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Fulltext Complex Proximal Humeral Fracture Fixation with PHILOS Plate using Minimal Invasive Percutaneous Plate Osteosynthesis (MIPPO) Technique: A Series of 30 Patients

Narayanan VL, Balasubramanian N

Malays Orthop J, 2018 Jul;12(2):20-24.
PMID: 30112124 DOI: 10.5704/MOJ.1807.004

Introduction: Proximal humerus fracture fixation using plate osteosynthesis depends on the quality of the bone, design of the fixation devices and intra-operative soft tissue dissection. This study evaluates the functional outcome of minimally invasive percutaneous plate osteosynthesis using locking compression plate in proximal humerus fracture treatment. Materials and Methods: The study was conducted on 30 patients with complex proximal humerus fractures treated by minimally invasive percutaneous plate osteosynthesis using locking compression plate (PHILOS). There were 21 males and 9 females. The average age of our study group was 58.8 years. All the patients were evaluated at six weeks, three months, four months, six months and 12 months following surgery. Results: All patients had fracture union at an average of 13.2 weeks. The mean DASH score at the follow-up was 8.69 (2.5 to 17.16), the average range of flexion was 143.83 degrees (100 to 170 degrees) and abduction was 121.49 degrees (90 to 160 degrees). We had superficial infection in three patients which resolved with a short course of antibiotics. There was excellent outcome in 26 patients, good and fair in two patients each. Conclusion: Proximal humerus fractures treated with minimally invasive percutaneous plate osteosynthesis using locking compression plate with minimal soft tissue dissection, provides good functional outcome and early return of shoulder function.
A Cost-Effective Delivery System for FloSeal During Endoscopic and Microscopic Brain Surgery

Brand Y, Narayanan V, Prepageran N, Waran V

World Neurosurg, 2016 Jun;90:492-495.
PMID: 26987637 DOI: 10.1016/j.wneu.2016.03.018

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.
Fulltext Cerebral white matter microstructural changes in isolated maxillofacial trauma and associated neuropsychological outcomes

Sreedharan S, Veeramuthu V, Hariri F, Hamzah N, Ramli N, Narayanan V

Int J Oral Maxillofac Surg, 2020 Sep;49(9):1183-1192.
PMID: 32224001 DOI: 10.1016/j.ijom.2020.03.002

Isolated traumatic maxillofacial injury without concomitant brain injury may cause delayed post-concussive symptoms. Early identification allows optimal diagnosis, prognostication, and therapeutic intervention. The aim of this prospective observational study was to investigate longitudinal microstructural changes of the white matter (WM) tracts based on diffusion tensor imaging (DTI) indices in patients with isolated maxillofacial injuries, immediately and 6 months post-trauma, and to correlate these DTI indices with neuropsychological changes observed. Twenty-one patients with isolated maxillofacial injuries and 21 age-matched controls were recruited. DTI was performed and indices were calculated for 50 WM tracts. The neuropsychological evaluation was done using the screening module of the Neuropsychological Assessment Battery. Patients were subjected to repeat DTI and neuropsychological evaluation at 6 months post-trauma. Reduced fractional anisotropy (FA) and increased median (MD) and radial diffusivity (RD) in the acute phase were seen in major association, projection, and commissural fibre bundles, indicative of vasogenic oedema. These changes correlated with attention and executive function deficits in the acute phase, as well as improvement in memory and visuospatial function in the chronic phase. Isolated maxillofacial trauma patients develop WM microstructural damage, which may impair cognitive performance acutely and over time. DTI indices can serve as predictive imaging biomarkers for long-term cognitive deficits in isolated maxillofacial injuries.
Knowledge, attitude, and practices of operating theatre staff towards environmentally sustainable practices in the operating theatres

Lim BLS, Narayanan V, Nah SA

Pediatr Surg Int, 2023 Mar 17;39(1):152.
PMID: 36930355 DOI: 10.1007/s00383-023-05400-6

BACKGROUND: Successful implementation of environmentally sustainable practices in the operating theatre (OT) requires stakeholder engagement. We evaluate the knowledge, attitudes, and practices of OT users in our institution towards sustainable practices in the OT.
METHODS: A survey was conducted among OT users in August 2022. Respondents completed a 44-question anonymised online survey covering sustainability in (1) knowledge, (2) attitude, (3) practice, and (4) proposed changes to current practices. Points were assigned to knowledge (15 points) and attitude (40 points) sections. Practice was evaluated based on proportion of measures practiced. Appropriate statistical tests were used, with significance p
Utility of multimaterial 3D printers in creating models with pathological entities to enhance the training experience of neurosurgeons

