Headaches, trauma, pregnancy complications - when do they become signs of something far more dangerous?
In this must-listen episode of Sinar Daily’s Life & Style podcast, Dr Nurhamizah Zulkifli sits down with renowned neurosurgeon Dr Moventhiran Ramakrishnan to talk about intracranial bleeding (ICB) - what causes it, how to spot the warning signs, and why fast action can save lives.
From trauma cases to a heartbreaking story of a pregnant woman with a ruptured aneurysm, this episode goes deep into real clinical cases and life-saving lessons.
Watch full episode on all Sinar Daily social media platforms.
#SinarDaily #LifeAndStylePodcast #BrainBleed #Neurosurgery #HeadacheAwareness #PregnancyHealth #ICB #TraumaCare
In this must-listen episode of Sinar Daily’s Life & Style podcast, Dr Nurhamizah Zulkifli sits down with renowned neurosurgeon Dr Moventhiran Ramakrishnan to talk about intracranial bleeding (ICB) - what causes it, how to spot the warning signs, and why fast action can save lives.
From trauma cases to a heartbreaking story of a pregnant woman with a ruptured aneurysm, this episode goes deep into real clinical cases and life-saving lessons.
Watch full episode on all Sinar Daily social media platforms.
#SinarDaily #LifeAndStylePodcast #BrainBleed #Neurosurgery #HeadacheAwareness #PregnancyHealth #ICB #TraumaCare
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NewsTranscript
00:00Hi, Assalamualaikum and welcome back with me Dr. Nurhamidzah Zulkifli to our monthly Sinar Daily's Life and Style Podcast.
00:07Your trusted platform for in-depth discussion on medicine and health.
00:11And today we have with us very special guest, I would say an expert in brain surgery to discuss on when the brain bleeds, trauma, aneurysm and also pregnancy risk.
00:23Dr. Movendra Ramakrishnan, welcome to our show. He is a neurosurgeon with extensive experience in treating critical brain conditions, especially intracranial bleeding, traumatic brain injuries and also neurosurgical emergency.
00:37He is currently practicing in Hospital Tengku Ampuan Rahimah Klang as well as also Hospital Shah Alam and also occasionally he will be in Hospital Sengen Buloh.
00:47Basically he covers all neurosurgical services in Selangor.
00:51Dr. Movendra Ramakrishnan is actually, he's just operated on a heartbreaking case involving a young pregnant woman with aneurysmal bleeding and we hope this conversation will bring both insight and awareness to these life-threatening conditions.
01:09So in this episode, we will delve deeply into the causes of intracranial bleeding, which ranges from trauma, hypertensive bleed and also to ruptured aneurysm, the signs and symptoms, which are the warning signs which normally present with headaches.
01:25So he will elaborate further, which when headache is a warning sign, management and surgical interventions and also to explore the rare and devastating causes like intracranial hemorrhage in pregnancy.
01:39So Dr. Movendra Ramakrishnan, let's begin with this.
01:42So first, we would like to go into the technical matters, especially the scientific matters, medical matters of what is intracranial bleeding.
01:52To start off, how do you actually define intracranial bleeding and what are the main types that you encounter?
01:58So hi everyone. So basically, when you have a patient in your emergency department that came in due to a brain bleed, we always divide into whether this is due to a trauma or accident or accident, fall.
02:14And number two is disease caused by any like hypertension, strokes, medication.
02:21And this is a two contributing factor for my workload that I have to travel everywhere to work.
02:27All right. So in daily practices, we divide this into a spontaneous and traumatic.
02:33In spontaneous, we divide into that hypertensive bleed and also other cause of stroke.
02:38And also the spontaneous in a young patient, like example, aneurysm, ruptured, AVM ruptured.
02:44So this is another cause of the brain bleed.
02:47But our main load, like I said, this is a two main load of my working schedule.
02:51Okay. So basically, how do you actually divide it?
02:56Like you said, you have trauma, normally accident-based, or you can have spontaneous.
03:00Sometimes you have malformation in the brain, which suddenly can rupture or due to hypertension as well, right?
03:06Okay. So from your experience with the movement, what are the leading costs of this intracranial bleeding?
03:13As you say that you have traumatic and also the spontaneous, which one would you see more, especially in Malaysia?
03:19All right.
03:20The trauma out, you know, outrank the hypertensive bleed and also the aneurysmal bleed?
03:25So, all right.
03:26We divide this into a two, one based on the age group.
03:30If you have a young patient, usually it's due to a trauma.
03:34Like in the statistic of Malaysia, every 60 minutes, there are one head injury going to happen everywhere in Malaysia.
03:40That mean we have about every day, about 18 to 24 cases of head injury that happened throughout Malaysia.
03:48And also now we move over about stroke.
03:50Stroke is a third leading cause of that in Malaysia.
03:53So sometimes you have a patient that referred to me, like because of a hypertensive bleed, sometimes because of a MCA infarct.
04:02That mean there are no bleeding yet, but it's already start to bleed.
04:05And also in a very rare occurrence, in a week, you get two or three aneurysm ruptured.
04:10So this is the most how we divide the patients.
04:14But like I said, the age group, trauma usually the young one.
04:17And in the elderly patients, not elderly, I mean 60 and above or 50 and above is hypertensive bleed.
04:26This is how we divide usually.
04:28Okay, all right, all right.
04:29But like what you have heard that Dr. Moven said, one in every 60 minutes.
04:35Yes.
04:35Yes, you would have a road traffic accident and that would cause some intracranial, some injury.
04:41It could be bleed or just traumatic brain injury.
04:44So imagine the workload that he is facing every single day, especially in Selangor.
04:50So since you already know the, I would say the etiology, the cause of this bleed and how we divide it,
04:57maybe you could walk us through in terms of the signs and symptoms.
05:02For example, what are the typical signs and symptoms that the patient would present?
05:06Or maybe the family members would pick up.
05:09Most of the time, they're always being extricated with headache.
05:12Yeah, and sometimes blurring of vision.
05:14So, and how does it differ between the etiologies that which symptoms comes first?
05:20All right.
05:21Basically, brain, the first warning sign, example, in the spontaneous bleed.
05:25Because trauma, usually they already come to us in the emergency department.
05:30So we usually don't need the specific sign for them.
05:33But in a hypertension bleed or hypertensive bleed or stroke or aneurysm ruptured,
05:38the number one causative sign and symptom is headache.
