1
|
Lo YT, Kalimuddin S, Keong NCH, Lie SA. An unusual case of dengue fever in aneurysmal subarachnoid haemorrhage: diagnosis and management nuances. Br J Neurosurg 2023; 37:1859-1862. [PMID: 34240635 DOI: 10.1080/02688697.2021.1946674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 06/18/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Dengue fever is highly prevalent in the Asia-Pacific region. Here we present an unusual case of dengue fever in a patient with a ruptured cerebral aneurysm causing subarachnoid (SAH) and intraventricular haemorrhage (IVH) and discuss the implications of dengue-related thrombopathies on the management of SAH and its complications. CASE REPORT A 56-year-old female with a two-day history of high-grade pyrexia and myalgia presented with sudden-onset drowsiness (presenting Glasgow Coma Scale, GCS: E1V1M4). Imaging revealed extensive SAH and IVH due to a ruptured right middle cerebral artery (MCA) aneurysm, with extensive vasospasm. Blood test revealed thrombocytopenia and a positive NS-1 antigen. She subsequently suffered from two episodes of re-rupture of the aneurysm and elevated intracranial pressure which required a decompressive craniectomy in addition to coilingof the MCA aneurysm. Cerebral perfusion and rheology were maintained with the triple-H therapy. Her GCS improved to E4V1M6, but remained aphasic. DISCUSSIONS Thrombocytopenia and deranged platelet functions in dengue infection might affect the stability of clot and increase the risk of re-rupture of aneurysm. Immediate securement of the aneurysm was paramount. In cases of severe dengue, plasma leakage could lead to intravascular depletion, and coupled with haemoconcentration and hypotension would further increase the risk for vasospasm.
Collapse
Affiliation(s)
- Yu Tung Lo
- Department of Neurosurgery, Singapore General Hospital, Singapore, Singapore
| | - Shirin Kalimuddin
- Department of Infectious Diseases, Singapore General Hospital, Singapore, Singapore
| | - Nicole Chwee Har Keong
- Department of Neurosurgery, Singapore General Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Sui An Lie
- Department of Surgical Intensive Care, Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore, Singapore
| |
Collapse
|
2
|
Lin X, Yuen JYE, Chan WQJ, Divakar TG, Keong NCH, Lee LCH, Kumar S, Tan CS, Soon KCP, Chew YPA, Yazid HM, Saleh FJM, Cai F, Chai FC, Azwan NFM, Faizal NM, Lou SC, Tan SSP, Jarimin CM, Stanley GM, Hussien K, Sanmwan N, Amran NH, Ramli N, Neo SXM, Tan LCS, Tan EK, Lum E. Using the consolidated framework for implementation research to guide a pilot of implementing an institution level patient informed consent process for clinical research at an outpatient setting. Pilot Feasibility Stud 2023; 9:6. [PMID: 36635739 PMCID: PMC9835029 DOI: 10.1186/s40814-023-01234-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 01/02/2023] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND In Singapore, research teams seek informed patient consent on an ad hoc basis for specific clinical studies and there is typically a role separation between operational and research staff. With the enactment of the Human Biomedical Research Act, there is increased emphasis on compliance with consent-taking processes and research documentation. To optimize resource use and facilitate long-term research sustainability at our institution, this study aimed to design and pilot an institution level informed consent workflow (the "intervention") that is integrated with clinic operations. METHODS We used the Consolidated Framework for Implementation Research (CFIR) as the underpinning theoretical framework and conducted the study in three stages: Stage 1, CFIR constructs were used to systematically identify barriers and facilitators of intervention implementation, and a simple time-and-motion study of the patient journey was used to inform the design of the intervention; Stage 2, implementation strategies were selected and mapped to the Expert Recommendations for Implementing Change (ERIC) taxonomy; Stage 3, we piloted and adapted the implementation process at two outpatient clinics and evaluated implementation effectiveness through patient participation rates. RESULTS We identified 15 relevant CFIR constructs. Implementation strategies selected to address these constructs were targeted at three groups of stakeholders: institution leadership (develop relationships, involve executive boards, identify and prepare champions), clinic management team (develop relationships, identify and prepare champions, obtain support and commitment, educate stakeholders), and clinic operations staff (develop relationships, assess readiness, conduct training, cyclical tests of change, model and simulate change, capture and share local knowledge, obtain and use feedback). Time-and-motion study in clinics identified the pre-consultation timepoint as the most appropriate for the intervention. The implementation process was adapted according to clinic operations staff and service needs. At the conclusion of the pilot, 78.3% of eligible patients provided institution level informed consent via the integrated workflow implemented. CONCLUSIONS Our findings support the feasibility of implementing an institution level informed consent workflow that integrates with service operations at the outpatient setting to optimize healthcare resources for research. The CFIR provided a useful framework to identify barriers and facilitators in the design of the intervention and its implementation process.
