National Neuroscience Institute Research Articles

The Development of Postoperative Hydrocephalus following Midline Posterior Cranial Fossa Tumors with Hydrocephalus Surgery with Preoperative Ventriculoperitoneal (V-P) shunt in Pediatric Patients

Background: Posterior cranial fossa tumors are the most common tumors in children and constitute about two-thirds of pediatric brain tumors. Such pediatric patient presents with symptoms and signs of raised intracranial pressure. All pediatric patients were diagnosed with midline posterior cranial fossa tumors with hydrocephalus. The ventriculoperitoneal shunt was done before definitive surgery for all patients. Definitive surgery was done later on. These patients were followed up to the 7th postoperative day following definitive surgery. We assessed the development of postoperative hydrocephalus. Objectives: The objective of the study was to assess the development of postoperative hydrocephalus of midline posterior cranial fossa tumors with hydrocephalus after definitive surgery following ventriculoperitoneal (V-P) shunt in pediatric patients. Methods: This cross-sectional experimental study was conducted in the Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, and the Department of Pediatrics Neurosurgery, National Institute of Neurosciences & Hospital, Dhaka from March 2018 to September 2019. A total of 43 pediatric patients were included in this study. All pediatric patients were diagnosed with midline posterior cranial fossa tumors with hydrocephalus. The ventriculoperitoneal shunt was done before definitive surgery. Later on, definitive surgery was performed. Follow-up of these patients was done up to the 7th postoperative day. The development of postoperative hydrocephalus was observed. Data were processed and then analyzed. Demographic data were expressed in numbers and percentages. The development of postoperative hydrocephalus was expressed in number and percentage. Logistic regression was done to predict the relationship between the dependent variable (development of hydrocephalus) and independent variables (age, sex, and the extent of tumor removal). The odds ratio (OR) was calculated by using the Chi-square test. The chi-square test gave a Wald statistic by observing at the 95% CI of the odds ratio. Statistical significance was set to p-value <0.05. Results: A total of 43 pediatric patients were included in the study from March 2018 to September 2019. In the study, the maximum patients were in the age group 11-15 years. The mean age of the patients was 8.25 years ± 4.14. The male-to-female ratio was 1.26:1. The study showed preoperative clinical features which includes headache 40 (93%), vomiting 37 (86%), visual disturbance 24 (55.8%), altered level of consciousness 3 (7.0%), gait disturbance 30 (69.8%), swallowing disturbance 9 (20.9%), papilledema 38 (88.4%), lower cranial nerves palsy 8 (18.6%). Among them, 25 patients developed postoperative complications after definitive surgery. Development of postoperative hydrocephalus was found in 2 (4.65%) patients. Logistic regression was found to be statistically non-significant in this study. Conclusion: The development of postoperative hydrocephalus of midline posterior cranial fossa tumors with hydrocephalus after definitive surgery following ventriculoperitoneal (V-P) shunt in pediatric patients was not the major complication among others. Bang. J Neurosurgery 2024; 13(2): 86-95

Events of children responsible for the development of epilepsy in patients with cerebral palsy

Background: Cerebral palsy (CP) is characterized by abnormal muscle tone, ‘posture, and movement’, thereby limiting the activity of the affected person. Epilepsy is said to occur in 15-90% of children with CP. The aim of this study was to evaluate the events of children responsible for the development of epilepsy considering natal, postnatal characteristics and associated impairment in patients with CP. Methods: This was a case-control study and was conducted in the Department of Pediatric Neurology at the National Institute of Neurosciences and Hospital, Dhaka, Bangladesh during the period from January 2020 to December 2020. In total 150 children with cerebral palsy were enrolled in this study who were divided into two groups. In the ‘CP with epilepsy’ group, there were 50 patients, and in the CP without epilepsy group taken as a case group, there were 100 age-sex matched CP patients without epilepsy patients were taken as a control group. Informed written consent was taken from all the parents. Along with baseline characteristics, data regarding natal, postnatal events, general clinical findings, psychological assessment, computed tomography (CT) scan findings of the head, and electroencephalogram (EEG) findings in epilepsy cases were recorded in a predesigned questionnaire and analyzed. Results: In distributing the CP patients’ comparison regarding postnatal complications neonatal seizures were a strong predictor for epilepsy (p≤0.001). 1st seizure during 1st year of life and family history of epilepsy was also a significant event of epilepsy (p≤0.001). In the case of microcephaly, no significant difference was observed between groups (p=0.278). A significant difference was observed when the distribution of severity of intellectual disability of CP patients was compared between groups (p<0.001). Abnormal CT scan findings of the head were significantly higher in CP with epilepsy 42 (84.0%) than in CP without epilepsy 46 (46.0%) (p≤0.001). The total mean age at the onset of epilepsy was 13.58±14.47 months. Epilepsy was most common in spastic quadriplegic CP (54%). 38.0% had focal epileptiform activity on EEG. Clinically focal epilepsy was found in 36.0% of cases. Conclusions: This study demonstrates the presence of a history of neonatal seizure, 1st seizure during 1st year of life, a family history of epilepsy, CT scan abnormalities, severe intellectual disability, and spastic quadriplegic CP were the events responsible for the development of epilepsy in children with CP.

