1.Evaluation of time-dependent pathways in an acute ischemic stroke protocol that incorporates CT perfusion: A tertiary referral center experience
Hilwati Hashim ; Radhiana Hassan ; Syazarina Sharis ; Shahrul Azmin ; Rabani Remli ; Shahizon Azura Mukari ; Nafisah Yahya ; Hui Jan Tan ; Norlinah Mohamed Ibrahim ; Mohd Saiboon Ismail ; Sobri Muda ; Ramesh Sahathevan
Neurology Asia 2013;18(4):355-360
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.
2.POEMS syndrome
Wint Wint Thu Nyunt ; Rabani REMLI ; Farah Azima ABDUL
The Malaysian Journal of Pathology 2017;39(3):297-303
POEMS syndrome is the syndrome of Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonalprotein and typical Skin changes. A 65-year-old lady presented with the 2-day-history of inabilityto walk, 4-month-history of progressive worsening of muscle weakness of both lower limbs and1-year-history of progressive worsening of bilateral numbness of lower limbs. Nerve conduction studyrevealed generalized sensorimotor demyelinating polyneuropathy. She was initially treated as chronicinflammatory demyelinating polyradiculoneuropathy with intravenous immunoglobulin (IVIG) andhigh-dose prednisolone. However, she had no significant neurological improvement despite gettingstandard therapy. In addition to peripheral neuropathy, the presence of hepatosplenomegaly, skinchanges, polycythaemia and thrombocytosis prompted for further investigations. She was diagnosedas POEMS syndrome based on the presence of two mandatory major criteria [polyneuropathy,monoclonal plasma cell proliferative disorder (lambda)], one major criterion (sclerotic bone lesions)and three minor criteria (organomegaly, skin changes and thrombocytosis/polycythaemia). Shereceived treatment with melphalan and prednisolone. She achieved clinical improvement and partialresponse (haematologic and radiological) after six cycles of therapy. We highlight the awarenessof this rare syndrome, for patients presenting with peripheral neuropathy and not responding to itsstandard therapy, by recognizing other associated clinical manifestations and proceeding furtherdiagnostic work-up.
3.Labrune’s Syndrome Presenting With Stereotypy-Like Movements and Psychosis: A Case Report and Review
Chun-Yang SIM ; Shahizon Azura Mohamed MUKARI ; Lock-Hock NGU ; Chia-Yin LOH ; Rabani REMLI ; Norlinah Mohamed IBRAHIM
Journal of Movement Disorders 2022;15(2):162-166
Labrune’s syndrome, or leukoencephalopathy with brain calcifications and cysts (LCC), is a rare genetic syndrome with variable neurological presentations. Psychiatric manifestations and involuntary movements are uncommonly reported. We report the case of a 19-year-old female, initially diagnosed with Fahr’s syndrome, who presented to us with acute psychosis, abnormal behavior and involuntary movements. Her brain computed tomography showed extensive bilateral intracranial calcifications without cysts. Genetic testing detected two compound heterozygous variants, NR_033294.1 n.*9C>T and n.24C>T, in the SNORD118 gene, confirming the diagnosis of LCC. We discuss the expanding phenotypic spectrum of LCC and provide a literature review on the current diagnosis and management of this rare syndrome.
