Challenges of practicing neuro-endovascular interventions in a resource-limited country; Ghana in focus.

OBJECTIVE: Now is the time to reflect on the situation of neuro-endovascular interventions (NEVT) in Africa, particularly Ghana, and to renew our commitment to provide high-quality health care to our people. This evaluation is significant because it seeks to assess progress toward our goals and identify potential obstacles for remedial action and to highlight the challenges of NEVT in Ghana. METHODS: Retrospective review of all endovascular treatments performed between January 1, 2019, and December 31, 2021, at two Ghanaian hospitals. A descriptive analysis was done having entered data in Microsoft Excel utilizing frequencies and percentages. Four experienced specialist radiologists discussed NEVT issues in Ghana. The fishbone diagram was used to depict the challenges and problems of NEVT practices in Ghana. RESULTS: From January 2019 to December 2021, 278 patients' records were analyzed at two Ghanaian hospitals. The majority of patients (71.9%) had digital subtraction angiography of the head and neck. The high cost of medical supplies, lack of vendor interest, and limited awareness of symptoms by general practitioners were noted as obstacles associated with neuro-endovascular treatment in Ghana. CONCLUSION: Although the future of NEVT is bright, Interventional Neuroradiologists and other stakeholder need to make conscious effort to improve quality, accessibility, and cost of NEVT in Ghana.

Computed Tomography Findings of Patients Presenting With Headache: 4-Year Retrospective Two-Center Study in Central and Western Regions of Ghana.

Objectives: The radiographic assessment of the head is a crucial part of headache care. A computed tomography (CT) scan enables a more detailed analysis of the condition and more focused care. This study examined head CT scans to determine what kinds of anomalies were present in patients with headaches as their primary complaint. Methods: We evaluated 4 years' worth of CT scan data from head exams conducted at two diagnostic facilities in Ghana's western and central regions. We examined data on 477 patients with a headache as their primary complaint between January 2017 and December 2020. We employed chi-square and Fisher's exact tests (where applicable) to compare head CT diagnoses between age groups, gender, headache subtypes, and brain lesion subgroups. Results: There were 53.5% (n = 255) females and 46.5% (n = 222) males in the study. The average age of patients was 38.67 ± 17.23 years, with an annual rate of abnormal CT diagnoses ranging from 35.9% in 2017 to 45.4% in 2022. Abnormal head CT diagnoses are strongly correlated with age groups and patient gender (p = 0.011 and p = 0.009, respectively). Of the 202 patients, 15.3% and 24.3% were classified as intracranial lesions and extracranial lesions, respectively. Maxillary sinusitis affected nearly 60% of the patients, while tumors and hemorrhages affected 25.2% and 11.9%, respectively. Conclusions: A CT scan of the head is essential to detect abnormalities in nearly 50% of patients suffering from various degrees of headache. Sinusitis, brain tumors, and hemorrhage were common lesions detected. It is crucial to create local standard operating procedures to promote better utilization of this type of imaging service, particularly among patients who have been diagnosed with headaches.

Radiologic patterns of distant organ metastasis in advanced breast cancer patients: Prospective review of computed tomography images.

BACKGROUND: Breast cancer (BC) metastases to the abdomen and pelvis affect the liver, mesentery, retroperitoneum, peritoneum, bladder, kidney, ovary, and uterus. The study documented the radiological pattern and features of the chest, bone, abdominal and pelvic (AP) metastases among advanced BC patients. AIM: The aim is to document the radiological pattern and features of breast cancer metastasis in the chest, abdomen, pelvis and bones. MATERIALS AND RESULTS: Chest, abdominal, and pelvic computed tomography scan images of 36 patients with advanced BC were collated from Cape Coast Teaching Hospital and RAAJ Diagnostics. The images were prospectively assessed for metastasis to the organs of the chest, AP soft tissues, and bones. Radiologic features of metastasis of the lungs, liver, lymph nodes (LNs), and bones were documented. Patients' demographics, clinical data, and histopathology reports were also collected. The data were captured using UVOSYO and exported to Microsoft Excel templates. The data obtained were descriptively analyzed. Only 2.8% of BCs exhibited metaplastic BC, whereas 97.2% had invasive ductal BC. Triple-negative cases were 55.6%. Of 36 patients, 31 (86.1%), 21 (58.3%), and 14(38.8%) were diagnosed of chest, AP, and bone tissues metastasis, respectively. LN involvement was reported in 26 (72.2%) patients. Majority, 21 (58.3%) were diagnosed of multiple sites metastasis with 15 (41.7%) showing single site. Lungs (77.4%, 24/31) and liver (47.6%, 10/21) were the most affected distant organs. Most bone metastases were lytic lesions (92.9%, 13/14) with the vertebrae (85.7%, 12/14) been the most affected. CONCLUSION: According to the study, advanced BC patients have a higher-than-average radiologic incidence of lung, liver, bone, and LN metastases.

