R., Latif, A. Z., Sobri, M.

Malaysian Journal of Medicine and Health Sciences, 2010;6(1):91-99.
MyJurnal

Introduction: An arteriovenous malformation (AVM) is an abnormal collection of blood vessels in which arterial blood flows directly into the draining vein without the normal interposed capillaries. The Spetzler-Martin grading system has been widely accepted worldwide to estimate the pretreatment risks and predict the outcome of patients with intracranial AVM. In Malaysia, we still do not have the baseline data of this grading system. Methods: A total of 33 patients from a tertiary referral hospital diagnosed with intracranial AVM based on neuroimaging findings over a 4-year period were studied. Medical
records were traced and neuroimaging findings were analysed. The AVMs were graded according to the Spetzler-Martin grading system and Fisher’s exact test was used to assess statistical difference between the grades of the AVM and management plan for the patients. Results: Four patients were graded as Grade 1, 9 patients as Grade II, 10 patients as Grade III, 6 patients as Grade IV and 4 patients as Grade V. Ten patients were treated conservatively; six patients underwent surgery and embolisation respectively. Four patients underwent radiosurgery and a combination of embolisation while surgery and radiosurgery were given to 5 patients and 2 patients respectively. Statistically significant difference (p=0.016) was found between the Spetzler-Martin grading system and the management of intracranial AVMs. Conclusion: The management decision was not made based on the
grading of the AVMs. It is recommended that all AVM patients be routinely graded according to this system prior to treatment.

Matched MeSH terms: Neuroimaging
Fulltext A Preliminary Insight into an Islamic Mechanism for Neuroethics

Baharuddin A, Musa MN, Salleh SS

Malays J Med Sci, 2016 Jan;23(1):1-3.
PMID: 27540319 MyJurnal

Muslim relies on the structure or guideline of shari'ah or the maqasid al-shariah, which consist of five essential values, namely preservation/protection of faith, life, intellect, property, and dignity/lineage - to guide them in discovering guiding principles for new concerns such as posed by neuroscience. Like in the case of brain imaging technology, there is in need for proper explanation within Islamic and among the Muslim scientists/scholars on how Islamic beliefs, values, and practices might cumulatively provide 'different' meanings to the practice and application of this technology, or whether it is in line with the shari'ah - in the context of preservation of health and protection of disease. This paper highlights the Islamic mechanism for neuroethics as basis for a holistic ethical framework of neuroscience to cope with its new, modern, and emerging technologies in the globalised world, and how Muslim should response to such changes.

Matched MeSH terms: Neuroimaging
Fulltext CNS toxoplasmosis presenting with obstructive hydrocephalus in patients of retroviral disease--a case series

Basavaprabhu A, Mahalingam S, Deepak M, Satish R

Med J Malaysia, 2012 Apr;67(2):214-6.
PMID: 22822648

CNS toxoplasmosis presenting as hydrocephalus is a very rare entity. We present three cases of HIV positive patients whose brain imaging revealed hydrocephalus and who improved with anti toxoplasma medication along with intravenous steroids and did not require any CSF shunting procedures. The mechanism of hydrocephalus in CNS toxoplasmosis is usually due to compression of CSF outflow pathway by ring enhancing lesions but even in their absence hydrocephalus can be rarely seen due to ventriculitis. Hence in HIV positive patients with unexplained hydrocephalus CNS toxoplasmosis should be considered and such patients if started on treatment early have a good prognosis without requiring neurosurgical intervention.

Matched MeSH terms: Neuroimaging
Parkinson's disease: Cause factors, measurable indicators, and early diagnosis

Bhat S, Acharya UR, Hagiwara Y, Dadmehr N, Adeli H

Comput Biol Med, 2018 11 01;102:234-241.
PMID: 30253869 DOI: 10.1016/j.compbiomed.2018.09.008

Parkinson's disease (PD) is a neurodegenerative disease of the central nervous system caused due to the loss of dopaminergic neurons. It is classified under movement disorder as patients with PD present with tremor, rigidity, postural changes, and a decrease in spontaneous movements. Comorbidities including anxiety, depression, fatigue, and sleep disorders are observed prior to the diagnosis of PD. Gene mutations, exposure to toxic substances, and aging are considered as the causative factors of PD even though its genesis is unknown. This paper reviews PD etiologies, progression, and in particular measurable indicators of PD such as neuroimaging and electrophysiology modalities. In addition to gene therapy, neuroprotective, pharmacological, and neural transplantation treatments, researchers are actively aiming at identifying biological markers of PD with the goal of early diagnosis. Neuroimaging modalities used together with advanced machine learning techniques offer a promising path for the early detection and intervention in PD patients.

