Publications by authors named "Vicknes Waran"

37 Publications

Equitable access to state-of-the-art medical technology - a Malaysian mini-Public Private Partnership (PPP) Case Study.

World Neurosurg 2021 Oct 20. Epub 2021 Oct 20.

Academic Neurosurgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom.

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http://dx.doi.org/10.1016/j.wneu.2021.10.112DOI Listing
October 2021

Clinical Studies and Pre-clinical Animal Models on Facial Nerve Preservation, Reconstruction, and Regeneration Following Cerebellopontine Angle Tumor Surgery-A Systematic Review and Future Perspectives.

Front Bioeng Biotechnol 2021 18;9:659413. Epub 2021 Jun 18.

Department of Neurosurgery, University Malaya Specialist Centre, University of Malaya, Kuala Lumpur, Malaysia.

Tumorous lesions developing in the cerebellopontine angle (CPA) get into close contact with the 1st (cisternal) and 2nd (meatal) intra-arachnoidal portion of the facial nerve (FN). When surgical damage occurs, commonly known reconstruction strategies are often associated with poor functional recovery. This article aims to provide a systematic overview for translational research by establishing the current evidence on available clinical studies and experimental models reporting on intracranial FN injury. A systematic literature search of several databases (PubMed, EMBASE, Medline) was performed prior to July 2020. Suitable articles were selected based on predefined eligibility criteria following the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. Included clinical studies were reviewed and categorized according to the pathology and surgical resection strategy, and experimental studies according to the animal. For anatomical study purposes, perfusion-fixed adult New Zealand white rabbits were used for radiological high-resolution imaging and anatomical dissection of the CPA and periotic skull base. One hundred forty four out of 166 included publications were clinical studies reporting on FN outcomes after CPA-tumor surgery in 19,136 patients. During CPA-tumor surgery, the specific vulnerability of the intracranial FN to stretching and compression more likely leads to neurapraxia or axonotmesis than neurotmesis. Severe FN palsy was reported in 7 to 15 % after vestibular schwannoma surgery, and 6% following the resection of CPA-meningioma. Twenty-two papers reported on experimental studies, out of which only 6 specifically used intracranial FN injury in a rodent ( = 4) or non-rodent model ( = 2). Rats and rabbits offer a feasible model for manipulation of the FN in the CPA, the latter was further confirmed in our study covering the radiological and anatomical analysis of perfusion fixed periotic bones. The particular anatomical and physiological features of the intracranial FN warrant a distinguishment of experimental models for intracranial FN injuries. New Zealand White rabbits might be a very cost-effective and valuable option to test new experimental approaches for intracranial FN regeneration. Flexible and bioactive biomaterials, commonly used in skull base surgery, endowed with trophic and topographical functions, should address the specific needs of intracranial FN injuries.
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http://dx.doi.org/10.3389/fbioe.2021.659413DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8259738PMC
June 2021

Employment status after traumatic brain injury and the effect of concomitant injuries on return to work.

Brain Inj 2021 07 6;35(8):949-956. Epub 2021 Jun 6.

Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia.

Purpose: This study aims to describe the employment status and pattern among survivors of traumatic brain injury after motor vehicle accidents, and to explore the effects of demographic, injury variables and concomitant injuries on the employment status .

Method: A retrospective analyses of 370 medical reports written for patients who sustained traumatic brain injury from motor vehicle accidents was conducted. To establish the employment pattern, the pre-injury employment history was compared to the latest employment status documented. Types and severity of concomitant injuries were rated according to Abbreviated Injury Scale criteria. All significant variables were further analyzed using logistic regression to explore predictors of employment.

Results: Up to 87% of the patients sustained concomitant injuries, with more than two-thirds (72%) scoring ≤ 2 on the Abbreviated Injury Scale. One hundred and eighty-two patients (49.2%) successfully returned to work. Among those who returned to work, 34% returned to former employment with pre-injury job description. Severity of traumatic brain injury, length of acute hospital stay, ambulation status and cognitive status were found to be significant predictive factors for employment status post traumatic brain injury. Presence of concomitant extremity injuries was found to influence the employment pattern among traumatic brain injury survivors.

Conclusion: The return to work rate was somewhat low and was not influenced by presence of concomitant injuries. .
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http://dx.doi.org/10.1080/02699052.2021.1934729DOI Listing
July 2021

The utilisation of 3D printing in paediatric neurosurgery.

Childs Nerv Syst 2021 05 18;37(5):1479-1484. Epub 2021 Mar 18.

Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.

3D printing technology has evolved over the years and there is a growing interest in its application in paediatric neurosurgery. Modern 3D printers have enabled the development of patient-specific 3D models that provide a realistic representation of complex anatomies and will aid in planning complex procedures. Paediatric neurosurgical operations are challenging and hands-on training is restricted. Surgical simulation training with biomodel has provided a new paradigm for trainees to master their surgical skills before encountering similar scenarios in real-life environment. This paper reviews the aspects of 3D printing for preoperative planning and simulation-based surgical training in paediatric neurosurgery.
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http://dx.doi.org/10.1007/s00381-021-05123-wDOI Listing
May 2021

Telemedicine via Smart Glasses in Critical Care of the Neurosurgical Patient-COVID-19 Pandemic Preparedness and Response in Neurosurgery.

