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Anterior spinal cord syndrome as a rare complication of acute bacterial meningitis in an adult

Ng KS, Abdul Halim S

BMJ Case Rep, 2018 Oct 24;2018.
PMID: 30361450 DOI: 10.1136/bcr-2018-226082

Acute bacterial meningitis is not an uncommon central nervous system infection. In severe cases, it can be associated with various neurological or systemic complications. However, acute spinal cord dysfunction rarely occurs. We report a case of bacterial meningitis complicated with spinal cord infarction despite adequate treatment with antibiotics and corticosteroid therapy. He had residual paraplegia and was fully dependent in the activity of daily living.
Fulltext Cerebral venous sinus thrombosis in a patient with concomitant Graves' disease and squamous cell carcinoma of the cervix

Chee YC, Abdul Halim S

BMJ Case Rep, 2020 Dec 09;13(12).
PMID: 33298481 DOI: 10.1136/bcr-2020-236730

Cerebral venous sinus thrombosis (CVST) is caused by either acquired or inherited pro-thrombotic states. Hyperthyroidism is a less recognised predisposing factor of CVST, and the causality has been debated. We report a case of a life-threatening CVST in a 40-year-old woman, with uncommon dual risk factors: hyperthyroidism and advanced squamous cell carcinoma of the cervix. CVST should be considered as a differential diagnosis when a patient with hyperthyroidism presents with new-onset headache or other neurological symptoms. Further assessment to elucidate other covert risk factors may need to be continuously carried out, when the causal relationship of one apparent cause has not been well established.
Fulltext Persistent Intracranial Hypertension and Severe Hypoglycorrhachia in an Adult With Giant Congenital Melanocytic Naevi

Kong D, Abdul Halim S

Cureus, 2023 Dec;15(12):e51420.
PMID: 38299130 DOI: 10.7759/cureus.51420

A 29-year-old female, with giant congenital melanocytic naevi (GCMN) presented with a-year history of symptoms and signs of intracranial hypertension. Investigations revealed raised cerebrospinal fluid (CSF) pressure and severe hypoglycorrhachia (low CSF glucose) without pleocytosis. Initial contrast-enhanced brain MRI was normal, but a repeat MRI after a year showed meningeal enhancement with mild communicating hydrocephalus. The raised intracranial pressure was treated with a lumbar-peritoneal shunt. Intraoperative CSF cytology revealed an abundance of squamous epithelia and degenerative cells, but no malignant cells. Her symptoms recovered with CSF diversion via shunt placement, but the hypoglycorrhachia remained. This case highlights the rare occurrence of a non-inflammatory cause of both intracranial hypertension and severe hypoglycorrhachia in a GCMN adult patient, with progressive radiological changes over time, consistent with a diagnosis of neurocutaneous melanosis.
Intracranial Aneurysm: A Rare Neurological Finding in Ankylosing Spondylitis

Pairan MS, Abdul Halim S

Cureus, 2023 Nov;15(11):e49509.
PMID: 38152807 DOI: 10.7759/cureus.49509

Ankylosing spondylitis can present with various extra-articular manifestations. Vascular complications due to aortic aneurysm or aortitis have been documented. However, an association with intracranial vascular aneurysm is rarely reported. We report a case of a young male with positive HLA B27 ankylosing spondylitis, with extra-articular involvements, presented with recurrent unilateral headache. He was found to have an unruptured anterior communicating artery aneurysm. It was confirmed by a cerebral angiogram, and he was treated conservatively.
Fulltext Treatment response in osmotic demyelination syndrome presenting as severe parkinsonism, ptosis and gaze palsy