A comparison of multiple sclerosis disease characteristics across three genetically diverse Asian racial groups in Singapore

Studies in Western populations have shown that Black and Hispanic patients have an earlier age of Multiple Sclerosis (MS) onset and a more severe disease course characterised by faster disability accrual compared to Whites. It is yet unclear whether MS disease characteristics and clinical course differ amongst Asian racial groups. Singapore is uniquely poised to investigate this as its multi-racial population comprises three genetically diverse Asian racial groups—Chinese, Malay and South Asian. Herein, we sought to elucidate differences in the clinical phenotypes, disease-modifying therapy (DMT) usage, and disease course amongst these three Asian racial groups by performinga retrospective observational study on MS patients seen at the National Neuroscience Institute, Singapore. Data on demographics, disease characteristics, ancillary investigations, and DMT usage were collected. One hundred and eighty-eight patients were included (90 Chinese, 32 Malay, and 66 South Asian). Our findings showed that MS prevalence was the highest in South Asians followed by Malays and Chinese, while demographics, healthcare access, and longer-term disease course were identical across the racial groups. However, several differences and trends were elucidated: (1) South Asian patients had milder sentinel attacks (p = 0.006), (2) a higher proportion of Malay patients had enhancing lesions on their initial MRI (p = 0.057) and the lesion topography differed across the races (p = 0.034), and (3) more Malay patients switched out of their initial DMT (p = 0.051). In conclusion, MS disease characteristics were largely similar across these three Asian racial groups, and while there were some clinical and radiological differences at presentation, these did not influence longer-term outcomes.

Arsenic modifies the effect of folic acid in spina bifida prevention, a large hospital-based case-control study in Bangladesh

BackgroundSpina bifida, a developmental malformation of the spinal cord, is associated with high rates of mortality and disability. Although folic acid-based preventive strategies have been successful in reducing rates of spina bifida, some areas continue to be at higher risk because of chemical exposures. Bangladesh has high arsenic exposures through contaminated drinking water and high rates of spina bifida. This study examines the relationships between mother’s arsenic exposure, folic acid, and spina bifida risk in Bangladesh.MethodsWe conducted a hospital-based case-control study at the National Institute of Neurosciences & Hospital (NINS&H) in Dhaka, Bangladesh, between December 2016 and December 2022. Cases were infants under age one year with spina bifida and further classified by a neurosurgeon and imaging. Controls were drawn from children seen at NINS&H and nearby Dhaka Shishu Hospital. Mothers reported folic acid use during pregnancy, and we assessed folate status with serum assays. Arsenic exposure was estimated in drinking water using graphite furnace atomic absorption spectrophotometry (GF-AAS) and in toenails using inductively coupled plasma mass spectrometry (ICP-MS). We used logistic regression to examine the associations between arsenic and spina bifida. We used stratified models to examine the associations between folic acid and spina bifida at different levels of arsenic exposure.ResultsWe evaluated data from 294 cases of spina bifida and 163 controls. We did not find a main effect of mother’s arsenic exposure on spina bifida risk. However, in stratified analyses, folic acid use was associated with lower odds of spina bifida (adjusted odds ratio [OR]: 0.50, 95% confidence interval [CI]: 0.25-1.00, p = 0.05) among women with toenail arsenic concentrations below the median value of 0.46 µg/g, and no association was seen among mothers with toenail arsenic concentrations higher than 0.46 µg/g (adjusted OR: 1.09, 95% CI: 0.52–2.29, p = 0.82).ConclusionsMother’s arsenic exposure modified the protective association of folic acid with spina bifida. Increased surveillance and additional preventive strategies, such as folic acid fortification and reduction of arsenic, are needed in areas of high arsenic exposure.

Thyroid Hormone Status in Children Taking Antiepileptic Drugs (AEDs): An Experience in a Tertiary Care Hospital of Bangladesh.

