The second case of Sarcocystis infection in man is reported from an aborigine girl. It was an incidental finding at autopsy and two cysts were seen in the muscle of the oropharyngeal region. The cysts and zoites were similar to those in the previous case reported from Malaysia.
Parkinsonism as a neurologic manifestation of dengue infection is rare with only 1 reported case in an adult patient. We report a case of a 6-year-old child with self-limiting post-dengue encephalopathy and Parkinsonism. This is the first reported pediatric case of post-dengue Parkinsonism and expands the neurologic manifestations associated with dengue infection in children. Clinicians should consider the possibility of post-dengue Parkinsonism in children with a history of pyrexia from endemic areas of dengue.
AIM OF STUDY: This study investigated the consistency in Auditory Brainstem Response (ABR) waveform evaluations between two audiologists (inter-audiologist agreement) and within each of the audiologist (intra-audiologist agreement).
METHODS: Two audiologists from one of the audiology clinics in Kuantan, Pahang, Malaysia were involved in this study. Both audiologists were required to identify and mark the presence of Waves I, III and V in 66 ABR waveforms. Over a one-month interval, each audiologist was required to carry out the same procedure on the same ABR waveforms. This process was continued until we had three separate reviews from each audiologist.
RESULTS: There was a high inter-audiologist ABR waveform identification agreement (over the range 81.71-89.77%), but a lower intra-audiologist ABR waveform identification agreement (over the range 50%-78%) for both audiologists. Our results also showed a high intra-audiologist ABR latency agreement within 0.2 ms (>90%), but a slightly lower inter-audiologist latency agreement (75-84%) within 0.2 ms.
CONCLUSION: Our results support the need for the clinic to implement further strategies for improving the respective lower agreements and consistencies. These include conducting a continuous education program and using an objective algorithm to support their interpretations.
Study site:; International Islamic University, Malaysia (IIUM) Hearing
and Speech Clinic
hemangiopericytoma (hPC) is a rare tumor by definition and intracranial hPC makes up to less than one percent of all the intracranial tumors. It is a dural base tumor and its clinical features and radiological findings are similar to meningiomas. however, cerebellopontine angle hemangipericytoma had only been reported twice and would almost always be misdiagnosed. definite diagnosis is important, as the treatment of hPC is different from meningiomas and acoustic neuromas. we report a case of a young female who presented with atypical symptoms of left cerebellopontine angle mass. A literature review of the nature of the disease, radiological findings, immunohistochemical features and treatment options of the tumor are described.
We report a case 35-year-old lady who developed acute psychosis following administration of cefuroxime and metronidazole. Earliest mood changes occurred on the second day of antibiotics therapy. She developed hallucinations, delusions and bizarre behavior 1 day after the completion of the antibiotic therapy. All the relevant investigations including CT brain were normal. The psychosis resolved completely within 5 days of antipsychotic treatment.
This study aimed to evaluate the functional status and HRQoL in patients with primary intracranial tumours in Malaysia. Karnofsky Performance Scale (KPS) and Modified Barthel Index (MBI) were used to assess the functional status whereas EORTC core Quality of Life Questionnaire (QLQ-C30) and Brain Cancer Module (BN-20) questionnaires were used to assess the HRQoL. Thirty-eight patients with primary intracranial tumours admitted for surgery in University Malaya Medical Center were recruited. These assessments were administered before surgery (baseline) and six months after surgery (follow-up). All patients received some form of rehabilitation interventions after surgery. The global HRQoL and functional status of these patients showed improvement at six months after surgery. Emotional Functioning score showed the greatest improvement among the functional domains (63 vs 86, p=0.003). Reduction in symptom burden such as fatigue, nausea, vomiting, pain and headache were also noted at follow-up together with less future uncertainty (p<0.05). Pearson correlation revealed statistically significant positive correlation between functional status and HRQoL at baseline and follow-up, in particular, global health status (r=0.50 and r=0.67), physical functioning (r=0.53 and r=0.90) and role functioning (r=0.34 and r=0.77). Thus, from the correlation found, improving a patient's function and independence level throughout all stages of care, even before any surgical intervention is offered would improve the HRQoL concurrently.