05:42So they will complain mild headache, light headache, which is like a person might be normal all through.
05:49They not been diagnosed with hypertension, but they will say, I have a headache today.
05:53But the headache is bad.
05:54It's kind of bad.
05:55And subsequently, they will start to have other symptoms like vomiting.
06:00This is sign of a raised intracranial pressure.
06:03And subsequently, brain is a very specific and beautiful structure.
06:08That means if you have a bleed in a certain area, you have a certain symptoms.
06:12Like most commonly in a stroke, in a hypertensive bleed, usually in a basal ganglia,
06:17which is 60% of, sorry, 58% is in a basal ganglia.
06:21They will come with a weakness.
06:23That means unilateral weakness.
06:24They have a weakness of the right arm, left arm, and also a right leg, left leg.
06:29It depends how big the clot and how severe the bleeding is.
06:32All right.
06:33Okay.
06:34So mainly, so if you have a headache, so now we would like to go because I think headache,
06:39if you just, any Tom, Dick and Harry out there, if you ask them, they would have headache, isn't it?
06:45And especially, and they will always attribute it to stress, you know, not enough lack of sleep, you know, those things.
06:52And easily being misdiagnosed as migraine.
06:55So when does it that these people, when they complain of headache, but this should raise,
07:02this is like a red flag sign that this is something which is not just a normal headache,
07:06and they can't just be brushed off from the counter like that.
07:09All right.
07:10In this kind of brain bleed especially, so we are in hypertension,
07:16the headache is always in a very short term of period, short term of time,
07:21because they will associate with other symptoms as well, like weakness.
07:24So sometimes they don't tell they have a headache for one, two weeks or three weeks before of that.
07:30And so it can happen like you wake up, you go for your breakfast,
07:33suddenly you are sitting down, you have a headache and you drop.
07:36Okay.
07:36That means it's very sudden.
07:38But in aneurysm ruptured, example, this is a very specific.
07:43So this is a typical sign that always miss actually.
07:46In a one or two weeks before the major incident to happen, they will start to have a headache.
07:51That means the headache is like something is like, why I got a headache?
07:55Because I'm not a migraine person.
07:58I was not in a migraine medication or anything.
08:01So what happened?
08:02We call it sentinel hemorrhage.
08:03That means the ruptured of aneurysm start to happen slowly, slowly.
08:08Irritates the brain and brain gives the symptoms.
08:10But on the day of the event, they will have that.
08:13They know this is my thunderclap headache.
08:17This is the bad headache that I never had before.
08:20You might be lucky if you can walk to our emergency department, but most of them will come in at a reduced conscious level.
08:29But when they wake up, when we ask them, they will tell that it's that headache that I won't forget in my life.
08:35So for example, this aneurysm, especially because if trauma, normally they will come and then they will bleed and they are already in emergency department.
08:45Those with hypertension, normally most of them, they will know because they will tell they forgot to take their medications when they check their blood pressure.
08:52It's high.
08:52But this aneurysm is like a silent killer.
08:55I mean, it's a bit, I mean, they just have headaches.
08:57But for example, how would you know, I mean, is it like something, would it, the intensity would increase regularly?
09:04Like, like you said, they will have prior to that few weeks before.
09:07Yes.
09:07I mean, sometimes they take, they just take panel actually fast and just goes away.
09:11Is it something which is okay for us to just brush it off?
09:15All right.
09:16This is a way balanced.
09:18You have to balance.
09:19All right.
09:19In a country like Japan, so when I went for my attachment in Japan for vascular, every patient who have a headache, they will get a CT scan or MRI be done to them.
09:31That's why their pickup rate for aneurysm ruptured are very, very, very fast compared to other countries.
09:39Okay, because the accessibility of the CT brain, how your medical, medical knowledge that you are available in a certain country like Japan, example, they clip aneurysm because we do a clipping of aneurysm almost every day.
09:54Every day.
09:55Like, because they diagnose, if patient is healthy, patient are very healthy, then they go and clip the aneurysm.
10:02But for us, is it like example today, tomorrow lah, I got headache.
10:06Okay, how fast I need a CT scan, right?
10:10Yeah, true.
10:11But that's the reason we said it's a very, very, very much in dilemma.
10:17If you have a headache more than a month, more than two months or three months, I will always say don't take Panadol.
10:23Okay.
10:24Take a better solution.
10:25Do a CT scan, do MRI because you have to understand we are moving in the current era of the world.
10:32So, our bleeding rate in the young patient age group, especially 30 to 40, increasing.
10:39In my practices, I've seen a lot of aneurysm ruptured.
10:43Usually, we see aneurysm ruptured in a young prospect of age group.
10:47So, if you're able to do a CT scan when you have a headache, it's a very big relief in your life.
10:56So, basically, that's a very important point for not just those in the hospitals, those for our audience out there, but also, I think, for the general practitioners also.
11:06Because sometimes, it's easily that easy way out is we would say, oh, this person would have a migraine.
11:13So, we just start them on migraine medications.
11:15But sometimes, there could be some more sinister pathology in the brain that needs a CT scan.
11:21So, I would say, like as per Dr. Moven said, if the headache is very much frequent, constantly coming, and sometimes there's no precipitating factor,
11:32it's better to just write a raffle letter to the higher institutions for them to proceed with a CT scan.
11:37Yeah, I think it's okay to over-treat compared to under-treat.
11:42I mean, I always tell, I always get a call from my friends in the general practitioner, especially chief, what do you think?
11:50I said, to be clear, to be safe, why don't we get a CT scan?
11:54Because it will tell you better and also clearly any pathology in the brain.
11:59So, I think better be safe because it's okay to over-treat.
12:05That's always my theme of work.
12:08True, true.
12:09So, because I think that's how we need to move forward.
12:11Like what you say, in Japan, it's very easy for them to get the CT scan or the MRI or the CTA, right?
12:17And then, when you pick up early, so you can intervene early and you can prevent all this catastrophic injuries to the patients.
12:26So, Dr. Mo, I just want to ask, is there any common misconception in the patients that you treat or maybe in the society when you give your talks,
12:35especially when it comes to headache, when it comes to all this blurring of vision,
12:39sometimes they will say, oh, like I said, they will just brush it off saying it's migraine, it's not important, I don't need it to be treated.
