1.Subperiosteal Drainage versus Subdural Drainage in the Management of Chronic Subdural Hematoma (A Comparative Study)
Adrian Ng Wei Chih ; Albert Wong Sii Hieng ; Noor Azman A. Rahman ; Jafri Malin Abdullah
Malaysian Journal of Medical Sciences 2017;24(1):21-30
Introduction: Symptomatic chronic subdural hematomas (CSDH) remain one of the most frequent diagnoses in current neurosurgical practice. Burr-hole craniostomy with irrigation and placement of close-system drainage is the current recommended surgery for symptomatic CSDH. The aim of this study is to perform a direct comparison between two surgical techniques in the treatment of symptomatic CSDH, which have been proven in previous studies to be efficient. Our main objective was to compare the efficacy of placement of a subperiosteal drain (SPD) and a subdural drain (SDD) following single burr-hole craniostomy and irrigation, and to demonstrate any significant differences in terms of overall surgical complications, functional outcome at three months and mortality rate. Materials and Methods: The study was carried out in two local neurosurgical centres. The SPD group was performed in Hospital Umum Sarawak (HUS) and the SDD group was performed in Hospital Sultanah Aminah Johor Bahru (HSAJB), from 1 January 2012 till 30 January 2014 with a total of 30 patients in both treatment groups. Results: Overall, there were no statistically significant difference in terms of patient general characteristics, pre-operative and post-operative symptoms, Markwalder grades, postoperative hematoma volume and recurrence, mortality and functional outcome at discharge and at three month follow-up between both groups. Albeit not achieving statistical significance, we observed a lower rate of surgical complication especially for post-operative intracranial hematoma with placement of the SPD system. Conclusions: Our study concludes that both treatment methods proved to be highly effective in the treatment of CSDH. However, with a lower overall surgical complication rate, treatment with single burr-hole craniostomy, irrigation and placement of the SPD system can be considered a treatment of choice for the management of symptomatic CSDH.
2.Inflammatory Biomarkers and Their Value in Predicting Survival and Outcome among Patients with Spontaneous Intracerebral Haemorrhage
Senthil Kumar Rajapathy ; Zamzuri Idris ; Regunath Kandasamy ; Albert Wong Sii Hieng ; Jafri Malin Abdullah
Malaysian Journal of Medical Sciences 2017;24(3):51-65
Background: Spontaneous intracerebral haemorrhage (SICH) has emerged as one of
the most devastating forms of stroke in recent decades. This disease is noted to carry a 30-day
mortality rate of approximately 45%. An increasing number of studies have implicated a complex
immune-mediated and inflammation-mediated cascade of responses in the pathophysiology
of SICH and the resultant neurologic outcome. Several clinical studies have demonstrated an
association between inflammatory markers and outcome in patients with SICH. However, the
exact relationship between serum biomarkers and functional outcomes amongst survivors has not
been clearly elucidated. This study aimed to evaluate the changes in peripheral leukocyte count
(WBC count) and C-reactive protein (CRP) levels in patients with SICH and to correlate these
findings with survival and functional outcome.
Methodology: A prospective, descriptive and correlational study was conducted at
Sarawak General Hospital (SGH) over the span of two years (April 2013–April 2015). Patients
aged between 30 years and 75 years with supratentorial intracerebral bleed secondary to
uncontrolled hypertension were recruited in this study. Data pertaining to the demography,
clinical and radiological parameters, peripheral WBC count and CRP levels were obtained.
Mortality and functional outcomes were determined at 6 months post ictus. Patients were
recruited following the fulfilment of exclusion and inclusion criteria, and all obtained data were
analysed with the Statistical Package for Social Sciences (SPSS) for Windows version 21.0.
Results: A total of 60 patients with a mean age of 56 years were recruited in this study.