World Neurosurg 2021 01 18;145:e53-e60. Epub 2020 Sep 18.

Division of Neurosurgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. Electronic address:

Objective: The coronavirus disease 2019 pandemic poses major risks to health care workers in neurocritical care. Recommendations are in place to limit medical personnel attending to the neurosurgical patient as a protective measure and to conserve personal protective equipment. However, the complexity of the neurosurgical patient proves to be a challenge and an opportunity for innovation. The goal of our study was to determine if telemedicine delivered through smart glasses was feasible and effective in an alternative method of conducting ward round on neurocritical care patients during the pandemic.

Methods: A random pair of neurosurgery resident and specialist conducted consecutive virtual and physical ward rounds on neurocritical patients. A virtual ward round was first conducted remotely by a specialist who received real-time audiovisual information from a resident wearing smart glasses integrated with telemedicine. Subsequently, a physical ward round was performed together by the resident and specialist on the same patient. The management plans of both ward rounds were compared, and the intrarater reliability was measured. On study completion a qualitative survey was performed.

Results: Ten paired ward rounds were performed on 103 neurocritical care patients with excellent overall intrarater reliability. Nine out of 10 showed good to excellent internal consistency, and 1 showed acceptable internal consistency. Qualitative analysis indicated wide user acceptance and high satisfaction rate with the alternative method.

Conclusions: Virtual ward rounds using telemedicine via smart glasses on neurosurgical patients in critical care were feasible, effective, and widely accepted as an alternative to physical ward rounds during the coronavirus disease 2019 pandemic.
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http://dx.doi.org/10.1016/j.wneu.2020.09.076DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7500328PMC
January 2021

Management and outcomes following emergency surgery for traumatic brain injury - A multi-centre, international, prospective cohort study (the Global Neurotrauma Outcomes Study).

Int J Surg Protoc 2020 28;20:1-7. Epub 2020 Feb 28.

National Institute of Health Research Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, CB2 0QQ, United Kingdom.

Introduction: Traumatic brain injury (TBI) accounts for a significant amount of death and disability worldwide and the majority of this burden affects individuals in low-and-middle income countries. Despite this, considerable geographical differences have been reported in the care of TBI patients. On this background, we aim to provide a comprehensive international picture of the epidemiological characteristics, management and outcomes of patients undergoing emergency surgery for traumatic brain injury (TBI) worldwide.

Methods And Analysis: The Global Neurotrauma Outcomes Study (GNOS) is a multi-centre, international, prospective observational cohort study. Any unit performing emergency surgery for TBI worldwide will be eligible to participate. All TBI patients who receive emergency surgery in any given consecutive 30-day period beginning between 1st of November 2018 and 31st of December 2019 in a given participating unit will be included. Data will be collected via a secure online platform in anonymised form. The primary outcome measures for the study will be 14-day mortality (or survival to hospital discharge, whichever comes first). Final day of data collection for the primary outcome measure is February 13th. Secondary outcome measures include return to theatre and surgical site infection.

Ethics And Dissemination: This project will not affect clinical practice and has been classified as clinical audit following research ethics review. Access to source data will be made available to collaborators through national or international anonymised datasets on request and after review of the scientific validity of the proposed analysis by the central study team.
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http://dx.doi.org/10.1016/j.isjp.2020.02.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082548PMC
February 2020

Identifying the Sources of Error When Using 3-Dimensional Printed Head Models with Surgical Navigation.

World Neurosurg 2020 Feb 19;134:e379-e386. Epub 2019 Oct 19.

Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. Electronic address:

Objectives: The evaluation of sources of error when preparing, printing, and using 3-dimensional (3D) printed head models for training purposes.

Methods: Two 3D printed models were designed and fabricated using actual patient imaging data with reference marker points embedded artificially within these models that were then registered to a surgical navigation system using 3 different methods. The first method uses a conventional manual registration, using the actual patient's imaging data. The second method is done by directly scanning the created model using intraoperative computed tomography followed by registering the model to a new imaging dataset manually. The third is similar to the second method of scanning the model but eventually uses an automatic registration technique. The errors for each experiment were then calculated based on the distance of the surgical navigation probe from the respective positions of the embedded marker points.

Results: Errors were found in the preparation and printing techniques, largely depending on the orientation of the printed segment and postprocessing, but these were relatively small. Larger errors were noted based on a couple of variables: if the models were registered using the original patient imaging data as opposed to using the imaging data from directly scanning the model (1.28 mm vs. 1.082 mm), and the accuracy was best using the automated registration techniques (0.74 mm).

Conclusion: Spatial accuracy errors occur consistently in every 3D fabricated model. These errors are derived from the fabrication process, the image registration process, and the surgical process of registration.
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http://dx.doi.org/10.1016/j.wneu.2019.10.080DOI Listing
February 2020

Evolving Strategies for Resection of Sellar/Parasellar Synchronous Tumors via Endoscopic Endonasal Approach: A Technical Case Report and Systematic Review of the Literature.