Collapse
Affiliation(s)
- Xuling Lin
- grid.276809.20000 0004 0636 696XDepartment of Neurology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433 Singapore
| | - Joanne Yong Ern Yuen
- grid.276809.20000 0004 0636 696XDepartment of Neurology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433 Singapore
| | - Wei Quan Jeremy Chan
- grid.276809.20000 0004 0636 696XDepartment of Neurology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433 Singapore
| | - Tushar Gosavi Divakar
- grid.276809.20000 0004 0636 696XDepartment of Neurology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433 Singapore
| | - Nicole Chwee Har Keong
- grid.276809.20000 0004 0636 696XDepartment of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Lester Chee How Lee
- grid.276809.20000 0004 0636 696XDepartment of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Sumeet Kumar
- grid.276809.20000 0004 0636 696XDepartment of Neuroradiology, National Neuroscience Institute, Singapore, Singapore
| | - Chew Seah Tan
- grid.276809.20000 0004 0636 696XDepartment of Neurology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433 Singapore
| | - Kim Chin Pauline Soon
- grid.276809.20000 0004 0636 696XDepartment of Neurology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433 Singapore
| | - Yee Pheng Amy Chew
- grid.276809.20000 0004 0636 696XDepartment of Neurology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433 Singapore
| | - Heriati Mohd Yazid
- grid.276809.20000 0004 0636 696XDepartment of Neurology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433 Singapore
| | - Farah Julieanna Mohd Saleh
- grid.276809.20000 0004 0636 696XDepartment of Neurology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433 Singapore
| | - Fenglong Cai
- grid.276809.20000 0004 0636 696XDepartment of Neurology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433 Singapore
| | - Fui Chih Chai
- grid.276809.20000 0004 0636 696XDepartment of Neurology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433 Singapore
| | - Nur Fakhirah Mohamed Azwan
- grid.276809.20000 0004 0636 696XDepartment of Neurology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433 Singapore
| | - Nurhidayah Mohamad Faizal
- grid.276809.20000 0004 0636 696XDepartment of Neurology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433 Singapore
| | - Siew Choo Lou
- grid.276809.20000 0004 0636 696XDepartment of Neurology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433 Singapore
| | - Siew Sin Priscilla Tan
- grid.276809.20000 0004 0636 696XDepartment of Neurology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433 Singapore
| | - Cut Marini Jarimin
- grid.163555.10000 0000 9486 5048Specialist Outpatient Clinic Ambulatory Department, Singapore General Hospital, Singapore, Singapore
| | - Gowri Michael Stanley
- grid.163555.10000 0000 9486 5048Specialist Outpatient Clinic Ambulatory Department, Singapore General Hospital, Singapore, Singapore
| | - Khadijah Hussien
- grid.163555.10000 0000 9486 5048Specialist Outpatient Clinic Ambulatory Department, Singapore General Hospital, Singapore, Singapore
| | - Nurhazah Sanmwan
- grid.163555.10000 0000 9486 5048Specialist Outpatient Clinic Ambulatory Department, Singapore General Hospital, Singapore, Singapore
| | - Nur Hidayah Amran
- grid.163555.10000 0000 9486 5048Specialist Outpatient Clinic Ambulatory Department, Singapore General Hospital, Singapore, Singapore
| | - Nurliana Ramli
- grid.163555.10000 0000 9486 5048Specialist Outpatient Clinic Ambulatory Department, Singapore General Hospital, Singapore, Singapore
| | - Shermyn Xiu Min Neo
- grid.276809.20000 0004 0636 696XDepartment of Neurology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433 Singapore
