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Fulltext Paroxysmal dyskinesia as an unusual and only presentation of subcortical white matter ischaemia: a report of two cases

Norlinah MI, Shahizon AM

Med J Malaysia, 2008 Dec;63(5):410-2.
PMID: 19803303 MyJurnal

Secondary paroxysmal dyskinesias (PxD) have been previously reported in patients with multiple sclerosis, lacunar infarcts, head trauma, metabolic disorders such as hyperglycaemia, hypocalcaemia, migraine and central nervous system (CNS) infections. The causative lesions typically involve the basal ganglia structures, medulla and rarely the spinal cord. We report two patients who presented with paroxysmal dyskinesias as the only manifestation of subcortical white-matter ischaemia. Patient 1 presented with 3-year history of paroxysmal kinesigenic dyskinesia (PKD) and patient 2 with 6-month history of paroxysmal nonkinesigenic dyskinesia (PNKD). All investigations, including CSF oligoclonal bands were negative, except for a brain MRI which showed multiple, non-enhancing subcortical white matter lacunar infarcts. Therefore, subcortical white matter ischaemia should also be included in the differential diagnosis of PxD.
Fulltext Prominent Oromandibular Dystonia as Levodopa-induced Dyskinesia in Idiopathic Parkinson's Disease

Tee TY, Khoo CS, Norlinah MI

Mov Disord Clin Pract, 2019 Apr;6(4):330-331.
PMID: 31061844 DOI: 10.1002/mdc3.12759
Fulltext Angioinvasive cerebral aspergillosis presenting as acute ischaemic stroke in a patient with diabetes mellitus

Norlinah MI, Ngow HA, Hamidon BB

Singapore Med J, 2007 Jan;48(1):e1-4.
PMID: 17245496

Cerebral angioinvasive aspergillosis is a rare manifestation of disseminated aspergillosis which may result in stroke in immunocompromised individuals. Reports of such disease in patients with diabetes mellitus are rare. We describe a 45-year-old man with diabetes mellitus who presented with a three-day history of right-sided limb weakness and aphasia. Cerebral computed tomography showed features of an acute infarct involving the left anterior and middle cerebral arteries. He was initially treated for an acute ischaemic stroke. Further history revealed that he was investigated for a growth in the sphenoid sinus two months earlier. Culture of the biopsied material from the sphenoid sinus grew Aspergillus fumigatus. Magnetic resonance imaging showed an extension of the growth to the brain, causing the acute ischaemic stroke. He was subsequently diagnosed with angioinvasive cerebral aspergillosis and was commenced on intravenous amphotericin B. Unfortunately, he succumbed to his illness despite treatment.
Fulltext Review of emotion recognition in stroke patients

Yuvaraj R, Murugappan M, Norlinah MI, Sundaraj K, Khairiyah M

Dement Geriatr Cogn Disord, 2013;36(3-4):179-96.
PMID: 23899462 DOI: 10.1159/000353440

OBJECTIVE: Patients suffering from stroke have a diminished ability to recognize emotions. This paper presents a review of neuropsychological studies that investigated the basic emotion processing deficits involved in individuals with interhemispheric brain (right, left) damage and normal controls, including processing mode (perception) and communication channels (facial, prosodic-intonational, lexical-verbal).
METHODS: An electronic search was conducted using specific keywords for studies investigating emotion recognition in brain damage patients. The PubMed database was searched until March 2012 as well as citations and reference lists. 92 potential articles were identified.
RESULTS: The findings showed that deficits in emotion perception were more frequently observed in individuals with right brain damage than those with left brain damage when processing facial, prosodic and lexical emotional stimuli.
CONCLUSION: These findings suggest that the right hemisphere has a unique contribution in emotional processing and provide support for the right hemisphere emotion hypothesis.
SIGNIFICANCE:
This robust deficit in emotion recognition has clinical significance. The extent of emotion recognition deficit in brain damage patients appears to be correlated with a variety of interpersonal difficulties such as complaints of frustration in social relations, feelings of social discomfort, desire to connect with others, feelings of social disconnection and use of controlling behaviors.
Levodopa-induced myocardial infarction in a patient with Parkinson's disease and severe coronary artery disease

Ng CF, Tiau PW, Tan HJ, Norlinah MI

J R Coll Physicians Edinb, 2019 Mar;49(1):37-39.
PMID: 30838990 DOI: 10.4997/JRCPE.2019.108

