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Spinal tuberculous disease is common in tuberculous meningitis

Mei-Ling Sharon TAI ; Hazman Mohd NOR ; Shanthi VISWANATHAN ; Kartini RAHMAT ; Norzaini Rose Mohd Zain ; Zhen Yuan POW ; Lay Sim ONG ; Mohd Hanip RAFIA ; Chong Tin TAN

Neurology Asia.2017;22(4):313-323.

Background: Tuberculous disease of spine (spinal TB) is under-recognized in tuberculous (TB) meningitis.The objective of the study was to evaluate the frequency, clinical and neuroimaging changes, andoutcome in the patients with spinal TB. Methods: All the patients with spinal TB admitted in the twolargest tertiary hospitals in Kuala Lumpur from 2009 to 2017 were recruited, the clinical features weredocumented, the magnetic resonance imaging (MRI) of the spine was performed. Clinical outcome wasassessed with Modified Rankin scale (MRS). Results: Twenty two patients were recruited. This wasout of 70 TB meningitis patients (31.4%) seen over the same period. Eighteen (81.8%) patients hadconcomitant TB meningitis. The clinical features consisted of systemic symptoms with fever (63.6%),meningitis symptoms with altered sensorium (45.5%), myelopathy with paraparesis (36.4%). Thefindings on spinal MRI were discitis (36.4%), spinal meningeal enhancement (31.8%), spinal cordcompression (31.8%), psoas abscess (27.3%), osteomyelitis (22.7%), and cord oedema (22.7%). Allexcept two patients (90.9%) had involvement in psoas muscle, bone or leptomeningeal enhancement,features that can be used to differentiate from myelopathy that affect the parenchyma only, such asdemyelination. Unusual manifestations were syringomyelia and paradoxical manifestations seen in 3patients each. The outcome were overall poor, with 68% having MRS 3 or more.Conclusion: Spinal TB is common in TB meningitis. The outcome is overall poor. A heightenedawareness is crucial to enable early diagnosis and treatment.

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Level 4 comprehensive epilepsy program in Malaysia, a resource-limited country

Kheng-Seang LIM ; Sherrini Ahmad Bazir Ahmad ; Vairavan NARAYANAN ; Kartini RAHMAT ; Norlisah Mohd RAMLI ; Kein-Seong MUN ; Kum-Thong WONG ; Noraini ISMAIL ; Shweh-Fern LOO ; Chong-Tin TAN

Neurology Asia.2017;22(4):299-305.

Background and Objective: There is a great challenge to establish a level 4 epilepsy care offeringcomplete evaluation for epilepsy surgery including invasive monitoring in a resource-limited country.This study aimed to report the setup of a level 4 comprehensive epilepsy program in Malaysia and theoutcome of epilepsy surgery over the past 4 years. Methods: This is a retrospective study analyzingcases with intractable epilepsy in a comprehensive epilepsy program in University Malaya MedicalCenter (UMMC), Kuala Lumpur, from January 2012 to August 2016. Results: A total of 92 caseshad comprehensive epilepsy evaluation from January 2012 till August 2016. The mean age was 35.57years old (range 15-59) and 54 (58.7%) were male. There were 17 cases having epilepsy surgeryafter stage-1 evaluation. Eleven cases had mesial temporal sclerosis and 81% achieved Engel classI surgical outcome. Six cases had lesionectomy and 60% had Engel class I outcome. A total of 16surgeries were performed after stage-2 evaluation, including invasive EEG monitoring in 9 cases.Among those with surgery performed more than 12 months from the time of data collection, 5/10(50%) achieved Engel I outcome, whereas 2 (20%) had worthwhile improvement (Engel class III)with 75% and 90% seizure reduction.Conclusion: Level 4 epilepsy care has an important role and is possible with joint multidisciplinaryeffort in a middle-income country like Malaysia despite resource limitation.