World Neurosurg 2020 Jan 30;133:381-391.e2. Epub 2019 Aug 30.

Department of Neurosurgery, University Malaya Specialist Centre, University of Malaya, Kuala Lumpur, Malaysia.

Background: Data on the endonasal endoscopic approach (EEA) to treat sellar/parasellar synchronous tumors remain sparse. This work aims to describe a minimally invasive approach with intraoperative magnetic resonance imaging (MRI) to remove a large sellar/parasellar synchronous tumor, and presents a systematic literature review.

Methods: The preoperative MRI of a 54-year-old woman revealed a sellar lesion (28 × 19 × 16 mm), presumably a pituitary macroadenoma, and a second extra-axial lesion (22 × 36 × 20 mm) expanding from the tuberculum sellae to the planum sphenoidale with encasement of the anterior communicating complex, presumably a meningioma. We used intraoperative MRI to assess the extent of the resection before reconstructing the large skull base defect. Furthermore, we systematically reviewed pertinent articles retrieved by a PubMed/Embase database search between 1961 and December 2018.

Results: Out of 63 patients with synchronous tumors reported in 43 publications, we found 3 patients in which the tumor was removed by EEA. In these 3 patients and the presented case, the resection of both lesions was successful, without major approach-related morbidity or mortality. More extensive removal of endonasal structures to gain an adequate tumor exposure was not necessary. We did not find any previous reports describing the benefits of intraoperative MRI in the presented setting.

Conclusions: In the rare case of a synchronous meningioma and pituitary adenoma of the sellar region, intraoperative MRI might be beneficial in confirming residual disease before skull base reconstruction, and therefore radiologic follow-up.
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http://dx.doi.org/10.1016/j.wneu.2019.08.102DOI Listing
January 2020

Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury : Consensus statement.

Acta Neurochir (Wien) 2019 07 28;161(7):1261-1274. Epub 2019 May 28.

Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.

Background: Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach.

Methods: The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries.

Results: The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval.

Conclusions: In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.
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http://dx.doi.org/10.1007/s00701-019-03936-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6581926PMC
July 2019

Frequency and Causes of Line of Sight Issues During Neurosurgical Procedures Using Optical Image-Guided Systems.

World Neurosurg 2019 Feb 19;122:e449-e454. Epub 2018 Oct 19.

Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. Electronic address:

Background: Navigation (image guidance) is an essential tool in modern neurosurgery, and most surgeons use an optical tracking system. Although the technology is accurate and reliable, one often is confronted by line of sight issues that interrupt the flow of an operation. There has been feedback on the matter, but the actual problem has not been accurately quantified, therefore making this the primary aim of this study. It is particularly important given that robotic technology is gradually making its way into neurosurgery and most of these devices depend on optical navigation when procedures are being conducted.

Methods: In this study, the frequency and causes of line of sight issues is assessed using recordings of Navigation probe locations and its synchronised video recordings.

Results: The mentioned experiment conducted for a series of 15 neurosurgical operations. This issue occured in all these surgeries except one. Maximum duration of issue presisting reached up to 56% of the navigation usage time.

Conclusions: The arrangment of staff and equipment is a key factor in avoiding this issue.
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http://dx.doi.org/10.1016/j.wneu.2018.10.069DOI Listing
February 2019

Endoscopic Transsphenoidal Resection of Craniopharyngioma.

J Neurol Surg B Skull Base 2018 Feb 16;79(2):S203-S204. Epub 2018 Jan 16.

Neurosurgery Division, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.

 To demonstrate, step-by-step, the technique and efficacy of endoscopic transsphenoidal approach in resection of a suprasellar craniopharyngioma.  The video shows a step-by-step approach to the resection, covering the exposure, access, resection, and confirmation of resection and reconstruction.  The surgery was performed in the University of Malaya Medical Centre, a tertiary referral center in the capital of Malaysia.  Surgery was performed jointly by Professor Prepageran from the department of otorhinolaryngology and Professor Vicknes Waran from the division of neurosurgery. Both surgeons are from the University of Malaya. Video compilation, editing, and voice narration was done by Dr. Kong Yew Liew.  Completeness of resection and avoidance of intra- and postoperative complications.  Based on intraoperative views and MRI findings, the tumor was completely resected with the patient suffering only transient diabetes insipidus.  Central suprasellar tumors can be removed completely via an endoscopic transsphenoidal approach with minimal morbidity to the patient. The link to the video can be found at: https://youtu.be/ZNIHfk12cYg .
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http://dx.doi.org/10.1055/s-0037-1620243DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5796879PMC
February 2018

Electroacupuncture-Assisted Craniotomy on an Awake Patient.

J Acupunct Meridian Stud 2017 Jan 15;10(1):45-48. Epub 2016 Sep 15.

University Malaya, Faculty of Medicine, Jalan University, Kuala Lumpur, Malaysia.

