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Health-related quality of life measurements, are commonly used to quantify burden of disease, to evaluate treatment method, and to facilitate benchmarking. The aim of the current study was to determine the Clinically Important Difference (CID) for a Chinese version of Stroke-specific Quality of Life (SS-QOL) in an aneurysmal subarachnoid hemorrhage (SAH) patient cohort. The study recruited SAH patients in a neurosurgical unit in Hong Kong. SAH patients who completed both 3-month and 1-year assessments were included in the analysis. The study received ethical approvals from the joint CUHK-NTEC Clinical Ethics Committee and written informed consent was obtained from all participants or their next of kins. Over a 2-year period, 65 eligible patients were included in the study. Employing the anchor-based approach with global rating of change, the CID estimate of SS-QOL total score was 4.7 (95% confidence interval [CI]: 2.5-5.3), the CID estimate for SSQOL physical subscore was 2.1 (95% CI: 0.3-2.4), and the CID estimate for SS-QOL psychosocial subscore change was 2.8 (95% CI: 1.8-3.7). In conclusion, our study defined the CID for SS-QOL applied to SAH patients and should be further validated in another SAH patient population., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objectives: Experimental evidence has indicated the benefit of simvastatin in the treatment of subarachnoid hemorrhage (SAH). Recently, acute simvastatin treatment was not shown to be beneficial in neurological outcome using modified Rankin Scale. Cognitive function is another important dimension of outcome assessment and yet had not been investigated in statin studies for aneurysmal subarachnoid hemorrhage. We therefore explored whether acute simvastatin treatment would improve cognitive outcomes., Methods: The study recruited SAH patients with acute simvastatin treatment enrolled in a randomized controlled double-blinded clinical trial (ClinicalTrials.gov Identifier: NCT01038193). A control cohort of SAH patients without simvastatin treatment was identified with propensity score matching of age and admission grade. Primary outcome measure was Montreal Cognitive Assessment (MoCA). Secondary outcome measures were delayed ischaemic deficit (DID), delayed cerebral infarction, modified Rankin Scale (mRS), and Mini-Mental State Examination (MMSE)., Results: Fifty-one SAH patients with acute simvastatin treatment and 51 SAH patients without simvastatin treatment were recruited for analysis. At 3 months, there were no differences in MoCA scores (MoCA: 21+/-6 vs. 21+/-5, p=0.772). MoCA-assessed cognitive impairment (MoCA<26) was not different (75% vs. 80%, OR 0.7, 95%CI 0.3 to 1.8, p=0.477). There were also no differences in DID, delayed cerebral infarction, favorable mRS outcome, and MMSE scores, and MMSE-assessed cognitive impairment between both groups., Conclusions: The current study does not support that acute simvastatin treatment improves cognitive outcome after aneurysmal subarachnoid hemorrhage., (Copyright © 2015 Elsevier B.V. All rights reserved.)

We report a case of spontaneous intracranial hypotension with classic symptoms of orthostatic headache and acute presentation of subdural haematoma on computed tomographic scan. Conventional approach with conservative treatment was initially adopted. The patient's condition, however, deteriorated after 2 weeks, requiring surgical evacuation of the intracranial haemorrhage. We reviewed the clinical features of this disease and the correlated magnetic resonance imaging findings with the pathophysiological mechanisms, and described treatment strategies in the local setting. Subtle findings on initial computed tomographic scan are also reported which might improve pathology recognition. Spontaneous intracranial hypotension is not uncommonly encountered in Hong Kong, and physicians must adopt a high level of clinical suspicion to facilitate early diagnosis and appropriate management. In addition, novel therapeutic approaches may be required in those with recurrent symptoms or who are refractory to current treatment strategies.

