Accidental carbon monoxide poisoning in countries with cold climates is commonly related to indoor heating. This condition appears to be relatively uncommon in tropical Asian countries and therefore the diagnosis may be unsuspected. We report a case of a Malaysian patient who presented with a severe, and ultimately fatal, delayed (biphasic) neuropsychiatric syndrome due to carbon monoxide poisoning. The diagnosis was made only when a history compatible with carbon monoxide poisoning subsequently surfaced, and neuroimaging demonstrated the typical pallidal lesions, associated with marked leukoencephalopathy, seen in this condition. Our case is unique because the poisoning occurred in the setting of indoor operation of a portable electricity generator in a karaoke centre because of power failure. Karaoke is a highly popular form of entertainment in many parts of Asia and we suggest that a high index of suspicion of carbon monoxide poisoning is required in this setting.

Rupture of one or more cardiac chambers following domestic blunt chest trauma is rare. A positive outcome depends on high level of suspicion and early surgical intervention. We report here an interesting case of a ruptured right atrial appendage in a four year old boy following a blunt crushing injury to the chest and abdomen by a heavy porcelain sink which was successfully repaired. Therefore, accurate diagnosis is very important for appropriate management.

Hyponatraemia with rapid correction of serum sodium may cause an osmotic demyelination syndrome (ODS) with damage to pontine and/or extrapontine areas of the brain. The prognosis of ODS can range from complete recovery to death; at present, our ability to predict clinical outcome is very limited. We describe here a patient with ODS and increased signal intensity in the striatum on diffusion-weighted MRI, with corresponding low apparent diffusion coeffi cient values (indicating restricted water diffusion). This case provides a further example of the typical MRI appearance of extrapontine ODS and suggests the potential value of diffusion-weighted MRI in predicting prognosis in ODS.

Background & Objectives: The literature on cerebral venous thrombosis (CVT) in South East Asia is limited. The objectives were to evaluate the clinical profile, predisposing factors and clinical outcome of the CVT patients in Malaysia. Methods: We conducted a retrospective descriptive study of the CVT patients admitted to the neurology ward. The clinical presentation, predisposing factors, radiological findings, treatment and prognostic characteristics were evaluated from the charts. Clinical outcome on discharge and six months was measured by Modified Rankin Scale (mRS) scores. Poor outcome and good outcome was defined as Modified Rankin Scale (mRS) scores of 3-6 and 0-2 respectively. Results: Forty nine CVT patients who presented between 2007 and 2017 were recruited. The mean age was 43.51±16.52. The patients consisted of 39 Malaysians (13 Indians, 12 Malays, 12 Chinese, one Iban, one Eurasian descent), and ten non-Malaysians. Thirty (61.2%) patients were women. The most common presenting complaint was headache (75.5%). Six percent had multiple risk factors, whereas 51% had idiopathic CVT. The most common predisposing factors were oral contraceptive pill use (18.4%), followed by infection (12.2%), especially central nervous system (CNS) infection (6.1%); 11.8% had prothrombotic disorder. The most common location for CVT was superior sagittal sinus (83.7%). On neuroimaging, 77.6% had parenchymal lesions, 53.1% had venous infarcts and 38.8% had intracerebral haemorrhage, one patient had CVT complicated by rare venous collateral channels. Poor outcome on discharge and at six months was 38.8% and 33.3% respectively. On univariate analysis, female gender (p=0.002), seizures (p=0.037) and cerebral oedema (p=0.018) were associated with poor functional outcome. On binary logistic regression, female gender (OR=14.50, 95% CI 2.10-99.94,p=0.003) and seizures (OR=6.54, 95% CI 1.33-32.07, p=0.017) were associated with poor outcome. Conclusion: The CVT patients in this study had a higher proportion of CNS infections. Poor outcome was independently associated with female gender and seizures.

Objective: The primary objective of this study was to describe the neuroimaging changes of tuberculous meningitis (TBM), and to determine the role of neuroimaging in the diagnosis of TBM. Methods: Between January 2009 and July 2015, we prospectively recruited TBM patients in two hospitals in Malaysia. Neuroimaging was performed and findings were recorded. The control consists of other types of meningo-encephalitis seen over the same period. Results: Fifty four TBM patients were recruited. Leptomeningeal enhancement was seen in 39 (72.2%) patients, commonly at prepontine cistern and interpeduncular fossa. Hydrocephalus was observed in 38 (70.4%) patients, 25 (46.3%) patients had moderate and severe hydrocephalus. Thirty four patients (63.0%) had cerebral infarction. Tuberculoma were seen in 29 (53.7%) patients; 27 (50.0%) patients had classical tuberculoma, 2 (3.7%) patients had “other” type of tuberculoma, 18 (33.3%) patients had ≥5 tuberculoma, and 11 (20.4%) patients had < 5 tuberculoma. Fifteen (37.2%) patients had vasculitis, 6 (11.1%) patients had vasospasm. Close to nine tenth (88.9%) of the patients had ≥1 classical neuroimaging features, 77.8% had ≥ 2 classical imaging features of TBM (basal enhancement, hydrocephalus, basal ganglia / thalamic infarct, classical tuberculoma, and vasculitis/vasospasm). Only 4% with other types of meningitis/encephalitis had ≥1 feature, and 1% had two or more classical TBM neuroimaging features. The sensitivity of the imaging features of the imaging features for diagnosis of TBM was 88.9% and the specificity was 95.6%. Conclusion: The classic imaging features of basal enhancement, hydrocephalus, basal ganglia/thalamic infarct, classic tuberculoma, and vasculitis are sensitive and specific to diagnosis of TBM.
Tuberculosis, Meningeal