Although acupuncture has existed for over 2000 years, its application as an anesthetic aid began in the 1950s in China. The first surgical procedure performed under acupuncture anesthesia was a tonsillectomy. Soon thereafter, major and minor surgical procedures took place with electroacupuncture alone providing the anesthesia. The procedures performed were diverse, ranging from cardiothoracic surgery to dental extractions. Usage of acupuncture anesthesia, specifically in neurosurgery, has been well documented in hospitals across China, especially in Beijing, dating back to the 1970s. We present a case of a 65-year-old man who presented with right-sided body weakness. He had a past medical history of uncontrolled diabetes mellitus, hypertension, and obstructive sleep apnea requiring use of a nasal continuous positive airway pressure device during sleep. We performed a computed tomography brain scan, which revealed a left-sided acute on chronic subdural hemorrhage. Due to his multiple comorbidities, we decided to perform the surgical procedure under electroacupuncture anesthesia. The aim of this case report is to describe a craniotomy performed under electroacupuncture on an elderly patient with multiple comorbidities who was awake during the procedure and in whom this procedure, if it had been performed under general anesthesia, would have carried high risk.
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http://dx.doi.org/10.1016/j.jams.2016.06.005DOI Listing
January 2017

Neuropsychological Outcomes in Patients with Complicated Versus Uncomplicated Mild Traumatic Brain Injury: 6-Month Follow-Up.

World Neurosurg 2017 Jan 15;97:416-423. Epub 2016 Oct 15.

Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.

Objective: To compare the extent of persistent neuropsychological impairment in patients with complicated mild traumatic brain injury (mTBI) and those with uncomplicated mTBI.

Methods: Sixty-one patients with mTBI (Glasgow Coma Scale score 13-15) were recruited prospectively, categorized according to baseline computed tomography findings, and subjected to neuropsychological assessment at initial admission (n = 61) as well as at a 6-month follow-up (n = 30). The paired t test, Cohen's d effect size calculation, and repeated-measures analysis of variance were used to establish the differences between the 2 groups in terms of neuropsychological performance.

Results: A trend toward poorer neuropsychological performance among the patients with complicated mTBI was observed during admission; however, performance in this group improved over time. In contrast, the uncomplicated mTBI group showed slower recovery, especially in tasks of memory, visuospatial processing, and executive functions, at follow-up.

Conclusions: Our findings suggest that despite the broad umbrella designation of mTBI, the current classification schemes of injury severity for mild neurotrauma should be revisited. They also raise questions about the clinical relevance of both traumatic focal lesions and the absence of visible traumatic lesions on brain imaging studies in patients with milder forms of head trauma.
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http://dx.doi.org/10.1016/j.wneu.2016.10.041DOI Listing
January 2017

Missense Mutation of Brain Derived Neurotrophic Factor (BDNF) Alters Neurocognitive Performance in Patients with Mild Traumatic Brain Injury: A Longitudinal Study.

PLoS One 2016 20;11(7):e0158838. Epub 2016 Jul 20.

Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia.

The predictability of neurocognitive outcomes in patients with traumatic brain injury is not straightforward. The extent and nature of recovery in patients with mild traumatic brain injury (mTBI) are usually heterogeneous and not substantially explained by the commonly known demographic and injury-related prognostic factors despite having sustained similar injuries or injury severity. Hence, this study evaluated the effects and association of the Brain Derived Neurotrophic Factor (BDNF) missense mutations in relation to neurocognitive performance among patients with mTBI. 48 patients with mTBI were prospectively recruited and MRI scans of the brain were performed within an average 10.1 (SD 4.2) hours post trauma with assessment of their neuropsychological performance post full Glasgow Coma Scale (GCS) recovery. Neurocognitive assessments were repeated again at 6 months follow-up. The paired t-test, Cohen's d effect size and repeated measure ANOVA were performed to delineate statistically significant differences between the groups [wildtype G allele (Val homozygotes) vs. minor A allele (Met carriers)] and their neuropsychological performance across the time point (T1 = baseline/ admission vs. T2 = 6th month follow-up). Minor A allele carriers in this study generally performed more poorly on neuropsychological testing in comparison wildtype G allele group at both time points. Significant mean differences were observed among the wildtype group in the domains of memory (M = -11.44, SD = 10.0, p = .01, d = 1.22), executive function (M = -11.56, SD = 11.7, p = .02, d = 1.05) and overall performance (M = -6.89 SD = 5.3, p = .00, d = 1.39), while the minor A allele carriers showed significant mean differences in the domains of attention (M = -11.0, SD = 13.1, p = .00, d = .86) and overall cognitive performance (M = -5.25, SD = 8.1, p = .01, d = .66).The minor A allele carriers in comparison to the wildtype G allele group, showed considerably lower scores at admission and remained impaired in most domains across the timepoints, although delayed signs of recovery were noted to be significant in the domains attention and overall cognition. In conclusion, the current study has demonstrated the role of the BDNF rs6265 Val66Met polymorphism in influencing specific neurocognitive outcomes in patients with mTBI. Findings were more detrimentally profound among Met allele carriers.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0158838PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4954696PMC
July 2017

A Cost-Effective Delivery System for FloSeal During Endoscopic and Microscopic Brain Surgery.