Introduction: Antiepileptic drugs (AEDs) may alter thyroid hormone homeostasis at the level of biosynthesis, release, transport, metabolism and excretion of thyroid hormones. The purpose of the study was to see the thyroid hormone status in children with epilepsy treating with common antiepileptic drugs. Materials & Method: The cross-sectional study was carried out in department of pediatric neurology, National Institute of Neurosciences and Hospital (NINS), Dhaka. One hundred and sixty epileptic children aged 1 year to 14 years who were on monotherapy or polytherapy with the most commonly used Antiepileptic drugs (AEDs) for at least 6 months or more were enrolled. Serum TSH and FT4 were measured in all selected patients with early morning serum sample. Result: Nearly one third of study subjects had thyroid dysfunction, most of which were Subclinical hypothyroidism (SCH). The frequency of SCH was 29.2% in carbamazepine(CBZ), 50% in oxcabazepine (OXC), 28.6% in phenobarbitone(PHB) and 13% in valproic acid (VPA) treated epileptic children. No child was found to have subclinical hypothyroidism with topiramate and ethosuximide monotherapy. Antiepileptic drugs (AEDs) monotherapy or polytherapy had no significant difference in alteration on thyroid hormone level. Use of CBZ for long duration significantly altered thyroid function. Doses of Antiepileptic drugs (AEDs) didn’t show any significant thyroid dysfunction. Conclusion: Commonly used Antiepileptic drugs (AEDs) in children with epilepsy were associated with alteration of thyroid hormones, most commonly subclinical hypothyroidism. BANGLADESH J CHILD HEALTH 2022; VOL 46 (2) : 58-64

Clinico demographic profile and short-term outcome of Pediatric Idiopathic Intracranial Hypertension in a tertiary care hospital of Bangladesh

Background: Diagnosis of IIH (idiopathic intracranial hypertension) in children is challenging. The pathogenesis of IIH is still largely unknown. The aim of this study to evaluate the clinico-demographic profile and short-term outcome of IIH among Bangladeshi children. Methodology: This observational cohort study was done in pediatric Neurology Department, National Institute of Neurosciences and Hospital Bangladesh from January 2018 to July 2019. Total 19 cases were enrolled who were clinically suspected and/or had normal CSF with opening pressure (OP) above 250 mmH2O. They were further categorized as “definite IIH”, definite IIH without papilledema, and “probable IIH”. Clinical, radiological profile and short-term outcome were analyzed by SPSS version 22. Result: Among them most were probable IIH (74%). Episodic (57.9%), moderate, diffuse headache was the predominant symptom along with vomiting, double vision, unilateral VI nerve palsy and papilledema. Obesity was found in 21% cases. Mean CSF pressure was 21.84+7.62cm H2O and found high in definite IIH. All the cases were treated with acetazolamide and serial LP was done in 4(15.8%) cases. Definite IIH requires longer hospital stay (6.42 ± 2.87days). Recurrence was observed in 10.5% cases and visual impairment was found in 15.8% cases. Conclusion: This study found wide range of diversity between clinical feature and CSF opening pressure in Pediatric IIH and diagnostic confirmation was challenging. Initial treatment response was satisfactory with a low recurrence rate. J Bangladesh Coll Phys Surg 2024; 42: 161-168

In Case You Haven't Heard…

Individuals with Parkinson's disease may be at significantly higher risk for suicidal thinking and behavior than people without the disease, according to a meta‐analysis published last week in JAMA Neurology. “Patients with [Parkinson's disease] possess multiple risk factors for suicidality, such as advanced age, living with a chronic condition, as well as limitations in physical mobility and functional ability,” wrote Aaron Shengting Mai, M.S., of the National University of Singapore; Yinxia Chao, M.D., Ph.D., of the National Neuroscience Institute Singapore; and colleagues. Efforts at early detection and management of suicidality in patients with Parkinson's can help to reduce patients' risk of death and improve their quality of life, they continued. “Patients with [Parkinson's disease] often experience great psychiatric comorbidity, of which the most prominent is depression,” the researchers wrote. “Depressive mood disorders are the greatest risk factors for both suicidal ideation and suicidal behavior and are present in almost half of patients with Parkinson's.”

Diagnostic Validity of Flagellin Gene (fliC) in Urine for the Detection of Typhoid Fever

