1.A Randomised Control Trial on the Use of Topical Methicillin in Reducing Post-Operative Ventriculoperitoneal Shunt Infection
Sharon Casilda Theophilus ; Johari Siregar Adnan
Malaysian Journal of Medical Sciences 2011;18(1):30-37
Background: A double-blind randomised control study was conducted on all patients who
were admitted or referred to the Department of Neurosurgery, Sultanah Aminah Hospital, Johor
Bahru, with a diagnosis of hydrocephalus where a ventriculoperitoneal shunt was indicated.
Methods: The period of study was from November 2005 to May 2007, and the follow-up
period was 3 months after surgery. Randomisation was carried out in the operating room prior
to the procedure. The scrub nurse selected a sealed envelope, which contained the assignment of
each patient to 1 of 2 treatment groups: Group 1 patients were treated with topical methicillin, and
Group 2 patients were not treated with topical methicillin. Prophylactic antibiotic, cefuroxime (25
mg/kg) was given intravenously at induction. Standard sterile operative technique was followed in
preparing and draping the patients.
Results: A total of 90 patients were recruited in the study, and 13 (14.4%) patients developed
an infection within 3 months post-operation. Group 1 had a 8.9% risk of infection, and Group 2 had
a 20% risk; however, there was no statistically significant post-operative ventriculoperitoneal shunt
(VPS) infection reduction with the use of topical methicillin in VPS surgery (P = 0.230). Multivariate
analysis showed that only duration of surgery had a significant influence on the incidence of postoperative
VPS infection in the non-methicillin group (P = 0.02). The non-methicillin group had an
8 times greater risk of developing post-operative VPS infection than the methicillin group if surgery
lasted longer than 1 hour.
Conclusion: Topical methicillin had no significance in the reduction of post-operative VPS
infection.
2.Treatment Outcome of Superficial Cerebral Abscess: An Analysis of Two Surgical Methods
Wei Ming Tan ; Johari Siregar Adnan ; Mohamad Saffari Mohamad Haspani
Malaysian Journal of Medical Sciences 2010;17(1):23-29
Background: The purpose of the study is to compare the two surgical methods (burr hole
and craniotomy) used as treatment for superficial cerebral abscess and its outcome in terms of
radiological clearance on brain CT, improvement of neurological status, the need for repeated
surgery, and survival and morbidity at three months after surgery. This report is a retrospective case
review of the patients who were treated surgically for superficial cerebral abscess in Hospital Kuala
Lumpur (HKL) and Hospital Sultanah Aminah (HSA) over a period of four years (2004 to 2007).
Methods: Fifty-one cases were included in this study: 64.7% of patients were male and
35.5% were female. Most of the patients were Malay (70.6%); 28 patients (54.9%) had undergone
craniotomy and excision of abscess, and the rest had undergone burr hole aspiration as their first
surgical treatment.
Results: This study reveals that patients who had undergone craniotomy and excision of
abscess showed a significantly earlier improvement in neurological function, better radiological
clearance and lower rate of re-surgery as compared to the burr hole aspiration group (P<0.05).
However, with respect to neurological improvement at 3 months, morbidity and mortality, there is
no significant difference between the two surgical methods.
Conclusion: The significance of these findings can only be confirmed by a prospective
randomised series. Further study will be required to assess the cost effectiveness, intensive care
needs, and possibility of shorter antibiotic usage as compared to burr hole aspiration.
3.The Implementation of Teleneurosurgery in the Management of Referrals to a Neurosurgical Department in Hospital Sultanah Amninah Johor Bahru
Risdhawati Hassan ; Johari Adnan Siregar ; Noor Azmana.Rahman @ Mohd
Malaysian Journal of Medical Sciences 2014;21(2):54-62
Background: Telemedicine in neurosurgery or teleneurosurgery has been widely used for transmission of clinical data and images throughout the country since its implementation in 2006. The impact is a reduction of patient number that need to be reviewed in the level III hospitals and an increment in the number of patients that are kept in level II hospitals for observation by the primary team. This translates to reduction of unnecessary transfer of patients and subsequently cost benefits for patients and medical providers. The main aim is to determine the amount of reduction in unnecessary transfer by the implementation of teleneurosurgery in the management of referrals to neurosurgical department in Hospital Sultanah Amninah Johor Bahru (HSAJB). Other factors associated with transfer decision are also evaluated.