Abdul Halim S, Mohd Amin NA

BMJ Case Rep, 2018 Oct 21;2018.
PMID: 30344146 DOI: 10.1136/bcr-2018-225751

Osmotic demyelination syndrome commonly affects the pons and infrequently involves the extrapontine region. We report a patient with severe hyponatraemia who developed osmotic demyelination syndrome as a consequence of rapid sodium correction. The condition manifested as acute severe parkinsonism, bilateral ptosis and gaze impairment. MRI revealed typical features of central pontine and extrapontine myelinolysis. The patient improved gradually after treatment with a combination of levodopa, intravenous immunoglobulin and dexamethasone. However, it is important to emphasise that the improvement of neurological symptoms is not necessarily causal with these experimental therapies.
Drivers of food waste generation: Case study of island-based hotels in Langkawi, Malaysia

Kasavan S, Mohamed AF, Abdul Halim S

Waste Manag, 2019 May 15;91:72-79.
PMID: 31203944 DOI: 10.1016/j.wasman.2019.04.055

Food waste (FW) generation from hotel operations have a significant negative impact on the environment, society and economy. Hence, the urgent need to introduce sustainable food management to reduce both FW and operational costs in hotels. The aim of this paper is to identify the drivers of FW generation and barriers to sustainable food waste management (SFWM) in island based hotels. The data were collected using in-depth interview coupled with the observations conducted at 23 selected hoteliers in Langkawi Island, Malaysia. Based on the analysis, using qualitative content analysis (QCA), eight FW drivers were identified and the drivers were classified into three categories of factors, mainly internal, external and intermediate influence. There are four FW drivers identified as internal factors that influenced the implementation of food waste management namely (1) poor hotel management and policies, (2) lack of skills in food preparation, (3) lack of facilities and FW technology and (4) non-implementation of waste audit and waste separation. For external factors, there are two FW drivers, including (5) unsustainable food consumption patterns of the customers and (6) risk of food ingredients spoilage. As for intermediate factors, two FW drivers were identified, which are (7) ineffective communication and (8) inadequate education and awareness. Findings from this study contribute towards a better understanding on the complexity of FW issues, particularly for island-based hotel sector. It was also suggested that a holistic approach with multi-stakeholders is crucial to reduce food wastage towards achieving SFWM.
Fulltext Damage control resuscitation: A case of thoraco-abdominal impalement

Nur AK, Mohd Mokhtar MA, Izzat I, Abdul Halim S, Nor Elayni B

Med J Malaysia, 2016 04;71(2):77-8.
PMID: 27326948 MyJurnal

Damage Control Resuscitation and Surgery is the concept of controlled hypotension, haemostatic resuscitation and abbreviated surgical procedures following severe trauma; the practice of which has resulted in improved mortality and morbidity. We describe a rare case of thoraco-abdominal impalement successfully managed based on the concept of Damage Control Resuscitation.
Paraneoplastic optic neuropathy secondary to adenocarcinoma of the lung

Yap JY, Wan HItam WH, Abdul Halim S, Masnon NA

BMJ Case Rep, 2021 May 12;14(5).
PMID: 33980562 DOI: 10.1136/bcr-2021-242082

We describe an uncommon cause of paraneoplastic optic neuropathy in adenocarcinoma of the lung. A 45-year-old healthy woman presented with seizure and encephalitis, followed by an acute visual loss in both eyes for 1 week. Her visual acuity was no perception of light in the right eye and hand movement in the left eye. There was a generalised restriction of extraocular muscle movements in both eyes. Funduscopy showed a bilateral pale optic disc. A paraneoplastic antigen autoimmune profile showed a positive anti-CV2/CRMP-5 antibody. CT of the thorax revealed the presence of right apical lung mass, confirmed to be adenocarcinoma through a biopsy. She was scheduled for lung lobectomy and chemotherapy. Unfortunately, her health deteriorated and she passed away eventually.
Fulltext Status epilepticus as the initial presentation of antibody-negative Goodpasture's syndrome