Background: Accurate diagnosis of typhoid fever is important issue for the treatment of the patients. Objective: The purpose of the present study was to evaluate the nested PCR for the diagnosis of suspected cases of typhoid fever targeting the flagellin gene (fliC) of Salmonella Typhi from urine. Methodology: This cross sectional study was conducted in the Department of Microbiology of Dhaka Medical College (DMC), Dhaka. Specimens were collected from OPD of DMCH, Dhaka Shishu Hospital (DSH), Dhaka and National Institute of Neurosciences and Hospital (NINSH), Dhaka from July 2013 to June 2014 for a period of one year. All suspected patients of typhoid fever irrespective of age, sex and history of antibiotic intake who attended the OPD of DMCH, DSH and NINSH were selected for this study. Diagnosed cases of febrile illness other than typhoid fever were excluded from the study. Blood and urine were collected and all isolates were tested for antimicrobial susceptibility by Kirby-Bauer modified disc-diffusion technique. Widal test and CRP were performed. Nested PCR was performed in the urine and blood to detect the DNA of Salmonella Typhi. Results: Among 72 typhoid fever patients, 33(45.8%) were Widal test positive and 42(55.5%) were blood culture positive. Out of 30 blood culture negative patients nested PCR in urine was positive in 5(16.7%) cases. The sensitivity, specificity, PPV, NPV and accuracy of nested PCR in urine were 97.6%, 83.3%, 89.1%, 96.1% and 91.7% respectively. Conclusion: In conclusion the nested PCR for the diagnosis of typhoid fever targeting the flagellin gene (fliC) of Salmonella Typhi from urine may be very useful diagnostic tool. Bangladesh Journal of Medical Microbiology, January 2023;17(1):34-39

Antecedent Infections and Hospital Outcomes in Demyelinating and Axonal type of Guillain-Barre Syndrome among adult Patients

Background: Many differences are observed with respect to hospital outcome among demyelinating and axonal type of Guillain-Barre Syndrome. Objective: Aims of this study was to compare the hospital outcome at discharge among demyelinating and axonal type of Guillain-Barre syndrome. Methodology: This prospective observational study was conducted from Oct, 2017 to September, 2018 at the National Institute of Neurosciences and Hospital, Dhaka, Bangladesh. All demyelinating and axonal variant of GBS, presented within 2 weeks were included in this study. The clinical parameters were taken for baseline analysis. Outcomes were measured at discharge by MRC score, length of hospital and ICU stay, recovery and death. Results: Out of 108 GBS cases 55 (50.9%) demyelinating & 53 (49.1%) were axonal subtype. Mean age; 40.20 ± 16.26 vs. 32.43 ± 14.93 years in demyelinating vs. axonal cases (p=0.011). Symptom onset and nadir of weakness are quicker in axonal than demyelinating cases (8.47±4.97 vs. 12.36±7.94) (p=0.017) and (6.7 ± 4.5 vs. 8.36 ± 4.59) (p=0.022)] days. Baseline MRC score were (18.04±9.85 vs 12.94±9.91) (p=0.009) demyelinating vs. axonal cases. At discharge, Mean MRC score, length of hospital stay, length of ICU stay were, (22.15±9.38 vs 17.39±9.46; p=0.013); (15.13±17.60 vs 23.58±23.55) days (p=0.038)} and (28.69±23.28 vs 37.0±20.01) days respectively. Conclusion: Hospital outcome of GBS patients is favorable to demyelinating subtype in respect of MRC score, length of hospital stay, length of ICU stay and also death and survivability. Bangladesh Journal of Medical Microbiology, January 2022;16(1):19-24

COVID-19 infection after SARS-CoV-2 mRNA vaccination in Multiple Sclerosis, AQP4-antibody NMOSD and MOGAD during the Omicron BA.1/2 wave in Singapore (P12-3.002)

<h3>Objective:</h3> To determine the factors associated with breakthrough COVID-19 infection despite at least two SARS-CoV-2 mRNA vaccines in multiple sclerosis (MS), aquaporin-4 neuromyelitis optica spectrum disorder (AQP4-Ab NMOSD) and myelin oligodendrocyte glycoprotein-antibody associated disease (MOGAD) patients during the Omicron BA.1/2 wave in Singapore. <h3>Background:</h3> While SARS-CoV-2 Omicron variant appears to cause mild disease, its high transmissibility remains a concern amongst people with neuroimmunological diseases, especially those on disease-modifying therapies (DMTs). <h3>Design/Methods:</h3> We performed a prospective study at the National Neuroscience Institute (NNI), Singapore during the Omicron BA.1/2 wave from January to April 2022. Data (demographics, disease history, DMTs, vaccination records and COVID-19 infection status) was collected via clinic and/or teleconsultation from January to August 2022. <h3>Results:</h3> Two hundred and one patients were included – 125 MS, 65 AQP4-Ab NMOSD, and 11 MOGAD. Forty-seven had COVID-19 infection of whom 14 were on anti-CD20 therapies and 4 on fingolimod. Two infections were of moderate severity while the rest were mild. Anti-CD20 therapies and fingolimod were associated with COVID-19 infection (p=0.039) while the other DMTs were not. On survival analysis, time to infection after 3 vaccinations was shorter in anti-CD20 therapies and fingolimod (as a group) compared to other DMTs (HR 2.96, p=0.006) and to no DMTs (HR 2.74, p=0.025). Receipt of a third dose of vaccine was associated with fewer infections (33/176, 18.8%; crude rate of 11.3 infections per 1000 person-years) compared to 2 doses only (14/25, 56.0%; crude rate of 21.8 infections per 1000 person-years) (p&lt;0.0001). <h3>Conclusions:</h3> Patients on anti-CD20 therapies and fingolimod are still at increased risk of COVID-19 infection after SARS-CoV-2 mRNA vaccinations although the majority of infections are mild. Receipt of a third dose confers additional protection, supporting the vaccination strategy in this group of patients. <b>Disclosure:</b> Dr. Tan has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Eisai. Dr. Tan has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Viela Bio. Dr. Tan has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Merck. Ms. Tye has nothing to disclose. Ms. Peng has nothing to disclose. Dr. Wong has nothing to disclose. The institution of Dr. Yeo has received personal compensation in the range of $0-$499 for serving as a Consultant for Edanz Pharma. The institution of Dr. Yeo has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Merck. The institution of Dr. Yeo has received personal compensation in the range of $0-$499 for serving as a Consultant for Novartis . The institution of Dr. Yeo has received personal compensation in the range of $0-$499 for serving on a Speakers Bureau for Terumo BCT. The institution of Dr. Yeo has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Euroimmun AG . The institution of Dr. Yeo has received personal compensation in the range of $0-$499 for serving on a Speakers Bureau for Merck. The institution of Dr. Yeo has received personal compensation in the range of $0-$499 for serving on a Speakers Bureau for Novartis . The institution of Dr. Yeo has received research support from National Medical Research Council (Singapore) . The institution of Dr. Yeo has received research support from Roche .