Traumatic Brain injury (TBI) is one of the most common causes of death and disability worldwide, with recent interest in the use of cholinomimetics in the treatment of TBI patients for cognitive impairments. Our patient who suffered TBI was started on a trial of an acetylcholinesterase inhibitor (Donepezil) for five weeks. Cognitive and memory testing with the Mini-Mental State Examination (MMSE) and Functional Independence Measurement (FIM) showed some degree of improvement: The three item recall component of MMSE improved and the FIM Memory score increased from 1 (Complete dependence) to 6 (Functional independence). Subjective assessment of his behaviour in the ward also showed improvement. This suggests that donepezil may help improve memory and behaviour of moderately severe traumatic brain injury patients, although more research in this direction should be undertaken.
Metastasis of an atrial myxoma to the brain is extremely rare. Thus far there are only 17 cases reported, including our present case. Most of the brain metastases manifest only in 3 to 6 decades, after an average time frame of one to two years after surgical removal of parental tumour. We present a case of brain metastases of atrial myxoma in a teenager of the youngest age among all reported cases, unusually as early as 15 years old. The progress of the metastatic process had been insidious for three years after heart surgery, The imaging demonstrated a rather sizeable tumour by the time when the patient is symptomatic. The location of the metastatic tumour is anyhow superficial to the cortical surface, enabling complete surgical excision of the tumour easily achievable with favourable outcome.
Stereotactic radiosurgery uses a single fraction high dose radiation while stereotactic radiotherapy uses multifractionated lower dose focused radiation.
We report a case of rhinocerebral mucormycosis in a 31 year old immunocompetent female presenting initially like acute rhinosinusitis with nasal stuffiness, severe headache, vomiting who soon developed isolated right lateral rectus palsy. Computed tomography (CT) scan of the Post-Nasal Spaces(PNS) showed an ill defined expansile heterogenous density mass in the sphenoid with extension into the ethmoids, nasal cavity, optic canal, superior orbital fissure, clivus and right temporal lobe with signal void in Magnetic Resonance Imaging (MRI). The debris and polypoid mucosa obtained on nasal endoscopy revealed mucormycosis on histopathologic examination. The patient was managed with urgent surgical debridement and medical management.
High grade gliomas, frequently with their infiltrative nature, often make the outcome from neurosurgical intervention alone unsatisfactory. It is recognized that adjuvant radiochemotherapy approaches offer an improved prognosis. For these reasons, we opted for surgical debulking, intraoperative radiation therapy (IORT) in combination with whole brain irradiation therapy and chemotherapy (temozolamide cycles) in the management of a 42 year-old lady with Glioblastoma Multiforme (GBM). Her troublesome symptoms improved after 3 months of this polymodal therapy and remained independently functional for more than two years.
This was a prospective observational study done to evaluate the role of a repeat head CT in patients with mild traumatic brain injury. The aim was to evaluate wether the repeat head CT were useful in providing information that leads to any neurosurgical intervention. 279 adult patients with a mild head injury (GCS 13-15) were enrolled, and these comprised of patients with an initial traumatic intracranial haemorrhage not warranting any surgical intervention. All patients were subjected to a repeat head CT within 48 hours of admission and these showed no change or improvements of the brain lesion in 217 patients (79.2%) and worsening in 62 patients (20.8%). In thirty-one patients, surgical intervention was done following the repeat head CT. All of these patients had a clinical deterioration prior to the repeat head CT. Even if a repeat head CT had not been ordered on these patients, they would have had a repeat head CT due to deteriorating neurological status. When the 62 patients with a worsening repeat head CT were compared with the 217 patients with an improved or unchanged repeat head CT, they were found to have older age, lower GCS on admission, presenting symptoms of headache, higher incidence of multiple traumatic intracranial pathology and lower haemoglobin level on admission. On stepwise multiple logistic regression analysis, three factors were found to independently predict a worse repeat head CT (Table IV). This includes age of 65 years or older, GCS score of less than 15 and multiple traumatic intracranial lesion on initial head CT. As a conclusion, we recommend that, in patients with a MTBI and a normal neurological examination, a repeat cranial CT is not indicated, as it resulted in no change in management or neurosurgical intervention. Close monitoring is warranted in a subset of patients with risk factors for a worsening repeat head CT.