Matched MeSH terms: Neuroimaging
Fulltext Tolerability, safety and intermediary pharmacological effects of cilostazol and isosorbide mononitrate, alone and combined, in patients with lacunar ischaemic stroke: The LACunar Intervention-1 (LACI-1) trial, a randomised clinical trial

Blair GW, Appleton JP, Flaherty K, Doubal F, Sprigg N, Dooley R, et al.

EClinicalMedicine, 2019 04 24;11:34-43.
PMID: 31317131 DOI: 10.1016/j.eclinm.2019.04.001

Background: Lacunar stroke, a frequent clinical manifestation of small vessel disease (SVD), differs pathologically from other ischaemic stroke subtypes and has no specific long-term secondary prevention. Licenced drugs, isosorbide mononitrate (ISMN) and cilostazol, have relevant actions to prevent SVD progression.
Methods: We recruited independent patients with clinically confirmed lacunar ischaemic stroke without cognitive impairment to a prospective randomised clinical trial, LACunar Intervention-1 (LACI-1). We randomised patients using a central web-based system, 1:1:1:1 with minimisation, to masked ISMN 25 mg bd, cilostazol 100 mg bd, both ISMN and cilostazol started immediately, or both with start delayed. We escalated doses to target over two weeks, sustained for eight weeks. Primary outcome was the proportion achieving target dose. Secondary outcomes included symptoms, safety (haemorrhage, recurrent vascular events), cognition, haematology, vascular function, and neuroimaging. LACI-1 was powered (80%, alpha 0.05) to detect 35% (90% versus 55%) difference between the proportion reaching target dose on one versus both drugs at 55 patients. Registration ISRCTN12580546.
Findings: LACI-1 enrolled 57 participants between March 2016 and August 2017: 18 (32%) females, mean age 66 (SD 11, range 40-85) years, onset-randomisation 203 (range 6-920) days. Most achieved full (64%) or over half (87%) dose, with no difference between cilostazol vs ISMN, single vs dual drugs. Headache and palpitations increased initially then declined similarly with dual versus single drugs. There was no between-group difference in BP, pulse-wave velocity, haemoglobin or platelet function, but pulse rate was higher (mean difference, MD, 6.4, 95%CI 1.2-11.7, p = 0.02), platelet count higher (MD 35.7, 95%CI 2.8, 68.7, p = 0.03) and white matter hyperintensities reduced more (Chi-square p = 0.007) with cilostazol versus no cilostazol.
Interpretation: Cilostazol and ISMN are well tolerated when the dose is escalated, without safety concerns, in patients with lacunar stroke. Larger trials with longer term follow-up are justified.
Funding: Alzheimer's Society (AS-PG-14-033).

Matched MeSH terms: Neuroimaging
Chronic neuronopathic type of Gaucher's disease with progressive myoclonic epilepsy in the absence of visceromegaly and bone involvement

Botross NP, Riad AA, Viswanathan S, Nordin RB, Lock HN

Scott Med J, 2014 May;59(2):e1-6.
PMID: 24671628 DOI: 10.1177/0036933014529868

Gaucher's disease is a lysosomal storage disorder caused by the deficiency of glucocerebrosidase. Gaucher's disease has three clinical types: non-neuronopathic (Type 1), Acute Neuropathic (Type 2) and chronic neuronopathic (Type 3). The chronic neuronopathic (Type 3) is characterised by a variety of disease variants with onset in childhood with hepatomegaly, skeletal lesions and later slow horizontal saccades, treatment-resistant generalised tonic-clonic and myoclonic seizures, dementia, progressive spasticity, cognitive deterioration, ataxia and death in the second or third decade of life.

