Clinicopathological profile and management challenges of congenital encephaloceles in a tertiary hospital in southwest Nigeria.

PURPOSE: A congenital encephalocele is the herniation of intracranial contents through skull defects of various sizes. Depending on the site, content, and size, it is associated with significant morbidity and mortality in children. There is a paucity of recent and comprehensive local clinical data regarding this anomaly. Understanding the peculiarities, clinical-pathologic profiles, and management challenges will help prevent and effectively manage congenital encephalocele to improve outcomes. METHODS: This was a retrospective study of all cases of congenital encephalocele managed between July 2000 and December 2023 at a tertiary hospital in the southwest region of Nigeria. Relevant demographic, clinicopathological, and management data were retrieved and analysed. RESULTS: There were 31 females and 11 males. Their ages ranged from 3 hours to 24 years. Sixteen (35.3%) were delivered in a non-health facility. Birth asphyxia was reported in 5 babies. Few mothers (4.8%) used preconception folic acid. Anaemia (n = 5) and sepsis (n = 4) were the common preoperative morbidities. All patients had definitive surgery, with 18 operated on within the first month of life. Cerebrospinal fluid (CSF) leak was the most common postoperative complication and was significantly observed in the sincipital group (p = 0.018). Thirty-one patients (73.8%) presented for follow-up after surgery, and the mean follow-up duration was 26.6 weeks. Mortality was recorded in a patient (2.4%) due to Klebsiella meningitis. CONCLUSION: Congenital encephaloceles are relatively common in our setting. Therefore, there is a need to address the associated poor maternal and neonatal health conditions. Early surgery can be performed with a favourable outcome.

Hydrocephalus Management Challenges in a Low-income Country: A Review Article.

Hydrocephalus is a very common brain disorder affecting both children and adult populations. Its global burden has been well documented in the literature, and its management is not without challenges and complications, especially in low-income countries. This study aims at reviewing the management of hydrocephalus in a tertiary hospital in Nigeria and illustrating two cases managed with peculiar challenges. This study is a retrospective clinical review of 170 patients with hydrocephalus amenable to ventriculoperitoneal shunting as primary treatment. Two cases of hydrocephalus with peculiar management challenges were illustrated. The first case was that of an abandoned infant with hydrocephalus. The second case was that of a 5-year-old boy with post-meningitic hydrocephalus with delays in having cerebrospinal fluid (CSF) shunting. Majority of the patients with hydrocephalus were infants (71.2%), and the top two most common etiologies were aqueductal stenosis (64.7%) and post-meningitic hydrocephalus (11.2%), respectively. Shunt infection was the most common complication (9.4%), which was within the lower limit of rates reported in the literature (8.6%-50%). Approximately 84% of shunting had no complication. In conclusion, ventriculoperitoneal shunting is the preferred treatment option for hydrocephalus in low-income countries, and it is not without management challenges that are peculiar to these climes. Shunt infection appeared to be the most common complication.

Clinicopathological Profile of Central Nervous System Tumors in a Tertiary Hospital in Southwest Nigeria.

Background: Central nervous system tumors are a complex heterogeneous group of neoplasm comprising both benign and malignant tumors with varied patterns in clinical picture and histologic profile. There have been some similarities and differences seen in the pattern of clinicopathological profile worldwide, however, there is a paucity of study to show the pattern in Nigeria. Aim: This study aimed at describing the clinical and histopathological pattern of central nervous system tumors in our institution. Materials and Methods: This was a retrospective review of cases of central nervous tumors from 2010 to 2021. Information on clinical presentations and histopathology of the tumors were reviewed and analyzed. Results: We found 115 cases of central nervous system tumor with a mean age of 43.7 years and female preponderance. The most common presentations were headache (59 cases, 55.5%) for brain tumors and neck/back pain (16 cases, 100%) for spinal tumors. Supratentorial tumors were the most common accounting for (69 cases, 60%), and sellar region, the commonest site accounting for (25 cases, 29%) of primary brain tumors. Neuroepithelial tumors accounted for the majority (35 cases, 30.4%). Conclusion: Central nervous system tumors were most common in the 5th decade with female preponderance. Neuroepithelial tumors have the highest incidence in the tumor groups.