12:46So, what are the common misconceptions that you have received as a neurosurgeon?
12:51The common misconception is, we talk about stroke.
12:55So, when in the stroke, first of all, if you diagnose with hypertension, make sure you take your medication, right?
13:02So, the problem is the misconception, if I take my medication and my BP is back to normal, I can stop it.
13:09So, when they stop, because the last follow-up, example, six months ago, the BP was 130 or over 80.
13:17So, okay, I can stop my medication.
13:20And after that, after six months, you will have a hemorrhagic stroke because your BP was not controlled.
13:25So, this is number one.
13:27Number two is always like, I have a headache because my daughter never sleep over the night, right?
13:33So, of course, but you have to see if what is keep on coming, keep on coming, but thank you because nowadays we have a lot of, I think we have a lot of influencers giving out a lot of positive thoughts that you have to do investigation, you have to do your, all this, follow up with the doctors.
13:53So, our pickup rate is increasing in trend, but in somehow, we need to approach overall population.
14:02We cannot miss in a town, but in the outside, outskirt, you miss a lot of things nowadays, especially when I got a patient from, because I cover the whole Selangor.
14:13So, especially when you have a patient from Tanjung Karang, from Banting, because the availability of like, you need to do this, you need to do that.
14:23Like, follow up with your doctors, or it's very far for me to see a neurologist or neurosurgeon, but you have to come.
14:31But I think that's the baby steps that if you can see our Ministry of Health, that we are trying to open up more hospitals, try to give, so outreach, those further part in the, like we say, the kampung-kampung, you know, in the distant areas.
14:47And even, I think like Dr. Moven said that for Banting, although it's quite far, but we have what we call a cluster, so they could actually send the patient over to Klang.
14:58So, and then they have Shah Alam also, they are coming.
15:00So, although we, I think neurosurgical services are expanding tremendously in Malaysia, I would say.
15:07We are expanding currently, because we get more numbers of neurosurgeon that's coming up.
15:12So, but the workload also expanding, because like, the pickup rates, like I said, the screening program, and also the awareness of the population that our workload is increasing.
15:23But it's okay, because we want to treat them, right?
15:26Yeah, if you can follow Dr. Moven's Instagram, he's very enthusiastic, a neurosurgeon, I would say.
15:33So, moving on, since we have already talked about the signs and symptoms, all the red flag signs of headaches, now you move on to trauma, because you are in hospital, Tengku Ampuan Rahim Maklang, which is, I would say, the hub of trauma, and it's a trauma center.
15:48How about in head trauma cases, which, what are the signs that you would raise a suspicion that there is an intracranial bleed?
15:57Because sometimes, not all patients which have probably some bruises over the head that they are having intracranial bleed.
16:03But when they arrive to the hospitals, what are the possible suspicions that you have if this patient might have a bleed inside the brain?
16:11So, like I said, I was, I am in a clang for a year. I think we operated almost 370 cases in a 12 month, which is only purely trauma.
16:26So, once you came to our emergency department, so we have a screening, so we will see how, is it the high impact injury or low impact injury?
16:36How fast you drive your car? Did you wear your helmet? Do you have any bruises?
16:41Like, we have a specific sign where, look, raccoon eyes. Like, example, your eyes having a blue-black, and also you have a battle sign.
16:47You have a bleeding behind your ears. This is a very suspicious, this patient might have an intracranial bleed.
16:54And also, basically, we go by a scale assessment. We call it Glasgow Coma Scale.
16:59Like, how is conscious are you, how are conscious are you, like your GCS level?
17:03So, that's a very key premium indicator. But nowadays, like I said, the availability of CT scan is wide, all right?
17:11So, if you, a bit, you are suspicious, like, we better do a CT scan.
17:15So, even, we don't find anything, but better be safe for the patient.
17:19Like you said, better be safe than sorry, right?
17:21So, like, example, like, the development in hospital Banting. Thank you, KKM.
17:25They put a CT scan in Banting.
17:27So, the pickup rate of a head injury in Banting is very fast.
17:30And we manage our Banting cases are very fast.
17:33And also, now, they are moving neurosurgeons, like, I move to Sha'alam to operate.
17:38I move to another hospital to operate.
17:41So, we give the best timeline for them.
17:43But the key symptoms, you come in, I mean, usually the emergency physician already know,
17:49okay, this patient need a CT brain.
17:50But they never say no for CT brain.
17:55Yeah, it's very easy to get a CT brain because nobody wants to be held responsible if there's
18:00something wrong out there and you did not do a CT brain, right?
18:03So, like, what he said, Dr. Moven has mentioned in terms of the consciousness level, which they
18:08have their own scale.
18:09scale and then in terms of the signs that they have, the, like, blowout signs, the raccoon eyes
18:15and then also the bleeding sometimes from the ear, nose and, you know, from the ear.
18:21How about, so once you have, for example, diagnose a patient in the trauma setting,
18:26the emergency department that they have intracranial bleed, what are the key factors
18:31that you would determine, this patient needs, urgent, I have to do the surgery within one
18:36hour, two hours, three hours time.
18:38Or, I would say one hour, right?
18:40No, I would like to do it.
18:41It shouldn't be two, three hours.
18:42So, one hour.
18:43And there are certain cases that you say, okay, this one maybe wait and watch.
18:48After 24, 48 hours, you repeat another CT brain.
18:50Or this one, you safely say, ah, this one is okay, no need to repeat CT brain.
18:54Just, maybe you could discharge after one or two days with a head injury advice.
18:58So, which one would you, how do you tailor your management?
19:03So, we follow the guidelines.
19:04We follow, I mean, brain trauma foundation guidelines.
19:08We follow a Malaysian trauma foundation guidelines.
19:10The moment you look at a scan, also the patient as a overall, you look, like example,
19:15when you have an extradural hemorrhage, it's a bleeding in the brain that caused by a trauma
19:19most commonly, you know it's more than 10 mm.
19:24It's a, it's very confined space, right?
19:26So, when you have anything more than 10 mm, you have like midline structures are pushed
19:31away, your unconscious level is low, say, don't wait, go in now.
19:34But very, very small, small contusional bleed, right?
19:37You can see like a patches here and there.
19:39We say, okay, wait and watch.
19:40Tomorrow, we repeat the CT brain after 24 hours.
19:43Sometimes, we even repeat the scan because sometimes we have a guideline.