Matched MeSH terms: Functional Neuroimaging
Alzheimer's disease prediction algorithm based on de-correlation constraint and multi-modal feature interaction

Cheng J, Wang H, Wei S, Mei J, Liu F, Zhang G

Comput Biol Med, 2024 Mar;170:108000.
PMID: 38232453 DOI: 10.1016/j.compbiomed.2024.108000

Alzheimer's disease (AD) is a neurodegenerative disease characterized by various pathological changes. Utilizing multimodal data from Fluorodeoxyglucose positron emission tomography(FDG-PET) and Magnetic Resonance Imaging(MRI) of the brain can offer comprehensive information about the lesions from different perspectives and improve the accuracy of prediction. However, there are significant differences in the feature space of multimodal data. Commonly, the simple concatenation of multimodal features can cause the model to struggle in distinguishing and utilizing the complementary information between different modalities, thus affecting the accuracy of predictions. Therefore, we propose an AD prediction model based on de-correlation constraint and multi-modal feature interaction. This model consists of the following three parts: (1) The feature extractor employs residual connections and attention mechanisms to capture distinctive lesion features from FDG-PET and MRI data within their respective modalities. (2) The de-correlation constraint function enhances the model's capacity to extract complementary information from different modalities by reducing the feature similarity between them. (3) The mutual attention feature fusion module interacts with the features within and between modalities to enhance the modal-specific features and adaptively adjust the weights of these features based on information from other modalities. The experimental results on ADNI database demonstrate that the proposed model achieves a prediction accuracy of 86.79% for AD, MCI and NC, which is higher than the existing multi-modal AD prediction models.

Matched MeSH terms: Neuroimaging/methods
Fulltext Leptomeningeal Carcinomatosis With Optic Nerve Metastasis Secondary to Breast Cancer

Chew C, Wan Hitam WH, Ahmad Tajudin LS

Cureus, 2021 Mar 31;13(3):e14200.
PMID: 33936906 DOI: 10.7759/cureus.14200

Leptomeningeal carcinomatosis (LC) and optic nerve metastasis are uncommon occurrences in breast cancer. We report a rare case of LC with optic nerve infiltration secondary to breast cancer. A 45-year-old lady who was a known case of treated right breast carcinoma six years ago presented with a blurring of vision in both eyes, floaters, and diplopia for one month. She also had recurrent attacks of seizure-like episodes, headache, and vomiting. Examination revealed high blood pressure with tachycardia. Her right eye visual acuity was counting fingers at two feet and 6/36 in the left eye. She had right abducens nerve palsy. Fundoscopy showed bilateral optic disc swelling with pre-retinal, flame-shaped haemorrhages and macular oedema. CT scan of brain and orbit was normal. She was admitted for further investigations. While in the ward, her vision deteriorated further. Her visual acuity in both eyes was at the level of no perception to light. She also developed bilateral abducens nerve palsy and right facial nerve palsy. Subsequently, she started having bilateral hearing loss. There were few episodes of fluctuations in conscious awareness. MRI brain showed mild hydrocephalus. Both optic nerves were thickened and enhanced on T1-weighted and post-gadolinium. Lumbar puncture was performed. There was high opening pressure. Cerebrospinal fluid cytology showed the presence of malignant cells. Family members opted for palliative care in view of poor prognosis. Unfortunately, she succumbed after a month's stay in hospital. Diagnosis of LC and optic nerve infiltration presents a formidable challenge to clinicians especially in the early stages where neuroimaging appears normal and lumbar puncture has high false negatives. Multiple high-volume taps are advised if clinical suspicion of LC is high.

Matched MeSH terms: Neuroimaging
Tumefactive demyelinating lesions versus CNS neoplasms, a comparative study

Chew SH, Achmad Sankala HB, Chew E, Md Arif MHB, Mohd Zain NR, Hashim H, et al.

Mult Scler Relat Disord, 2023 Nov;79:104992.
PMID: 37717306 DOI: 10.1016/j.msard.2023.104992

BACKGROUND: Differentiating tumefactive demyelinating lesions (TDL) from neoplasms of the central nervous system continues to be a diagnostic dilemma in many cases.
OBJECTIVE: Our study aimed to examine and contrast the clinical and radiological characteristics of TDL, high-grade gliomas (HGG) and primary CNS lymphoma (CNSL).
METHOD: This was a retrospective review of 66 patients (23 TDL, 31 HGG and 12 CNSL). Clinical and laboratory data were obtained. MRI brain at presentation were analyzed by two independent, blinded neuroradiologists.
RESULTS: Patients with TDLs were younger and predominantly female. Sensorimotor deficits and ataxia were more common amongst TDL whereas headaches and altered mental status were associated with HGG and CNSL. Compared to HGG and CNSL, MRI characteristics supporting TDL included relatively smaller size, lack of or mild mass effect, incomplete peripheral rim enhancement, absence of central enhancement or restricted diffusion, lack of cortical involvement, and presence of remote white matter lesions on the index scan. Paradoxically, some TDLs may present atypically or radiologically mimic CNS lymphomas.
CONCLUSION: Careful evaluation of clinical and radiological features helps in differentiating TDLs at first presentation from CNS neoplasms.