Methods: This prospective cohort study was conducted in HSAJB, Johor over four months. A total of 349 subjects referred to HSAJB are included with 12 subjects excluded. The subjects are followed up from the time of referral until three months post-referrals. Related data includes the decision before and after reviewing the radiological images on teleconsultation website with clinical data available.
Results: There was a significant reduction in the number of inter-hospital transfer. 37% of transfer is avoided and patients are best kept in their original hospitals. However, there are additional findings in which there are 20.1% of patients that thought does not require transfer based on clinical data alone, would have to be transferred when the clinical data and images are reviewed. This translates to an increment of 20.1% need to be observed in neurosurgical center. Without the images, these patients might be observed in the referral hospitals with higher risk of deterioration. Other factors that are related to transfer decision apart from images include Glasgow Coma Scale (GCS) and diagnosis. The GCS significantly associated with transfer when only clinical data is reviewed. However, in situation where clinical data and images are reviewed together, the GCS and diagnosis are significantly associated with transfer decision. On multi-factorial analysis, more of mild head injury being transferred for observation in neurosurgical unit after images and clinical data reviewed which correlates to an increment from 1.85% to 3.9%. Another finding is reduced of risk of patients transferred for trauma from 1.85% to 0.519% after the data reviewed.
Conclusion: Teleneurosurgery is beneficial in the management of referrals from level II hospitals. The inter-hospital transfer is significantly reduced, however there is an increased in the number of patients that need to be observed in neurosurgery unit for the risk of potential deterioration.
4.History of Neurosurgery in Malaysia
Azman Raffiq ; Jafri Malin Abdullah ; Saffari Haspani ; Johari Siregar Adnan
Malaysian Journal of Medical Sciences 2015;22(Special Issue):5-7
The development of neurosurgical services and training in Malaysia began in 1963, with the first centre established in its capital city at Hospital Kuala Lumpur, aimed to provide much needed neurosurgical services and training in the field of neurology and neurosurgery. This center subsequently expanded in 1975 with the establishment of the Tunku Abdul Rahman Neuroscience Institute (IKTAR); which integrated the three allied interdependent disciplines of neurosurgery, neurology and psychiatry. The establishment of this institute catalysed the rapid expansion of neurosurgical services in Malaysia and paved the way for development of comprehensive training for doctors, nurses, and paramedics. This culminated in the establishments of a local comprehensive neurosurgery training program for doctors in 2001; followed by a training program for nurses and paramedics in 2006. To date, there are more than 60 neurosurgeons providing expert care in 11 centers across Malaysia, along with trained personnel in the field of neurosciences.
5.Delayed traumatic intracranial haemorrhage and progressive traumatic brain injury in a major referral centre based in a developing country
Toh Charng Jeng ; Mohd Saffari Mohd Haspani ; Johari Siregar Adnan ; Nyi Nyi Naing
Malaysian Journal of Medical Sciences 2008;15(4):56-67
A repeat Computer Tomographic (CT) brain after 24 -48 hours from the 1st scanning is usually practiced in most hospitals in South East Asia where intracranial pressure
monitoring (ICP) is routinely not done. This interval for repeat CT would be shortened if there was a deterioration in Glasgow Coma Scale (GCS). Most of the
time the prognosis of any intervention may be too late especially in hospitals with high patient-to-doctor ratio causing high mortality and morbidity. The purpose of
this study was to determine the important predictors for early detection of Delayed Traumatic Intracranial Haemorrhage (DTICH) and Progressive Traumatic Brain
Injury (PTBI) before deterioration of GCS occurred, as well as the most ideal timing of repeated CT brain for patients admitted in Malaysian hospitals. A total