19:47This clot can expanded in this location after six hours.
19:51So, that's why my radiological colleague is like, why you always repeat the CT brain?
19:55And, of course, example, in neurosurgery places, even before I was in HR, I think
20:02even a general surgeon was like, now, when neurosurgery come, they have the priority.
20:08Because we always say, time is brain.
20:10Because, like I said, the moment I receive the patient, I receive the CT brain, my decision
20:15will be within 10, 15 minutes.
20:17Then, after that, we push to OT within one hour.
20:18So, we want to optimize the operative time and time is brain, the trauma time.
20:25So, you were saying 10 millimeters, that is actually one centimeter bleed, the width of
20:31it inside the brain.
20:32That itself can really cause a massive effect to the brain itself, yeah?
20:37Yes.
20:38Okay, okay.
20:39So, remember, maybe some people thought just one centimeter is not just like a very small
20:45little tiny bleed, but it actually can cause a catastrophic disaster.
20:50Okay.
20:50So, can you share a case where immediate surgery changed the outcome dramatically for a trauma
20:58patient?
20:58Because sometimes some people, they feel that when they have to go undergo, especially brain
21:04surgery, it's something which is very major.
21:06Of course, brain surgery is major.
21:07I would say even if you just make a hole or you have to remove your skull, it's already
21:13a major surgery.
21:14But, how would you, in your practice, that you would convince?
21:18Because I believe sometimes it's not very easy to convince the patients or maybe the family
21:25members because most of the time, the patients are already unconscious.
21:29They've already intubated.
21:30They have tubes and they can't give consent by themselves.
21:32So, in your practice, what are the, I would say, the challenges that you have faced in
21:41terms of getting, you're very enthusiastic to push the patient to OT, but you have issues
21:47with the consent.
21:48Sometimes they are worried, the public's not worried what would be the outcome.
21:51But maybe you could share some of your experiences that after the surgery, they really, really
21:56improve after that.
21:57Okay, the challenge is actually the surgery itself, all right?
22:01So, first of all, when you tell I'm going to do a brain surgery, everybody is like, their
22:05eyes are going to open up, right?
22:07It's like, really?
22:08So, yes.
22:10But, in the condition, like what we are talking about today, it's do or die.
22:15Example, if you do, you have chances of surviving.
22:19If you never do the high risk, the high likely, the high percentage that you're going to pass
22:25away.
22:26So, my option I always give to the patient is like, what I'm doing today is life-saving
22:32surgery.
22:33It's not like I'm going to make sure that he can walk back or make sure he can like function
22:38as a normal human.
22:39I say, no.
22:40At this moment, this time, you have 30 minutes to decide for me.
22:44It's like, do or die.
22:46So, I will explain everything regarding what are the possibilities that you might be in
22:51ICU for three months, four months, but the decision is still in the family hand, right?
22:59So, sometimes the challenges is like family wants to talk to somebody like, oh, doctor,
23:04I want to have a meeting with my family.
23:06So, when you ask when is a meeting, I say, no, you have no time.
23:09It's like, I need it.
23:10I give you maybe 15 minutes, 20 minutes because like the decision making is something is very
23:16big because like you told me, like how you mentioned just now, even putting a small hole
23:22in your, on your skulls and going inside the brain also, people think a lot.
23:26But in a dire emergency condition, they said the decision must be fast.
23:32So, that's why we said we give them time and we try to convince them.
23:37We try to explain what are the possibilities that can happen.
23:40Like, I might come up with my own statistic that what I did, my experience.
23:45So, they might be agree with you.
23:46Then, we proceed.
23:48In certain conditions, they will refuse.
23:49So, when they refuse, we have to respect the patient choice and family choice.
23:53Then, we have to ask them to sign the against refusal form.
24:00Right.
24:00So, for example, like you said, in terms of the, what are the usually the recovery phase?
24:07I mean, in those cases that you operate that they were initially unconscious and then they
24:14can actually the next few days, they recover.
24:16I mean, I mean, I know it depends on how severe is the injury, right?
24:21But have you seen, I mean, most of the time, if they operate today and then maybe the next
24:27few days, one week, you can actually see them start walking, be awake and...
24:31Okay.
24:32So, it depends on what type of bleed you have.
24:36Like, example in the extra dural, that mean bleeding outside the first layer of the brain.
24:40Even they came in the condition, like even the family member said, he can leave, like
24:46after you do the surgery, they can wake up the next day.
24:49So, I become a miracle worker.
24:52But it's actually the nature of the injury, right?
24:56So, number two, it depends on a lot of factors, like how bad the injury is, where is the bleeding.
25:02So, sometimes most of my patients in the acute setting for acute extra dural is usually, they
25:08wake up within two to three days if everything goes well.
25:12And also in subdural, we give them some time, two, three weeks, four weeks.
25:16In the contusional, big, big contusional bleed, they might go longer.
25:20I have a patient who stayed with me for 360 days, another five days.
25:23I tried to discharge him by, before it complete one year.
25:28So, yeah, I managed to discharge him, thank God.
25:30So, yeah.
25:31So, the recovery depends on what type of bleed, how severe, how bad you came in.
25:36But somehow, the aim is life-saving.
25:40And then, maybe you'd like to add in terms of why is it brain surgery is something that
25:46you really need to make the decision fast.
25:48I mean, how brain is a bit different because they don't regenerate, right?
25:52I mean, this is, I think, what the public should know because there are certain parts
25:56of our body, like our nails.
25:57If you cut, they keep growing again.
25:59Okay, there are certain parts of our bodies, but not the brain.
26:02And they are very susceptible to the lack of oxygen.
26:06So, maybe Dr. Movan can just shed some light.
26:09Whenever you have a brain injury or even bleeding in the brain, we said the golden timing is
26:16only four hours.
26:17Why?
26:17Because the brain is going to start changing.
26:20So, the area of bleed is going to stop the bleeding for a while.
26:25But what happened is that infarct is coming in.
26:28Infarct means there are no enough blood flow to the brain and the area is like goes off.
26:32Okay.
26:33So, when it goes off, there are no way I can do any miracle to reverse it back.
26:39So, we try to avoid this reversible injury.
26:42So, that's why we say within four hours, that's why I have to push.
26:45Sometimes, we open three OTs one time.
26:48Like example, I will operating one OT.
26:50My registrar another OT.
26:52My medical officer another OT.