Association of Epilepsy in Children Experiencing Febrile Seizure: Findings from National Institute of Neuroscience, Bangladesh

Background: Febrile seizure-(FS) remains the commonest benign convulsive childhood event. Prolonged-FS may have long-term consequences, including increased risk of subsequent-epilepsy. Objective: To assess if there is any association among epilepsy and epilepsy syndrome with FS. Methodology: This cross-sectional study was conducted in Epilepsy Clinic, National Institute of Neurosciences, Bangladesh, from January-June, 2021 involving one hundred 1-18 years-old-children diagnosed as epilepsy without secondary causes (intracranial space occupying lesion, head-trauma, CNS-infection, stroke). Patients were clinically evaluated thoroughly and were divided into two groups (Gp): Gp-A having a history of (H/O) FS and Gp-B, without FS. Demographically, clinical profile and electrophysiological-parameters were compared between the two groups for association with H/O FS. Pre-checked/cleaned-data were analyzed using SPSS.V.22.0 for proportional differences, taken p&lt;.05 as significant (95%-CI). It was distributed nearly equally among both sexes, irrespective of FS. Although generalized epilepsy was common in both 12/14 (85.71%) Gp-A Vs. 54/86 (62.79%) Gp-B; epilepsy syndrome (infantile spasm, LGS, JME, JAE) revealed significantly more among non-FS-children than genetic epilepsy FS+ was more in FS group (p = 0.04). On EEG, generalized slowing [2/14 (14.28%)], generalized discharge [3/14 (21.42%) and features of encephalopathy [3/14 (21.42)] was observed more in patients with H/O FS, than non-FS. Conclusion: In contrast to other types of epilepsy, our study revealed that genetic epilepsy febrile seizures + was associated with epileptic children who had H/O FS. The Journal of Ad-din Women's Medical College; Vol. 11 (1), Jan 2023; p 38-43

Unique Clinical, Radiological and Histopathological Characteristics of a Southeast Asian Cohort of Patients with Limb-Girdle Muscular Dystrophy 2G/LGMD-R7-Telethonin-Related.

We describe a cohort of five patients with limb-girdle muscular dystrophy (LGMD) 2G/LGMD-R7 in a South-east Asian cohort. LGMD2G/LGMD-R7-telethonin-related is caused by mutations in the TCAP gene that encodes for telethonin. We identified consecutive patients with LGMD2G/LGMD-R7-telethonin-related, diagnosed at the National Neuroscience Institute (NNI) and National University Hospital (NUH) between January 2000 and June 2021. At onset, three patients presented with proximal lower limb weakness, one patient presented with Achilles tendon contractures, and one patient presented with delayed gross motor milestones. At last follow up, three patients had a limb girdle pattern of muscle weakness and two had a facioscapular humeral pattern of weakness. Whole body muscle MRI performed for one patient with a facioscapular-humeral pattern of weakness showed a pattern of muscle atrophy similar to facioscapular-humeral dystrophy. One patient had histological features consistent with myofibrillar myopathy; electron microscopy confirmed the disruption of myofibrillar architecture. One patients also had reduced staining to telethonin antibody on immunohistochemistry. We report the unique clinical and histological features of a Southeast Asian cohort of five patients with LGMD2G/LGMD-R7-telethonin-related muscular dystrophy and further expand its clinical and histopathological spectrum.