Levodopa is the most effective medical treatment for Parkinson's disease (PD) to date. As dopamine is known to increase cardiac inotropism and vasomotor tone, peripheral dopamine decarboxylase inhibitor is coadministered to suppress the peripheral conversion of levodopa to dopamine. Levodopa poses potential cardiovascular risks, thus its use in patients with existing coronary artery disease needs to be carefully monitored. We report a case of an elderly male with newly diagnosed PD who developed non-ST-elevation myocardial infarction following levodopa (Madopar) initiation.
Fulltext The predictors of early infection after an acute ischaemic stroke

Hamidon BB, Raymond AA, Norlinah MI, Jefferelli SB

Singapore Med J, 2003 Jul;44(7):344-6.
PMID: 14620725

Infection is a frequent complication after an acute stroke and may affect stroke outcome. We identified predictors of early infection, type of infection, their relation to initial disability, and the eventual outcome during the inpatient period.
Risk factors and predictors of levodopa-induced dyskinesia among multiethnic Malaysians with Parkinson's disease

Hashim HZ, Norlinah MI, Nafisah WY, Tan HJ, Raymond AA, Tamil AM

Int J Neurosci, 2014 Mar;124(3):187-91.
PMID: 23952588 DOI: 10.3109/00207454.2013.833511

Chronic pulsatile levodopa therapy for Parkinson's disease (PD) leads to the development of motor fluctuations and dyskinesia. We studied the prevalence and predictors of levodopa-induced dyskinesia among multiethnic Malaysian patients with PD.
Fulltext Prevalence of depression in stroke patients with vascular dementia in universiti kebangsaan malaysia medical center

Khoo KF, Tan HJ, Rosdinom R, Raymond AA, Norlinah MI, Shamsul A, et al.

Med J Malaysia, 2013 Apr;68(2):105-10.
PMID: 23629553 MyJurnal

Depression among patients with vascular dementia is frequently overlooked and potentially causes significant morbidity. There is limited data in Malaysia on the subject and this study was conducted to determine the prevalence of depression in vascular dementia (VaD) in UKMMC.
Fulltext Post-dengue parkinsonism

Azmin S, Sahathevan R, Suehazlyn Z, Law ZK, Rabani R, Nafisah WY, et al.

BMC Infect Dis, 2013;13:179.
PMID: 23594500 DOI: 10.1186/1471-2334-13-179

BACKGROUND: Dengue is a common illness in the tropics. Equally common are neurological complications that stem from dengue infection. However, to date, parkinsonism following dengue has not been reported in medical literature.
CASE PRESENTATION: A previously well 18-year old man developed parkinsonism, in addition to other neurological symptoms following serologically confirmed dengue fever. Alternative etiologies were excluded by way of imaging and blood investigations.
CONCLUSIONS: The authors detail the first reported case of parkinsonism complicating dengue fever. Keeping rare presentations of common illnesses in mind, it behoves clinicians to consider parkinsonism as a complication following dengue infection. This would prevent injudicious treatment with L-dopa and dopamine agonists. Immunosuppression with steroids has been shown to be helpful in certain cases.
Sleep disturbances in Malaysian patients with Parkinson's disease using polysomnography and PDSS

Norlinah MI, Afidah KN, Noradina AT, Shamsul AS, Hamidon BB, Sahathevan R, et al.

Parkinsonism Relat Disord, 2009 Nov;15(9):670-4.
PMID: 19362875 DOI: 10.1016/j.parkreldis.2009.02.012

Sleep disturbances such as sleep fragmentation, sleep disordered breathing (SDB), periodic limb movements (PLM), excessive daytime somnolence (EDS) and insomnia are prevalent in Parkinson's disease (PD). However, studies in the Asian population are limited.
Fulltext Intramuscular injection of botulinum toxin for the treatment of wrist and finger spasticity after stroke

Jahangir AW, Tan HJ, Norlinah MI, Nafisah WY, Ramesh S, Hamidon BB, et al.