Idiopathic intracranial hypertension: Proposal of a stratification strategy for monitoring risk of disease progression.

OBJECTIVES: A general consensus based on a multidisciplinary perspective involving an international panel was recently developed for management of patients with idiopathic intracranial hypertension (IIH). In this paper, the authors sought to develop further on the aspect of this consensus that concerns monitoring progression of the disease. PATIENTS AND METHODS: A systematic literature review of previous publications on monitoring disease progression in IIH and a meta-analysis to examine efficacy of method of monitoring employed in each study. The authors present a brief descriptive analysis of challenges with monitoring progression of the disease and propose a risk stratification to aid monitoring. RESULTS: Of a total of 382 publications identified from the literature search, only 8 studies (144 patients) satisfied inclusion criteria and were included for analysis. Among these, 3 were based on ICP monitoring while the remaining 5 focused on ophthamological evaluation. Interestingly, there were neither any studies on monitoring with progression of clinical features nor any study on monitoring with symptomatology associated with IIH among the selected studies. CONCLUSION: There is a paucity of studies in the literature on methods of monitoring disease progression in IIH. Though close attention to adequate evaluation and proper care of patients with IIH remains the key in managing this problem, this proposed risk stratification will be an objective tool and useful guide to better monitor these patients according to their extent of risk from the disease and possibly for planning treatment and intervention.

The pattern, peculiarities, and management challenges of spina bifida in a teaching hospital in Southwest Nigeria.

PURPOSE: Spina bifida is a common congenital anomaly of the nervous system. It is frequently associated with significant morbidity and sometimes mortality in affected children. In this paper, we review the clinico-epidemiological pattern, peculiarities, and therapeutic challenges of this condition in our practice setting. METHODS: This is a retrospective study of all cases of spina bifida managed from July 2000 to March 2016 at a tertiary health facility located in the southwest region of Nigeria. Relevant information was retrieved from the medical records. The data was collected using a pro forma and analyzed with SPSS version 22. RESULTS: Data from 148 patients was reviewed and analyzed. There were 78 males and 70 females. Only 5.8% of these children were delivered at the health institution. A fifth (20%) of the patients were first born of their mothers. The mean maternal age was 29 years. Few (10.1%) mothers use folate medication prior to conception and only 58% of the mothers use folate during antenatal care. Mean duration of pregnancy was 38 weeks. The most common anatomical site was lumbosacral region (74.3%) while the most common pathology was myelomeningocele 80.4%. Mean age at surgery was 88.68 h. Mean duration of surgery was 92.8 min. Mean follow-up duration was 46.8 weeks. As many as 59% of the patients had some neurologic improvement noticed during follow-up clinic visits. CONCLUSION: Spina bifida occurs frequently in our environment. Low socio-economic status and poor antenatal clinic visits contributes significantly to its occurrence.

Paediatric day-case neurosurgery in a resource challenged setting: Pattern and practice.

BACKGROUND: It has been generally observed that children achieve better convalescence in the home environment especially if discharged same day after surgery. This is probably due to the fact that children generally tend to feel more at ease in the home environment than in the hospital setting. Only few tertiary health institutions provide routine day-case surgery for paediatric neurosurgical patients in our sub-region. OBJECTIVE: To review the pattern and practice of paediatric neurosurgical day-cases at our hospital. PATIENTS AND METHODS: A prospective study of all paediatric day-case neurosurgeries carried out between June 2011 and June 2014. RESULTS: A total of 53 patients (34 males and 19 females) with age ranging from 2 days to 14 years were seen. Majority of the patients (77.4%) presented with congenital lesions, and the most common procedure carried out was spina bifida repair (32%) followed by ventriculoperitoneal shunt insertion (26.4%) for hydrocephalus. Sixty-eight percentage belonged to the American Society of Anesthesiologists physical status class 2, whereas the rest (32%) belonged to class 1. General anaesthesia was employed in 83% of cases. Parenteral paracetamol was used for intra-operative analgesia for most of the patients. Two patients had post-operative nausea and vomiting and were successfully managed. There was no case of emergency re-operation, unplanned admission, cancellation or mortality. CONCLUSION: Paediatric day-case neurosurgery is feasible in our environment. With careful patient selection and adequate pre-operative preparation, good outcome can be achieved.