Ting IP, Abdul Halim S, Adnan A, Jaafar H

BMJ Case Rep, 2017 Aug 01;2017.
PMID: 28765179 DOI: 10.1136/bcr-2017-219628

Goodpasture's syndrome is a rare pulmonary-renal disease. It is characterised by presence of auto-antibodies directed against the glomerular basement membrane (GBM) antigen. These antibodies that bind to the GBM antigens cause rapidly progressive glomerulonephritis. The alveolar basement membrane also contains similar antigen, leading to pulmonary haemorrhage in active disease. We report a case of a young man who initially presented with status epilepticus and later was found to have rapidly progressive glomerulonephritis with pulmonary haemorrhage. Serum anti-GBM antibody was negative but the renal biopsy confirmed the diagnosis by showing typical linear IgG along the GBM on immunofluorescent study. He was treated with plasmapheresis and high-dose steroid in combination with oral cyclophosphamide. His renal function normalised after treatment.
Fulltext Intracranial bleeding (ICB) as a catastrophic complication of Streptococcus gordonii infective endocarditis (IE) in an immunocompetent patient

Pairan MS, Mohammad N, Abdul Halim S, Wan Ghazali WS

BMJ Case Rep, 2018 Sep 10;2018.
PMID: 30206067 DOI: 10.1136/bcr-2018-225265

We present an interesting case of late-onset intracranial bleeding (ICB) as a complication of Streptococcus gordonii causing infective endocarditis. A previously healthy young woman was diagnosed with infective endocarditis. While she was already on treatment for 2 weeks, she had developed seizures with a localising neurological sign. An urgent non-contrasted CT brain showed massive left frontoparietal intraparenchymal bleeding. Although CT angiogram showed no evidence of active bleeding or contrast blush, massive ICB secondary to vascular complication of infective endocarditis was very likely. An urgent decompressive craniectomy with clot evacuation was done immediately to release the mass effect. She completed total 6 weeks of antibiotics and had postoperative uneventful hospital stay despite having a permanent global aphasia as a sequel of the ICB.
Fulltext Recurrent bilateral occipital infarct with cortical blindness and anton syndrome

Kwong Yew K, Abdul Halim S, Liza-Sharmini AT, Tharakan J

Case Rep Ophthalmol Med, 2014;2014:795837.
PMID: 24744933 DOI: 10.1155/2014/795837

Bilateral cortical blindness and Anton syndrome, are most commonly caused by ischaemic stroke. In this condition, patients have loss of vision but deny their blindness despite objective evidence of visual loss. We report a case of a patient with multiple cardiovascular risk factors who developed recurrent bilateral occipital lobe infarct with Anton syndrome. A suspicion of this condition should be raised when the patient has denial of blindness in the presence of clinical and radiological evidence of occipital lobe injury. Management of this condition should focus on the underlying cause, in which our patient requires secondary stroke prevention and rehabilitation.
Outcome of acute ischaemic stroke patients after intravenous alteplase in Hospital Universiti Sains Malaysia

Wong KY, Baharuddin KA, Masykurin MM, Abdul Halim S, Chee YC, Sapiai NA, et al.

Med J Malaysia, 2021 Nov;76(6):870-875.
PMID: 34806675

INTRODUCTION: Intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rt-PA) is effective in treating acute ischaemic stroke. Our primary objective is to assess the outcome of these acute ischaemic stroke (AIS) patients after IV alteplase with the modified Rankin scale (mRS).
METHODS: This is a cross-sectional study in which patients receiving IV alteplase in Hospital Universiti Sains Malaysia, from January 2017 to April 2020 were recruited. Demographical data, National Institutes of Health Stroke Scale (NIHSS) scores, door-to-needle time were recorded. Modified Rankin scale (mRS) scores were evaluated at 90 days after initial therapy. Good and poor functional outcomes were defined as 0-2 and 3-6, respectively.
RESULTS: A total of 30 patients were included in the study with a mean age of 59±11.47 years old. 76.7% of them were male and the rest were female. From the study, onset-toneedle time was 197.47±51.74 minutes, whereas door-toneedle time was 120.93±53.63 minutes. Seventeen (56.3%) patients achieved a favourable score of 0-2 on the mRS at 90 days after treatment. Haemorrhagic transformation occurred in eight (26.7%) of the patients with a mortality rate of 13.3%.
CONCLUSION: 56.7% of our patients showed improvement in the mRS at 90 days post thrombolysis for AIS. Higher baseline NIHSS scores and diabetes mellitus were associated with poorer functional outcomes after thrombolysis.
Fulltext Subthalamic Nucleus (STN)-Deep Brain Stimulation Reduces the Power of Mu and Beta Rhythms and Enhances Synchrony at the Motor Cortices in Parkinson's Disease: A Report of Two Cases

