1.The Risk Factors of External Ventricular Drainage-Related Infection at Hospital Kuala Lumpur: An Observational Study
Mohamad Azhari Omar ; Mohd Saffari Mohd Haspani
Malaysian Journal of Medical Sciences 2010;17(3):48-54
Background: External ventricular drainage (EVD) has been widely used for the purpose of
cerebrospinal fluid (CSF) diversion at Hospital Kuala Lumpur (HKL).
Method: This prospective observational study was conducted in HKL from December 2006
to December 2008 among patients who were subjected for EVD, following strict inclusion and
exclusion criteria.
Results: The frequency of EVD-related infection was as high as 32.2% (95% CI 23.3% to
42.57%) among 87 patients studied. This study clearly demonstrates that tunnelling the catheter for
more than 5 cm under the scalp, from the burr hole to the exit site of the skin, carried a significantly
lower risk of infection compared with tunnelling the catheter for 5 cm or less (OR = 0.184, 95% CI
0.083 to 0.406, P < 0.001). The majority of cases (19 out of 28) with EVD-related infection occurred
among patients catheterised for more than 10 days (OR = 0.334, 95% CI 0.171 to 0.652, P < 0.001).
Conclusion: The technique of subgaleal tunnelling of more than 5cm and the duration of the
ventricular catheterisation of 10 days and less should be implemented as standardised protocol at
health institutions to reduce the risk of EVD-related infections.
2.Prediction of Histological Grade and Completeness of Resection of Intracranial Meningiomas: Role of Peritumoural Brain Edema
Kamalanathan Palaniandy ; Mohammad Saffari Mohammad Haspani ; Norzaini Rose Mohd Zain
Malaysian Journal of Medical Sciences 2017;24(3):33-43
Background: Meningioma is the commonest primary intracranial tumour in adults.
Excision is curative for low grade meningioma, whereas high-grade meningioma requires
adjuvant therapy following surgery. Several studies have examined the association between
peritumoural brain Edema — a common feature in meningioma — and histological grading with
mixed results. The present study attempted to elucidate this association and if peritumoural brain
Edema affects the intra-operative judgement of surgeons on the completeness of resection.
Methods: An observational study was conducted among those who underwent surgery
for meningioma. Eighteen subjects were recruited each for low- and high-grades, respectively.
Magnetic resonance imaging (MRI) prior to surgery was employed for interpreting the Edema
index and MRI after surgery was used to determine residual tumour.
Results: Median age was 50 years, male to female ratio was 1:3.5, 69.4% had peritumoural
brain Edema and 75% had reported gross resection. Among the reported gross total resection
cases, 40.7% had residual tumour. Analysis showed statistically significant association between
peritumoural brain Edema (P = 0.027) and tumour volume (P = 0.001) with high-grade
meningioma, however multivariate analysis did not present any association. No association was
noted between judgement of tumour resection by surgeons and peritumoural brain Edema.
Conclusion: Odds ratio for peritumoural brain Edema remained high and the
tumour volume exhibited marginal P-value marginal significance for prediction of high grade
meningioma. These two factors may still contribute to the tumour grade and should be included in
further studies on the prognosis of meningioma.
3.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 .
4.Correlations between subdural empyema and paraclinical as well as clinical parameters amongst urban Malay paediatric patients
Saiful Azli Mat Nayan ; Mohd Shafie Abdullah ; Nyi Nyi Naing ; Mohd Saffari Mohd Haspani ; Ahmad Razali Md Ralib
Malaysian Journal of Medical Sciences 2008;15(4):19-27
Paediatric subdural empyema is frequently seen in developing Asean countries
secondary to rinosinusogenic origins. A cross-sectional analysis on the surgical
treatment of intracranial subdural empyema in Hospital Kuala Lumpur (HKL), a
major referral center, was done in 2004. A total number of 44 children who fulfilled
the inclusion criteria were included into this study. The methods of first surgery,
volume of empyema on contrasted CT brain, improvement of neurological status,
re-surgery, mortality and morbidity, as well as the demographic data such as age,
gender, sex, duration of illness, clinical presentation, probable origin of empyema,
cultures and follow-up were studied. Chi-square test was performed to determine
the association between surgical methods and the survival of the patients,
neurological improvement, clearance of empyema on CT brain, re-surgery and
long morbidity among the survivors. If the 20% or more of the cells were having
expected frequency less than five, then Fisher’s Exact test was applied. The level
of significance was set at 0.05. SPSS version 12.0 was used for data entry and data
analysis. There were 44 patients who were less than 18 years. Their mean age was
5.90 ± 6.01 years. There were 30 males (68.2%) and 14 females (31.8%) involved
in the study. Malays were majority with 28 (63.6%) followed by Indian 8 (18.2%),
Chinese 5 (11.4%) and others 3 (6.8%). The variables which were under interest
were gender, race, headache, vomiting, seizures, sign of meningism, cranial nerve
palsy, thickness site of abscess, first surgical treatment, improvement in neurological
deficit, clearance of CT and whether re-surgery was necessary. All variables were
found not to be associated with Henk W Mauser Score for PISDE grading.
Comparison between this urban study and a rural setting study by the same
corresponding author in the same period on subdural empyema was done. Common
parameters were compared and it was found out that seizures were more prevalent
in urban study where the patients are more than one year old (p=0.005). Mortality
was much higher in urban study than the rural one (p=0.040). The larger proportion
of urban group had volume of abscess less than or equal to 50 ml (p=< 0.001).