Objectives: The role of serum α-fetoprotein (AFP) measurements in the diagnosis of hepatocellular carcinoma (HCC) remains controversial. Some guidelines have advised against the use of AFP in the diagnosis of HCC. This study was conducted to evaluate the performance of AFP in the diagnosis of HCC, and to identify the optimal cut-off value of serum AFP in the diagnosis of HCC in patients with a hepatic mass., Methods: Patients who presented during the period from May 1997 to March 2003 with hepatic lesions, for whom paired data on serum AFP values at baseline and lesion histology were available, were reviewed. The performance of AFP in the diagnosis of HCC was determined using receiver operating characteristic curve analysis., Results: Data for a total of 805 patients were evaluated. The mean AFP value was 26,900 ng/ml (range: 0-1,965,461 ng/ml). The histological diagnosis was HCC in 557 patients. The optimal AFP cut-off value was 10 ng/ml (for sensitivity of 82.6% and specificity of 70.4%). At a cut-off level of 200 ng/ml, sensitivity, specificity, and positive and negative predictive values were 47.7%, 97.1%, 97.5% and 44.4%, respectively. The diagnostic performance of AFP remains similar in patients with chronic hepatitis B virus infection, despite a lower negative predictive value. Common aetiologies of liver lesions associated with elevated AFP include cholangiocarcinoma and neuroendocrine tumours., Conclusions: In Asian patients with suspicious liver lesions, the cut-off AFP level of 200 ng/ml is useful to achieve a diagnosis of HCC with high specificity and reasonable sensitivity. The measurement of serum AFP should not be excluded from guidelines for the diagnosis of HCC., (© 2013 International Hepato-Pancreato-Biliary Association.)

Aim: To compare the risk of postoperative haemorrhage with different sizes of brain biopsy needles., Patients and Method: A cohort of patients using a 2.5-mm outer diameter side-cutting biopsy needle was compared to a subsequent cohort using a 1.8-mm needle of the same type. All data were collected prospectively. A CT scan was done within 12 h after surgery. Any visible haemorrhage at the operated site was documented., Results: From 2007 to 2013, 54 stereotactic brain biopsies (all frameless except for one frame-based) were performed. The 2.5-mm group comprised 29 procedures from 2007 to 2009. The 1.8-mm group comprised the subsequent 25 procedures. The diagnostic yields were 90 and 96% in the 2.5- and the 1.8-mm group, respectively (p = 0.615). Comparing the 2.5- and the 1.8-mm group, haemorrhage was significantly reduced: incidence (72 vs. 40%, p = 0.016); size of haemorrhage (mean 7.2 vs. 2.6 mm, p = 0.002); proportion of haemorrhage size >10 mm (34.5 vs. 4%, p = 0.006). Symptomatic haemorrhage rates were 3.4 and 0.0% in the 2.5- and the 1.8-mm group, respectively (p = 1.00)., Conclusion: The 1.8-mm outer diameter needle carried a lower risk of postoperative haemorrhage than the 2.5-mm one, without compromising the diagnostic yield.

Objectives: To assess the outcome of acute ischaemic stroke patients who received intra-arterial therapy in our unit., Design: Case series., Setting: A tertiary hospital in Hong Kong., Patients: Patients with ischaemic stroke due to large artery occlusion treated within 6 hours from symptom onset between January 2007 and May 2011., Intervention: Acute intra-arterial revascularisation therapy., Main Outcome Measures: Primary outcome was functional independence (modified Rankin Scale score of ≤ 2) at 3 months. Secondary outcome was rate of recanalisation. Safety outcomes were symptomatic intracranial haemorrhage and 3-month mortality., Results: Twenty-one patients with a mean age of 67 years fulfilled the inclusion criteria. Their mean National Institutes of Health Stroke Scale score was 18. The mean onset-to-puncture time was 212 minutes. Nine received intra-arterial tissue plasminogen activator alone, 11 had an adjunctive mechanical thrombectomy, and one received balloon angioplasty without tissue plasminogen activator. At the end of the procedure, thrombolysis grade 2a or better was attained in 18 (86%) of the patients, and 8 (38%) achieved functional independence at 3 months. Rates of symptomatic intracranial haemorrhage and 3-month mortality were 10% and 24%, respectively., Conclusion: In this setting, intra-arterial revascularisation therapy appeared safe and efficacious for this selected group of ischaemic stroke patients with large artery occlusions. Experience gained from this pilot study may help improve clinical outcomes of such patients.