Zakaria Z, Idris Z, Abdul Halim S, Ghani ARI, Abdullah JM

Cureus, 2023 Feb;15(2):e35057.
PMID: 36942168 DOI: 10.7759/cureus.35057

The motor circuit in Parkinson's disease (PD) involves the basal ganglia, thalamus, motor cortex, and cerebellum. Hence, subthalamic nucleus (STN) or globus pallidus internus deep brain stimulation is commonly used in treating refractory Parkinson's patients. During the procedure, the local field potential (LPF) is commonly made along the trajectory of the STN. Two cases were assessed, where an electroencephalographic recording at the sensorimotor cortices was also performed with and without stimulation at the optimal STN electrode site. The 'on' stimulation state associated with clinical improvement correlated with a marked reduction in the late theta (7.5 Hz), alpha (10.5 Hz) (Mu wave), and beta (20 Hz) wave power. Besides, more synchronized and coherent brainwaves were noted when the stimulation was 'on'.
Fulltext Comparison of 3 Grading Systems (House-Brackmann, Sunnybrook, Sydney) for the Assessment of Facial Nerve Paralysis and Prediction of Neural Recovery

Mat Lazim N, Ismail H, Abdul Halim S, Nik Othman NA, Haron A

Medeni Med J, 2023 Jun 20;38(2):111-119.
PMID: 37338861 DOI: 10.4274/MMJ.galenos.2023.42383

OBJECTIVE: Currently, multiple classification systems exist for the assessment of facial nerve paralysis. This study was designed to choose the most practical system for use in a clinical setting depending on the clinician need. We compared the responsiveness of the 3 facial nerve grading systems, i.e., House-Brackmann, Sydney, and Sunnybrook, as the subjective method and compared the outcomes with the objective method, i.e., the nerve conduction study. The correlation between the subjective and objective assessments was determined.
METHODS: A total of 22 consented participants with facial palsy was assessed with photos and videography recordings where they performed 10 standard facial expressions. The severity of facial paralysis was evaluated with the House-Brackmann, Sydney, and Sunnybrook grading scales subjectively and with the facial nerve conduction study objectively. The assessments were repeated after 3 months.
RESULTS: A Wilcoxon signed-rank test showed that there were statistically significant change in all three gradings after 3-month of assessment. The responsiveness of the nerve conduction study was significant for the nasalis and orbicularis oris muscles. It was not significant for the orbicularis oculi muscle. The nasalis and orbicularis oculi showed statistically significant correlation with the three classification systems except for the orbicularis oculi muscle.
CONCLUSIONS: All three grading systems, House-Brackmann, Sydney, and Sunnybrook, showed statistically significant responsiveness after 3 months of evaluation. The nasalis and orbicularis oculi muscle can be used to predict facial palsy recovery because they showed strong positive and negative correlations with the extent of facial nerve degeneration from the nerve conduction study.
Fulltext Desmoplastic Fibroma of the Phalanx of the Hand: A Rare Case Report