of 81 patients were included in this study over a period of six months. The CT scan brain was studied by comparing the first and second CT brain to diagnose the
presence of DTICH/PTBI. The predictors tested were categorised into patient factors, CT brain findings and laboratory investigations. The mean age was 33.1 ±
15.7 years with a male preponderance of 6.36:1. Among them, 81.5% were patients from road traffic accidents with Glasgow Coma Scale ranging from 4 – 15 (median
of 12) upon admission. The mean time interval delay between trauma and first CT brain was 179.8 ± 121.3 minutes for the PTBI group. The DTICH group, 9.9% of
the patients were found to have new intracranial clots. Significant predictors detected were different referral hospitals (p=0.02), total GCS status (p=0.026),
motor component of GCS (p=0.043), haemoglobin level (p<0.001), platelet count (p=0.011) and time interval between trauma and first CT brain (p=0.022). In the
PTBI group, 42.0% of the patients were found to have new changes (new clot occurrence, old clot expansion and oedema) in the repeat CT brain. Univariate
statistical analysis revealed that age (p=0.03), race (p=0.035), types of admission (p=0.024), GCS status (p=0.02), pupillary changes (p=0.014), number of intracranial lesion (p=0.004), haemoglobin level (p=0.038), prothrombin time (p=0.016) as the best predictors of early detection of changes. Multiple logistics regression analysis indicated that age, severity, GCS status (motor component) and GCS during
admission were significantly associated with second CT scan with changes. This study showed that 9.9% of the total patients seen in the period of study had DTICH
and 42% had PTBI. In the early period after traumatic head injury, the initial CT brain did not reveal the full extent of haemorrhagic injury and associated cerebral
oedema. Different referral hospitals of different trauma level, GCS status, motor component of the GCS, haemoglobin level, platelet count and time interval between
trauma and the first CT brain were the significant predictors for DTICH. Whereas the key determinants of PTBI were age, race, types of admission, GCS status,
pupillary changes, number of intracranial bleed, haemoglobin level, prothrombin time and of course time interval between trauma and first CT brain. Any patients
who had traumatic head injury in hospitals with no protocol of repeat CT scan or intracranial pressure monitoring especially in developing countries are advised to have to repeat CT brain at the appropriate quickest time .
6.Limited Evaluation of Image Quality Produced by a Portable Head CT Scanner
Ariz Chong Abdullah ; Johari Siregar Adnan ; Noor Azman A. Rahman ; Ravikant Palur
Malaysian Journal of Medical Sciences 2017;24(1):104-112
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.
7.Teleneurosurgery: Outcome of Mild Head Injury Patients Managed in Non-Neurosurgical Centre in the State of Johor
Mohd Syahiran Mohd Sidek ; Johari Adnan SIREGAR ; Abdul Rahman Izani Ghani ; Zamzuri IDRIS
Malaysian Journal of Medical Sciences 2018;25(2):95-104
Background: With teleneurosurgery, more patients with head injury are managed in the primary hospital under the care of general surgical unit. Growing concerns regarding the safety and outcome of these patients are valid and need to be addressed.Method: This study is to evaluate the outcome of patients with mild head injury which were managed in non-neurosurgical centres with the help of teleneurosurgery. The study recruits samples from five primary hospitals utilising teleneurosurgery for neurosurgical consultations in managing mild head injury cases in Johor state. Two main outcomes were noted; favourable and unfavourable, with a follow up review of the Glasgow Outcome Scale (GOS) at 3 and 6 months.Results: Total of 359 samples were recruited with a total of 11 (3.06%) patients have an unfavourable. no significant difference in GOS at 3 and 6 months for patient in the unfavourable group (P = 0.368).Conclusion: In this study we have found no significant factors affecting the outcome of mild head injury patients managed in non-neurosurgical centres in Johor state using the help of teleneurosurgery.
