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.

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.

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.

Background: Traumatic brain injury (TBI) has been associated with an acute stress response mediated by the sympathoadrenomedullary axis, which can be assessed by measuring blood glucose level. Methods: This prospective observational study was conducted for a year in 2007 among 294 patients who had been treated for TBI in Hospital Kuala Lumpur. Patients fulfilling the set criteria were recruited into the study and data, including blood glucose level and Glasgow Outcome Score at 3-month follow-up, were collected. Results: 294 patients were included in the study: 50 females (17.0%) and 244 males (83.0%). The majority of cases were young adult patients (mean age of 34.2 years, SD 13.0). The mean blood glucose level during admission and post-surgery were 6.26 mmol/L (SD 1.30, n = 294) and 6.66 mmol/L (SD 1.44, n = 261), respectively. Specifically, the mean admission glucose level associated with mild TBI was 5.04 mmol/L (SD 0.71); moderate TBI, 5.78 mmol/L (SD 1.02); and severe TBI, 7.04 mmol/L (SD 1.18). The mean admission glucose level associated with a poor outcome in patients with isolated TBI was 6.98 mmol/L (SD 1.21). Patients with admission glucose of 5.56 mmol/L (SD 1.21) were more likely to have a favourable outcome. Conclusion: Mild, moderate, and severe TBI were associated with an increase in blood glucose levels during admission, and the mean increase in glucose levels is based on the severity of the isolated TBI. Surgical intervention did not cause further significant changes in blood glucose levels. Patients with isolated TBI and minimal increases in blood glucose levels were more likely to have a favourable outcome.

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.

Background: To investigate factors influencing disconnection hyperprolactinemia, including tumour volume, degree of pituitary stalk displacement and extent of tumour growth based on a modified Wilson-Hardy classification in a non-functioning pituitary macroadenoma and to confirm reductions in serum prolactin levels after endoscopic transphenoidal surgery. Methods: This prospective, descriptive study was conducted in the Department of Neurosurgery, General Hospital Kuala Lumpur from Jan 1, 2011 to Jan 1, 2013. Forty patients fulfilling the inclusion criteria were enrolled. All patients underwent endoscopic transphenoidal resection of non-functioning pituitary macroadenoma. Pituitary stalk angle, tumour volume and extent of tumour growth were measured from Magnetic Resonance Imaging (MRI) pre- and post-operatively. These variables were compared to serum prolactin levels measured pre and post operatively. SPSS 21 was used to perform statistical analyses. Results: In 40 patients, the mean tumour volumes were 10.58 cm3 (SD 7.81) pre-operatively and 3.1 cm3 (SD 3.45) post-operatively. There was a 70% reduction in tumour volume post-operatively (P < 0.01). The mean serum prolactin was 457 mIU/L (SD 66.93) pre-operatively and 297 mIU/L (SD 6.73) post-operatively. There was a 65% reduction in prolactin serum levels after surgery (P < 0.01). The mean pituitary stalk angles were 93.45 ± 3.89 degrees pre-operatively and 51.45 ± 1.46 degrees post-operatively (P = 0.01). The mean pituitary stalk angle in the control group was 50.4 ± 8.80 degrees. Hence, there was a 98% reduction in pituitary stalk angle after surgery (P < 0.01). This study showed a linear correlation between the pre-operative and post-operative tumour volumes and serum prolactin levels (P = 0.01 pre-and post-operative) and between serum prolactin levels and pituitary stalk angle (P = 0.20 pre-operative; P = 0.01 post-operative). Conclusion: Tumour volume and pituitary stalk angle displacement have positive predictive values for disconnection hyperprolactinemia in non-functioning pituitary macroadenoma. However, a larger sample size and further objective studies are needed to confirm these findings.
Hyperprolactinemia

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 .

Primary central nervous system atypical rhabdoid/teratoid tumour (ATRT) is a rare and highly malignant tumour that tends to occur in infancy and early childhood. The majority of tumours (approximately two-third) arise in the posterior fossa. The optimal treatment for ATRT remains unclear. Options of treatment include surgery, radiotherapy, and chemotherapy. Each of their role is still not clearly defined until now. The prognosis of the disease is generally unfavourable. This is a case report of ATRT in an atypical site in a 9-year-old girl.

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).

Background: Meningiomas are the most common intracranial tumours; they accountfor 13%–26% of all the primary intracranial tumours. Skull base meningiomas make up 25% of allmeningiomas and are one of the most difficult intracranial tumours to be managed surgically. Thisis due to the fact that it is difficult to approach the lesions which are also close to vital structuressuch as cranial nerves and major blood vessels. Despite the abundance of these cases in Malaysia,local data on meningiomas is scarce.Methods: This is a retrospective study consisting of 199 patients with meningiomaswho have been operated at the Kuala Lumpur General Hospital from January 2010–December2014. They were categorised into skull base and non-skull base groups. Demography, tumourcharacteristics, and patient outcomes were analysed. Kaplan-Meier survival curves as well asCox hazard univariable and multivariable regressions for the possible predictors of survival wereanalysed.Results: 97.5% of the patients (n = 194) had WHO grade I meningioma and only fivepatients had WHO grade II meningioma. There was a female predominance (n = 134; 67.3%), witha male-to-female ratio of 1:2. Some 27.1 % patients had skull base meningiomas. Patients with skullbase meningiomas had poorer outcomes and discharge conditions (n = 23; 42.6% P < 0.01), inaddition to higher risk of incomplete resections (n = 34; 63% P < 0.01). Multivariate cox hazardregressions showed that the skull base meningioma group had four times the risk of death of thenon-skull base group.Conclusions: Symptomatic meningiomas can be curative if the tumour is completelyremoved. Our study has revealed that skull base meningiomas which were operated locallyhad higher rates of incomplete resection and poorer surgical outcomes as compared to the nonskullbase group. Patients with skull base meningiomas had four times the risk of death vis-à-visnon-skull base ones. More local studies are needed to look into skull base meningiomas for theimprovement of its surgical outcomes.