Waran V, Narayanan V, Karuppiah R, Owen SL, Aziz T

J. Neurosurg., 2014 Feb;120(2):489-92.
PMID: 24321044 DOI: 10.3171/2013.11.JNS131066

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.
Pattern of tissue expression of CA-125 and HE4 in primary epithelial ovarian tumours and correlation with serum CA-125 levels

Devan SM, Pailoor J, Sthaneshwar P, Narayanan V

Asian Pac J Cancer Prev, 2013;14(8):4545-8.
PMID: 24083699

The objective of this study is to assess tissue expression of CA-125 and HE4 protein in primary benign and malignant epithelial tumours of the ovary and correlate with serum CA-125 levels. A total of 100 formalin-fixed, paraffin embedded sections of ovarian tumours which included serous adenoma (11), mucinous adenoma (42), serous carcinoma (20), mucinous carcinoma (12) and endometrioid carcinoma (15), histologically diagnosed between 1st January 2004 to 31st December 2012 at the University Malaya Medical Centre, were stained for HE4 (rabbit polyclonal antibody, Abcam, UK) and CA-125 (mouse monoclonal antibody clone: OC125, Cell Marque Corporation, Rocklin, California, USA). Pre-operative serum CA-125 levels were obtained from the laboratory information system. Immunoscore (I score) for HE4 and CA-125 was given based on the intensity of staining and percentage of positive tumour cells and considered significant when it was >50 (intensity of staining multiplied by percentage of positive tumour cells). Serum CA-125 levels were compared with the I score of HE4 and CA-125 in tissues. We noted that the CA-125 levels in serum and tissues were significantly raised in malignant compared to benign ovarian tumours (p value<0.05). Tissue expression of HE4 protein was also significantly raised in malignant tumours compared to benign tumours (p value<0.05). We conclude that HE4 can be a useful tissue immunomarker in addition to CA-125.
Single Port Endoscope-Assisted Excision of Forehead Lesions: An Innovative Way of Improving the Optical Cavity

Narayanan V, Jayapalan RR, Singh Sidhu A, Koh KMR

J Craniofac Surg, 2019 2 27;30(3):841-842.
PMID: 30807473 DOI: 10.1097/SCS.0000000000005185

Exophytic lesions involving the face present with an undesirable esthetic deformity and usually necessitate surgical excision. Conventional open excision techniques may lead to scar formation or pigmentation issues postoperatively. Minimally invasive endoscope-assisted surgery will be able to overcome these problems. However, this technique is not widely used because of the limited optical cavity working space, which hinders good visualization. We describe a technique to improve the optical cavity workspace to enable adequate endoscope-assisted surgical excision of forehead lesions in 2 cases. Foley's catheter and ribbon gauze were used in both cases to gain optical cavity workspace. The surgical technique is described in detail. One case had a frontal osteoma, whereas other was a nodular fasciitis of the forehead, confirmed by histology. Postoperative follow-up showed good outcomes at 1 year with no recurrences. Both patients were satisfied with the surgical and cosmetic outcomes. Endoscopic excision of a forehead lesion using the described technique is both safe and reliable. It is an excellent method for excising benign growths over the forehead while being cosmetically acceptable.
The effectiveness of handout assisted versus verbal consent on post-operative recall and understanding - A randomized control study

Koong JK, Rajandram R, Sidambram N, Narayanan V

Surgeon, 2021 May 08.
PMID: 33975807 DOI: 10.1016/j.surge.2021.04.002

BACKGROUND: Consent is an important component of surgical care. Poorly attempted consent bears significant ethical and legal implications. We assessed the effectiveness of handouts in improving postoperative consent understanding and recall compared to standard verbal consent during laparoscopic cholecystectomy as a tool that may improve information retention and leads to better treatment satisfaction.
METHODS: This is a prospective block randomized, non-blinded study conducted at a single tertiary hospital. Patients undergoing elective laparoscopic cholecystectomy between August 2017 and October 2018 were recruited and randomized into Handout Assisted Consent (HC) and Verbal Consent (VC) group. The HC group was given an adjunct handout on laparoscopic cholecystectomy during consent process in addition to the standard verbal consent. A validated open-ended verbal understanding and recall questionnaire was administered to all patients in both groups at Day 1, 30 and 90 after surgery. Patient satisfaction of the consent process was evaluated with Likert scale.
RESULTS: A total of 79 patients were enrolled, 41 patients and 38 patients in VC and HC groups respectively. Level of understanding among patients were equal and consistent across time in both groups (P > 0.05). There was significant decline (P 0.05).
CONCLUSION: There is good consistent understanding of the surgery in both groups. However, recall of specific surgical consent items decreased significantly over time in both groups. Handouts may have increased satisfaction among patients but did not improve recall in this preliminary study.
TRIAL REGISTRATION: MREC No.:201783-5468.
Frequency and Causes of Line of Sight Issues During Neurosurgical Procedures Using Optical Image-Guided Systems