26:53Because we say brain is time.
26:55So, that's the time.
26:57Because it's very, very fast.
26:59Usually, when you have no oxygen to your brain, for eight minutes, you already have brain damage.
27:04That's why our CPR must be fast.
27:07Our intubation must be fast.
27:09Our surgery must be fast.
27:10That's why my people say, neurosurgeon, everything fast, fast, fast, fast, fast.
27:15Step, step, step.
27:17So, my order is very simple.
27:19I want now.
27:22So, I guess that's the take-home message for the public out there.
27:26I mean, decision-making must be fast.
27:28And also, for the, probably, I would say, the medical practitioners, for you to consult the neurosurgical team, have to be very fast.
27:38Any suspicion, I think Dr. Moven and his team is very open to their phone.
27:43I mean, they can just, they will just pick up even two, three o'clock in the morning.
27:46Because I have referred cases to him.
27:48If I think that it's very urgent intervention, I'll just give him a call at four o'clock in the morning.
27:53And he'll just wake up like, huh, hello, Misa?
27:55I'm trained for it.
27:58Yeah, I'm trained for it.
27:59Okay, so, let's move on to a bit more, I would say, tricky subtopic in intracranial bleeding in pregnancy.
28:09So, the case that really shocked us, right?
28:12I know this is not your first case that you have operated.
28:15We're not going to go into the detail of it, of the surgery itself.
28:18But, recently, you managed a tragic case involving a pregnant woman with a ruptured aneurysmal rupture.
28:25So, can you share with us in terms of the, what makes managing intracranial bleed in pregnancy particularly challenging?
28:34Because, as you know, being pregnant is already, I wouldn't say it's a disease, it's already a change in the condition of a human being.
28:40And then, some of it, you add on another pathology.
28:44So, basically, what I'm trying to say to the public, any department wouldn't want to touch a pregnant lady because it is a very, very, I would say, high risk cases.
28:56So, how is it challenging in managing a pregnancy with the intracranial bleed?
29:00The first word challenging is pregnant lady.
29:04So, the moment my medical officer will call and say, boss, I have a pregnant lady case.
29:10You know, even at what time our eyes are wide open, we won't even see the scan.
29:15We will just jump into our computers or laptop to see, look at the scan because our decision need to be very accurate and fast.
29:23So, when you're pregnant, your body changes.
29:26So, your blood flow is increased.
29:29So, what happened with this?
29:31This is a time when something that was not diagnosed can be diagnosed.
29:36Like, mostly the cases that I operated and I experienced throughout my service, usually they don't know they have aneurysm.
29:44They don't know they have an AVM.
29:46Because if they were diagnosed before the pregnancy, we will advise them in a lot of methods what you're supposed to do.
29:54So, what happened was the blood flow changes the hemodilution because your blood become thick, sometimes thin, and you'll be on medication, and sometimes you can be stressed, right?
30:06And you can strain and everything.
30:08This caused the blood flow to show up, increase more to your brain.
30:12And this, the basic pathology is the aneurysm might be there.
30:16Like, you know, like I said, one out of ten of us might be walking with aneurysm.
30:21So, what happened, the body changes caused that symptoms to start to appear.
30:28Like, particularly, go back, they will have a headache.
30:31So, this headache in pregnancy is always a red flag sign.
30:34And you have to understand, this is where we become problematic when they have a light headache because CT scan are not safe for pregnancy.
30:41So, we need to do MRI for them.
30:45So, sometimes they will say, okay, we push for the MRI.
30:49But in a dire emergency cases where they already in your emergency department, we say, we have no choice.
30:54We have to proceed with the CT brain.
30:56We have to become mother first.
30:58We try to save the mother first.
31:00But it's very tragic because aneurysm ruptured is one minute time bomb.
31:05I will say not one, 30 seconds.
31:07Because you are talking now, you can drop in next 30 seconds.
31:11So, in this case, like particular case or certain aneurysm in pregnancy, it never be small.
31:19Like, example, that size is not like 2mm or 3mm.
31:22It can be 10mm.
31:23It can be 15mm.
31:25MM sounds small.
31:26But when you do a surgery, we call it a giant aneurysm.
31:29You know, it's called giant anything more than 10mm.
31:31Oh, sorry, 15mm.
31:33So, and when you have a giant aneurysm in pregnancy, that make you to sit down and think, what am I supposed to do?
31:40So, this is where we will call and say, you know what, you have to take out the baby.
31:44I have to operate on a brain.
31:46So, I think most of the time, sometimes I will be waiting to start until the baby deliver.
31:52The moment I heard the baby sound like crying, okay, I said, can I start?
31:55Can.
31:55So, I start.
31:57So, yeah, this is, the pathology is already there, but the body changes cause the appearance of the symptoms happen.
32:05So, basically what I'm trying to say is that it just exacerbates the whatever, because I think not just brain aneurysm, it seems goes to sometimes those who have valvular heart disease, they could be undetected.
32:16Then once they are pregnant, then everything will just set into place.
32:20You can see all the hemodynamic changes, meaning that because their pressures would be much more because they need to support another living, another living baby inside, right?
32:31So, all these hemodynamic changes, you can just increase the pressure and everything will just going to be a haywire inside the body.
32:39So, like you have just mentioned, if in an emergency condition, yes, CT scan would be, because basically you would just want to get the diagnosis.
32:47Because once the bleed is already there, just a plain CT scan, you can see the bleed.
32:51But those who have subtle, subtle symptoms such as headaches, maybe they are pregnant, but they have these headaches.
32:57And with, I think with our podcast, maybe most of the pregnant ladies out there are a bit more worried.
33:03So, they might have a headache now.
33:05So, every time they have a headache, maybe they might be thinking.
33:08And then what would be the better options?
33:11MRI?
33:12I mean, is it really safe?
33:13MRI is safe for your pregnancy, which is accessible and safe.
33:18Even everything has a risk.
33:19But, rather than going undetectable with your aneurysm, APM, better to do MRI.
33:27If you indicate an example, your headache getting worse and worse and worse and your BP is normal, you are on medication, you know.
33:33And you start to have other cardinal symptoms like you have a blurring of vision.
33:37You start to have some weakness or some other symptoms.
33:41I think we say, don't wait, push for MRI.
33:43MRI, because in MRI, we do MRI, MRA, MRV, MRS.
33:50There are a lot of fractured in MRI.