We here presented a rare disease entity with a clinical presentation mimicking aneurysmal subarachnoid haemorrhage. A 43-year-old woman presented with a 1-week history of neck pain and dizziness. Computed tomography of brain showed communicating hydrocephalus and subarachnoid hyperintensity suspicious of previous subarachnoid haemorrhage. Investigations revealed no underlying vascular lesion and leptomeningeal biopsy showed diffuse melanocytosis. We go on to discuss the diagnostic features and clinical course of this entity.

Objectives: To investigate the frequency of pseudoprogression of glioblastoma in Chinese patients receiving concomitant chemoradiotherapy and investigate its association with pseudoprogression and tumour molecular marker O(6)-methylguanine-DNA methyltransferase promoter methylation status., Design: Case series with internal comparisons., Setting: University teaching hospital, Hong Kong., Patients: Patients with glioblastoma treated with concomitant chemoradiotherapy during April 2005 to June 2010 were reviewed. Magnetic resonance imaging brain scans, pre- and post-concomitant chemoradiotherapy and 3-monthly thereafter were reviewed by an independent neuroradiologist according to Macdonald's criteria. Relevant patient information (clinical condition, performance score, development of new neurological deficits, use of steroids, and survival) was retrieved. For each patient, O(6)-methylguanine-DNA methyltransferase methylation status was investigated with genomic DNA from formalin-fixed or paraffin-embedded sections of tumour tissues by methylation-specific polymerase chain reaction., Results: During the study period, 28 primary glioblastoma patients underwent concomitant chemoradiotherapy. The mean age of the patients was 48 (range, 16-71) years. Thirteen patients (13/28, 46%) developed early radiological progression of the tumour after completion of concomitant chemoradiotherapy, of whom five (39%) were subsequently found to have had pseudoprogression. Patients with pseudoprogression showed a trend towards longer survival (22 months in pseudoprogression vs 17 months in all others vs 11 months in those with genuine progression). Among the 27 patients tested for O(6)-methylguanine-DNA methyltransferase promoter status, 12 (44%) were methylated. Two (2/12, 17%) in the methylated group had pseudoprogression, while three (3/15, 20%) in the unmethylated group had pseudoprogression., Conclusions: Nearly half of all patients (46%) developed early radiological progression (within 3 months of completing concomitant chemoradiotherapy). Moreover, about one in three of such patients had pseudoprogression. Pseudoprogression is an important clinical condition to be aware of to prevent premature termination of an effective treatment.

Objective: To investigate the safety and efficacy of stroke thrombolysis in a local hospital., Design: Historical cohort study., Setting: A tertiary hospital in Hong Kong., Patients: The outcome of acute ischaemic stroke patients treated with intravenous tissue plasminogen activator between October 2008 and May 2011 was compared to those admitted during the same period who were thrombolysis-eligible, but treated conservatively due to unavailability of the thrombolysis service after-hours., Interventions: Intravenous tissue plasminogen activator., Main Outcome Measures: Primary outcome was functional independence (modified Rankin Scale score of 2 or below) at 3 months. Safety outcomes were symptomatic intracranial haemorrhage and 3-month mortality. Secondary outcomes were hospital length of stay, direct home discharge, and nursing home discharge., Results: A total of 48 thrombolysis and 63 non-thrombolysis patients were identified. Fifty-two percent of the thrombolysis group achieved functional independence compared to 24% of non-thrombolysis group (P=0.003), without significant increase in mortality (15% vs 13%, P=0.51) or symptomatic intracranial haemorrhage (4% vs 2%, P=0.58). Twenty-nine percent of the thrombolysis group patients were discharged home directly, versus 6% of non-thrombolysis group (P<0.001). Mean length of stay was shorter for the thrombolysis group (25 vs 35 days; P=0.034). A similar percentage from each group was discharged to nursing homes., Conclusion: Implementation of the stroke thrombolysis service in Hong Kong appeared safe and efficacious. Patients who received thrombolysis had better outcomes compared to non-thrombolysis cohort. Further studies are needed to investigate the economics of stroke thrombolysis in Hong Kong, which may help to improve funding for provision of this service.