Mehbodniya AH, Moghavvemi M, Narayanan V, Waran V

World Neurosurg, 2019 Feb;122:e449-e454.
PMID: 30347306 DOI: 10.1016/j.wneu.2018.10.069

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.
Fulltext A rare case of perivascular epithelioid cell tumour metastases to the brain

Jayapalan RR, Bahuri NFA, Mun KS, Narayanan V

SAGE Open Med Case Rep, 2019;7:2050313X19828539.
PMID: 30783531 DOI: 10.1177/2050313X19828539

Perivascular epithelioid cell tumour is a rare mesenchymal tumour with distinct immunohistochemical profile. While it is known to occur in various anatomical sites, the central nervous system had always been a protected site for primary or secondary perivascular epithelioid cell tumours. We describe a 61-year-old lady who presented with symptoms of raised intracranial pressure, 3 months after the resection of duodenal and thoracic tumours which were histologically consistent with perivascular epithelioid cell tumour. She was investigated and then subsequently subjected to resection of two metastatic intracranial lesions. The radiological, intraoperative as well as histopathological findings of the metastatic lesions are discussed. Metastatic perivascular epithelioid cell tumour of the brain is extremely rare. However, patients who are stratified as high risk for recurrence or metastases should undergo an early magnetic resonance imaging/computed tomography of the brain in addition to a whole-body positron emission tomography scan, to allow for early detection and management of these tumours.
Fulltext Electroacupuncture-Assisted Craniotomy on an Awake Patient

Sidhu A, Murgahayah T, Narayanan V, Chandran H, Waran V

J Acupunct Meridian Stud, 2017 Jan;10(1):45-48.
PMID: 28254101 DOI: 10.1016/j.jams.2016.06.005

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.
Reflections on: Intraoperative Pectoral Nerve Block or "Surgical PECS"

Suresh V, Magoon R, Narayanan V, Sethuraman RM

Indian J Surg Oncol, 2023 Sep;14(3):635-636.
PMID: 37900656 DOI: 10.1007/s13193-023-01740-w
Neurosurgical endoscopic training via a realistic 3-dimensional model with pathology

Waran V, Narayanan V, Karuppiah R, Thambynayagam HC, Muthusamy KA, Rahman ZA, et al.

Simul Healthc, 2015 Feb;10(1):43-8.
PMID: 25514588 DOI: 10.1097/SIH.0000000000000060

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

Narayanan V, Narayanan P, Rajagopalan R, Karuppiah R, Rahman ZA, Wormald PJ, et al.

Eur Arch Otorhinolaryngol, 2015 Mar;272(3):753-7.
PMID: 25294050 DOI: 10.1007/s00405-014-3300-3

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.
Video clip transfer of radiological images using a mobile telephone in emergency neurosurgical consultations (3G Multi-Media Messaging Service)

Waran V, Bahuri NF, Narayanan V, Ganesan D, Kadir KA

Br J Neurosurg, 2012 Apr;26(2):199-201.
PMID: 21970777 DOI: 10.3109/02688697.2011.605482

The purpose of this study was to validate and assess the accuracy and usefulness of sending short video clips in 3gp file format of an entire scan series of patients, using mobile telephones running on 3G-MMS technology, to enable consultation between junior doctors in a neurosurgical unit and the consultants on-call after office hours.
Microstructural Change and Cognitive Alteration in Maxillofacial Trauma and Mild Traumatic Brain Injury: A Diffusion Tensor Imaging Study

Veeramuthu V, Hariri F, Narayanan V, Tan LK, Ramli N, Ganesan D

J Oral Maxillofac Surg, 2016 Jun;74(6):1197.e1-1197.e10.
PMID: 26917201 DOI: 10.1016/j.joms.2016.01.042

The aim of the present study was to establish the incidence of maxillofacial (MF) injury accompanying mild traumatic brain injury (mTBI) and the associated neurocognitive deficits and white matter changes.
Fulltext Quantification and visualization of lipid landscape in glioma using in -and opposed-phase imaging