Matched MeSH terms: Neuroimaging
Fulltext Posterior reversible encephalopathy syndrome: Malaysian haemato-oncological paediatric case series

Choong, Yi Fong, Chaw, Su Hlaing, Aye, Aye Mya Min, Chee, Geap Tay, Lai, Choo Ong, Hany Ariffin

Neurology Asia, 2015;20(3):275-281.
MyJurnal

Background & Objective: Posterior reversible encephalopathy syndrome (PRES) is associated with
immunosuppressive agents used in children with haemato-oncological diseases. There are no reports
to date from the South Asia and South East Asia region. We report a Malaysian tertiary centre case
series of children with haemato-oncological disease who developed PRES. Methods: Retrospective
study of children seen with haemato-oncology diseases seen at the University Malaya Medical Centre
Kuala Lumpur who developed PRES from 2011 – 2013. Clinical details were obtained from medical
records and brain neuroimaging was reviewed. Results: Five patients met the inclusion criteria. All
5 patients had significant hypertension acutely or subacutely prior to neurology presentation. Four
presented with acute seizures and the remainder 1 presented with encephalopathy.Three patients
were on chemotherapy, 1 had renal impairment and 1 had prior immunosupression for bone marrow
transplantation. A full recovery was seen in 4 patients and 1 patient had mild residual quadriplegia.
Conclusion: Our case series expands the clinico-radiological spectrum of PRES in children with
underlying haemato-oncological disorders. It is the first to show that prior cyclosporin intake as long
as 2 months is a potential risk factor for PRES. Clinicians need to be vigilant for development of
PRES and closely monitor the blood pressure in these children who are receiving or recently had
immunosuppressive drugs and present with acute neurological symptoms.

Matched MeSH terms: Neuroimaging
Fulltext The association between subcortical and cortical fMRI and lifetime noise exposure in listeners with normal hearing thresholds

Dewey RS, Francis ST, Guest H, Prendergast G, Millman RE, Plack CJ, et al.

Neuroimage, 2020 01 01;204:116239.
PMID: 31586673 DOI: 10.1016/j.neuroimage.2019.116239

In animal models, exposure to high noise levels can cause permanent damage to hair-cell synapses (cochlear synaptopathy) for high-threshold auditory nerve fibers without affecting sensitivity to quiet sounds. This has been confirmed in several mammalian species, but the hypothesis that lifetime noise exposure affects auditory function in humans with normal audiometric thresholds remains unconfirmed and current evidence from human electrophysiology is contradictory. Here we report the auditory brainstem response (ABR), and both transient (stimulus onset and offset) and sustained functional magnetic resonance imaging (fMRI) responses throughout the human central auditory pathway across lifetime noise exposure. Healthy young individuals aged 25-40 years were recruited into high (n = 32) and low (n = 30) lifetime noise exposure groups, stratified for age, and balanced for audiometric threshold up to 16 kHz fMRI demonstrated robust broadband noise-related activity throughout the auditory pathway (cochlear nucleus, superior olivary complex, nucleus of the lateral lemniscus, inferior colliculus, medial geniculate body and auditory cortex). fMRI responses in the auditory pathway to broadband noise onset were significantly enhanced in the high noise exposure group relative to the low exposure group, differences in sustained fMRI responses did not reach significance, and no significant group differences were found in the click-evoked ABR. Exploratory analyses found no significant relationships between the neural responses and self-reported tinnitus or reduced sound-level tolerance (symptoms associated with synaptopathy). In summary, although a small effect, these fMRI results suggest that lifetime noise exposure may be associated with central hyperactivity in young adults with normal hearing thresholds.