Keywords: Computed tomography, brain injury, Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia
The National Stroke Registry (NSR) was established in 2009 under National Neurology Registry (NNeuR) . The main objectives of NSR were to describe the demographic and disease pattern of stroke patients in Malaysia, to examine the risk factors and evaluate the specified treatment and outcomes. This prospective observational study was carried out from August 2009 until December 2010 using a standardized case report form which involved two participating hospital, namely Hospital Sultanah Nur Zahirah, Kuala Terengganu and Hospital Seberang Jaya, Pulau Pinang. There were 1018 patients registered. Ischemic stroke accounted for the majority of cases (73.3%). The most common risk factor was hypertension (75.5 %), followed by diabetes mellitus, previous stroke or Transient Ischemic Attack (TIA), hyperlipidemia and active smoker: 45.6%, 25.1%, 22.4%, and 19.4%, respectively. Overall, our stroke management, based on nine stroke key performance indicators (KPI) still needs to be improved. There was a total of 121 mortality cases with the main contributing factor was massive cerebral bleed (21.6%). In conclusion, the findings highlight the important of primary and secondary stroke management. Further and continuous observation with more site date provider (SDP) involvement is needed to get a more comprehensive data on stroke in Malaysia.
This analysis is a case-series to document the outcome of term newborns with hypoxic ischaemic encephalopathy (HIE), enrolled into total body hypothermia therapy, in a tertiary neonatal unit in Malaysia. The method used to achieve total body hypothermia is a novel method using just environmental temperature, without the need of expensive equipment. A total of 17 babies were eligible to be included in this study, from the 1st of January 2010 to the 31st of December 2010. 14 out of 15 babies who had Stage 2 HIE had no neurological deficit at follow-up. All Stage 3 HIE babies passed away. Allowing for the small sample size, we can conclude that total body hypothermia therapy is feasible and is a safe treatment modality for HIE Stage 2 babies in a Malaysian setting, by manipulating environmental temperature to achieve therapeutic hypothermia. Further work is needed to determine the long-term outcome of passive cooling total body hypothermia in Stage 2 HIE babies in Malaysia.
Intensive care for severe head injury patients is very important in the prevention and treatment of secondary brain injury. However, in a resources constraint environment and limited availability of Intensive Care Unit (ICU) beds in the hospitals, not all severe head injury patients will receive ICU care. This prospective study is aimed to evaluate the outcome of severe head injured patients who received ICU and general ward care in Sarawak General Hospital (SGH) over a 6-month period. A total of thirty five severe head injury patients were admitted. Twenty three patients (65.7%) were ventilated in general ward whereas twelve patients (34.3%) were ventilated in ICU. Overall one month mortality in this study was 25.7%. Patients who received ICU care had a lower one month mortality than those who received general ward care (16.7% vs 30.4%), although it was not statistically different. Multivariate analysis revealed only GCS on admission (OR 0.731; 95% CI 0.460 to 0.877; P=0.042) as the independent predictive factor for one month mortality in this study.
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
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.
This report deals with an elderly lady with Guillain-Barre Syndrome (GBS), who presented with features of unusually severe hyponatraemia. The hyponatraemia was probably due to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The hyponatraemia resolved with water restriction and infusion of hypertonic saline; GBS was treated with human immunoglobulin (IVIG). This patient's experience stresses the importance of monitoring serum sodium levels as hyponatraemia has been identified to be a marker of poor prognosis in GBS.