Seow P, Narayanan V, Hernowo AT, Wong JHD, Ramli N

Neuroimage Clin, 2018;20:531-536.
PMID: 30167373 DOI: 10.1016/j.nicl.2018.08.003

Objectives: This study maps the lipid distributions based on magnetic resonance imaging (MRI) in-and opposed-phase (IOP) sequence and correlates the findings generated from lipid map to histological grading of glioma.
Methods: Forty histologically proven glioma patients underwent a standard MRI tumour protocol with the addition of IOP sequence. The regions of tumour (solid enhancing, solid non-enhancing, and cystic regions) were delineated using snake model (ITK-SNAP) with reference to structural and diffusion MRI images. The lipid distribution map was constructed based on signal loss ratio (SLR) obtained from the IOP imaging. The mean SLR values of the regions were computed and compared across the different glioma grades.
Results: The solid enhancing region of glioma had the highest SLR for both Grade II and III. The mean SLR of solid non-enhancing region of tumour demonstrated statistically significant difference between the WHO grades (grades II, III & IV) (mean SLRII = 0.04, mean SLRIII = 0.06, mean SLRIV = 0.08, & p 
Attitudes toward epilepsy in East Malaysia using the Public Attitudes Toward Epilepsy (PATE) scale

Chia ZJ, Lim KS, Fong SL, Sim RS, Rajahram GS, Narayanan V, et al.

Epilepsy Behav, 2020 09;110:107158.
PMID: 32512367 DOI: 10.1016/j.yebeh.2020.107158

BACKGROUND: Epilepsy stigma is an important issue affecting people with epilepsy (PWE) in various social aspects of life. Most studies on stigma were among the metropolitan population but rarely on indigenous people. Hence, this study aimed to understand the attitudes toward epilepsy of the East Malaysians, comparing with the West Malaysians previously reported.
METHOD: This study was performed among the indigenous people in Kuching and Sibu (Sarawak) and Kota Kinabalu (Sabah) using the Public Attitudes Toward Epilepsy (PATE) scale. A higher score indicates poorer attitude.
RESULT: A total of 360 respondents (41.7% Kadazan-Dusun, 30.6% Bidayuh, and 24.7% Iban) aged 34.6 ± 12.6 years completed the questionnaire. They were predominantly females and had lower education level and income compared with the West Malaysians. The Sabah population had significantly lower mean scores (better attitudes) than those in Sarawak, in both personal and general domains (p 
Visible-Light Driven Effective Photocatalytic Degradation of Methylene Blue Dye Using Perforated Curly Zn0.1Ni0.9O Nanosheets

Karthikeyan V, Gnanamoorthy G, Varun Prasath P, Narayanan V, Sagadevan S, Umar A, et al.

J Nanosci Nanotechnol, 2020 Sep 01;20(9):5759-5764.
PMID: 32331175 DOI: 10.1166/jnn.2020.17898

Herein, we report the facile synthesis, characterization and visible-light-driven photocatalytic degradation of perforated curly Zn0.1Ni0.9O nanosheets synthesized by hydrothermal process. The X-ray diffraction (XRD) and scanning electron microscopy (SEM) studies confirmed the cubic phase crystalline structure and growth of high density perforated curly Zn0.1Ni0.9O nanosheets, respectively. As a photocatalyst, using methylene blue (MB) as model pollutant, the synthesized nanosheets demonstrated a high degradation efficiency of ~76% in 60 min under visible light irradiation. The observed results suggest that the synthesized Zn0.1Ni0.9O nanosheets are attractive photocatalysts for the degradation of toxic organic waste in the water under visible light.
Enhanced Photocatalytic Performance of Sn6SiO8 Nanoparticles and Their Reduced Graphene Oxide (rGO) Nanocomposite

Gnanamoorthy G, Muthukumaran M, Varun Prasath P, Karthikeyan V, Narayanan V, Sagadevan S, et al.

J Nanosci Nanotechnol, 2020 09 01;20(9):5426-5432.
PMID: 32331114 DOI: 10.1166/jnn.2020.17814

Photocatalysts provide excellent potential for the full removal of organic chemical pollutants as an environmentally friendly technology. It has been noted that under UV-visible light irradiation, nanostructured semiconductor metal oxides photocatalysts can degrade different organic pollutants. The Sn6SiO8/rGO nanocomposite was synthesized by a hydrothermal method. The Sn6SiO8 nanoparticles hexagonal phase was confirmed by XRD and functional groups were analyzed by FT-IR spectroscopy. The bandgap of Sn6SiO8 nanoparticles (NPs) and Sn6SiO8/GO composites were found to be 2.7 eV and 2.5 eV, respectively. SEM images of samples showed that the flakes like morphology. This Sn6SiO8/rGO nanocomposite was testing for photocatalytic dye degradation of MG under visible light illumination and excellent response for the catalysts. The enhancement of photocatalytic performance was mainly attributed to the increased light absorption, charge separation efficiency and specific surface area, proved by UV-vis DRS. Further, the radical trapping experiments revealed that holes (h+) and superoxide radicals (·O-₂) were the main active species for the degradation of MG, and a possible photocatalytic mechanism was discussed.

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