| | - Louis Chew Seng Tan
- grid.276809.20000 0004 0636 696XDepartment of Neurology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433 Singapore
| | - Eng King Tan
- grid.276809.20000 0004 0636 696XDepartment of Neurology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433 Singapore
| | - Elaine Lum
- grid.428397.30000 0004 0385 0924Health Services & Systems Research, Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| |
Collapse
|
3
|
Lim JX, Lim YG, Kumar A, Cheong TM, Han JX, Chen MW, Wen D, Lim W, Ng IHB, Ng VYP, Kirollos RW, Keong NCH. Relevance of presenting risks of frailty, sarcopaenia and osteopaenia to outcomes from aneurysmal subarachnoid haemorrhage. BMC Geriatr 2022; 22:333. [PMID: 35428266 PMCID: PMC9013113 DOI: 10.1186/s12877-022-03005-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 03/30/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Aneurysmal subarachnoid haemorrhage (aSAH) is a condition with significant morbidity and mortality. Traditional markers of aSAH have established their utility in the prediction of aSAH outcomes while frailty markers have been validated in other surgical specialties. We aimed to compare the predictive value of frailty indices and markers of sarcopaenia and osteopaenia, against the traditional markers for aSAH outcomes. Methods An observational study in a tertiary neurosurgical unit on 51 consecutive patients with ruptured aSAH was performed. The best performing marker in predicting the modified Rankin scale (mRS) on discharge was selected and an appropriate threshold for the definition of frail and non-frail was derived. We compared various frailty indices (modified frailty index 11, and 5, and the National Surgical Quality Improvement Program score [NSQIP]) and markers of sarcopaenia and osteopaenia (temporalis [TMT] and zygoma thickness), against traditional markers (age, World Federation of Neurological Surgery and modified Fisher scale [MFS]) for aSAH outcomes. Univariable and multivariable analysis was then performed for various inpatient and long-term outcomes. Results TMT was the best performing marker in our cohort with an AUC of 0.82, Somers’ D statistic of 0.63 and Tau statistic 0.25. Of the frailty scores, the NSQIP performed the best (AUC 0.69), at levels comparable to traditional markers of aSAH, such as MFS (AUC 0.68). The threshold of 5.5 mm in TMT thickness was found to have a specificity of 0.93, sensitivity of 0.51, positive predictive value of 0.95 and negative predictive value of 0.42. After multivariate analysis, patients with TMT ≥ 5.5 mm (defined as non-frail), were less likely to experience delayed cerebral ischaemia (OR 0.11 [0.01 – 0.93], p = 0.042), any complications (OR 0.20 [0.06 – 0.069], p = 0.011), and had a larger proportion of favourable mRS on discharge (95.0% vs. 58.1%, p = 0.024) and at 3-months (95.0% vs. 64.5%, p = 0.048). However, the gap between unfavourable and favourable mRS was insignificant at the comparison of 1-year outcomes. Conclusion TMT, as a marker of sarcopaenia, correlated well with the presenting status, and outcomes of aSAH. Frailty, as defined by NSQIP, performed at levels equivalent to aSAH scores of clinical relevance, suggesting that, in patients presenting with acute brain injury, both non-neurological and neurological factors were complementary in the determination of eventual clinical outcomes. Further validation of these markers, in addition to exploration of other relevant frailty indices, may help to better prognosticate aSAH outcomes and allow for a precision medicine approach to decision making and optimization of best outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03005-7.