8.The Factors Associated with Outcomes in Surgically Managed Ruptured Cerebral Aneurysm
Lai Chuang CHEE ; Johari Adnan SIREGAR ; Abdul Rahman Izani Ghani ; Zamzuri IDRIS ; Noor Azman A Rahman @Mohd
Malaysian Journal of Medical Sciences 2018;25(1):32-41
Background: Ruptured cerebral aneurysm is a life-threatening condition that requires urgent medical attention. In Malaysia, a prospective study by the Umum Sarawak Hospital, Neurosurgical Center, in the year 2000–2002 revealed an average of two cases of intracranial aneurysms per month with an operative mortality of 20% and management mortality of 25%. Failure to diagnose, delay in admission to a neurosurgical centre, and lack of facilities could have led to the poor surgical outcome in these patients. The purpose of this study is to identify the factors that significantly predict the outcome of patients undergoing a surgical clipping of ruptured aneurysm in the local population. Material and Method: A single center retrospective study with a review of medical records was performed involving 105 patients, who were surgically treated for ruptured intracranial aneurysms in the Sultanah Aminah Hospital, in Johor Bahru, from July 2011 to January 2016. Information collected was the patient demographic data, Glasgow Coma Scale (GCS) prior to surgery, World Federation of Neurosurgical Societies Scale (WFNS), subarachnoid hemorrhage (SAH) grading system, and timing between SAH ictus and surgery. A good clinical grade was defined as WFNS grade I–III, whereas, WFNS grades IV and V were considered to be poor grades. The outcomes at discharge and six months post surgery were assessed using the modified Rankin’s Scale (mRS). The mRS scores of 0 to 2 were grouped into the “favourable” category and mRS scores of 3 to 6 were grouped into the “unfavourable” category. Only cases of proven ruptured aneurysmal SAH involving anterior circulation that underwent surgical clipping were included in the study. The data collected was analysed using the Statistical Package for Social Sciences (SPSS). Univariate and multivariate analyses were performed and a P-value of < 0.05 was considered to be statistically significant. Result: A total of 105 patients were included. The group was comprised of 42.9% male and 57.1% female patients. The mean GCS of the patients subjected to surgical clipping was 13, with the majority falling into the good clinical grade (78.1%). The mean timing of the surgery after SAH was 5.3 days and this was further categorised into early (day one to day three, 45.3%), intermediate (day four to day ten, 56.2%), and late (after day ten, 9.5%). The total favourable outcome achieved at discharge was 59.0% as compared to 41.0% of the unfavourable outcome, with an overall mortality rate of 10.5%. At the six-month post surgery review (n = 94), the patients with a favourable outcome constituted 71.3% as compared to 28.7% with an unfavourable outcome. The mortality, six months post surgery was 3.2%. On a univariate analysis of early surgical clipping, patients with a better GCS and good clinical grade had a significantly better outcome at discharge. Based on the univariate study, six months post surgery, the timing of the surgery and the clinical grade remained significant predictors of the outcome. On the basis of the multivariate analysis, male patients of younger age, with a good clinical grade, were associated with favourable outcomes, both at discharge and six months post surgery. Conclusion: In this study, we concluded that younger male patients with a good clinical grade were associated with a favourable outcome both at discharge and six months post surgery. We did not find the timing of the surgery, size of the aneurysm or duration of surgery to be associated with a patient’s surgical outcome. Increasing age was not associated with the surgical outcome in a longer term of patient’s follow up.
9.A Retrospective Study on the First Cerebrospinal Fluid Taken from External Ventricular Drainage Insertion in Meningitis Patients with Hydrocephalus
Asma ; Mohamad Afifi ; Jafri Malin Abdullah ; Johari Adnan Siregar ; Zamzuri Idris
Malaysian Journal of Medical Sciences 2019;26(5):64-73
Background: Ventriculoperitoneal (VP) shunting is a permanent form of cerebrospinal
fluid (CSF) diversion that can be performed for hydrocephalus. Sterility of the CSF is an important
prerequisite for permanent shunt placement. It has been hypothesised that in early stage of
meningitis, ventricular CSF remains sterile. A study is conducted on the first CSF sample taken
from patients suspected to have meningitic hydrocephalus.
Method: A retrospective review case records of patients who had undergone external
ventricular drainage (EVD) for suspected meningitic hydropcephalus in Hospital Sultanah Aminah
Johor Bahru (HSAJB), Johor, Malaysia.
Results: Fifty-one cases were analysed. Mean age of patients was 37.27 years old, with
64.7% of them was male. Univariate analysis revealed that the main parameters to determine CSF
sterility were CSF glucose (95% CI, 0.852, 10.290, P = 0.001), CSF protein (CI 95%, 0.722, 14.898,
P < 0.001), CSF gram stain (95% CI, 16.437, 0.877, P < 0.001 ) and CSF appearance ( 0.611, 6.362,
P = 0.012). Multivariate analysis had proven that gram stain was the main parameter in the CSF
analysis (CI 95%, 16.437, 0.029, P = 0.016). No significant differences in CSF results were observed
from EVD and lumbar puncture.
Conclusion: The most significant parameter in CSF to determine infection was gram stain.