Tumefactive Perivascular Spaces Causing Obstructive Hydrocephalus.

HomeRadiologyVol. 307, No. 1 PreviousNext Reviews and CommentaryFree AccessImages in RadiologyTumefactive Perivascular Spaces Causing Obstructive HydrocephalusDaniel D. L. Loh, Saravana Kumar Swaminathan Daniel D. L. Loh, Saravana Kumar Swaminathan Author AffiliationsFrom the Departments of Neurosurgery (D.D.L.L.) and Neuroradiology (S.K.S.), National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore 308433.Address correspondence to S.K.S. (email: [email protected]).Daniel D. L. LohSaravana Kumar Swaminathan Published Online:Dec 6 2022https://doi.org/10.1148/radiol.221724MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In A 71-year-old woman presented with a 3-week history of intermittent dizziness. Clinical examination was unremarkable. Presentation MRI (Figure) demonstrated a cluster of closely spaced, well-demarcated, variably sized intraparenchymal cysts centered in the midbrain and thalami. No associated solid component, enhancement, or perilesional edema was detected. The cyst contents were isointense to cerebrospinal fluid on all sequences. Associated mass effect resulted in obstructive hydrocephalus from compression of the cerebral aqueduct with lateral and third ventricular dilatation. A diagnosis of tumefactive perivascular spaces was made based on these imaging appearances. The hydrocephalus and dizziness resolved after ventriculoperitoneal shunting.Images in a 71-year-old woman who presented with a 3-week history of intermittent dizziness. (A) Axial MRI T2-weighted and (B) postcontrast T1-weighted scans demonstrate a cluster of well-demarcated, variably sized cysts (short arrows) within the midbrain and thalami that were isointense to cerebrospinal fluids, causing obstructive hydrocephalus (long arrows demonstrate compressed cerebral aqueduct). There was no associated enhancement, restricted diffusion, or calcification. The findings were diagnostic for tumefactive perivascular spaces, causing obstructive hydrocephalus.Download as PowerPointOpen in Image Viewer Perivascular spaces are intraparenchymal, pial-lined, interstitial fluid-filled structures that follow the penetrating arteries but do not directly communicate with the subarachnoid space. When large (>1.5 cm), they exert significant mass effect and are called tumefactive perivascular spaces (1). The mesencephalothalamic region is one of the most common locations of giant (or tumefactive) perivascular spaces (1). While the differential diagnosis includes cystic neoplasms, infarcts, and infections, these other pathologic conditions are all distinct from this entity with MRI (1–3).Disclosures of conflicts of interest: D.D.L.L. No relevant relationships. S.K.S. Patents planned, issued, or pending with National Neuroscience Institute.

Lower white matter hyperintensity is associated with lower mild behavioral impairment severity among pre‐dementia people with higher education attainment

AbstractBackgroundMild behavioral impairment (MBI) describes the emergence of neurobehavioral symptoms in later life as harbingers of neurodegeneration. Emerging evidence suggests that white matter hyperintensity (WMH), a known risk factor for cognitive impairment, is associated with MBI. Furthermore, education level which reflects cognitive reserve, influences the risk of dementia. However, the role of education levels on the relationship between WMH and MBI is unknown. Here, we aim to evaluate the effects of education levels on WMH and MBI among a pre‐dementia cohort from a memory clinic in Singapore.MethodIn this retrospective cross‐sectional study, 210 pre‐dementia participants (mean age 64.31, mean MMSE 27.77, mean education level 12.60, 37.6% males), underwent cognitive assessment, Magnetic Resonance Imaging (MRI) and completed the MBI‐checklist (MBI‐C) self‐report in National Neuroscience Institute Singapore from 2017 to 2021. Multiple linear regression models evaluated the main effects of WMH total ratings and years of education on MBI, while moderation analysis evaluated the effects of years of education with WMH on MBI. All analyses were controlled for age and sex.ResultWhile education levels and WMH were not associated with MBI‐C total scores independently (p&gt;0.05), we found that education levels moderated the effects of WMH on MBI‐C total score (β=0.269 , p=0.038). Specifically, higher education attainment is associated with lower MBI‐C total scores among individuals with lower burden of WMH; while higher MBI‐C total score is observed with higher education among people with high WMH burden (Figure 1).ConclusionHigher education attainment is associated with a lower risk of MBI when the WMH load is lower. Our findings support interventions to reduce WMH load in pre‐dementia people with higher education attainment to reduce MBI severity.