Matched MeSH terms: Functional Neuroimaging*
Fulltext Mild cognitive impairment and its management in older people

Eshkoor SA, Hamid TA, Mun CY, Ng CK

Clin Interv Aging, 2015;10:687-93.
PMID: 25914527 DOI: 10.2147/CIA.S73922

Mild cognitive impairment (MCI) is a common condition in the elderly. It is characterized by deterioration of memory, attention, and cognitive function that is beyond what is expected based on age and educational level. MCI does not interfere significantly with individuals' daily activities. It can act as a transitional level of evolving dementia with a range of conversion of 10%-15% per year. Thus, it is crucial to protect older people against MCI and developing dementia. The preventive interventions and appropriate treatments should improve cognitive performance, and retard or prevent progressive deficits. The avoidance of toxins, reduction of stress, prevention of somatic diseases, implementation of mental and physical exercises, as well as the use of dietary compounds like antioxidants and supplements can be protective against MCI. The modification of risk factors such as stopping smoking, as well as the treatment of deficiency in vitamins and hormones by correcting behaviors and lifestyle, can prevent cognitive decline in the elderly. The progressive increase in the growth rate of the elderly population can enhance the rate of MCI all over the world. There is no exact cure for MCI and dementia; therefore, further studies are needed in the future to determine causes of MCI and risk factors of progression from MCI to dementia. This will help to find better ways for prevention and treatment of cognitive impairment worldwide.

Matched MeSH terms: Neuroimaging
Fulltext A multi-resolution textural approach to diagnostic neuropathology reporting

Fauzi MF, Gokozan HN, Elder B, Puduvalli VK, Pierson CR, Otero JJ, et al.

J Neurooncol, 2015 Sep;124(3):393-402.
PMID: 26255070 DOI: 10.1007/s11060-015-1872-4

We present a computer aided diagnostic workflow focusing on two diagnostic branch points in neuropathology (intraoperative consultation and p53 status in tumor biopsy specimens) by means of texture analysis via discrete wavelet frames decomposition. For intraoperative consultation, our methodology is capable of classifying glioblastoma versus metastatic cancer by extracting textural features from the non-nuclei region of cytologic preparations based on the imaging characteristics of glial processes, which appear as anisotropic thin linear structures. For metastasis, these are homogeneous in appearance, thus suitable and extractable texture features distinguish the two tissue types. Experiments on 53 images (29 glioblastomas and 24 metastases) resulted in average accuracy as high as 89.7 % for glioblastoma, 87.5 % for metastasis and 88.7 % overall. For p53 interpretation, we detect and classify p53 status by classifying staining intensity into strong, moderate, weak and negative sub-classes. We achieved this by developing a novel adaptive thresholding for detection, a two-step rule based on weighted color and intensity for the classification of positively and negatively stained nuclei, followed by texture classification to classify the positively stained nuclei into the strong, moderate and weak intensity sub-classes. Our detection method is able to correctly locate and distinguish the four types of cells, at 85 % average precision and 88 % average sensitivity rate. These classification methods on the other hand recorded 81 % accuracy in classifying the positive and negative cells, and 60 % accuracy in further classifying the positive cells into the three intensity groups, which is comparable with neuropathologists' markings.

Matched MeSH terms: Neuroimaging
Fulltext Chloral hydrate as a sedating agent for neurodiagnostic procedures in children

Fong CY, Tay CG, Ong LC, Lai NM

Cochrane Database Syst Rev, 2017 Nov 03;11(11):CD011786.
PMID: 29099542 DOI: 10.1002/14651858.CD011786.pub2