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Clues to differentiate Dravet syndrome from febrile seizures plus at the first visit

Hsiu-Fen LEE ; Ching-Shiang CHI

Neurology Asia.2017;22(4):307-312.

Objective: To investigate the clinical clues to differentiate between Dravet syndrome (DS) and febrileseizures plus (FS+). Methods: From September 2001 to March 2014, 44 consecutive patients whowere diagnosed with DS or FS+, were recruited. We retrospectively analyzed the characteristics of thefirst seizure and findings of patients exhibiting seizures during hot water immersion at the first visit.Comparisons between the two groups were analyzed. Results: Thirty-two DS and 12 FS+ patientswere enrolled. The most prevalent body temperature classification in the DS group was afebrile(43.8% vs. 25%, p=0.001), followed by 37-37.9oC (31.3% vs. 8.3%, p=0.02), and that in the FS+group was at 39oC or above (33.3% vs. 9.4%, p=0.001). The most prevalent seizure type in the DSgroup was focal motor seizures (43.8% vs. 25%, p=0.001), followed by alternating hemiconvulsiveseizures (12.5% vs. 0%, p=0.005), and that in the FS+ group was generalized clonic and/or tonic-clonicseizures (83.3% vs. 37.5%, p=0.002). Compared with the FS+ group, there was a greater prevalenceof vaccination-related seizure as the first presenting feature among the DS patients (46.9% vs. 8.3%,p<0.001). During hot water immersion, myoclonic seizure was seen significantly in the DS group(46.4% vs. 25.5%, p=0.013).Conclusions: Afebrile and mild body temperature variation below 38oC, focal motor seizure oralternating hemiconvulsive seizure types, and vaccination-related first seizure were found to be cluesfor highly suspected DS.

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Association studies of genetic polymorphism and environmental factors in ischemic stroke with atherosclerotic middle cerebral artery stenosis

Zhengsheng ZHANG ; Xiang-yan CHEN ; Larry BAUM ; Ho Keung NG ; Vincent MOK ; Ka Sing WONG ; ZS ZHANG ; XY CHEN

Neurology Asia.2017;22(4):291-297.

Objectives: Intracranial atherosclerosis, especially the middle cerebral artery (MCA), is the commonestvascular lesion for ischemic stroke the Chinese population. We explored the association of geneticpolymorphism and environmental factors in MCA atherosclerosis in the Chinese population. Methods:One hundred fifty-six ischemic stroke patients with MCA stenosis and 181 well-matched ischemicstroke patients without MCA stenosis were examined by polymerase chain reaction (PCR). ThePCR products were analyzed for lipoprotein lipase (LPL) S447X and paraoxonase1 (PON1) Q192Rpolymorphisms by restriction enzyme digestion. Medical history documentation and investigationof biochemical markers were performed for each subject. Results: Univariate analysis showed thatthe levels of systolic blood pressure (SBP) were higher in the MCA stenosis group. There were nosignificant differences in the genotype and allele frequencies of the LPL S447X and PON1 Q192Rpolymorphism observed between the two groups. But, in the patients above 60 years of age with andwithout MCA stenosis, LPL X carriers have higher level of SBP than the LPL SS genotype carriers.Multivariate logistic regression found that SBP was the significant, independent predictor of thepresence of MCA stenosis patients above 60 years of age (P < 0.001, OR=1.206, 95% confidenceintervals: 1.014-1.032).Conclusions: SBP appears to contribute to the pathogenesis of MCA stenosis among Chinese. Thegene polymorphism of LPL S447X may be associated with atherosclerotic MCA stenosis in Chinesepopulation.

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“Nine” syndrome and its MRI brain findings

Yong Muh NG ; Pei San KANG ; Chiew Gek KHOR ; Ping Seung ONG ; Ramanathan Gr LETCHUMAN

Neurology Asia.2017;22(4):349-352.