We found that approximately 16 patients were less than or equal to 50 years old (26.7%) and that
44 patients belonged to the older age group of above 50 years (73.3%). The Glasgow Coma Scale
(GCS) score on admission ranged from 9 to 14/15 with a median value of 11/15. The mean clot
volume was 20.1 cm3. The GCS score on admission and clot volume were significantly associated
with the Glasgow Outcome Scale (GOS) at 6 months and overall survival (P < 0.05). The elevated
WBC count and CRP level on admission and at 72 hours post admission were significantly
associated with GOS at 6 months and overall survival (P < 0.05). Thus, the GCS score, clot volume,
WBC count and CRP levels on admission and at 72 hours post admission can be used to predict
functional outcome at 6 months and overall survival in patients with SICH.
Conclusion: We could conclude via this study that for patients with SICH, the main
determinants or predictors of functional outcome at 6 months and overall survival were noted to be the GCS score on admission, clot size, WBC count and CRP levels on admission and at 72 hours
post admission.
3.Brain and Spinal Tumour
Chin Hwee Goh ; Yeow Yen Lu ; Bik Liang Lau ; Jacqueline Oy Leng Wong ; Hock Keong Lee ; Donald Ngian San Liew ; Albert Sii Hieng Wong
The Medical Journal of Malaysia 2014;69(6):261-267
This study reviewed the epidemiology of brain and spinal
tumours in Sarawak from January 2009 till December 2012.
The crude incidence of brain tumour in Sarawak was 4.6 per
100,000 population/year with cumulative rate 0.5%.
Meningioma was the most common brain tumour (32.3%)
and followed by astrocytoma (19.4%). Only brain metastases
showed a rising trend and cases were doubled in 4 years.
This accounted for 15.4% and lung carcinoma was the
commonest primary. Others tumour load were consistent.
Primitive neuroectodermal tumour (PNET) and astrocytoma
were common in paediatrics (60%). We encountered more
primary spinal tumour rather than spinal metastases.
Intradural schwannoma was the commonest and frequently
located at thoracic level. The current healthcare system in
Sarawak enables a more consolidate data collection to
reflect accurate brain tumours incidence. This advantage
allows subsequent future survival outcome research and
benchmarking for healthcare resource planning.
4.The use of magnetic resonance phase-contrast cine in Chiari malformation with syringomyelia
Goh Chin Hwee ; Mohammad Radzi Hamzah ; Regunath Kandasamy ; Abdul Rahman Izaini Ghani ; Wong Sii Hieng ; Zamzuri Idris ; Jafri Malin Abdullah
The Medical Journal of Malaysia 2020;75(6):666-671
mesodermal origin and is commonly associated withsyringomyelia. Foramen magnum decompression is thefirst-line of standard treatment in symptomatic patients witha confirmed radiographic diagnosis. Magnetic resonance(MR) cine allows accurate evaluation of cerebrospinal fluid(CSF) physiology at the craniovertebral junction but oftenthis is under-utilised in Malaysia. Methods: In this series, we looked into nine cases of CM withsyringomyelia from clinical and radiological perspectivebefore and after surgery. The radiological parameters wereherniated tonsillar length, syrinx: cord ratio, syrinx lengthand diameter. Flow velocity and morphologic changes inChiari were illustrated. Results: Seven patients showed either reduction in syrinxlength, syrinx: cord ratio or both postoperatively. Clinicalrecovery somewhat varied in motor and sensory symptoms.Four patients gained better functional grade in modifiedRankin scale (MRS) while the rest remained similar. Thestudy highlighted the advantage of CSF flow dynamicsinformation over MR anatomical radiographic improvementin addressing the neurologic and functional recovery. Wealso discussed the practicality of cine sequence inpreoperative patient selection, syrinx analysis andpostoperative flow evaluation in anticipation of clinicaloutcome. Conclusion: Phase-contrast cine MRI is a useful tooldictated by resource availability. We recommend its routineuse in preoperative analysis and subsequent observationalfollow-up after surgery.