Collapse
|
4
|
Loh DDL, Chen MW, Lim JX, Keong NCH, Kirollos RW. Endoscopic excision of an aqueduct of Sylvius cavernoma causing obstructive hydrocephalus: technical note. Br J Neurosurg 2022:1-4. [PMID: 35001779 DOI: 10.1080/02688697.2021.2024501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 12/21/2021] [Accepted: 12/27/2021] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND IMPORTANCE Acquired lesions within the aqueduct of Sylvius are rare and their surgical management is challenging. Open transcranial approaches require dissection and manipulation of surrounding eloquent structures. Use of an endoscope can avoid potential morbidity from traversing and handling eloquent structures during open approaches whilst providing better visualisation of an intraventricular lesion. CLINICAL PRESENTATION A 62-year-old female presented with insidious onset short-term memory loss, unsteady gait, urinary incontinence and left-sided dysaesthesia. Magnetic resonance imaging (MRI) revealed hydrocephalus from an obstructive haemorrhagic lesion consistent with a cavernoma at the central midbrain within the aqueduct of Sylvius. An endoscopic approach was selected to provide optimal visualisation of the lesion. As only a single instrument could be accommodated, rotational movements were employed to tease out the lesion. Gross total resection was achieved. Her symptoms improved immediately postoperatively and she made a complete recovery by 2 months. Post-operative MRI showed resolution of hydrocephalus and no evidence of residual/recurrence of the lesion. Unfortunately, she developed hydrocephalus 3 months post-op and required placement of a ventriculoperitoneal shunt. CONCLUSIONS Endoscopic resection is safe and feasible for selected periaqueductal lesions as it provides direct access while minimising disruption of the surrounding anatomical structures. The limitation of only having a single instrument can be overcome by employing rotational movements.
Collapse
Affiliation(s)
- Daniel De-Liang Loh
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Min Wei Chen
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Jia Xu Lim
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | | | - Ramez Wadie Kirollos
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| |
Collapse
|
5
|
Lo YT, Kumar S, Tan LQ, Lock C, Keong NCH. The topology of ventricle surfaces and its application in the analysis of hydrocephalic ventricles: a proof-of-concept study. Neuroradiology 2021; 63:1689-1699. [PMID: 33860336 DOI: 10.1007/s00234-021-02698-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/22/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The cerebral ventricles deform in a non-uniform fashion in response to increased CSF volume and/or pressure in hydrocephalic syndromes. Current research is focused on volumetric analyses, while topological analysis of ventricular surfaces remains understudied. We developed a method of quantitatively modeling the curvature of ventricular surfaces to analyze changes in ventricular surfaces in normal pressure hydrocephalus (NPH) and Alzheimer's disease (AD), using the left frontal horn as an example. METHODS Twenty-one patients with NPH were recruited from our institution, and 21 healthy controls (HC) and patients with Alzheimer's disease (AD) were identified from the Alzheimer's Disease Neuroimaging Initiative (ADNI) database. On T1-weighted fine-cut magnetic resonance sequences, 3D Slicer was used to segment the left frontal horn. Next, the mean curvatures at a set of points on the ventricular surface were determined. The frontal horns were scaled and centered into normalized volumes, allowing for pooling across the study subjects. The frontal horn was divided into superolateral, superomedial, inferolateral, and inferomedial surfaces, and locoregional mean curvatures were analyzed. Statistical comparisons were made between NPH, AD, and HC groups. RESULTS Significant differences in the mean curvature of lateral surfaces of the ventricles distinguished patterns of distortion between all three cohorts. Significant flattening of the superomedial surface discriminated NPH from HC and AD. However, significant rounding of the inferomedial surface compared to controls was a distinguishing feature of NPH alone. CONCLUSION NPH ventricles deform non-uniformly. The pattern of surface distortion may be used as an additional tool to differentiate between these hydrocephalic conditions.