Plasma Oligomeric Amyloid‐β partially mediates the effects of Diabetes Mellitus on Cognition in Mild Cognitive Impairment

AbstractBackgroundOligomeric amyloid‐beta (OAβ) is postulated to be the major neurotoxic species that is implicated in the pathophysiology of Alzheimer’s disease (AD). Emerging evidence suggest that plasma OAβ levels are higher in AD compared to cognitively unimpaired individuals and correlate well with AD biomarkers. Diabetes Mellitus (DM) is consistently linked to cognitive dysfunction and epidemiological studies show that patients with DM have an increased risk of AD. While cerebral amyloid deposition is hypothesized to be the link between AD and DM, the association of OAβ and DM on cognition among mild cognitive impairment (MCI) remains unknown. Here, we aim to evaluate the effects of plasma OAβ levels and DM on cognition among MCI patients from a memory clinic in Singapore.MethodIn this retrospective cross‐sectional study, 54 MCI patients (mean age 68.31, 44.4% males) stratified by DM diagnosis, underwent cognitive assessment and plasma OAβ measurements using the Multimer Detection System‐Oligomeric Aβ (MDS‐OAβ) in National Neuroscience Institute Singapore between 2019 to 2021. Multiple linear regression models evaluated the main effects of OAβ and DM on cognition while mediation analysis evaluated the effect of DM on cognition mediated via OAβ. All analyses were controlled for age, sex, education.Result13 (24.1%) of the total MCI cohort had DM and OAβ levels were higher in DM patients (0.68 vs 0.53 ng/ml, p=0.023).OAβ levels were associated with lower MMSE scores (β= ‐4.08, p=0.004) while DM was associated with lower MMSE (β = ‐1.26, p=0.046) and MoCA (β = ‐1.83, p=0.025) scores. Plasma OAβ partially mediates the effect of DM on MoCA scores (Figure 1).ConclusionThe effect of DM on poorer global cognition is partially mediated by higher plasma OAβ levels. While these results need to be replicated in a larger cohort, our findings suggest that optimizing DM control among MCI may reduce the burden of OAβ and improve cognition.

Epidemiologic Features and Surgical Treatment of Spontaneous Pyogenic Spondylodiscitis in Bangladesh

Background: Spontaneous pyogenic spondylodiscitis is an uncommon clinical condition. But in our country it is not infrequent. High level of clinical suspicion is necessary for diagnoses of spontaneous pyogenic spondylodiscitis. There is no study regarding this issue in Bangladesh. Objective: The objective of this study was to see the epidemiological feature and types of surgical treatment of spontaneous pyogenic spondylodiscitis in Bangladesh Materials and Methods: This is a retrospective observational study. This study was done in the Department of Neurosurgery, National Institute of Neurosciences and Hospital, Dhaka, Bangladesh. The study period was January, 2016 to July, 2021 for a period of 5.5 years. 17 patients who were undergone surgery included in the study. The data were collected from questionnaires and hospital records and analyzed. Results: In our study the highest incidence was found in 4th (23.52%) and 6th (29.42%) decade of life which was around 53%. The male to female ratio was about 2: 1.The present study showed the most common involvement was in lumbar region (35.31%), in dorsal and sacral region it was 23.52% and the cervical region in 17.65%. Regarding surgical treatment in cervical region both anterior (with fixation) and posterior approach was done, in dorsal, lumbar and sacral region posterior approach with or without fixation was done. Conclusion: In Bangladesh the incidence of Spontaneous pyogenic spondylodiscitis is relative high. It is more common in advance age with male predominance. Most frequently affected region was lumber. Surgical technique was individualized for every case. Bang. J Neurosurgery 2022; 11(2): 64-69

Components of Metabolic Syndrome and Stroke: A Case-Control Study in Bangladesh

Background: Stroke is increasingly recognized as a global public health concern which is one of the leading causes of death and disability. Metabolic syndrome increases the risk of developing stroke. Recently, studies have been undergone world-wide on metabolic syndrome and stroke but studies are yet limited among Bangladeshi population. Thus, the aim of this study was to investigate the relationship between metabolic syndrome and stroke in Bangladeshi population. Methods: This center-based case-control study was conducted from January 2020 to January 2021 among 66 cases and 66 age and sex matched controls at National Institute of Neurosciences and Hospital (NINS), Dhaka, Bangladesh. Participants were interviewed by a pre-tested semi-structured questionnaire. A checklist was used to document waist circumference, blood pressure and reports of biochemical investigations. Results: Mean age of the cases was 54.36 ± 9.94 years and controls was 52.66 ± 9.03 years. Among the components of metabolic syndrome, hypertension (p &lt; 0.05, OR 1.51, 95% CI 1.04-2.19), elevated triglyceride (p &lt; 0.05, OR 1.74, 95% CI 1.21-2.50) and reduced HDL (p = 0.018, OR 2.436, 95% CI 1.066-5.566) were associated with stroke. The proportion of abdominal obesity in cases was 22.7% while a higher proportion was found in controls (30.3%). This study revealed a significant association between metabolic syndrome and stroke (χ2 = 7.891, p &lt;0.05, OR 0.354, 95% CI 0.17- 0.74). Conclusion: This study showed that components of metabolic syndrome were more prevalent in stroke.