Outcome of a posterior spinal fusion technique using spinous process wire and vertical strut.

BACKGROUND/OBJECTIVE: Spinal fusion is a rapidly developing area of spine surgery. Many of the implants often used are not within the reach of the patients in the developing world. In this study, we describe the outcome of a novel technique of posterior spinal fusion using the rush nail and spinous process wire. MATERIALS AND METHODS: We prospectively evaluated patients who underwent the technique since October 2006. We reviewed the patients' biodata, clinical diagnosis, imaging studies, indications for surgery, type of operations, and complications related to the implants and the technique. Clinical test of instability was also determined. RESULTS: The technique was used in 11 female and 19 male patients. The age range was 11-82 years. The indication for surgery was trauma in 15 patients, degenerative disease in seven patients, tuberculosis of the spine in four patients, and four patients had neoplasms. Occipitocervical fusion was performed in three patients, cervical fusion in six patients, thoracic fusion in 10 patients, thoracolumbar fusion in seven patients, lumbar fusion in three patients, and lumbosacral fusion in one patient. The distal segment of the implant backed out in one patient following fracture of the spinal process. The implant was eventually removed. Clinical evidence of instability necessitating external orthotics was also seen in one patient. Two patients had wound infection. These were managed without removing the implants. We did not observe significant complications in other patients. CONCLUSION: The technique appears safe and effective in carefully selected cases. The technique needs further evaluation in a larger patient population and with a longer duration of follow-up.

Epidemiology of neurotrauma in Ife-Ijesha zone of Nigeria.

BACKGROUND AND OBJECTIVE: Trauma remains one of the important causes of severe disability and high mortality. In this study, we looked at the epidemiology of neurotrauma in our region so as to highlight essential factors for trauma prevention program. METHODOLOGY: This is a cross-sectional study of all neurotrauma cases admitted to the neurosurgery service of our hospital over an 18-month period. Information was obtained on patients' demographic data, etiology of injury, duration of injury, site, and cause of accident among others. RESULTS: One hundred forty-three patients were included in the study. The injuries occurred mostly in males and in the third decade. Most of the patients were students and traders. Eighty-one percent of the accidents were due to road traffic crash (RTC), and the most common contributory factors were head-on collision (46.2%) and overtaking (28.6%). Five of six patients who had RTC in the first decade of life were pedestrians. There were more crashes within the cities. None of the patients who had motorcycle accidents used helmet and only four patients used seatbelts at the time of the accident. Transfer to hospital was mostly in vehicles other than ambulance. CONCLUSION: Neurotrauma in our study was mostly due to RTC and it is most common in young male students. Contributory factors were head on collision and overtaking.

CRASH-3 - tranexamic acid for the treatment of significant traumatic brain injury: study protocol for an international randomized, double-blind, placebo-controlled trial.

BACKGROUND: Worldwide, over 10 million people are killed or hospitalized because of traumatic brain injury each year. About 90% of deaths occur in low- and middle-income countries. The condition mostly affects young adults, and many experience long lasting or permanent disability. The social and economic burden is considerable. Tranexamic acid (TXA) is commonly given to surgical patients to reduce bleeding and the need for blood transfusion. It has been shown to reduce the number of patients receiving a blood transfusion by about a third, reduces the volume of blood transfused by about one unit, and halves the need for further surgery to control bleeding in elective surgical patients. METHODS/DESIGN: The CRASH-3 trial is an international, multicenter, pragmatic, randomized, double-blind, placebo-controlled trial to quantify the effects of the early administration of TXA on death and disability in patients with traumatic brain injury. Ten thousand adult patients who fulfil the eligibility criteria will be randomized to receive TXA or placebo. Adults with traumatic brain injury, who are within 8 h of injury and have any intracranial bleeding on computerized tomography (CT scan) or Glasgow Coma Score (GCS) of 12 or less can be included if the responsible doctor is substantially uncertain as to whether or not to use TXA in this patient. Patients with significant extracranial bleeding will be excluded since there is evidence that TXA improves outcome in these patients. Treatment will entail a 1 g loading dose followed by a 1 g maintenance dose over 8 h.The main analyses will be on an 'intention-to-treat' basis, irrespective of whether the allocated treatment was received. Results will be presented as appropriate effect estimates with a measure of precision (95% confidence intervals). Subgroup analyses for the primary outcome will be based on time from injury to randomization, the severity of the injury, location of the bleeding, and baseline risk. Interaction tests will be used to test whether the effect of treatment differs across these subgroups. A study with 10,000 patients will have approximately 90% power to detect a 15% relative reduction from 20% to 17% in all-cause mortality. TRIAL REGISTRATION: Current Controlled Trials ISRCTN15088122; Clinicaltrials.gov NCT01402882.