Collapse
Affiliation(s)
- Yu Tung Lo
- Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Sumeet Kumar
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Leanne Qiaojing Tan
- Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Christine Lock
- Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Nicole Chwee Har Keong
- Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.
| |
Collapse
|
6
|
Ng ASL, Tan YJ, Yong ACW, Saffari SE, Lu Z, Ng EY, Ng SYE, Chia NSY, Choi X, Heng D, Neo S, Xu Z, Keong NCH, Tay KY, Au WL, Tan LCS, Tan EK. Utility of plasma Neurofilament light as a diagnostic and prognostic biomarker of the postural instability gait disorder motor subtype in early Parkinson's disease. Mol Neurodegener 2020; 15:33. [PMID: 32503574 PMCID: PMC7275464 DOI: 10.1186/s13024-020-00385-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 05/28/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The main motor subtypes of Parkinson's disease (PD) include tremor-dominant (TD) and postural instability gait disorder (PIGD), with varying disease course that warrant the development of biomarkers capable of predicting progression according to motor subtype. The PIGD subtype is associated with a poorer prognosis, hence identification of a biomarker associated with PIGD is clinically relevant. Neurofilament light (NfL) chain is a potential biomarker of disease severity in neurological disorders including PD. However, no study has investigated NfL and PD motor subtypes. Here, we aimed to investigate the diagnostic and prognostic utility of plasma NfL for PD motor subtypes in early Parkinson's disease. Given the higher risk for cognitive and motor decline in PIGD, we hypothesized that plasma NfL is a potential biomarker for PIGD. METHODS Plasma NfL was measured in 199 participants (149 PD and 50 healthy controls, HC) using an ultrasensitive single molecule array. Patients were classified into TD or PIGD based on MDS-UPDRS components. After 2 years, 115 patients were reassessed. Association between NfL and clinical measures in PIGD and TD at baseline and at 2-year follow-up were analysed. RESULTS At baseline, plasma NfL levels were higher in PD than HC (8.8 ± 3.4 vs 16.2 ± 7.6 pg/ml, p < 0.0001), and differentiated PD from HC with a good diagnostic accuracy (AUC = 0.833, p < 0.001). At 2 years, NfL was higher in PIGD than TD (18.4 ± 14.5 vs 12.6 ± 4.4 pg/ml, p = 0.039). Within the PIGD group, higher NfL associated significantly with worse global cognition and UPDRS motor scores at baseline, and was able to predict motor and cognitive decline at a mean follow-up duration of 1.9 years, controlled for age, sex and disease duration. CONCLUSIONS In this longitudinal study, we demonstrated for the first time the potential utility of plasma NfL as a diagnostic and prognostic biomarker in PIGD even at early stages of PD. These important novel findings will require further confirmation in larger, longitudinal PD cohorts.
Collapse
Affiliation(s)
- Adeline Su Lyn Ng
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Bukit Merah, 308433, Singapore. .,Neuroscience and Behavioural Disorders Program, Duke-NUS Medical School, 8 College Road, Bukit Merah, 169857, Singapore.
| | - Yi Jayne Tan
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Bukit Merah, 308433, Singapore
| | - Alisa Cui Wen Yong
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Bukit Merah, 308433, Singapore
| | - Seyed Ehsan Saffari
- Center for Quantitative Medicine, Duke-NUS Medical School, Bukit Merah, Singapore
| | - Zhonghao Lu
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Bukit Merah, 308433, Singapore
| | - Ebonne Yulin Ng
- Department of Neurology, National Neuroscience Institute, Singapore General Hospital, 20 College Road, Bukit Merah, 169856, Singapore
| | - Samuel Yong Ern Ng
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Bukit Merah, 308433, Singapore
| | - Nicole Shuang Yu Chia
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Bukit Merah, 308433, Singapore
| | - Xinyi Choi
- Department of Neurology, National Neuroscience Institute, Singapore General Hospital, 20 College Road, Bukit Merah, 169856, Singapore