33:53So, for us to study the brain properly and see, this could be the cause.
33:56Okay, so meaning that, even you would say that, of course, anything would have their risk.
34:04But MRI is relatively a safer choice as compared to CT scan or, I mean, because this is based on the radiology, I mean, the radioactive imagings, right?
34:14Okay, so if you have, like you said, when you had the patients with the aneurysmal rupture or maybe those who are not ruptured yet and you manage to detect it on MRI,
34:26is it safe for them to undergo intervention when they are still pregnant?
34:30I mean, because if they want to wait until they complete their pregnancy, then they are at risk to have ruptured.
34:36But are they safe? Is it safe?
34:39This is where we come in the multidisciplinary talk.
34:42You know, we will have a discussion with the obstetric and gynecologist, our interventional radiologist, and everybody say,
34:50okay, the option now, I say, example, we have a patient with aneurysm.
34:54She is now 24 weeks or 27 weeks because usually this happened in 24, 27, 32 weeks, right?
35:01So we said, can we deliver the baby?
35:02So because, like, my concern is I need to clip without, I don't want to cause any harm for the baby.
35:10So I'll have to open up the question to the floor, to everybody there.
35:15Is it safe to deliver the baby?
35:17So when you have a neonatologist support, is it can?
35:20So is it can?
35:22OENG are willing to come in, can we take out the baby?
35:25You settle your brain part.
35:26So it's a win-win situation.
35:28But when this is in undetected, in the aneurysm, usually, okay, in my statistics, we have a lot of aneurysm last year.
35:38Last past two years, especially in Selangor, increasing in rate, especially in pregnancy.
35:43Sometimes we have to say, okay, we deliver the baby in the same time we do the surgery.
35:47Because aneurysm clipping is a very complex surgery, because you have to spend a lot of time, and as a neurosurgeon, you spend a lot of time under your microscope to find the aneurysm.
35:58It's not easy, because if a tumor is there, if a blood clot is there, but aneurysm, you have to trace from that first branch of your blood vessel, and you have to look, where is it?
36:09Where is it?
36:09Where is it?
36:10So sometimes, it took me about, I had aneurysm, I clip after 18 to 20 hours, because we cannot find it.
36:17So we find until it reach.
36:19So very complex, delicate, so we have to decide every overall, especially for the baby.
36:25But in the early pregnancy, this is a problem.
36:29So we have to, I think usually one case, we have an AVM.
36:33AVM is an arterial venous malformation.
36:36We admit the vision from eight weeks of pregnancy.
36:38We waited her every morning.
36:41Without fail, I'll go and see her in the morning.
36:43And before I go back, I'll say, are you okay?
36:45Do you have a headache?
36:46No.
36:47Okay, stay here.
36:47This is your home.
36:49She was there until 32 weeks.
36:50Thank God, we delivered the baby, and I exercised the AVM.
36:54And after the exision, after two years, she's pregnant again.
36:58So congratulations.
36:59She messaged me.
37:00She WhatsAppped me and said, doctor, I'm pregnant again.
37:02Is it safe?
37:03I said, okay, I think the last MRI clear for you for pregnancy.
37:07Please go on.
37:08Okay, right, right.
37:09That's a successful story from the aneurysm.
37:13So it's very important for not just the pregnant ladies.
37:16I think for anyone who has headaches and then you are a bit suspicious,
37:21don't really, like we just mentioned just now, just get yourself checked.
37:24Don't hesitate.
37:25Because this is actually the aim of our podcast, to create the awareness,
37:28to make sure to, we don't want you to sit in the dark and not show what you need to do after this.
37:37So since we've already talked about the imaging, the signs and symptoms,
37:41how we would like to move on in terms of the innovations, in terms of the,
37:46you have mentioned the CT scan, I mean, plain CT scan, and then you have the CTA, MRA,
37:52whatever MR that you have, MRS.
37:55I mean, how is it different?
37:57I mean, we don't want to go into detail in terms of the radiological terminologies,
38:02but when do you decide for CT scan?
38:05Just like a normal trauma is a CT scan, on like you say aneurysm is MRA.
38:10When is when you decide for all these things?
38:12Okay, number one is based on our experience.
38:15Whenever you see it, because the number one rule is whenever patient,
38:19they will come with a plain CT brain.
38:21Whenever you look at it, it's like, this doesn't look like a normal stroke bleed, right?
38:28Why don't we get a CTA?
38:29Once you get a CTA, ah, this is an aneurysm.
38:32Because the bleeding itself, they have the pattern.
38:35They have the first picture, they're going to tell you, what am I there?
38:39So like aneurysm, they have a star-shaped sign, you know?
38:41The moment they put up the scan, like people like me will say,
38:45hey, this is an aneurysm.
38:46So this is a hypertensive bleed.
38:48And we'll say, hey, this is a tumoral bleed.
38:50So because we see, we experience, this is a pathological,
38:56how you learn before you become a neurosurgeon.
39:00You must know this before you become a neurosurgeon.
39:03So there.
39:04Okay, so basically it's based on maybe the initial screening that they would do
39:08is just a normal plain CT scan with no contrast.
39:12Then from there, once, depending on the bleed, the nature,
39:16I mean, and then maybe the history.
39:18That's very important in terms of the history presentation
39:20and also the imaging, the initial imaging,
39:22then you would actually decide if you need further imaging
39:25to confirm your diagnosis.
39:28So, you have been a neurosurgeon for, I would say, five years?
39:33Five years.
39:33Five years.
39:34Okay.
39:34So what are the advancements in neurosurgery?
39:37Okay, you have talked about how is it like in Japan,
39:39how they have detect aneurysm at the very initial stages.
39:45Maybe here in Malaysia, what are the neurointervention
39:48and I mean like the neurosurgical, the new advancements that you have seen.
39:53Maybe you want to share what you have outside Malaysia
39:56and also in Malaysia as well
39:57and how it has have a significant improvement
40:01on the outcomes of the patients.
40:04There are a lot of advancements, especially even in Malaysia itself.
40:08Like example, take an example in the centre that Hospital Sungai Buloh,
40:12like a neurosurgery team in the Hospital Sungai Buloh,
40:15we are known as a neurofunctional centre.
40:17So what we do, like example we do,
40:19you know, we put a lead for the deep brain stimulation
40:23for Parkinson's patients.