Med J Malaysia, 2007 Oct;62(4):319-22.
PMID: 18551937 MyJurnal

Botulinum toxin is effective in reducing spasticity post stroke. As there are limited data on post stroke spasticity in Asia, we undertake this study to determine the effectiveness and safety of intramuscular injection of botulinum toxin type-A (BTX-A), in the treatment of chronic focal post-stroke hand spasticity, and the impact of BTX-A on the activities of daily living and quality of life, in comparison to placebo, in Malaysian stroke patients. This was a randomized, double-blind, placebo-controlled study to assess the efficacy and safety of BTX-A in 27 subjects with wrist and finger spasticity after a stroke. The outcome measures were assessed with the Modified Ashworth Scale (MAS) to assess spasticity of the flexor muscles, Barthel Index (BI) for activities of daily living and EQ-5D and EQ VAS for quality of life. Assessments were performed at baseline and 1 and 3 months after injection. Compared to placebo, the BTX-A group had greater improvement in the flexor tone of the wrist and fingers (p = 0.001 and p < 0.001, respectively), at first month follow-up visit and sustained the improvement through to three months. Although there was an improvement in the measures of global function and quality of life in the BTX-A group, there was no significant improvement in between the two groups. No serious BTX-A related adverse effects were reported. The results of this study demonstrate that intramuscular injection of botulinum toxin A is safe and effective in the treatment of chronic focal post-stroke spasticity of the hand.
Fulltext AMSAN variant of Guillain Barre syndrome progressing to chronic inflammatory demyelinating polyneuropathy in a patient with Marfan's syndrome and pulmonary tuberculosis

Soehardy Z, Yuhanisa A, Thein SS, Rohana AG, Fauzi AR, Norlinah MI, et al.

Med J Malaysia, 2005 Dec;60(5):655-6.
PMID: 16515122

We report a 40-year-old man who has Marfan's syndrome and was recently diagnosed to have pulmonary tuberculosis when he presented with chronic cough. He was admitted with bilateral lower limb weakness which was ascending in nature. He eventually required ventilation. It was initially thought to be isoniazid-neuropathy. However, stopping the drug did not improve the condition and the patient developed bilateral lower motor neuron 7th cranial nerve palsy. Nerve conduction, MRI and CSF studies were done to confirm a first case report of AMSAN variant progressing to CIDP in a patient with Marfan's syndrome and pulmonary tuberculosis.
Oral trehalose maybe helpful for patients with spinocerebellar ataxia 3 and should be better evaluated

Noorasyikin MA, Azizan EA, Teh PC, Farah Waheeda T, Siti Hajar MD, Long KC, et al.

Parkinsonism Relat Disord, 2020 01;70:42-44.
PMID: 31841943 DOI: 10.1016/j.parkreldis.2019.12.007
Tuberculous meningitis mimicking Creutzfeldt-Jakob disease

Khoo CS, Krishnan L, Ng CF, Teh PC, Norlinah MI, Tan HJ

Rev Neurol (Paris), 2021 03;177(3):319-321.
PMID: 32747046 DOI: 10.1016/j.neurol.2020.05.013
Fulltext The effects of short-term, rapid glycemic control on the peroneal nerve function and serum VCAM-1 and AGE in type 2 diabetic patients in Malaysia

Norlinah MI, Hamizah R, Md Isa SH, Wan Nazaimoon WM, Khalid BA

Indian J Med Sci, 2009 Apr;63(4):131-8.
PMID: 19414982

BACKGROUND: The role of endothelial injury and circulating adhesion molecule in the development and progression of diabetic peripheral neuropathy in the long-term has been established previously.
AIMS: To study the effects of short-term glycemic control using insulin and oral hypoglycemic agent therapy (OHA) on the peroneal nerve function and vascular cell adhesion molecule-1 (VCAM-1) and advanced glycation endproducts (AGE) levels in type 2 diabetic patients.
SETTINGS AND DESIGN: A randomized controlled study involving poorly controlled (HbA1c, 7.5%-11%) type 2 diabetic patients attending the endocrinology outpatient center in a tertiary hospital in Kuala Lumpur.
MATERIALS AND METHODS: Twenty-nine patients were randomized to receive insulin (n=15) or OHA (n=14) for 8 weeks. The glycemic variables (HbA1c, fasting plasma glucose [FPG], fructosamine), VCAM-1, serum AGE and the peroneal motor conduction velocity (PMCV) were measured at baseline and at 4-week intervals.
STATISTICAL ANALYSIS USED: Paired 't' test or Kruskal Wallis test; and the unpaired 't' test or Mann-Whitney U test were used for within-group and between-group analyses, respectively. Correlation was analyzed using Spearman's correlation coefficient.
RESULTS: Within-group analysis showed significant progressive improvement in HbA1c at weeks 4 and 8 in the insulin group. The PMCV improved significantly in both groups by week 8, and by week 4 (P = 0.01) in the insulin group. PMCV correlated negatively with VCAM-1 (P = 0.031) and AGE (P = 0.009) at week 8.
CONCLUSION: Aggressive glycemic control with insulin improves the peroneal nerve function within 4 weeks. Improvement in the serum VCAM-1 and AGE levels correlated significantly with improvement in peroneal nerve conduction velocity only in the insulin group.
Study site: Tertiary endocrinology outpatient center in Kuala Lumpur, Malaysia
Fulltext Stroke thrombolysis at 5.5 hours based on computed tomography perfusion