| | - Dede Heng
- Department of Neurology, National Neuroscience Institute, Singapore General Hospital, 20 College Road, Bukit Merah, 169856, Singapore
| | - Shermyn Neo
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Bukit Merah, 308433, Singapore
| | - Zheyu Xu
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Bukit Merah, 308433, Singapore
| | - Nicole Chwee Har Keong
- Neuroscience and Behavioural Disorders Program, Duke-NUS Medical School, 8 College Road, Bukit Merah, 169857, Singapore.,Department of Neurosurgery, National Neuroscience Institute, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Bukit Merah, 308433, Singapore
| | - Kay Yaw Tay
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Bukit Merah, 308433, Singapore
| | - Wing Lok Au
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Bukit Merah, 308433, Singapore
| | - Louis Chew Seng Tan
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Bukit Merah, 308433, Singapore
| | - Eng-King Tan
- Neuroscience and Behavioural Disorders Program, Duke-NUS Medical School, 8 College Road, Bukit Merah, 169857, Singapore.,Department of Neurology, National Neuroscience Institute, Singapore General Hospital, 20 College Road, Bukit Merah, 169856, Singapore
| |
Collapse
|
7
|
Lo YT, Kirollos RW, Chen MW, Cheong TM, Keong NCH. Aqueductal Compression by Dilated Virchow-Robin Spaces in the Mesencephalic-Pontine Region Presenting with Symptoms Mimicking Normal Pressure Hydrocephalus: A Case Report and Review of Literature. World Neurosurg 2020; 138:390-397. [PMID: 32200017 DOI: 10.1016/j.wneu.2020.03.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/06/2020] [Accepted: 03/06/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Dilatation of Virchow-Robin spaces (dVRS) have been described in the development of hydrocephalic syndromes. We report an unusual case of a type III dVRS presenting as a mimic of normal pressure hydrocephalus (NPH), due to distortion at the level of the cerebral aqueduct. CASE DESCRIPTION A 59-year-old woman presented with mild traumatic brain injury and possible NPH, due to a history of progressive gait disturbance, recurrent falls, and cognitive decline over a year, in the context of ventriculomegaly. Detailed structural imaging of the brain revealed multiple dilated cystic lesions consistent with dVRS causing distortion at the level of the cerebral aqueduct. Cerebrospinal fluid examination was negative for infection. The patient was treated with endoscopic third ventriculostomy; at 12 months postoperatively, she demonstrated a sustained improvement in gait and stabilization of cognitive decline. CONCLUSIONS This is an illustrative case of a subacute obstructive hydrocephalus due to a collection of periaqueductal dVRS, leading to an insidious clinical presentation mimicking NPH. We reviewed the literature for key clinical presentations and describe neuroanatomical considerations as well as primary treatment strategies. Various hydrocephalic syndromes may present with classic symptoms from Hakim's triad; such symptoms are not specific to idiopathic NPH. Both endoscopic third ventriculostomy and shunting may be efficacious. In our case, dVRS may serve as both a cause of and compensatory mechanism in a subacute obstructive hydrocephalus of unknown etiology. Our case highlights the need to understand the neuroanatomy of aberrant cerebrospinal fluid spaces in hydrocephalic syndromes. Further studies of dVRS would provide valuable insights into the pathogenesis of hydrocephalus.
Collapse
Affiliation(s)
- Yu Tung Lo
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Ramez Wadie Kirollos
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore; Department of Neurosurgery, SingHealth Duke-NUS Neuroscience Academic Clinical Program, Singapore, Singapore
| | - Min Wei Chen
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Tien Ming Cheong
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Nicole Chwee Har Keong
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore; Department of Neurosurgery, Duke-NUS Medical School, Singapore, Singapore.