Singh BP, Abdul Halim S, Yahaya S, Mat Zin NA, Tuan Sharif SE, Wan Ismail WF

Case Rep Oncol, 2023;16(1):478-483.
PMID: 37485013 DOI: 10.1159/000529895

Desmoplastic fibroma is a rare primary benign bone tumour that typically affects the long bones, mandible, and pelvis. It has a similar local aggressiveness to soft tissue fibromatosis. It rarely involves the small bones of the hand. We describe an extremely rare case of desmoplastic fibroma of the proximal phalanx of the hand in a patient who presented with an aggressively enlarging but painless mass on the left ring finger. Radiological features suggested malignancy; however, an initial biopsy revealed fibrotic tissue. Trans-metacarpal amputation of the ring and little fingers and soft tissue reconstruction were performed using a local ulnar-based flap of the little finger. The final histopathological evaluation revealed desmoplastic fibroma. Aggressively growing masses in the hand should be treated according to a sarcoma management protocol, and desmoplastic fibroma should be included in the differential diagnosis.
Fulltext A Case Report of Bilateral Optic Perineuritis With Idiopathic Intracranial Hypertension: Challenges in Diagnosis and Management

Shahrudin NH, Muhammed J, Wan Hitam WH, Sapiai NA, Abdul Halim S

Cureus, 2024 Feb;16(2):e54692.
PMID: 38523970 DOI: 10.7759/cureus.54692

Optic perineuritis (OPN) refers to the inflammation of the optic nerve sheath and it is a rare form of idiopathic orbital inflammatory disease. We report a rare case of bilateral OPN in an obese female teenager with idiopathic intracranial hypertension (IIH). She was initially presented with painless bilateral blurring of vision that was progressively worsening for three weeks duration. Visual acuity of both eyes was hand movement with no relative afferent pupillary defect detected. The confrontation visual field test showed central scotoma. Both anterior segments were unremarkable. Fundoscopy showed a swollen optic disc bilaterally, with extensive flame-shaped hemorrhages surrounding the disc area and dot blot hemorrhages in the posterior pole. A magnetic resonance imaging scan of the brain and orbit revealed the presence of bilateral optic nerve sheath enhancement with empty sella turcica. The patient was diagnosed with bilateral OPN with IIH. She received an initial high dose of systemic corticosteroid followed by a slow tapering dose. She was monitored by the neuromedical team for her IIH. She was followed up for about a year. The final best corrected visual acuity in the right eye was 6/36 and the left eye was 6/60. In conclusion, OPN poses challenges in diagnosis and management. This case emphasizes the importance of considering OPN in the differential diagnosis of optic nerve-related symptoms, as prompt recognition and intervention are crucial for favorable outcomes.
Neurological Examination Techniques of Speech in Bahasa Malaysia for Adults: Simple Approach Practiced in Hospital Universiti Sains Malaysia

Noorsham AH, Abdullah MM, Abdul Halim S, Ghani ARI, Idris Z, Abdullah JM

Malays J Med Sci, 2020 Dec;27(6):148-182.
PMID: 33447142 DOI: 10.21315/mjms2020.27.6.14

There are four classification levels for speech disorders namely dysphonia, dysarthria, dysprosody and dysphasia. In general, speech examination mainly focuses on three main components that are spontaneous speech, auditory comprehension, and oral motor examination. Quick bedside assessment on speech in Bahasa Malaysia is essential to assist the speech language therapist (SLT) and other physicians to determine the disorders. Speech therapy is also essential in monitoring and continuous assessment for patients with speech and language disorders such as dysphasia and dysarthria. Speech clinicians in Hospital Universiti Sains Malaysia (HUSM) have been adapting two most widely used batteries of speech assessment tools namely Western aphasia battery-revised (WAB-R) by Andrew Kertesz and Boston diagnostic aphasia examination (BDAE). These tools have been modified into simple and validated speech assessments in Bahasa Malaysia. This video manuscript will demonstrate the use of both tools in performing bedside speech assessment for patients with speech disorders. The Bahasa Malaysia speech examination should not be difficult when WAB-R and BDAE speech assessment tools are applied. The aim of this simple approach using the adapted version of BDAE and WAB-R is to assist the clinician to achieve quick and accurate diagnosis with a validated scoring system.
Fulltext Prevalence of aspirin resistance in diabetic patients and its associated factors