40:24And the patient will be awake throughout the surgery
40:26and we put a lead and it reduces the Parkinson's.
40:29In like my area of expertise, example,
40:32I love, not to say I love, my, I prefer to,
40:36it's my forte.
40:37Your forte.
40:38My forte is more slight, I like, I love tumours.
40:40So I like to take out the tumours from the brain.
40:43So we have like example in a high grade,
40:45like tumours, we give a dye
40:47that going to lights up during the surgery.
40:50Example, I will be in a dark room
40:52and the tumour will be there.
40:53So under my microscope,
40:54I try to take out as much as I can.
40:56And we have an intraoperative radiotherapy.
40:59We open up the patient
41:00and we give a radiotherapy while operating.
41:03Of course, it's a risk,
41:04but we want to give the best outcome for the patient.
41:06The advancement is that spinal cord stimulation,
41:09transmagnetic stimulation,
41:11there are a lot.
41:12And we are doing it in Malaysia.
41:14We are not far behind actually
41:16because most of our neurosurgeons are certified
41:18for all this advancement.
41:20And we always been sent out by our department
41:24to go for a training, come back.
41:26It's not just training.
41:28You come back, you have to do it.
41:29Yeah, you have to practice it.
41:30You have to bring the new things to Malaysia.
41:32Make sure what I send you is worth it
41:34and you come back and do it, all right?
41:37Okay, okay.
41:38And then actually,
41:39maybe just a little bit of neurosurgeon.
41:42They are just not operating on the brain
41:44and brain matter,
41:47but they also do the spinal cord
41:48and also the spine injuries as well, right, Dr. Movan?
41:52Yeah, so it's not an easy task for them to manage.
41:56Okay, so what is your...
41:58Before we move on,
41:59I mean, we are almost reaching
42:01to our last few questions.
42:02What would you be your message
42:04to the general practitioners out there
42:06or maybe the emergency doctors,
42:08emergency physicians,
42:09especially in the rural cases.
42:11Sometimes I think there are still certain hospitals
42:14which they don't have the CT scan.
42:16So mainly they have to basically
42:18go by their clinical findings
42:20and how to act fast in suspected ICB,
42:25I mean intracranial bleeding cases.
42:27So like I said,
42:27when I was a medical student,
42:30the most hard,
42:31the hardest,
42:32one of the hardest topic is neurology.
42:34I think we don't like neurology, right?
42:37Because the problem is,
42:38brain is something
42:39which is not properly understood
42:42until the day itself, right?
42:44There's all these new things that are coming out.
42:45So whenever you,
42:47when I was an undergrad student,
42:48I always tell,
42:49why is it so hard to understand?
42:52So it's like,
42:52you know,
42:53that's a topic you don't want to give,
42:55like,
42:55it's okay,
42:56I won't be a,
42:57anything to do with neuro in the future.
42:59Then after like five years back,
43:01they put me as a neurosurgery medical officer.
43:03I was like,
43:03okay,
43:04and now I'm a neurosurgeon.
43:06So it's basically the knowledge.
43:08You need to keep with the knowledge.
43:09Like sometimes,
43:10there are certain signs,
43:12it's very,
43:13very much subtle example,
43:15your eye movement.
43:16Like example,
43:17you have a stroke
43:17and suddenly you say,
43:19might be a stroke.
43:20when you do an examination
43:21of your eye examination,
43:23you have an nystagmus
43:24that pointing that,
43:25eh,
43:25this is a stroke.
43:26Nystagmus is actually,
43:27actually the movement of the eye.
43:29Okay.
43:29Towards,
43:30we call it a firing of the eye.
43:32All right.
43:32So this is,
43:33you just move your finger,
43:34you know,
43:34this is a,
43:35this is a stroke.
43:37So the district will say,
43:39you can talk easy lah,
43:41you are a neurosurgeon.
43:42But always equip,
43:44like,
43:44I don't know,
43:44equip your knowledge
43:45and make sure you know.
43:47If you,
43:48like for me,
43:48for district,
43:49any district,
43:50that call me up,
43:50I'll say,
43:51send over.
43:51Okay.
43:52I say,
43:52send over.
43:53Right.
43:53Because we cannot be jack
43:54of all trades.
43:55Yep.
43:55We cannot be,
43:56I,
43:56I'm not good in,
43:57uh,
43:57obstetric and gynecology
43:59or any,
43:59even I,
44:00you cannot ask me
44:01to do a laparotomy.
44:02So I cannot open up
44:03my abdomen,
44:04right?
44:04So,
44:05so,
44:05but sometimes it's okay.
44:06You have a limitation,
44:07send over.
44:08If you have any doubt,
44:09always reach out,
44:10reach out,
44:11reach out.
44:11That's all.
44:12Because I think nowadays,
44:13uh,
44:14Malaysians,
44:14the,
44:15the,
44:15I would say the
44:17Ministry of Health,
44:18um,
44:18our health services
44:20has expanded tremendously.
44:22And,
44:23um,
44:23like I said,
44:24before this,
44:24we try to reach out,
44:26uh,
44:26to those,
44:27um,
44:28which is,
44:28um,
44:29the far,
44:29you know,
44:30in the rural areas.
44:31And we,
44:33we are always there.
44:34Those,
44:34uh,
44:34we are in the urban areas.
44:36They can always send over.
44:37Just the problem is,
44:37sometimes it's the,
44:39the transport,
44:40the duration.
44:40The doctors will always be there
44:41because we don't sleep
44:42when we're on call.
44:43But the problem is,
44:44it might take some time
44:45for them to reach.
44:46So that is very crucial.
44:48Uh,
44:48the time of raffle
44:49is very,
44:50very important.
44:51Do not delay.
44:51Any suspicion,
44:52any doubt,
44:53you can just call up
44:54at the moment.
44:55I mean,
44:55whoever the nurse is.
44:56For example,
44:57what happened recently,
44:58I will say,
44:59so funny.
45:00So,
45:00uh,
45:01told my wife about this case
45:02because I was,
45:03I was on call
45:04when I was looking
45:05through my phone.
45:06Yeah.
45:06Suddenly,
45:07I see a TikTok message.
45:09I was like,
45:09okay,
45:10usually I won't open
45:11my TikTok message.
45:12But I see a doctor name,
45:13particular doctor,
45:15say,
45:15boss,
45:16I'm from hospital here.
45:18This patient have this problem.