Integrative multi-omics approach to targeted therapy for glioblastoma

This review describes recent technological advances applied to glioblastoma (GBM), a brain tumor with dismal prognosis. International consortial efforts suggest the presence of molecular subtypes within histologically identical GBM tumors. This emphasizes that future treatment decisions should no longer be made based solely on morphological analyses, but must now take into consideration such molecular and cellular heterogeneity. The use of single-cell technologies has advanced our understanding and assignation of functional subtypes revealing therapeutic vulnerabilities. Our team has developed stratification approaches in the past few years, and we have been able to identify patient cohorts enriched for various signaling pathways. Importantly, our Glioportal brain tumor resource has been established under the National Neuroscience Institute Tissue Bank in 2021. This resource offers preclinical capability to validate working hypotheses established from patient clinical datasets. This review highlights recent developments with the ultimate goal of assigning functional meaning to molecular subtypes, revealing therapeutic vulnerabilities.

EMR adoption in Dhaka, Bangladesh: a template to index pediatric central nervous system tumor care and a review of preliminary neuro-oncologic observations.

PurposeTo describe the design, implementation, and adoption of a simplified electronic medical record (EMR) and its use in documenting pediatric central nervous system (CNS) tumors at a tertiary care referral hospital in South-East Asia.MethodsA novel EMR, cataloguing pediatric CNS tumors was used to collect data from August 2017 to March 2020 at National Institute of Neurosciences and Hospital (NINS&H) in Dhaka, Bangladesh.ResultsTwo hundred forty-nine pediatric patients with a CNS tumor were admitted to NINS&H. Fifty-eight percent of patients were male, and the median age was 8 years. A total of 188/249 patients (76%) underwent surgery during their index admission. Radiographic locations were known for 212/249 (85%) of cases; the most common radiographic locations were infratentorial (81/212; 38%), suprasellar (45/212; 21%), and supratentorial (29/212; 14%). A histopathological classification was reported on 156/249 (63%) of patients’ cytology. The most common infratentorial pathologies were medulloblastoma (22/47; 47%) and pilocytic astrocytoma (14/47; 30%). The median time between admission and surgery was 36 days, while the median post-operation stay was 19.5 days.ConclusionsThe feasibility of a basic EMR platform for a busy pediatric neurosurgery department in a lower-middle income country is demonstrated, and preliminary clinical data is reviewed. A wide variety of pediatric CNS tumors were observed, spanning the spectrum of anatomic locations and histopathologic subtypes. Surgical intervention was performed for the majority of patients. Barriers to care include limited molecular diagnostics and unavailable data on adjuvant therapy. Future targets include improvement of clinical documentation in the pre-operative and post-operative period.

Longitudinal Healthcare Utilization and Costs in Parkinson’s Disease: Pre-Diagnosis to 9 Years After

There is currently insufficient long-term data on costs of treatment in patients with Parkinson's disease (PD), which is chronic and progressive, and associated with substantial healthcare costs. Identifying patterns in healthcare utilization and cost may illuminate further discussion on early intervention. To characterize long-term healthcare utilization and costs of PD in newly diagnosed patients managed by movement disorder specialists. Using a longitudinal matched-cohort study of linked data from the National Neuroscience Institute Parkinson's disease and Movement Disorder and healthcare administrative databases in Singapore from 2008-2017, we compared healthcare utilization and costs between patients and controls matched on age, sex, race, and Charlson Comorbidity Index score. 1,162 patients met study inclusion criteria and 1,157 matched controls were identified. The total mean annual healthcare cost (at 2017 costs) was significantly increased in patients compared to controls from years 1-9 post-diagnosis. The increased cost was observed 2 years before diagnosis (USD2322 vs. 2052; p < 0.001). Mean annual cost attributable to PD increased from USD1854 at 1-year post-diagnosis to USD2652 at 9 years. Over 9 years, average costs were significantly higher across all domains of healthcare utilization except primary care-cost of intermediate and long-term care was increased by a factor of 2.5, specialist care by 2.3, emergency department visits by 1.6, and hospital admissions by 1.3. PD results in higher healthcare utilization and costs. Pre-diagnosis increase in healthcare utilization observed in patients supports the presence of prodromal PD symptoms and may present an opportunity for early diagnosis.