Cerebral amyloid angiopathy (CAA) accounts for approximately 10–20% of spontaneous intracerebral haemorrhage (ICH). This figure is thought to be higher in the elderly population. With the increasing life expectancy of our population, we anticipate that the prevalence of CAA- related ICH will increase in tandem. Although CAA-related ICH and hypertension-related ICH are distinct entities based on histopathology and imaging, the clinical presentation of the two conditions is similar. The use of brain computed tomography (CT) scans remain the ICH imaging modality of choice in Malaysia due to its availability, cost, and sensitivity in detecting acute bleeds. On the other hand, the use of brain magnetic resonance imaging (MRI) with susceptibility-weighted imaging (SWI) sequencing enables the clinician to determine the presence of chronic blood products in the brain, especially clinically silent microbleeds associated with CAA. However, the use of brain MRI scans in our country is limited and leads to a blurring of lines when differentiating between hypertension-related ICH and CAA-related ICH. How this misrepresentation affects the management of these conditions is unclear. In this study, we present two cases of ICH to illustrate this point and to serve as a springboard to question current practice and promote discussion.

Background & Objectives: There is increasing interest in the impact of delirium on mortality and morbidity in stroke patients. Whilst there are published studies assessing this impact, they are primarily focused on the short/long-term physical and cognitive outcomes of stroke survivors. We conducted a systematic review of the literature to determine the impact of delirium on participation in allied health interventions and measurable outcomes immediately following a stroke. Methods and Results: We used a broad search strategy and interrogated three online databases; CINAHL, EMBASE and MEDLINE. Our initial search yielded no results specific to stroke. The search was then expanded to include studiesin any patient population and the final result yielded two publications that fulfilled inclusion criteria. One was a case report of a post-arthroplasty patient, and the second an observational study in an ICU.Both groups concluded that delirium had a negative impact on participation in allied health therapy. Conclusion: The lack of research on the impact of delirium on participation in allied health therapies in stroke patients is surprising. Intuitively, we would assume a negative association but this needs to be studied systematically to identify the incidence, risk factors, and potential interventions aimed at improving outcomes. The overall management of stroke must keep pace with the gains shown in hyperacute stroke management to ensure maximal benefit to stroke survivors.

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.

Background and Objective: Intravenous thrombolysis service for stroke was introduced at the Universiti Kebangsaan Malaysia Medical Centre (UKMMC) in 2009, based on the recommendations of a multidisciplinary team of clinicians. We report the experience at our center in establishing a stroke protocol incorporating computed tomography perfusion (CTP) of the brain, to assess the feasibility of incorporating CTP in the stroke protocol. Methods: A retrospective review of all patients who had a CTP between January 2010 and December 2011 was performed. Results: Of 272 patients who were admitted with acute ischemic stroke, 44 (16.2%) arrived within 4.5 hours from symptom onset and had a CTP performed with the intention to treat. The median time for symptom-to-door, symptom-to-scan and door-to-scan was 90.0 minutes (62.5 – 146.3), 211.0 minutes (165.5 – 273.5) and 85.0 minutes (48.0 – 144.8) respectively. Eight patients (2.9%) were thrombolysed of whom five received IV thrombolysis and three underwent mechanical thrombolysis. The median symptom-to-needle and door-to-needle times were 290.5 minutes (261.3 – 405.0) and 225.0 minutes (172.5 – 316.8) respectively. Four patients were thrombolysed despite being outside the window of treatment based on the CTP findings. Six of the thrombolysed patients had a Modified Rankin Score (MRS) of 1-2 at 5 months post procedure. Conclusions: CTP provides a benefit to management decisions and subsequent patient outcome. It is feasible to incorporate CTP as a standard imaging modality in a stroke protocol. The delays in the time-dependent pathways are due to our work flow and organisational process rather than performing the CTP per se.

Background & Objectives: The burden of stroke is increasing, in part due to increasing prevalence of diabetes mellitus. Given the high prevalence of diabetes in the Malaysian population (22.6%), we aimed to determine the prevalence of diabetes in our stroke population. We also aimed to study the stroke subtype associated with diabetes. We hypothesized that lacunar infarction would be more prevalent in diabetics. Methods: We retrospectively reviewed data of consecutive patients with acute ischaemic stroke admitted from October 2004 to December 2010 from our stroke registry. Demographic data, risk factors profile and stroke subtypes were reviewed and analyzed. Results: Eight hundred and fifty eight patients were identified from the registry. As high as 59.3% (n=509) of our patients were diabetics, of which 49.2% (n=422) had pre-existing diabetes and 10.1% (n=87) were newly diagnosed. Lacunar infarction was the commonest stroke subtype, comprising 60.6% (n=519) of all strokes. Diabetes was significantly associated with lacunar infarction (OR 1.5, CI 95% 1.16-2.01, p=0.003), particularly in those aged ≤ 55 years (OR 2.29, 95% CI 1.12-4.67) and HbA1C ≥ 6.5% (χ²=8.77, p=0.003). Conclusions: The prevalence of diabetes in our stroke patients is amongst the highest reported. Diabetes mellitus, particularly those with poor glycaemic control is strongly associated with lacunar infarction.
Diabetes Mellitus ; Stroke