The social and economic impacts of epilepsy on women in Nigeria.

BACKGROUND: Persons with epilepsy in sub-Saharan Africa experience stigma and social marginalization. There is paucity of data on the social and economic impacts of epilepsy in these patients and in particular, groups like women. We sought to determine the social and economic impacts of epilepsy on Nigerian women and especially how it affects their treatment and outcomes. METHODS: We carried out a cross-sectional survey of 63 women with epilepsy (WWE) and 69 controls matched for age, social status and site of care. A structured questionnaire was used to document information on demographic characteristics, education, employment status, economic status, health care use, personal safety and perceived stigma. The data were collated and analyzed with SPSS version 15. RESULTS: Unemployment, fewer years of formal education, lower marriage rates and higher stigma scores were more frequent among WWE than controls. Physical and sexual abuse with transactional sex was also reported among WWE. We also noted poorer environmental and housing conditions and lower mean personal and household incomes among WWE compared to the control group. CONCLUSION: WWE in this sample from Nigeria have worse social and economic status when compared with women with other non-stigmatized chronic medical conditions.

The technique of using rigid vertical strut and spinal process wire for posterior spinal stabilization.

BACKGROUND AND OBJECTIVE: High cost of conventional spinal instrumentation and the need for intraoperative imaging have forced us to consider other methods of spinal stabilization especially suitable in low-income societies. In this article, we describe our technique of spinal fusion using spinous process wiring and rigid vertical strut. TECHNIQUE AND METHODOLOGY: Vertical strut which has been bent at one end is passed through loops of wire introduced into the base of the spinous processes to be instrumented. Another vertical strut is passed through the loose ends of the loops. We currently use Rush nail as the vertical strut. RESULTS: The loose ends of the loops of wire are pulled snugly and twisted. This results in immediate rigid stabilization of the spine. CONCLUSIONS: The technique seems safe and efficient in stabilizing the spine pending definitive bony fusion.

The role of human immunodeficiency virus infection in infranuclear facial paralysis.

BACKGROUND: This study describes the pattern of idiopathic infranuclear facial palsy (facial neuropathy) and highlights the role of human immunodeficiency virus (HIV)/AIDS in its occurrence and management. PATIENTS AND METHODS: This study conducted in Ile-Ife, Nigeria, assessed individuals with idiopathic facial neuropathy seen at the neurology; maxillofacial surgery; and ear, nose and throat outpatient clinics between 1994 and 2006. RESULTS: Eighty-eight patients with idiopathic facial neuropathy were seen during the 13-year study period. Forty-six (52.3%) were males, and the age range was 15 to 76 years, with a median of 35.5 years and interquartile range of 24.5 to 54 years. The right side was affected in 59.1%, compared with 40.9% on the left side. Twenty-six patients (29.5%) were HIV positive at presentation: 16 males, 10 females; mean age for HIV-positive patients was 29.15 +/- 8.12 years and 44.39 +/- 18.48 years for HIV-negative patients. There was a significant relationship among the status of the patients and the severity at presentation (p = .035), treatment given (p = .019), and the occurrence of flu-like symptoms (p = .004). CONCLUSION: A high index of suspicion of seroconversion is essential in patients presenting with idiopathic facial neuropathy since it has implications for management. Serological testing for HIV, especially in patients at risk and those with history of recent flu-like symptoms, is recommended.