World Neurosurg 2016 Jun 14;90:492-495. Epub 2016 Mar 14.

Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. Electronic address:

Objective: To share our experience with a new delivery system for the flowable hemostatic matrix, FloSeal, in endoscopic and microscopic skull base surgery.

Methods: We prospectively analyzed the use of FloSeal with a hemostatic delivery system in transnasal endoscopic and microscopic skull base procedures performed at the authors' institution from January 1, 2015, to June 30, 2015. In all cases the number of aliquots was noted for the entire operation, and the total number of FloSeal ampules of 5 mL was also recorded.

Results: Our device allowed controlled application of small amounts (0.5-1 mL) of FloSeal to the site of bleeding. This controlled application resulted not only in increased visibility during its application, but it also reduced the amount of FloSeal required during the procedure. We were able to use 5-10 applications per 5-mL ampule of FloSeal within an individual procedure. No procedure required more than one 5-mL ampule of FloSeal. Therefore, the use of our device results in a reduction of costs. Prior to the use of our device, we were often only able to use 1 vial of 5 ml of material for 1 or 2 applications, especially in transnasal endoscopic procedures when working along a deep corridor.

Conclusions: Our results indicate that our delivery device of FlowSeal can effectively control hemostasis by applying small amounts of FlowSeal to the site of bleeding. This results in increased visibility during hemostasis and a reduction of cost.
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http://dx.doi.org/10.1016/j.wneu.2016.03.018DOI Listing
June 2016

Endoscopic transnasal approach to anterior and middle cranial base lesions.

Neurol India 2015 Sep-Oct;63(5):673-80

Department of Otolaryngology, Faculty of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia.

We present our experience in managing pathologies involving the anterior and middle cranial base using an endoscopic transnasal approach, highlighting the surgical technique, indications, and complications. The different types of endoscopic approaches used include the transtuberculum/transplanum, transcribiform, transsellar, and cavernous sinus approaches. The common indications include repair of cerebrospinal fluid leaks (both spontaneous and post traumatic) and excision of pituitary adenomas, meningiomas, craniopharyngiomas, esthesioneuroblastomas, and other malignancies of the anterior cranial base. Careful reconstruction is performed with the multilayer technique utilizing fat, fascia lata, and fibrin sealant. The endoscopic transnasal approach, coupled with the present-day sophisticated neuronavigation systems, allows access to lesions in the midline extending from the cribriform plate to the craniovertebral junction. However, preoperative planning and careful selection of cases with evaluation of each case on an individual basis with regard to the lateral extension of the lesion are imperative.
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http://dx.doi.org/10.4103/0028-3886.166539DOI Listing
October 2015

Integrated Anterior, Central, and Posterior Skull Base Unit - A New Perspective.

Front Surg 2015 21;2:32. Epub 2015 Jul 21.

Department of Otorhinolaryngology, University Malaya Medical Centre , Kuala Lumpur , Malaysia.

The skull base is one of the most complex anatomical regions and forms the floor of the cranial cavity. Skull base surgery involves open, microscopic, and endoscopic approaches to the anterior, middle, or posterior cranial fossa. A multispecialty team approach is essential in treating patients with skull base lesions. Traditionally, rhinologists are involved in providing access to anterior skull base lesions while otologists are involved in the treatment of lesions of the posterior skull base. This is the case in most skull base centers today. In this article, we share a new perspective of an integrated skull base unit where a team of otolaryngologists and neurosurgeons treat anterior, middle, and posterior skull base pathologies. The rationale for this approach is that most technical skills required in skull base surgery are interchangeable and apply whether an endoscopic or microscopic approach is used. We show how the different skills apply to the different approaches and share our experience with an integrated skull base unit.
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http://dx.doi.org/10.3389/fsurg.2015.00032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4508483PMC
August 2015

Combined endoscopic transnasal and transoral approach for extensive upper cervical osteoradionecrosis.

Eur Spine J 2015 Dec 26;24(12):2776-80. Epub 2015 Jul 26.

Department of Neurosurgery, Faculty of Medicine, University Malaya, Lembah Pantai, 50603, Kuala Lumpur, Malaysia.

Purpose: Osteoradionecrosis (ORN) is a rare yet well-recognized complication following radiotherapy to the head and neck. We illustrate the only case of a spontaneous extrusion of the sequestered C1 arch through the oral cavity and discuss our experience with a combined endoscopic transnasal and transoral approach for cervical ORN.

Methods: A 56-year-old female presented with a 3-month history of blood-stained nasal discharge. She had been treated with radiotherapy for nasopharyngeal carcinoma 25 years earlier. Flexible nasal endoscopy demonstrated an exposed bone with an edematous posterior nasopharyngeal mass. Computed tomography showed a pre-vertebral mass with destruction of C1 and C2. She underwent occipito-cervical fusion followed by a combined transnasal and transoral endoscopic debridement of non-viable bone in the same perioperative setting. Healing of the raw mucosa was by secondary intention and reconstruction was not performed.

Results: Histopathological examination reported ulcerated inflamed granulation tissue with no evidence of malignancy. During follow-up, she remained neurologically intact with no recurrence.