Objectives: (1) To compare the survival of concomitant chemotherapy and radiotherapy with radiotherapy alone in Chinese patients with primary glioblastoma. (2) To determine the methylation status of O(6)Methylguanine DNA methyltransferase in Chinese primary glioblastoma, and to assess the prognostic value of O(6)Methylguanine DNA methyltransferase methylation status in such patients., Design: Retrospective correlative analysis., Setting: University teaching hospital, Hong Kong., Patients: Patients diagnosed with histologically proven primary glioblastoma in the period of March 2005 to June 2007 were recruited. Genomic DNA was isolated from formalin-fixed and paraffin-embedded sections of glioblastoma tissues. Methylation-specific polymerase chain reaction for O(6)Methylguanine DNA methyltransferase was performed. Patients' information at presentation was collected (age, performance status, steroid use, extent of resection, complications, radiotherapy data, use of chemotherapy). Primary outcome was measured by overall survival while secondary outcome was measured by progression-free survival. Overall and progression-free survivals were estimated by the Kaplan-Meier technique. Outcomes were assessed for groups with and without concomitant chemoradiotherapy and for groups with and without O(6)Methylguanine DNA methyltransferase methylation., Results: A total of 35 glioblastoma patients were recruited; 27 were male and 8 female. Their mean age was 50 years. In all, 17 received concomitant chemoradiotherapy, and 18 received radiotherapy only. Their median overall survival was 12 (range, 7-17) months and the median progression-free survival was 5 (range, 3-6) months. In the radiotherapy alone group, the median progression-free survival and overall survival was 4 (range, 3-5) months and 6 (range, 2-10) months, respectively. In the concomitant radiochemotherapy group, the median progression-free survival and overall survival was 6 (range, 2-10) months and 13 (range, 8-18) months, respectively. Fifteen (43%) of the tumour samples showed methylation of O(6)Methylguanine DNA methyltransferase. There was a trend towards overall longer survival in the group with methylated tumours compared to those with unmethylated tumours; respective values for median survival (ranges) were 17 (13-21) versus 10 (6-14) months (P=0.105)., Conclusions: Our single-centre results indicated that Chinese glioblastoma patients who had received concomitant chemoradiotherapy showed a trend towards longer overall survival compared to those receiving radiotherapy alone. Approximately 43% of our Chinese glioblastoma samples showed methylation of O(6)Methylguanine DNA methyltransferase. O(6)Methylguanine DNA methyltransferase methylation may be a significant prognostic factor in Chinese glioblastoma patients.

To exclude underlying vascular abnormalities in patients with spontaneous intracerebral hemorrhage, the traditional paradigm requires investigation using digital subtraction angiography (DSA) in both the acute and subacute phases. We investigated whether MRI and magnetic resonance angiography (MRA), in the subacute stage of intracerebral hematoma, had high positive predictive values (PPV) and negative predictive values (NPV) in screening for vascular abnormality in the routine clinical setting. In a regional neurosurgical center in Hong Kong, we retrospectively reviewed 151 patients investigated with both MRI and DSA for underlying structural vascular abnormalities during the subacute phase. Sensitivity, specificity, and intermodality agreement were assessed. A total of 70/151 (46%) vascular lesions accountable for the hemorrhage were found. Patients with vascular abnormalities tended to be younger (mean age+/-standard deviation [SD], 33+/-15years), less likely to be hypertensive (6.3%), and the lesion was more likely to be accompanied by intraventricular hemorrhage (22%). In terms of cerebral arteriovenous malformation and dural arteriovenous fistulas, MRI/MRA had a PPV of 0.98 and a NPV of 1.00. We concluded that MRI/MRA was able to detect most structural vascular abnormalities in the subacute phase in most patients and, thus, its use is recommended as the screening test.