| |
Collapse
|
8
|
Keong NCH. Commentary: Utility of Preoperative Simulation for Ventricular Catheter Placement via a Parieto-Occipital Approach in Normal-Pressure Hydrocephalus. Oper Neurosurg (Hagerstown) 2019; 16:E159-E160. [PMID: 30189023 DOI: 10.1093/ons/opy226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 07/20/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Nicole Chwee Har Keong
- Department of Neurosurgery, National Neuroscience Institute, and Duke-NUS Medical School, Singapore
| |
Collapse
|
9
|
Tan SYZ, Keong NCH, Selvan RMP, Li H, Ooi LQR, Tan EK, Chan LL. Periventricular White Matter Abnormalities on Diffusion Tensor Imaging of Postural Instability Gait Disorder Parkinsonism. AJNR Am J Neuroradiol 2019; 40:609-613. [PMID: 30872421 DOI: 10.3174/ajnr.a5993] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 01/18/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND PURPOSE Postural instability gait disorder is a motor subtype of Parkinson disease associated with predominant gait dysfunction. We investigated the periventricular white matter comprising longitudinal, thalamic, and callosal fibers using diffusion tensor MR Imaging and examined clinical correlates in a cohort of patients with Parkinson disease and postural instability gait disorder and healthy controls. MATERIALS AND METHODS All subjects underwent the Tinetti Gait and Balance Assessment and brain MR imaging. The DTI indices (fractional anisotropy, mean diffusivity, axial diffusivity, and radial diffusivity) from ROIs dropped over the superior and inferior longitudinal fasciculi, inferior fronto-occipital fasciculus, anterior thalamic radiation, anterior and posterior limbs of the internal capsule, and the genu and body of corpus callosum were evaluated. RESULTS Our findings showed that the superior longitudinal fasciculus, inferior longitudinal fasciculus, inferior fronto-occipital fasciculus, anterior thalamic radiation, genu of the corpus callosum, and body of the corpus callosum are more affected in postural instability gait disorder than in those with Parkinson disease or healthy controls, with more group differences among the longitudinal fibers. Only the callosal fibers differentiated the postural instability gait disorder and Parkinson disease groups. DTI measures in the superior longitudinal fasciculus, frontostriatal fibers (anterior thalamic radiation, anterior limb of the internal capsule), and genu of the corpus callosum fibers correlated with clinical gait severity. CONCLUSIONS Findings from this case-control cohort lend further evidence to the role of extranigral pathology and, specifically, the periventricular fibers in the pathophysiology of postural instability gait disorder.
Collapse
Affiliation(s)
- S Y Z Tan
- From the Department of Diagnostic Radiology, Singapore General Hospital, Singhealth (S.Y.Z.T., N.C.H.K., H.L., E.K.T., L.L.C.), Singapore
| | - N C H Keong
- From the Department of Diagnostic Radiology, Singapore General Hospital, Singhealth (S.Y.Z.T., N.C.H.K., H.L., E.K.T., L.L.C.), Singapore
- Departments of Neurosurgery, Research and Neurology, National Neuroscience Institute, Singhealth (N.C.H.K., R.M.P.S., L.Q.R.O., E.K.T.), Singapore
- Duke-NUS Medical School (N.C.H.K., E.K.T., L.L.C.), Singapore
| | - R M P Selvan
- Departments of Neurosurgery, Research and Neurology, National Neuroscience Institute, Singhealth (N.C.H.K., R.M.P.S., L.Q.R.O., E.K.T.), Singapore
| | - H Li
- From the Department of Diagnostic Radiology, Singapore General Hospital, Singhealth (S.Y.Z.T., N.C.H.K., H.L., E.K.T., L.L.C.), Singapore
| | - L Q R Ooi
- Departments of Neurosurgery, Research and Neurology, National Neuroscience Institute, Singhealth (N.C.H.K., R.M.P.S., L.Q.R.O., E.K.T.), Singapore
| | - E K Tan
- From the Department of Diagnostic Radiology, Singapore General Hospital, Singhealth (S.Y.Z.T., N.C.H.K., H.L., E.K.T., L.L.C.), Singapore
- Departments of Neurosurgery, Research and Neurology, National Neuroscience Institute, Singhealth (N.C.H.K., R.M.P.S., L.Q.R.O., E.K.T.), Singapore
- Duke-NUS Medical School (N.C.H.K., E.K.T., L.L.C.), Singapore
| | - L L Chan
- From the Department of Diagnostic Radiology, Singapore General Hospital, Singhealth (S.Y.Z.T., N.C.H.K., H.L., E.K.T., L.L.C.), Singapore
- Duke-NUS Medical School (N.C.H.K., E.K.T., L.L.C.), Singapore
| |
Collapse
|
10
|
Keong NCH, Bulters DO, Richards HK, Farrington M, Sparrow OC, Pickard JD, Hutchinson PJ, Kirkpatrick PJ. The SILVER (Silver Impregnated Line Versus EVD Randomized Trial). Neurosurgery 2012; 71:394-403; discussion 403-4. [DOI: 10.1227/neu.0b013e318257bebb] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Cerebrospinal fluid (CSF) infections associated with external ventricular drain (EVD) placement attract major consequences. Silver impregnation of catheters attempts to reduce infection.