45:20Can you help me?
45:21So I say,
45:22okay,
45:22why don't you WhatsApp me?
45:24So when the particular doctor
45:25WhatsApp me,
45:26I said,
45:26this is a brain tumor.
45:28I said,
45:28this is a very big brain tumor.
45:30Okay.
45:30I said,
45:30boss,
45:31how do I send?
45:32I said,
45:32you tell,
45:33you've spoken to me,
45:34send the patient now.
45:35And when the particular doctor
45:37sent over the patient
45:38and she followed the patient.
45:40Yeah.
45:40Until the,
45:41my emergency department.
45:43And I said like,
45:44how you get this referral?
45:46I said,
45:47TikTok.
45:48But thank God,
45:49we managed to operate
45:50this patient
45:51three weeks ago
45:53and patient,
45:53but that is a fast action
45:56and the way
45:57they are trying
45:58to reach you,
45:58you know,
45:59I cannot get your number.
46:00I don't have your number
46:00and this particular doctor,
46:02I mean,
46:03I can't,
46:03I can't recall her name,
46:04but I think
46:05she did a great job.
46:07Yeah.
46:07So basically,
46:08she tried to reach out
46:10for whatever she can
46:12and yeah,
46:13and then you can find,
46:14sometimes you don't find his name.
46:16Like,
46:16I think Movan's name
46:17on TikTok is Movan,
46:18but on his other things
46:19will be other.
46:20Maybe we will tag data
46:21in our podcast.
46:22I try to hide my identity
46:24as well to reduce my referral.
46:27But most important thing
46:28is that if you have
46:29any referrals,
46:30if you can't get through
46:31the WhatsApp,
46:32because I always make a point
46:33that I will WhatsApp
46:34if it's an urgent case,
46:36one or two minutes maximum.
46:39If I don't get the reply,
46:40call anytime,
46:42because most of the time
46:43we are on call
46:44and we are supposed
46:45to be awake
46:46and managing the patients,
46:48right?
46:49So I found a question
46:50is that what would you say
46:51to the general public
46:52since just now
46:53was more of a medical,
46:55I would say,
46:57message for the healthcare workers.
46:59In terms of the general public,
47:01what should everyone know
47:02about recognizing
47:03the early signs
47:04and getting immediate help?
47:06Like about do not delay
47:07the eight minutes rule.
47:09I mean,
47:09make sure the decision making
47:11must be fast.
47:13Make sure you bring
47:13if there's any symptoms.
47:14Anything else
47:15that you would like to add on
47:16for the general public out there?
47:17So for general population,
47:19like how let's say,
47:20first of all,
47:21make sure you get
47:22a correct person
47:23to give you the advice
47:24because there are
47:26so many advice.
47:27Not TikTok.
47:28Not non-credential doctors
47:30on TikTok.
47:31I mean,
47:32there are so many information
47:33that's available, right?
47:35So make sure you learn
47:37from or you get the message
47:39from a doctor
47:41who are trained in that field
47:42or even they are expert
47:44in that field.
47:45That is much more better.
47:46And stop googling so much
47:48because when you have
47:50a headache today,
47:51if you google now,
47:52you will have a brain tumor.
47:54So always try to consult.
47:57Identify your sign.
47:59Example,
48:00you know,
48:00Malaysians,
48:01I'm so sorry.
48:02I mean,
48:02including me,
48:03I have this
48:04tidak apa attitude.
48:05So don't delay
48:07because certain things
48:08when you never delay,
48:10when detected early,
48:11we can save
48:12and we give you
48:13a good quality of life
48:14and be healthy
48:16and then take your medication.
48:20Okay,
48:20so those are the few
48:22take-home messages
48:23from Dr. Mulvind
48:24and from our podcast itself.
48:26So make sure,
48:27like I said just now,
48:28the aim of this podcast
48:29is to create awareness
48:31because there's no point
48:32if the Ministry of Health,
48:35if the hospitals
48:35are opening up more,
48:37like more rampantly,
48:39but the patients
48:41are not coming to us
48:42or they come to us
48:43in the later stages
48:44that makes us difficult
48:45to manage.
48:47So thank you so much,
48:48Dr. Mulvind,
48:48for such an insightful session.
48:50I hope it's useful
48:51for all of the audience
48:53out there.
48:55ICB,
48:55intracranial bleed,
48:56can be silent
48:57until it becomes deadly.
49:01So we hope
49:01to this discussion
49:02helps to save lives
49:03by recognizing danger signs,
49:05early,
49:06acting quickly
49:06and understanding
49:07when a headache
49:08is more than
49:09just a headache.
49:10Remember,
49:10headache,
49:11if it's constant,
49:12it's getting much more intense
49:13and also associated
49:14with other symptoms
49:15such as
49:15burying of vision,
49:16weakness,
49:17please,
49:17but don't wait
49:18until you have the weakness.
49:19Anything you have,
49:20headache,
49:21if it's getting much more intense,
49:22come over to the hospital.
49:23And before we end,
49:24just a final shout out
49:26to all our listeners,
49:27especially the medical professionals.
49:31If you think
49:31that today's discussion
49:32has sparked your interest
49:33in trauma care
49:35and also surgical emergencies,
49:36don't forget
49:37that Dr. Moven Hill
49:38will be speaking
49:39at my TESC.
49:40My TESC is
49:41a Malaysian Trauma
49:42and Emergency
49:43Surgical Conference.
49:45It's happening soon
49:45on 12th and 13th September
49:472025
49:47in Double Tree Hilton,
49:49which features
49:50international speakers,
49:52hands-on learning
49:52and also cutting-edge
49:54sessions in trauma,
49:55neuro,
49:55and also emergency
49:56care surgery.
49:57So today is the final day
49:58for early registration,
50:00early birth registration,
50:00so don't forget
50:01to sign up
50:02before the rates go up.
50:03So we will tag
50:04the website
50:06and also you can find out
50:07on my TESC Instagram.
50:09So to all of our
50:10Sina Daily's audience,
50:13don't forget to follow
50:14all Sina Daily's
50:15social media platforms
50:16and download
50:17Sina Daily's
50:17new and improved
50:18mobile application.
50:20Stay tuned
50:20and I'll see you guys
50:21inshallah next month.
50:23Assalamualaikum.
50:24Bye.
50:24Thank you everyone.
50:33Bye.
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