Conclusion: Using both nasal and oral spaces allows placement of the endoscope in the nasal cavity and surgical instruments in the oral cavity without splitting the palate. Hence, the endoscopic transnasal and transoral approach has vast potential to be effective in carefully selected cases of cervical ORN.
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http://dx.doi.org/10.1007/s00586-015-4153-1DOI Listing
December 2015

Diffusion Tensor Imaging Parameters in Mild Traumatic Brain Injury and Its Correlation with Early Neuropsychological Impairment: A Longitudinal Study.

J Neurotrauma 2015 Oct 11;32(19):1497-509. Epub 2015 Jun 11.

2 University Malaya Research Imaging Center, University of Malaya , Kuala Lumpur, Malaysia .

We explored the prognostic value of diffusion tensor imaging (DTI) parameters of selected white matter (WM) tracts in predicting neuropsychological outcome, both at baseline and 6 months later, among well-characterized patients diagnosed with mild traumatic brain injury (mTBI). Sixty-one patients with mTBI (mean age=27.08; standard deviation [SD], 8.55) underwent scanning at an average of 10 h (SD, 4.26) post-trauma along with assessment of their neuropsychological performance at an average of 4.35 h (SD, 7.08) upon full Glasgow Coma Scale recovery. Results were then compared to 19 healthy control participants (mean age=29.05; SD, 5.84), both in the acute stage and 6 months post-trauma. DTI and neuropsychological measures between acute and chronic phases were compared, and significant differences emerged. Specifically, chronic-phase fractional anisotropy and radial diffusivity values showed significant group differences in the corona radiata, anterior limb of internal capsule, cingulum, superior longitudinal fasciculus, optic radiation, and genu of corpus callosum. Findings also demonstrated associations between DTI indices and neuropsychological outcome across two time points. Our results provide new evidence for the use of DTI as an imaging biomarker and indicator of WM damage occurring in the context of mTBI, and they underscore the dynamic nature of brain injury and possible biological basis of chronic neurocognitive alterations.
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http://dx.doi.org/10.1089/neu.2014.3750DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4589266PMC
October 2015

Combined transnasal and transoral endoscopic approach to a transsphenoidal encephalocele in an infant.

Childs Nerv Syst 2015 Jul 25;31(7):1165-9. Epub 2015 Feb 25.

Department of Otolaryngology, Faculty of Medicine, University Malaya, Lembah Pantai, 50603, Kuala Lumpur, Malaysia,

Purpose: This paper reports an unusual case of a transsphenoidal encephalocele and discusses our experience with a minimally invasive management. To the best of our knowledge, we present the first case of a combined endoscopic transnasal and transoral approach to a transsphenoidal encephalocele in an infant.

Methods: A 17-day-old boy, who was referred for further assessment of upper airway obstruction, presented with respiratory distress and feeding difficulties. Bronchoscopy and imaging revealed a transsphenoidal encephalocele. At the age of 48 days, he underwent a combined endoscopic transnasal and transoral excision of the nasal component of the encephalocele. This approach, with the aid of neuronavigation, allows good demarcation of the extra-cranial neck of the transsphenoidal encephalocele. We were able to cauterize and carefully dissect the sac prior to excision. The defect of the neck was clearly visualized, and Valsalva manoeuvre was performed to exclude any CSF leak. As the defect was small, it was allowed to heal by secondary intention.

Results: The patient's recovery was uneventful, and he tolerated full feeds orally on day 2. Postoperative imaging demonstrated no evidence of recurrence of the nasal encephalocele. Endoscopic follow-up showed good healing of the mucosa and no cerebrospinal fluid leak.

Conclusions: The surgical management of transsphenoidal encephalocele in neonates and infants is challenging. We describe a safe technique with low morbidity in managing such a condition. The combined endoscopic transnasal and transoral approach with neuronavigation is a minimally invasive, safe and feasible alternative, even for children below 1 year of age.
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http://dx.doi.org/10.1007/s00381-015-2667-9DOI Listing
July 2015

Neurosurgical endoscopic training via a realistic 3-dimensional model with pathology.

Simul Healthc 2015 Feb;10(1):43-8

From the Division of Neurosurgery (V.W., V.N., R.K., H.C.T., K.A.M.), Faculty of Medicine, and Department of Maxillofacial Surgery (Z.A.A.R.), Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia; and Department of Neurosurgery (R.W.K.), Addenbrookes Hospital, Cambridge University NHS Trust, Cambridge, United Kingdom.

Introduction: Training in intraventricular endoscopy is particularly challenging because the volume of cases is relatively small and the techniques involved are unlike those usually used in conventional neurosurgery. Present training models are inadequate for various reasons. Using 3-dimensional (3D) printing techniques, models with pathology can be created using actual patient's imaging data. This technical article introduces a new training model based on a patient with hydrocephalus secondary to a pineal tumour, enabling the models to be used to simulate third ventriculostomies and pineal biopsies.