Factors implicated for late presentations of gross congenital anomaly of the nervous system in a developing nation.

BACKGROUND: Gross congenital lesions of the nervous system are obvious at birth and usually present early for management and corrective surgery. However in tropical and developing nations, late presentations are common. AIMS: To determine the factors responsible for very late presentations of gross congenital lesions. METHODS: We conducted a prospective study of all cases of congenital CNS anomalies that presented very late (>6 months after birth) to our neurosurgical clinic over an eight year period (2000-2008). RESULTS: A total of 81 patients were seen during the study period. The age ranged from 6 months to 47 years. Hydrocephalus accounted for about half of the cases 37 (48.3%). The others were spina bifida 15 (18.5%), encephalocele 10 (12.4%), subgaleal inclusion dermoid cyst 7 (8.6%), and craniosynostosis 6 (7.4%), neurofibroma 4(4.9%), and anencephaly 2 (2.5%). Reasons given for late presentations were ignorance, poverty and in some the expectation that the baby would die. Other reasons for late presentation were that the patient was either about to start school or get married. CONCLUSION: Late presentations of congenital CNS lesions are associated with many complications most of which could have been avoided with early medical treatment. Health education should include issues regarding congenital malformations delivered by trained experts.

New onset neuromyelitis optica in a young Nigerian woman with possible antiphospholipid syndrome: a case report.

INTRODUCTION: Devic's neuromyelitis optica is an inflammatory demyelinating disease that targets the optic nerves and spinal cord. It has a worldwide distribution and distinctive features that distinguish it from multiple sclerosis. There has been no previous report of neuromyelitis optica from our practice environment, and we are not aware of any case associated with antiphospholipid syndrome in an African person. CASE PRESENTATION: We report the case of a 28-year-old Nigerian woman who presented with neck pain, paroxysmal tonic spasms, a positive Lhermitte's sign and spastic quadriplegia. She later developed bilateral optic neuritis and had clinical and biochemical features of antiphospholipid syndrome. Her initial magnetic resonance imaging showed a central linear hyperintense focus in the intramedullary portion of C2 to C4. Repeat magnetic resonance imaging after treatment revealed resolution of the signal intensity noticed earlier. CONCLUSION: Neuromyelitis optica should be considered in the differential diagnoses of acute myelopathy in Africans. We also highlight the unusual association with antiphospholipid syndrome. Physicians should screen such patients for autoimmune disorders.

Treatment of cerebrospinal fluid shunting complications in a Nigerian neurosurgery programme. Case illustrations and review.

BACKGROUND/AIMS: For a century since the first cerebrospinal fluid (CSF) shunt surgery, ventriculoperitoneal (VP) shunt insertion for the treatment of hydrocephalus has routinely been performed. A lot of common and rare complications following this procedure have been reported in 24-47% of the cases. The aim of this paper was to present our experience with the treatment of hydrocephalus in our centre and highlight our management of two unusual complications with the available resources. METHODS: Retrospective clinical review. RESULTS: A total of 86 patients with hydrocephalus were seen in our unit. There were 52 males and 34 females (male:female ratio 3:2). The age of the patients ranged from 1 day to 68 years. The majority of the patients (92%) were below 5 years of age. Sixty-five patients had shunting procedures [VP shunt: 62 (95.4%); endoscopic third ventriculostomy: 3 (4.6%)]. Of the 62 patients with VP shunts, 16 (25.8%) had complications while 2 of the 3 patients with endoscopic third ventriculostomies had complications. The complications following the VP shunts were CSF shunt sepsis (n = 12; 19.4%), abdominal complications (n = 3; 4.8%), subdural haematoma (n = 2; 3.2%) and scalp necrosis in 1 patient. CONCLUSION: VP shunt procedures have come to stay and will remain with us despite recent advances such as endoscopic third ventriculostomy. Care should be taken to prevent all complications whether common or rare by paying particular attention to patient selection, shunt selection and surgical details. The adaptation of local technology and justified use of limited facilities and resources can go a long way in the management of both common and rare complications in developing nations.