Habizal NH, Abdul Halim S, Bhaskar S, Wan Bebakar WM, Abdullah JM

Malays J Med Sci, 2015 Jan-Feb;22(1):50-7.
PMID: 25892950 MyJurnal

BACKGROUND: Aspirin resistance has posed a major dilemma in the prevention of cardiovascular disease and stroke. There have been many factors that have been associated with aspirin resistance. Among these factors, the inflammatory processes of diabetes and glycaemic control have been significantly associated with aspirin resistance. Our study evaluated the prevalence of aspirin resistance and its associated factors.
METHODS: This was a cross-sectional, interventional study, which was implemented from October to November 2012 at the Hospital Universiti Sains Malaysia (HUSM). Sixty-nine patients with diabetes who were taking aspirin were enrolled. The glycosylated haemoglobin (HbA1c) and C-reactive protein (CRP) levels were measured in these patients. The thromboelastography (TEG) level was measured using a TEG machine by a trained technician employing standard methods. The variables obtained were analysed for prevalence of aspirin resistance, HbA1c, CRP, and TEG level. The Chi-square test (and Fisher exact test where applicable) were used to evaluate the associations between aspirin resistance with glycaemic control (HbA1c) and inflammatory markers (CRP).
RESULTS: The prevalence of aspirin resistance was 17.4% (95%; CI 9.3, 28.4). Glycaemic control (HbA1c) and inflammatory markers (CRP) were not associated with aspirin resistance. Aspirin resistance was prevalent in our study population and was comparable to other studies. The mean HbA1c in the aspirin-resistant group was 8.9%, whereas the mean HbA1c in the aspirin-sensitive group was 8.6%.
CONCLUSION: There was no significant difference in HbA1c between the two groups. There was no significant association between CRP levels and aspirin resistance.
KEYWORDS: aspirin resistance; diabetes mellitus; thromboelastography
Study site: NeuroMedical Specialist Clinic, Hospital Universiti Sains Malaysia (HUSM), Kelantan, Malaysia
Fulltext Examination Approaches to Brachial Plexus Injury for Neurosurgical Residents

Saleh U, Tan GY, Fuad M, Abdullah JM, Idris Z, Ghani ARI, et al.

Malays J Med Sci, 2023 Dec;30(6):61-69.
PMID: 38239251 DOI: 10.21315/mjms2023.30.6.7

BACKGROUND: Brachial plexus injury is a severe peripheral nerve injury that affects the upper extremities and causes functional damage and disability. A detailed and accurate clinical examination is required to accurately localise the site of injury. This video manuscript aims to provide guidelines for the structured assessment of a patient with brachial plexus injury, specifically tailored to Malaysian medical students and trainees.
METHODS: A video demonstrating the examination of the brachial plexus was made. This video, created at the School of Medical Sciences at Universiti Sains Malaysia (USM), demonstrates the proper examination technique for brachial plexus.
CONCLUSION: We hope that this video will help students and young doctors evaluate patients with brachial plexus injury and reach accurate localisation of the injury.
What are Your Eyes Revealing? The Contemporary Bedside Neuro-Ophthalmological Examination

Ng PM, Abdullah JM, Idris Z, Ghani ARI, Abdul Halim S

Malays J Med Sci, 2021 Oct;28(5):142-148.
PMID: 35115897 DOI: 10.21315/mjms2021.28.5.15

The neuro-ophthalmological evaluation is done to assess the integrity of cranial nerves II, III, IV, VI. This work does not intend to substitute the examination in a fully equipped ophthalmology suite. The aim of this manuscript is to describe bedside examination of the eye by using simple apparatus that are easily available. This work incorporates the usage of smartphone application, as smartphone is deemed an accessory in almost every resident's pocket during review of patients as a consult in the emergency department. However, the essence of traditional physical examination remains the fundamental. Understanding of neuroanatomy and neurophysiology of the eye and the central nervous system can enhance the clinician's performance at the bedside.

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