We describe a rare presentation of pontine infarction in a lady who was on dual antiplatelet therapy.Her presentation includes one and a half syndrome, left facial nerve palsy and contralateral hemiataxia.Magnetic resonance imaging (MRI) of the brain revealed acute infarction of the dorsal pons. A diagnosisof “nine” syndrome secondary to lacunar stroke was made. She continued dual antiplatelet therapyand her symptoms resolved completely over three months.

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The prevalence and associated factors of neuropathic pain symptoms in a cohort of multi-ethnic Malaysian patients with diabetes mellitus

Li-Ying GOH ; Ezmeer Emiral SHAHROM ; Clarita Clarence GANESAN ; Shireene Ratna VETHAKKAN ; Khean-Jin GOH

Neurology Asia.2017;22(4):325-331.

Objective: To determine prevalence and factors associated with neuropathic pain symptoms in a multiethniccohort of Malaysian adult diabetic patients. Methods: This was aprospective cross-sectionalobservational study of hospital-based diabetic outpatients in Malaysia. Subjects were interviewedfor their demographic data and medical history. The painDETECT questionnaire was used to screenfor neuropathic pain symptoms and pain intensity was assessed using the numeric pain rating scale(NPRS). Neuropathy symptoms and signs were assessed using the Neuropathy Symptom Score(NSS) and Neuropathy Disability Score (NDS). Results:Of 242 patients,140 (58%) were women,with a mean age of 61 + 11.4 years (range 21 to 81). Ninety nine(40.9%) were Malay, 64 (26.4%)Chinese, 76 (31.4%) Indian and three (1.2%) were Eurasian. Mean duration of diabetes was 15.9+ 9.8years (range 1 to 53) and 232 (95.9%) patients had Type II diabetes. Peripheral neuropathy,based onNSS and NDS criteria, was found in 83 (34.3%). Thirteen (5.4%) patients were found to likely haveneuropathic pain symptoms and this was independently associated with peripheral neuropathy ((OR)= 3.40, 95% confidence interval (CI): 1.04, 11.14) and Indian ethnicity (OR = 5.44, 95% CI: 1.50,19.57)). Patients with neuropathic pain had higher average pain intensity scores.Conclusions: The prevalence of neuropathic pain symptoms in a Malaysian DM patient cohort waslow and was associated with the severity of neuropathy symptoms and Indian ethnicity. The causesfor ethnic differences are unknown and could be due socio-cultural or physiological differences inneuropathic pain perception.

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Hypothalamic endocrinopathy in multiple sclerosis and neuromyelitis optica syndrome

Nahid ASHJAZADEH ; Marjan JEDDI ; Mohammad Hossein DABBAGHMANESH ; Ali Akbar KADIVAR

Neurology Asia.2017;22(4):333-340.

Background: Neuromyelitis optica spectrum disorder (NMOSD) and multiple sclerosis (MS) are twoinflammatory disorders of the central nervous system with different pathogenesis. The aim of thisstudy is to evaluate endocrinopathy in these patients. Methods: By convenient sampling method, 20MS, 20 NMOSD and 20 normal age and sex matched as control were enrolled in this study. Hormonalassay including TSH, free T3, free T4, , FSH, prolactin, cortisol, IGFI, thyroid-stimulating hormone(TSH), free T3, free T4, luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin,cortisol, insulin-like growth factor I (IGF-I), urine specific gravity and anti-aquaporin immunoglobulinG (AQP4-IgG) level was measured. Also adrenocorticotropic hormone (ACTH) stimulation test wasdone for MS and NMOSD patients. Results: Hypothyroidism was prevalent and found in 30% of MS,40% of NMO patients, and only 9.5% of the controls. We detected greater rate of hypothyroidism inNMO patients compared to control (p=0.027). Mean level of anti-thyroglobulin antibody in MS andNMOSD patients was higher than control (p=0.037). One patient in MS group, 6 in NMOSD and 11control had IGFI level lower than lower limit of their age groups (p=0.001).Conclusions: Although the result of this study did not support significant hypothalamic-pituitary axisendocrinopathy in NMOSD compared to MS and controls, there is a higher prevalence of some hormonalabnormalities, especially thyroid dysfunction in NMOSD cases, that needs more clinicians’ attention.