Sahathevan R, Azmin S, Palaniappan S, Nafisah WY, Tan HJ, Norlinah MI, et al.

Malays J Med Sci, 2014 Mar;21(2):78-81.
PMID: 24876813 MyJurnal

A young man was admitted with sudden onset of right-sided weakness. He was assessed in the emergency department, and an immediate computed tomography (CT) perfusion study of the brain was arranged, which showed a left middle cerebral artery territory infarct with occlusion of the M1 segment. There was a significant penumbra measuring approximately 50% of the arterial territory. By the time his assessment was completed, it was 5.5 hours from the onset of symptoms. He was nonetheless administered intravenous recombinant tissue plasminogen activator (rtPA) based on the significant penumbra. He was discharged from the hospital after one week with significant residual deficit. At 2 months clinic follow-up, he showed almost complete recovery with a Modified Rankin Score of 1. We hope to demonstrate that a significant penumbra is an important determinant for good neurological recovery and outcome following stroke thrombolysis, even when patients present outside the 4.5 hours onset-to-treatment time window.
Fulltext Restless legs syndrome and its associated risk factors in Parkinson's disease

Azmin S, Khairul Anuar AM, Nafisah WY, Tan HJ, Raymond AA, Hanita O, et al.

Parkinsons Dis, 2013;2013:535613.
PMID: 24455416 DOI: 10.1155/2013/535613

Introduction. Restless legs syndrome has been shown to negatively impact the quality of life of patients. Studies have shown an association between restless legs syndrome and Parkinson's disease. We attempted to investigate the prevalence of restless legs syndrome in Parkinson's disease patients and to identify associated risk factors. Method. This was a cross-sectional study among patients with idiopathic Parkinson's disease. Exclusion criterion was a Mini Mental State Examination score of less than 21/30. The International Restless Legs Syndrome Study Group criterion was used to identify patients with restless legs syndrome. Results. A total of 113 patients were recruited. The prevalence rate of restless legs syndrome in our cohort was 9.7% and was significantly associated with a younger onset of Parkinson's disease (P = 0.023), male gender (P = 0.045), higher Mini Mental State Examination score (P = 0.004), and less advanced Hoehn & Yahr stage (P = 0.014). Conclusion. The prevalence rate of restless legs syndrome in our Parkinson's disease population is in keeping with other studies published worldwide. The significance of the association between a younger onset of Parkinson's disease and restless legs syndrome needs to be further investigated.
Fulltext Case of severe refractory myasthenia gravis in HUKM

Hamizah R, Norlinah MI, Tan HJ, Soehardy Z, Halim AG, Rohana AG, et al.

Med J Malaysia, 2006 Dec;61(5):633-5.
PMID: 17623968 MyJurnal

A 20-year-old girl first notice bilateral ocular muscle weakness in 2001. Two months later, she developed acute muscle paralysis and respiratory failure which required ventilation. Serum anti-acetylcholine receptor antibodies and repetitive nerve stimulation test was positive and consistent with myasthenia gravis (MG). CT scan thorax revealed thymic enlargement and she underwent a video assisted thymectomy (VATS). However, over the next three years, despite maximal doses of various immunosuppressive agents with plasmapheresis and intravenous immunoglobulin, she was admitted with recurrent myasthenic crisis without any obvious precipitant. She was then commenced on mycophenolate mofetil and together with regular plasmapheresis, cyclosporine and prednisolone, her symptoms have finally improved and brought under control.
Fulltext Biochemical aspirin resistance in stroke patients - a cross-sectional single centre study

Azmin S, Sahathevan R, Rabani R, Nafisah WY, Tan HJ, Raymond AA, et al.