Takayasu arteritis is a rare granulomatous vasculitis that is commonly classified as a large vessel disease. Small and medium vessel involvement are extremely rare, with only a few case reports describing neurovascular, ocular and cutaneous involvement. We describe a 21 year old Malaysian woman with pre-existing Takayasu arteritis confined to the large vessels, presenting one year later to our centre with status epilepticus. Extensive radiologic studies revealed diffuse encephalopathic changes and multifocal neurovascular involvement, with the vasculitis progressing to encompass the large, medium and small vessels. The patient was treated with high dose steroid therapy and discharged well with long term steroid and immunosuppressive therapy. Follow up MRI with vessel wall imaging sequence (VW-MR) and arterial spin labelling (ASL) perfusion imaging demonstrated intra and extracranial vessel wall inflammation, with generalized reduction in left sided cerebral blood flow. This case demonstrates that Takayasu arteritis is not exclusively a large vessel vasculitis, and that small and medium vessel involvement does not preclude its diagnosis.

INTRODUCTION: Intravenous (IV) thrombolysis with alteplase (rt-PA) is effective in ischaemic stroke. The primary objective was to evaluate predictors of functional outcome in acute ischaemic stroke (AIS) patients treated with IV rt-PA. The secondary objective was to assess the outcome with the modified Rankin scale (mRS). We also examined the predictive value of the Totaled Health Risks in Vascular Events (THRIVE) score. METHODS: AIS patients treated with IV rt-PA from February 2012 to August 2016 were recruited. Demographic data, National Institutes of Health Stroke Scale (NIHSS) scores, timing and neuroradiological findings were recorded. Patients received a dose of 0.9 mg/kg IV rt-PA within 4.5 hours of symptom onset. mRS score was evaluated at discharge and three months, and good and poor clinical outcomes were defined as scores of 0-2 and 3-6, respectively. Baseline THRIVE scores were assessed. RESULTS: 36 patients received IV rt-PA. 20 (55.6%) patients had an mRS score of 0-2 at three months. Based on THRIVE score, 86.1% had a good or moderately good prognosis. On univariate analysis, poor outcome was associated with NIHSS score before rt-PA (p = 0.03), THRIVE score (p = 0.02), stroke subtype (p = 0.049) and diabetes mellitus (DM; p = 0.06). Multiple logistic regression showed that outcome was significantly associated with NIHSS score before rt-PA (p = 0.032) and DM (p = 0.010). CONCLUSION Our newly developed Malaysian IV rt-PA service is safe, with similar outcomes to the published literature. Functional outcome after thrombolysis was associated with baseline NIHSS score and DM.

This study observed the functional changes in brain activity while performing real and imagery movement using functional MRI (fMRI); and to compare the fMRI changes of motor imagery before and after mindfulness meditation (MM) training for correlation with actual brain computer interface (BCI) performance. Thirty-eight participants completed a randomized control trial consisting of 2 groups (MM and non-intervention control groups) to study the effect of MM on BCI performance. The MM group participated in a 4-week MM intervention programme. Out of the 38 cohorts, five participants from the MM group and five from the control group were fMRI scanned for real and imagery movement of right hand, left hand and both feet, before and after intervention. Statistical parametric mapping was used for post processing and analysis of fMRI data. The MM group showed a significant improvement in BCI performance compared to the control group. The fMRI results showed activation of right hand, left hand and both feet motor imagery at fronto-parietal regions before MM training (p <0.05, family wise error). After MM training, the fMRI results revealed a focused activation in 3 out of 4 of the trained subjects during right hand motor imagery, 2 out of 4 of the trained subjects during both feet motor imagery and 1 out of 4 of the trained subjects during left hand motor imagery, compared to the control group. This is also correlated with the improvement of BCI accuracy of the intervention group after MM training. Mindfulness meditation improves BCI performance and is correlated with focused activation of the fronto-parietal region in fMRI during motor imagery.