Methods: Multiple models of the head of a patient with hydrocephalus were created using 3D rapid prototyping technique. These models were modified to allow for a fluid-filled ventricular system under appropriate tension. The models were qualitatively assessed in the various steps involved in an endoscopic third ventriculostomy and intraventricular biopsy procedure, initially by 3 independent neurosurgeons and subsequently by 12 participants of an intraventricular endoscopy workshop.

Results: All 3 surgeons agreed on the ease and usefulness of these models in the teaching of endoscopic third ventriculostomy, performing endoscopic biopsies, and the integration of navigation to ventriculoscopy. Their overall score for the ventricular model realism was above average. The 12 participants of the intraventricular endoscopy workshop averaged between a score of 4.0 to 4.6 of 5 for every individual step of the procedure.

Discussion: Neurosurgical endoscopic training currently is a long process of stepwise training. These 3D printed models provide a realistic simulation environment for a neuroendoscopy procedure that allows safe and effective teaching of navigation and endoscopy in a standardized and repetitive fashion.
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http://dx.doi.org/10.1097/SIH.0000000000000060DOI Listing
February 2015

Endoscopic skull base training using 3D printed models with pre-existing pathology.

Eur Arch Otorhinolaryngol 2015 Mar 8;272(3):753-7. Epub 2014 Oct 8.

Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia,

Endoscopic base of skull surgery has been growing in acceptance in the recent past due to improvements in visualisation and micro instrumentation as well as the surgical maturing of early endoscopic skull base practitioners. Unfortunately, these demanding procedures have a steep learning curve. A physical simulation that is able to reproduce the complex anatomy of the anterior skull base provides very useful means of learning the necessary skills in a safe and effective environment. This paper aims to assess the ease of learning endoscopic skull base exposure and drilling techniques using an anatomically accurate physical model with a pre-existing pathology (i.e., basilar invagination) created from actual patient data. Five models of a patient with platy-basia and basilar invagination were created from the original MRI and CT imaging data of a patient. The models were used as part of a training workshop for ENT surgeons with varying degrees of experience in endoscopic base of skull surgery, from trainees to experienced consultants. The surgeons were given a list of key steps to achieve in exposing and drilling the skull base using the simulation model. They were then asked to list the level of difficulty of learning these steps using the model. The participants found the models suitable for learning registration, navigation and skull base drilling techniques. All participants also found the deep structures to be accurately represented spatially as confirmed by the navigation system. These models allow structured simulation to be conducted in a workshop environment where surgeons and trainees can practice to perform complex procedures in a controlled fashion under the supervision of experts.
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http://dx.doi.org/10.1007/s00405-014-3300-3DOI Listing
March 2015

A minimally invasive endoscopic transnasal approach to the craniovertebral junction in the paediatric population.

Eur Arch Otorhinolaryngol 2014 Nov 2;271(11):3101-5. Epub 2014 Jul 2.

Department of Otolaryngology, Faculty of Medicine, University Malaya, Lembah Pantai, 50603, Kuala Lumpur, Malaysia,

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http://dx.doi.org/10.1007/s00405-014-3149-5DOI Listing
November 2014

Injecting realism in surgical training-initial simulation experience with custom 3D models.

J Surg Educ 2014 Mar-Apr;71(2):193-7. Epub 2013 Nov 22.

Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom.

Unlabelled: The traditionally accepted form of training is direct supervision by an expert; however, modern trends in medicine have made this progressively more difficult to achieve. A 3-dimensional printer makes it possible to convert patients imaging data into accurate models, thus allowing the possibility to reproduce models with pathology. This enables a large number of trainees to be trained simultaneously using realistic models simulating actual neurosurgical procedures. The aim of this study was to assess the usefulness of these models in training surgeons to perform standard procedures that require complex techniques and equipment.

Methods: Multiple models of the head of a patient with a deep-seated small thalamic lesion were created based on his computed tomography and magnetic resonance imaging data. A workshop was conducted using these models of the head as a teaching tool. The surgical trainees were assessed for successful performance of the procedure as well as the duration of time and number of attempts taken to learn them.

Findings: All surgical candidates were able to learn the basics of the surgical procedure taught in the workshop. The number of attempts and time taken reflected the seniority and previous experience of each candidate.

Discussion: Surgical trainees need multiple attempts to learn essential procedures. The use of these models for surgical-training simulation allows trainees to practice these procedures repetitively in a safe environment until they can master it. This would theoretically shorten the learning curve while standardizing teaching and assessment techniques of these trainees.
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http://dx.doi.org/10.1016/j.jsurg.2013.08.010DOI Listing
November 2014

Utility of multimaterial 3D printers in creating models with pathological entities to enhance the training experience of neurosurgeons.

J Neurosurg 2014 Feb 10;120(2):489-92. Epub 2013 Dec 10.

Division of Neurosurgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia;

The advent of multimaterial 3D printers allows the creation of neurosurgical models of a more realistic nature, mimicking real tissues. The authors used the latest generation of 3D printer to create a model, with an inbuilt pathological entity, of varying consistency and density. Using this model the authors were able to take trainees through the basic steps, from navigation and planning of skin flap to performing initial steps in a craniotomy and simple tumor excision. As the technology advances, models of this nature may be able to supplement the training of neurosurgeons in a simulated operating theater environment, thus improving the training experience.
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http://dx.doi.org/10.3171/2013.11.JNS131066DOI Listing
February 2014

Intrasellar pituitary mucocele: diagnostic dilemma.