EXCLI J, 2013;12:907-15.
PMID: 27092036

BACKGROUND: Aspirin use is known to reduce the recurrence of stroke. However, the clinical response to aspirin has been mixed. The rate of stroke recurrence whilst on aspirin treatment is still unacceptably high. A plausible explanation for this may be resistance to the effects of aspirin. The causes of aspirin resistance are manifold and multi-factorial. We conducted a study to investigate the prevalence rate of biochemical aspirin resistance in a cohort of aspirin-naïve stroke patients. We also sought to determine the inherent factors that may predispose towards the development of aspirin resistance.
METHOD: This was a cross-sectional, observational study conducted on patients admitted to our centre with an acute stroke who were aspirin-naïve. The diagnosis of an acute stroke was confirmed by clinical history and brain imaging. Fifty consecutive patients were prospectively enrolled. Socio-demographic data were collected and baseline blood investigations were performed. Patients were tested for biochemical aspirin resistance using Multiplate platelet analyser (Dynabyte, Munich, Germany) after 5 doses of aspirin, corresponding to a total dose of 900 mg.
RESULTS: The median age of patients was 65.5 years and 54 % of patients were female. There were 11 smokers; of these 10 were male. Twenty-six (52 %) patients were Chinese, 21 (41 %) were Malay and 3 (6.0 %) were Indian. Aspirin resistance was present in 14 % of our patients. There was an inverse relationship between the presence of aspirin resistance and plasma HDL levels (r = -0.394; p = 0.005). There was no relationship observed between aspirin resistance and total cholesterol, triglycerides, LDL, HbA1c, ALT, ALP, urea and creatinine levels. There were no significant differences in demographic profiles or smoking status between the aspirin resistant and non-aspirin resistant groups. We did not find any link between ethnicity and aspirin resistance.
CONCLUSIONS: Our results indicate that a lower HDL level is associated with biochemical aspirin resistance. This may increase platelet aggregation and consequently increase the risk of a recurrent stroke. The clinical implications for aspirin resistance are far reaching. Any evidence that correctable factors may negatively influence the action of aspirin warrants further investigation. The prevalence rate of biochemical aspirin resistance in our study is comparable to the findings in other studies performed in an Asian population. Further research is required to determine how our findings translate into clinical aspirin resistance and stroke recurrence.
KEYWORDS: Asia; antiplatelet therapy; aspirin; aspirin resistance; developing countries; ischaemic stroke; risk factors
Role of high resolution ultrasound in ulnar nerve neuropathy

Radhika S, Lee YL, Low SF, Fazalina MF, Sharifah Majedah IA, Suraya A, et al.

Med J Malaysia, 2015 Jun;70(3):158-61.
PMID: 26248778 MyJurnal

AIM: This study was conducted to measure the cross sectional area (CSA) of the ulnar nerve (UN) in the cubital tunnel and to evaluate the role of high-resolution ultrasonography in the diagnosis of ulnar nerve neuropathy (UNN).
MATERIALS AND METHODS: This was a cross sectional study with 64 arms from 32 patients (34 neuropathic, 30 nonneuropathic). Diagnosis was confirmed by nerve conduction study and electromyography. The ulnar nerves were evaluated with 15MHz small footprint linear array transducer. The ulnar nerve CSA was measured at three levels with arm extended: at medial epicondyle (ME), 5cm proximal and 5cm distal to ME. Results from the neuropathic and nonneuropathic arms were compared. Independent T-tests and Pearson correlation tests were used. P value of less than 0.05 was considered significant.
RESULTS: Mean CSA values for the UN at levels 5cm proximal to ME, ME and 5cm distal to ME were 0.055, 0.109, 0.045 cm(2) respectively in the neuropathic group and 0.049, 0.075, 0.042 cm2 respectively in the non-neuropathic group. The CSA of the UN at the ME level was significantly larger in the neuropathic group, with p value of 0.005. However, there was no statistical difference between the groups at 5cm proximal and distal to the ME, with p values of 0.10 and 0.35 respectively.
CONCLUSION: There is significant difference in CSA values of the UN at ME between the neuropathic and non-neuropathic groups with mean CSA value above the predetermined 0.10cm(2) cut-off point. High-resolution ultrasonography is therefore useful to diagnose and follow up cases of elbow UNN.

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