Myasthenia gravis (MG) is an immune mediated neuromuscular disease causing fatiguability, which can influence quality of life (QOL). MG disease status can be established with Myasthenia Gravis Quality of Life (MGQOL) 15 and Myasthenia Gravis Activities of Daily Living (MGADL) questionnaires to measure patients’ perception of MG-related dysfunction. This study aims to validate the translated Malay versions of the MGQOL15 and MGADL for use in Malay-speaking MG patients. By using the cross cultural adaptation process, both questionnaires were translated into Malay language. Two sets of MGQOL15 Malay version and MGADL Malay version were distributed to MG patients during their routine follow-up to be filled up one week apart. A total of 38 patients were recruited during this study comprising predominantly females compared to males (71% vs 29%) and Malays compared to non-Malays (60% vs 40%). The mean age was 52.5 years; with most of the patients in the 60-69 years old category (37%).The Spearman’s correlation coefficient was 0.987 for MGQOL-15 Malay version and 0.976 for MGADL Malay version, while the internal consistency for MGQOL15 Malay version was 0.952-0.957, and 0.677-0.694 for MGADL Malay version. The MGQOL15 Malay version and MGADL Malay version are reliable and valid instruments for the measurement of quality of life in MG patients in the local setting.
Myasthenia Gravis ; Quality of Life

Background: Impulse control behaviours are repetitive and excessive activities that may be subsyndromal and not fulfil the criteria for impulse control disorder. These activities have potential to negatively impact on the daily lives of sufferers. We conducted a study to investigate the prevalence of impulse control behaviours and its associated features in Parkinson’s disease in our population. Methods: We conducted a prospective cross-sectional study on consecutive patients attending neurology clinic. Inclusion criteria include idiopathic Parkinson’s disease patients with Hoehn & Yahr stage I-IV. Eighty patients were enrolled and screened for impulse control behaviours using the Questionnaire for Impulsive-Compulsive Disorder for Parkinson’s disease (QUIP). Results: Prevalence of impulse control behaviours among our cohort was 11.3%; the features significantly associated with it were higher level of education (p=0.02), advanced stage of disease (p=0.03) and higher levodopa dosage (p= 0.01). The commonest impulse control behaviour in our cohort was compulsive medication use (7.5%), followed by hobbyism (6.3%), hypersexuality (5%), compulsive buying (3.75%), punding (2.5%), walkabout (2.5%), compulsive eating (1.25%) and pathological gambling (1.3%). Conclusions: There is an association between impulse control behaviour and higher levodopa dosage in a study on patients with Parkinson’s disease in Malaysia. We also found a low prevalence of pathological gambling as compared to studies performed in the West.
Disruptive, Impulse Control, and Conduct Disorders ; Parkinson Disease

Background & Objectives: The National Institute of Health Stroke Scale (NIHSS) provides a valid and quick assessment of stroke severity in hyperacute stroke management. Stroke patients who are eligible for reperfusion therapy require prompt assessment. There is no validated Bahasa Malaysia (BM) version of the NIHSS that allows easier assessment by BM-speaking health professionals. This study aimed to translate and validate a BM version of the NIHSS. Methods: The English NIHSS was translated to BM, then back translated to ensure linguistic accuracy. We also adapted the language assessment of the NIHSS to be more culturally appropriate. Training and certification videos were downloaded from the NIH website and dubbed into BM. We determined intra-class correlation and unweighted kappa as the best measure of reliability. Median scores were used in the analysis for language items. Results: One hundred and one raters participated in the test-retest reliability study. Agreement between the original NIHSS and our translated version of the BM-NIHSS was good (ICC = 0.738, 95% CI: 0.611 to 0.823). Fair to moderate agreement was found on item-by-item analysis (unweighted κ=0.20-0.50) despite high observed agreement. Fifty patients participated in the language assessment arm. Scores were better in BM for reading, naming objects and repetition (Mdn = 100, p < 0.001). There was no difference in the median scores for the description component. Conclusions: The BM-NIHSS is a valid translation of the NIHSS, and may be used in clinical practice by BM-speaking healthcare professionals.

Background & Objectives: The reported incidence of post-stroke delirium varies substantially in current medical literature. The impact of delirium on mortality and morbidity is significant and there is need for sustained research on the topic. We aimed to determine the incidence, risk factors and outcome of delirium in acute ischaemic stroke. Methods: We conducted a cross-sectional observational study on consecutive patients with ischaemic stroke. The Confusion Assessment Method was used to diagnose delirium within seven days of stroke onset. Results: Two hundred and eighty patients were recruited (mean age 63.6 years) and 36 (12.9%) developed delirium. After adjustments for covariates, age >65 years (odds ratio, OR 5.2; 95% confidence interval 1.6-17.5); pre-existing dementia (6.5; 1.1-38.2); TACI (7.2; 1.5-35); and a National Institute of Health Stroke Scale of ≥10 (6.8; 1.7-26.4), were independently associated with a risk of developing delirium. Lacunar infarcts were not associated with delirium (0.07; 0.03-0.16). The majority of patients with delirium were cared for in a dedicated stroke unit but this proportion was not significant compared to those without delirium (69.4% vs 58.2%, p=0.20). Delirious patients had significantly higher in-patient mortality (8.3% vs 0%, p=0.002) and longer length of hospital stay (6.94 vs 3.98 days, p< 0.001). Conclusions: One in 8 patients with ischaemic stroke in our centre developed delirium. Older age, pre-existing dementia and severe stroke were independent predictors of delirium. Patients with lacunar infarcts did not develop delirium as often as those with other stroke types. Delirium significantly increased in-patient mortality and length of hospital stay.