5.High prevalence of diabetes in stroke patients and its association with lacunar infarction
Zhe Kang Law ; Wan Nur Nafisah ; Ramesh Sahathevan ; Jee Yong Hing ; Mohd Firdaus Zakaria ; Nurul Munirah Mohd Shuhari ; Nur Fathihah Ahmad ; Teong Kui Ting ; Hui Jan Tan ; Shahrul Azmin ; Rabani Remli ; Azmawati Mohammed Nawi ; Norlinah Mohamed Ibrahim
Neurology Asia 2015;20(2):121-127
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
6.Validation study of the Malay version of the Myasthenia Gravis Quality of Life (MGQOL)15 and Myasthenia Gravis Activities of Daily Living (MGADL) questionnaires
Alif Adlan Mohd Thabit ; Nor Azman Rosli ; Hana Maizuliana Solehan ; Zahariah Pilus ; Maskanah Mohammad Lotfie ; Ramesh Sahathevan ; Norlinah Mohamed Ibrahim ; Hui Jan Tan ; Wan Nur Nafisah Wan Yahya ; Hazlina Mahadzir ; Shahrul Azmin Md Rani ; Zhe Kang Law ; Rabani Remli
Neurology Asia 2016;21(1):33-39
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
7.Movement Disorders Resulting From Bilateral Basal Ganglia Lesions in End-Stage Kidney Disease: A Systematic Review
Kah Hui YAP ; Nurul Husna BAHARUDIN ; Abdul Halim Abdul GAFOR ; Rabani REMLI ; Shen-Yang LIM ; Wan Asyraf Wan ZAIDI ; Shahrul AZMIN ; Shahizon Azura Mohamed MUKARI ; Raihanah Abdul KHALID ; Norlinah Mohamed IBRAHIM
Journal of Movement Disorders 2022;15(3):258-263
Objective:
The basal ganglia (BG) are susceptible to fluctuations in blood urea levels, sometimes resulting in movement disorders. We described patients with end-stage kidney disease (ESKD) presenting with movement disorders associated with bilateral BG lesions on imaging.
Methods:
We report four patients and systematically reviewed all published cases of ESKD presenting with movement disorders and bilateral BG lesions (EBSCOhost and Ovid).
Results:
Of the 72 patients identified, 55 (76.4%) were on regular dialysis. Parkinsonism was the most common movement disorder (n = 39; 54.2%), followed by chorea (n = 24; 33.3%). Diabetes mellitus (n = 51; 70.8%) and hypertension (n = 16; 22.2%) were the most common risk factors. Forty-three (59.7%) were of Asian ethnicity. Complete clinical resolution was reported in 17 (30.9%) patients, while 38 (69.1%) had incomplete clinical resolution with relapse. Complete radiological resolution occurred in 14 (34.1%) patients.
Conclusion
Movement disorders associated with BG lesions should be recognized as a rare and potentially reversible metabolic movement disorder in patients with ESKD.
8.Impulse control behaviours in a Malaysian Parkinson’s disease population
Shahrul Azmin ; Eng Liang Tan ; Nik Jaafar Nik Ruzyanei ; Zakaria Hazli ; Azmawati Mohammed Nawi ; Zhe Kang Law ; Remli Rabani ; Wan Yahya Nafisah ; Ramesh Sahathevan ; Hui Jan Tan ; Nur Fadhlina M. Pakarul Razy ; Nor Azian Abdul Murad ; King-Hwa Ling ; Mohamed Ibrahim
Neurology Asia 2016;21(2):137-143
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
9.Concurrent stroke and ST-elevation myocardial infarction: Is it a contraindication for intravenous tenecteplase?
Wan Asyraf Wan Zaidi ; Suguna Elengoe ; Hamat Hamdi Che Hassan ; Afliza Abu Bakar ; Rabani Remli
The Medical Journal of Malaysia 2020;75(2):169-170
Acute ischemic stroke (AIS) and acute ST-elevation
myocardial infarction (STEMI) are leading causes of
mortality worldwide. Concurrent AIS presentation with
STEMI is rare and potentially fatal. Most importantly to date
many centres in Malaysia are still not aware on how to treat
this condition. We report a case of AIS, which was treated
with intravenous tenecteplase (TNK) according to ischemic
stroke dosage and lead to improvement of neurological
deficit.
10.A validation study of the Bahasa Malaysia version of the National Institute of Health Stroke Scale
Najma Kori ; Wan Asyraf Wan Zaidi ; Rabani Remli ; Azman Ali Raymond ; Norlinah Mohamed Ibrahim ; Hui Jan Tan ; Syed Zulkifli Syed Zakaria ; Zhe Kang Law ; Kartini Ahmad ; Wan Nafisah Wan Yahya ; Ramesh Sahathevan
Neurology Asia 2018;23(3):225-232
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.