OBJECTIVE:
To assess the efficacy of silver catheters against CSF infection.
METHODS:
We performed a randomized, controlled trial involving 2 neurosurgical centers (June 2005 to September 2009). A total of 356 patients requiring an EVD were assessed for eligibility; 325 patients were enrolled and randomized (167 plain, 158 silver); 278 patients were analyzed (140 plain, 138 silver). The primary outcome measure was CSF infection as defined by organisms seen on Gram stain or isolated by culture. Secondary outcome measures included ventriculoperitoneal (VP) shunting.
RESULTS:
There was a significant difference in infection risk between the 2 study arms: 21.4% (30/140) for plain catheters vs 12.3% (17/138) for silver catheters (P = .0427; 95% confidence interval [CI]: 1.015-3.713). Patients who had an EVD infection had more than double the risk of requiring a VP shunt compared with patients without an EVD infection (45.7% [21/46] vs 19.7% [45/229], respectively, P = .0002; 95% CI: 1.766-6.682). There was also a significant difference in VP shunt risk with infection: plain (55.2%; 16/29) vs the silver arm (29.4%; 5/17); P = .0244 (95% CI: 1.144-11.695). A multivariate analysis demonstrated that infection risk was increased by duration of EVD placement (odds ratio: 1.160), spontaneous intracranial hemorrhage (odds ratio 4.958) and decreased by silver catheters (odds ratio: 0.423).
CONCLUSION:
The study provides Class I evidence that silver-impregnated catheters reduce CSF infection.
Collapse
Affiliation(s)
- Nicole Chwee Har Keong
- Academic Neurosurgery Division, Department of Clinical Neurosciences, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Diederik Olivier Bulters
- Academic Neurosurgery Division, Department of Clinical Neurosciences, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | | | - Mark Farrington
- Health Protection Agency Microbiology Services Laboratory, Cambridge, United Kingdom
| | - Owen C. Sparrow
- Academic Neurosurgery Division, Department of Clinical Neurosciences, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - John D. Pickard
- Academic Neurosurgery Division, Department of Clinical Neurosciences, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Peter J. Hutchinson
- Academic Neurosurgery Division, Department of Clinical Neurosciences, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Peter J. Kirkpatrick
- Academic Neurosurgery Division, Department of Clinical Neurosciences, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| |
Collapse
|
11
|
Abstract
Penetrating head trauma may present challenging problems in the acute phase (removal of foreign bodies, control of haemorrhage, prevention of infection) and in the management of long-term sequelae (neurological deficit, cognitive impairment, seizures). Two unusual cases demonstrate the progress made in emergency medicine, radiology neurointensive care, and neurosurgical head injury management over 36 years.
Collapse
Affiliation(s)
- N C H Keong
- Academic Neurosurgery Unit, Department of Clinical Neurosciences, Addenbrooke's Hospital, Cambridge, UK
| | | | | |
Collapse
|
12
|
Abstract
OBJECTIVE To determine the best part of an ulcerated colorectal neoplasm from which to take a biopsy in order to prove that the lesion is invasive. PATIENTS AND METHODS In this experimental study, biopsies were obtained from 50 ulcerated colorectal tumours using colonoscopic biopsy forceps on the resected specimen after major colorectal resections. Four biopsy sites were chosen, the junction between the normal mucosa and the rolled edge, the top of the rolled edge, the junction between the rolled edge and the ulcer base, and the centre of the ulcer. A code was used so that the pathologist was not aware of the site of each biopsy. RESULTS Biopsies from the very edge of the lesion were positive for carcinoma in 16% of cases, from the top of the roll in 64%, from the inner aspect of the roll in 88% and from the centre of the ulcer in 90%. CONCLUSION Biopsies from ulcerated colorectal carcinomas are more likely to be positive if taken from the centre of the lesion, rather than the very edge.
Collapse
Affiliation(s)
- M A Lavelle
- Department of Surgery, Princess Royal Hospital, Haywards Heath, UK.
| | | | | |
Collapse
|