Br J Neurosurg 2014 Jun 22;28(3):390-2. Epub 2013 Jul 22.

Department of ORL-HNS, Faculty of Medicine, University Malaysia Sarawak , Sarawak , Malaysia.

Isolated intrasellar pituitary mucocele following transsphenoidal sinus surgery is extremely rare. The clinical features resemble a pituitary tumor, therefore careful radiological interpretation is crucial to reach the correct diagnosis. We report a case of intrasellar mucocele who had transsphenoidal sinus surgery performed 15 years prior.
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http://dx.doi.org/10.3109/02688697.2013.817535DOI Listing
June 2014

A new modified speculum guided single nostril technique for endoscopic transnasal transsphenoidal surgery: an analysis of nasal complications.

Br J Neurosurg 2013 Dec 7;27(6):742-6. Epub 2013 May 7.

Department of Neurosurgery, Faculty of Medicine, University of Malaya , Kuala Lumpur , Malaysia.

Abstract The endoscopic transnasal, transsphenoidal surgical technique for pituitary tumour excision has generally been regarded as a less invasive technique, ranging from single nostril to dual nostril techniques. We propose a single nostril technique using a modified nasal speculum as a preferred technique. We initially reviewed 25 patients who underwent pituitary tumour excision, via endoscopic transnasal transsphenoidal surgery, using this new modified speculum-guided single nostril technique. The results show shorter operation time with reduced intra- and post-operative nasal soft tissue injuries and complications.
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http://dx.doi.org/10.3109/02688697.2013.791667DOI Listing
December 2013

The creation and verification of cranial models using three-dimensional rapid prototyping technology in field of transnasal sphenoid endoscopy.

Am J Rhinol Allergy 2012 Sep-Oct;26(5):e132-6

Division of Neurosurgery, University of Malaya, Lembah Pantai, Kuala Lumpur, Malaysia.

Background: Surgical navigation systems have been used increasingly in guiding complex ear, nose, and throat surgery. Although these are helpful, they are only beneficial intraoperatively; thus, the novice surgeon will not have the preoperative training or exposure that can be vital in complex procedures. In addition, there is a lack of reliable models to give surgeons hands-on training in performing such procedures.

Methods: A technique using an industrial rapid prototyping process by three-dimensional (3D) printing was developed, from which accurate spatial models of the nasal cavity, paranasal sinuses (sphenoid sinus in particular), and intrasellar/pituitary pathology were produced, according to the parameters of an individual patient. Image-guided surgical (IGS) techniques on two different platforms were used during endoscopic transsphenoidal surgery to test and validate the anatomical accuracy of the sinus models by comparing the models with radiological images of the patient on IGS.

Results: It was possible to register, validate, and navigate accurately on these models using commonly available navigation stations, matching accurately the anatomy of the model to the IGS images.

Conclusion: These 3D models can be reliably used for teaching/training and preoperative planning purposes.
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http://dx.doi.org/10.2500/ajra.2012.26.3808DOI Listing
May 2013

Mural nodules in multiple cavernous haemangioma.

Clin Neurol Neurosurg 2013 Jul 30;115(7):1150-3. Epub 2012 Sep 30.

Department of Biomedical Imaging, University Malaya Research Imaging Centre, University of Malaya, Malaysia.

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http://dx.doi.org/10.1016/j.clineuro.2012.09.014DOI Listing
July 2013

The creation and verification of cranial models using three-dimensional rapid prototyping technology in field of transnasal sphenoid endoscopy.

Am J Rhinol Allergy 2012 Sep;26(5):132-136

Division of Neurosurgery, University of Malaya, Lembah Pantai, Kuala Lumpur, Malaysia.

Background: Surgical navigation systems have been used increasingly in guiding complex ear, nose, and throat surgery. Although these are helpful, they are only beneficial intraoperatively; thus, the novice surgeon will not have the preoperative training or exposure that can be vital in complex procedures. In addition, there is a lack of reliable models to give surgeons hands-on training in performing such procedures.

Methods: A technique using an industrial rapid prototyping process by three-dimensional (3D) printing was developed, from which accurate spatial models of the nasal cavity, paranasal sinuses (sphenoid sinus in particular), and intrasellar/pituitary pathology were produced, according to the parameters of an individual patient. Image-guided surgical (IGS) techniques on two different platforms were used during endoscopic transsphenoidal surgery to test and validate the anatomical accuracy of the sinus models by comparing the models with radiological images of the patient on IGS.

Results: It was possible to register, validate, and navigate accurately on these models using commonly available navigation stations, matching accurately the anatomy of the model to the IGS images.

Conclusion: These 3D models can be reliably used for teaching/training and preoperative planning purposes.
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http://dx.doi.org/10.2500/ajra.2012.26.3808DOI Listing
September 2012
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