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Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy with spinal cord lesion: A case report and literature review

Heqian DU ; Xinyuan LI ; Hongmei MENG ; Ziwen LU ; Lijun ZHU

Neurology Asia.2017;22(4):353-356.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy(CADASIL)is a common hereditary disease caused by NOTCH3 gene. The major clinical manifestations includerecurrent small-vessel ischaemic events, migraine, dementia and mood disturbance. Herein, wereport a 32-years-old male presented with right leg weakness and persistent migraine. We carried outneurological exams, genetic testing, blood and cerebrospinal fluid analysis (CSF) as well as magneticresonance imaging (MRI) for the brain and spinal cord. There were no anti-aquaporin-4 antibodiesand oligoclonal bands in the CSF and blood investigations were within the normal range. MRI scansrevealed multiple hyperintense regions in the brain and longitudinally hyperintense signal in spinal cord.Further, we identified a c.383G>A(p.Cys128Tyr) mutation in NOTCH3 gene. Therefore, the patientwas diagnosed with CADASIL concurrent with spinal cord lesion. The patient’s condition slightlyimproved after two weeks treatment with daily dosage of 0.5 g citicoline and 75 mg clopidogrel.

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Delayed hemorrhage after microvascular decompression in a hemifacial spasm patient associated with neurosyphilis

Ji-Qing QIU ; Yu CUI ; Li-Chao SUN ; Bin QI ; Zhan-Peng ZHU ; JQ QIU ; Y CUI

Neurology Asia.2017;22(4):357-362.

Microvascular decompression is an effective treatment for hemifacial spasm. Hemorrhage is oneof the complications of microvascular decompression. However, delayed hemorrhage is very rare.Here, we report a case of ipsilateral cerebellar hemorrhage at day seven following microvasculardecompression. A 45-year-old woman presented with left HFS for the previous two years. Diagnostictesting demonstrated the presence of neurosyphilis. Brain magnetic resonance image was unremarkableon presentation. She received microvascular decompression and her hemifacial spasm completelyresolved after surgery. At day seven post-operatively, the patient presented with a sudden onsetheadache. Emergency computed tomography scan showed a cerebellar hemorrhage. A suboccipitalcraniotomy was performed and a cerebellar hematoma was evacuated. The delayed hemorrhage wasattributed to possible microaneurysm from syphilis.

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Contralateral head leading turning accompanied by ipsilateral eye staring in a patient with seizure onset from posterior inferior temporal sulcus, a SEEG case report

Meng-yang WANG ; Jing WANG ; Jian ZHOU ; Yu-guang GUAN ; Feng ZHAI ; Chang-qing LIU ; Fei-fei XU ; Yi-xian HAN ; Zhaofen YAN ; Guo-ming LUAN

Neurology Asia.2017;22(4):363-368.

The epileptic eye and head movements during epileptic seizures may be much more complicated thanpeople originally understood, which can be ipsilateral or contralateral to the electroencephalographyfocus. Here, we describe a male patient with drug resistant focal seizures associated with a directionalseparation between head and eye movement before evolving into generalized tonic-clonic seizure.His contralateral head leading turning showed forced, sustained, and unnatural features companiedby ipsilateral eye staring. Stereoeletroencephalography monitoring was performed, and 4 habitualseizures were recorded over 5 days. Three seizures showed left head leading turning and generalizedtonic-clonic seizure, and only one showed dizziness and ringing in the ears. All the seizures showedthat the ictal onset contacts were located in the posterior inferior temporal sulcus which borders onthe anterolateral part of medial superior temporal area. The patient underwent a resection includingtemporooccipital region, and the histopathology showed focal cortical dysplasia type Ic. He has beenseizure free for two years after operation. The scores of the intelligence and memory quotient improvedhalf year after operation.

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