5.Large falcine meningioma presented as treatmentresistant depression: A case report
Sim Sze Kiat ; Khairul Aizad Bin Adzman ; Lim Swee San ; Albert Hieng Sii Wong
The Medical Journal of Malaysia 2019;74(1):87-89
Large intracranial tumour may present only with psychiatric
symptoms without any neurological deficits. Delay in
surgical treatment may significantly affect the quality of life
in these patients. We report a case of a young engineering
student who was diagnosed as treatment-resistant
depression without initial neuroimaging study. Further
neuroimaging studies revealed he has a large falcine
meningioma. His psychiatric symptoms resolved following
surgical resection of the tumour. We emphasized the
importance of initial neuroimaging study in young patients
presenting with psychiatric symptoms.
6.Tranexamic acid in traumatic brain injury
Nelson Kok Bing Yap ; Albert Sii Hieng Wong ; Zamzuri Idris
The Medical Journal of Malaysia 2020;75(6):660-665
General Hospital. In all 167 of them wereadministered with TXA and another 167 of the patients werenot. The primary outcome expected is the number of goodoutcomes in isolated TBI patients given TXA. Goodoutcome is defined by Glasgow Outcome Score-Extended(GOSE) of five and above. Secondary outcome was clotexpansion of an intracranial bleed seen on the first scan thathad expanded by 25% or more on any dimension on thesecond scan. Results: The TXA did not show significant trend of goodoutcome in terms of GOSE (p=0.763). However, for moderateand severe acute subdural haemorrhage (SDH) subgroups,there was a significant difference (p=0.042). Clot expansionwas present in 14 patients (12.7%) with TXA given and in 54patients (38.8%) without TXA. The difference wasstatistically significant (p<0.001). Of the patients whoreceived TXA, there was one case (0.6%) of deep veinthrombosis. Apart from that, TXA showed non-significanttrend in reducing mortality (p=0.474). Conclusions: Tranexamic acid reduces the rate of clotexpansion in TBI by 26.1% (38.8-12.7%) without significantlyincreasing the risk of a thrombotic event. It can also improvethe outcome of moderate and severe TBI patients with acuteSDH.
7.Comparing the outcome of monitored anaesthesia care and local anaesthesia for carpal tunnel syndrome surgery by neurosurgeons
Goh Chin Hwee ; Lau Bik Liang ; Teong Sook Yee ; Law Wan Chung ; Tan Peter Chee Seong ; Ravindran Vashu ; Liew Donald Ngian San ; Wong Albert Sii Hieng
The Medical Journal of Malaysia 2019;74(6):499-503
Introduction: Carpal tunnel syndrome (CTS) is the
commonest median nerve entrapment neuropathy of the
hand, up to 90% of all nerve compression syndromes. The
disease is often treated with conservative measures or
surgery. The senior author initially intended to treat his own
neurosurgical patients concurrently diagnosed with carpal
tunnel syndrome in 2014, subsequently, he began to pick up
more referrals from the primary healthcare group over the
years. This has led to the setup of a peripheral and spine
clinic to act as a hub of referrals. Objective: Department of
Neurosurgery Sarawak aimed to evaluate the surgical
outcome of carpal tunnel release done over five years.
Methods: The carpal tunnel surgeries were done under local
anaesthesia (LA) given by neurosurgeons (Bupivacaine
0.5% or Lignocaine 2%). Monitored anaesthesia care (MAC)
was later introduced by our hospital neuroanaesthetist in
the beginning of 2018 (Target-controlled infusion propofol
and boluses of fentanyl). We looked into our first 17 cases
and compared these to the two anaesthesia techniques (LA
versus MAC + LA) in terms of patient’s pain score based on
visual analogue scale (VAS).
Results: Result showed MAC provided excellent pain control
during and immediately after the surgery. None experienced
anaesthesia complications. There was no difference in pain
control at post-operation one month. Both techniques had
equal good clinical outcome during patients’ clinic follow
up.
Conclusion: Neurosurgeons provide alternative route for
CTS patients to receive surgical treatment. Being a
designated pain free hospital, anaesthetist collaboration in
carpal tunnel surgery is an added value and improves
patients overall experience and satisfaction.