BACKGROUND: Paediatric neurodiagnostic investigations, including brain neuroimaging and electroencephalography (EEG), play an important role in the assessment of neurodevelopmental disorders. The use of an appropriate sedative agent is important to ensure the successful completion of the neurodiagnostic procedures, particularly in children, who are usually unable to remain still throughout the procedure.
OBJECTIVES: To assess the effectiveness and adverse effects of chloral hydrate as a sedative agent for non-invasive neurodiagnostic procedures in children.
SEARCH METHODS: We used the standard search strategy of the Cochrane Epilepsy Group. We searched MEDLINE (OVID SP) (1950 to July 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, Issue 7, 2017), Embase (1980 to July 2017), and the Cochrane Epilepsy Group Specialized Register (via CENTRAL) using a combination of keywords and MeSH headings.
SELECTION CRITERIA: We included randomised controlled trials that assessed chloral hydrate agent against other sedative agent(s), non-drug agent(s), or placebo for children undergoing non-invasive neurodiagnostic procedures.
DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the studies for their eligibility, extracted data, and assessed risk of bias. Results were expressed in terms of risk ratio (RR) for dichotomous data, mean difference (MD) for continuous data, with 95% confidence intervals (CIs).
MAIN RESULTS: We included 13 studies with a total of 2390 children. The studies were all conducted in hospitals that provided neurodiagnostic services. Most studies assessed the proportion of sedation failure during the neurodiagnostic procedure, time for adequate sedation, and potential adverse effects associated with the sedative agent.The methodological quality of the included studies was mixed, as reflected by a wide variation in their 'Risk of bias' profiles. Blinding of the participants and personnel was not achieved in most of the included studies, and three of the 13 studies had high risk of bias for selective reporting. Evaluation of the efficacy of the sedative agents was also underpowered, with all the comparisons performed in single small studies.Children who received oral chloral hydrate had lower sedation failure when compared with oral promethazine (RR 0.11, 95% CI 0.01 to 0.82; 1 study, moderate-quality evidence). Children who received oral chloral hydrate had a higher risk of sedation failure after one dose compared to those who received intravenous pentobarbital (RR 4.33, 95% CI 1.35 to 13.89; 1 study, low-quality evidence), but after two doses there was no evidence of a significant difference between the two groups (RR 3.00, 95% CI 0.33 to 27.46; 1 study, very low-quality evidence). Children who received oral chloral hydrate appeared to have more sedation failure when compared with music therapy, but the quality of evidence was very low for this outcome (RR 17.00, 95% CI 2.37 to 122.14; 1 study). Sedation failure rates were similar between oral chloral hydrate, oral dexmedetomidine, oral hydroxyzine hydrochloride, and oral midazolam.Children who received oral chloral hydrate had a shorter time to achieve adequate sedation when compared with those who received oral dexmedetomidine (MD -3.86, 95% CI -5.12 to -2.6; 1 study, moderate-quality evidence), oral hydroxyzine hydrochloride (MD -7.5, 95% CI -7.85 to -7.15; 1 study, moderate-quality evidence), oral promethazine (MD -12.11, 95% CI -18.48 to -5.74; 1 study, moderate-quality evidence), and rectal midazolam (MD -95.70, 95% CI -114.51 to -76.89; 1 study). However, children with oral chloral hydrate took longer to achieve adequate sedation when compared with intravenous pentobarbital (MD 19, 95% CI 16.61 to 21.39; 1 study, low-quality evidence) and intranasal midazolam (MD 12.83, 95% CI 7.22 to 18.44; 1 study, moderate-quality evidence).No data were available to assess the proportion of children with successful completion of neurodiagnostic procedure without interruption by the child awakening. Most trials did not assess adequate sedation as measured by specific validated scales, except in the comparison of chloral hydrate versus intranasal midazolam and oral promethazine.Compared to dexmedetomidine, chloral hydrate was associated with a higher risk of nausea and vomiting (RR 12.04 95% CI 1.58 to 91.96). No other adverse events were significantly associated with chloral hydrate (including behavioural change, oxygen desaturation) although there was an increased risk of adverse events overall (RR 7.66, 95% CI 1.78 to 32.91; 1 study, low-quality evidence).
AUTHORS' CONCLUSIONS: The quality of evidence for the comparisons of oral chloral hydrate against several other methods of sedation was very variable. Oral chloral hydrate appears to have a lower sedation failure rate when compared with oral promethazine for children undergoing paediatric neurodiagnostic procedures. The sedation failure was similar for other comparisons such as oral dexmedetomidine, oral hydroxyzine hydrochloride, and oral midazolam. When compared with intravenous pentobarbital and music therapy, oral chloral hydrate had a higher sedation failure rate. However, it must be noted that the evidence for the outcomes for the comparisons of oral chloral hydrate against intravenous pentobarbital and music therapy was of very low to low quality, therefore the corresponding findings should be interpreted with caution.Further research should determine the effects of oral chloral hydrate on major clinical outcomes such as successful completion of procedures, requirements for additional sedative agent, and degree of sedation measured using validated scales, which were rarely assessed in the studies included in this review. The safety profile of chloral hydrate should be studied further, especially the risk of major adverse effects such as bradycardia, hypotension, and oxygen desaturation.

Matched MeSH terms: Neuroimaging
Fulltext Neurodevelopmental effects of childhood malnutrition: A neuroimaging perspective

Galler JR, Bringas-Vega ML, Tang Q, Rabinowitz AG, Musa KI, Chai WJ, et al.

Neuroimage, 2021 05 01;231:117828.
PMID: 33549754 DOI: 10.1016/j.neuroimage.2021.117828

Approximately one in five children worldwide suffers from childhood malnutrition and its complications, including increased susceptibility to inflammation and infectious diseases. Due to improved early interventions, most of these children now survive early malnutrition, even in low-resource settings (LRS). However, many continue to exhibit neurodevelopmental deficits, including low IQ, poor school performance, and behavioral problems over their lifetimes. Most studies have relied on neuropsychological tests, school performance, and mental health and behavioral measures. Few studies, in contrast, have assessed brain structure and function, and to date, these have mainly relied on low-cost techniques, including electroencephalography (EEG) and evoked potentials (ERP). The use of more advanced methods of neuroimaging, including magnetic resonance imaging (MRI) and functional near-infrared spectroscopy (fNIRS), has been limited by cost factors and lack of availability of these technologies in developing countries, where malnutrition is nearly ubiquitous. This report summarizes the current state of knowledge and evidence gaps regarding childhood malnutrition and the study of its impact on neurodevelopment. It may help to inform the development of new strategies to improve the identification, classification, and treatment of neurodevelopmental disabilities in underserved populations at the highest risk for childhood malnutrition.

Matched MeSH terms: Neuroimaging
A rare case of methicillin resistant Staphylococcus aureus (MRSA) cerebral abscess secondary to conjunctivitis

Gan YK, Azmi AZ, Ghani SA, Samsudin A

Med J Malaysia, 2017 06;72(3):197-198.
PMID: 28733571 MyJurnal

This case report discusses the rare association of cerebral abscess related to conjunctivitis in an otherwise healthy child. A 6 year old boy presented with conjunctivitis was treated with topical antibiotics and resolved after a week. Conjunctival swab cultures grew MRSA. A month later he developed status epileptics and CT scans revealed a large cerebral abscess. He was treated with intravenous antibiotics which covered for MRSA, along with an incision and drainage for the cerebral abscess. Pus cultures grew MRSA. The patient recovered well with no disturbance in visual acuity or visual field. On post-operative follow ups, he had no other neurological deficit apart from a slight limp.

Matched MeSH terms: Neuroimaging
Fulltext Characteristic differences in neuroimaging and physical findings between non-accidental and accidental traumatic brain injury in young children. A local experience in general hospital of Kuala Lumpur

Hafiz MZ, Saffari MH

Med J Malaysia, 2011 Jun;66(2):95-100.
PMID: 22106685 MyJurnal

OBJECTIVE: The objective of this study is to identify the characteristic neuroimaging (namely brain CT) as well as physical findings found in young children with nonaccidental traumatic brain injury (TBI) and to compare them with accident cases of the similar age group, in order to study the specific features of the former group more precisely.
MATERIALS AND METHODS: A cross sectional study was done involving 92 children aged 3 years old and below who were admitted to the Kuala Lumpur Hospital with diagnosis of moderate to severe traumatic brain injury from period of June 2007 to September 2009. These children were categorized into non-accidental and accidental TBI and their physical examination data, brain computed tomography and skeletal surveys were done within one week from the date of admission were compared.
RESULTS: There was a male predominance in both non-accidental and accidental TBI groups with male-to-female ratio of 2:1 and 3:1 respectively. The majority of the non-accidental TBI cases presented with no definite history of trauma (52.2%) while most of the accidental TBI cases were caused by motor vehicle accidents (69.9%). Subdural haematomas appeared to be significantly the most common brain haematomas among the nonaccidental TBI as compared to the accidental group while extradural haematomas were only present in the accidental TBI group. Cerebral edema was also significantly more common in the non-accidental group. Signs of pre-existing brain injury, including cerebral atrophy and subdural hygroma/effusion were present in 23.9% and 19.6% respectively among children with non-accidental TBI and in none of the children with accidental TBI. None of the children in the non-accidental group diagnosed to have shear injury while 6 (13.0%) of the children in the accidental group was diagnosed with diffuse axonal injury. In our series, retinal haemorrhage was significantly more common in the non-accidental TBI group (93.5%) as opposed to only 4(8.7%) children noted to have retinal haemorrhage in the accidental group. Seizures also occurred significantly more often in children with non-accidental TBI. Depressed skull fractures were only found in the accidental TBI group (19.6%), while other types of skull fractures occur more or less similar in both groups. Bodily fractures were also more predominant among the accidental group of TBI. Bodily lacerations/abrasions were only found in the accidental group while findings of bodily bruises were quite equal in both groups.
KEY WORDS: Traumatic brain injury, Non-accidental head injury (NAI), Young children

Matched MeSH terms: Neuroimaging*

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