Carbapenem-Resistant Acinetobacter baumannii Bloodstream Infection in a Ghanaian Patient with Unilateral Diaphragmatic Eventration and HIV Type 1 Infection.

Carbapenem-resistant Acinetobacter baumannii infection is a critically prioritized pathogen by the World Health Organization and a cause for growing concern due to increased mortality among hospitalised patients. Phrenic nerve palsy is a rare complication of herpes zoster infection of the C3, C4, and C5 nerve roots. We present a case of bloodstream carbapenem-resistant A. baumannii infection in a Ghanaian patient with HIV type 1 infection and multiple risk factors, including unilateral diaphragmatic eventration with compression atelectasis likely secondary to phrenic nerve palsy due to herpes zoster infection, consequently leading to recurrent hospital and ICU admission. In this case, we emphasize the need for clinicians in LMICs to be aware of CRAB, in order to advocate for the availability of evidence-based medicines in resource-limited settings for appropriate treatment. In addition, we illustrate the importance of a high index of suspicion for infection with carbapenem-resistant organisms such as A. baumannii and highlight a rare and severe complication of herpes zoster infection in the form of phrenic nerve palsy and consequent diaphragmatic eventration.

Imaging patterns of the arterial supply of the prostate gland in adult Ghanaian men.

Background: Prostatic arterial embolization (PAE) is a novel procedure in West Africa and Ghana. A thorough understanding of the prostate artery's (PA) anatomy and pattern is required for successful prostatic arterial embolization and to guarantee targeted intervention. This study focuses on prostate arterial supply in adult males, including prevalence, variability, and imaging pattern. Methodology: A prospective cross-sectional study was conducted, at Euracare Advanced Diagnostics and Heart Centre. Patients who presented for Computed Tomography Angiography of the pelvis were included in the study. A total of 52 males were included and 104 pelvic CT angiography (one for each side) were analyzed, including: prostatic artery diameter, prostatic gland volume and prostate artery branching pattern. The PA branching pattern was classified using de Assis et al. classification. Result: Thirty-seven (71.15%) men had enlarged prostate volume (>30ml). On each side there was only one prostatic artery and no accessory one was found. Only three types of arterial branching were identified: type I, II,III. The type I artery was the most common origin 58.7% (61/104). PA originating from the anterior division of the internal iliac artery (type II) and the type III is from the internal pudendal artery, accounted for 16.3% (17/104) and 25% (26/104) respectively. Conclusion: The most frequent type of PA origin was type I followed by type III then II. Knowing the different and most frequent types of anatomy of PA may help standardization and effectiveness of the PAE in developing countries.

Transient cortical blindness, a rare complication during cerebral digital subtraction angiography: A case report and literature review.

Transient cortical blindness (TCB) is a rare consequence of cerebral angiography with no recognized cause. TCB was observed in a patient with a wide-neck cavernous aneurysm during digital subtraction angiography. One hour after angiography, vision returned spontaneously, with no neurological damage. An MRI was performed three hours after the incident and revealed no abnormalities.

Prevalence and characterization of asymptomatic thyroid nodules in Assin North District, Ghana.

BACKGROUND: Ultrasound is now the initial imaging modality of choice for detection and characterization of lesions of the thyroid gland. Ultrasound imaging studies of the thyroid gland report varied prevalence of asymptomatic thyroid nodules (ATN), ranging from 20 to 67%. This study estimated the prevalence, characterized and determined factors associated with ATN in selected communities in the Assin North Municipality, Central Region, Ghana. METHODS: The study was a cross-sectional design, involving 320 participants from six (6) communities in the Assin North District of the Central Region of Ghana. Socio-demographic data and data from ultrasound examination of the thyroid gland were analyzed using descriptive and inferential statistical techniques. RESULTS: The prevalence of ATN was 11.3% among 320 participants with the mean age of 56.53(±16.5) years. ATNs were common in the left lobe (69%) and predominantly solitary (64%). ATNs increased with age and body mass index (BMI). Those aged 60 years and above had significantly higher odds (OR = 24.40, 95% CI = 2.59-229.86) of having ATNs, likewise overweigh (OR = 5.32, 95% CI = 1.12-25.20) and obese (OR = 12.51, 95% CI = 1.47-106.58) individuals. CONCLUSION: The prevalence of ATN in our study population was relatively low, and more predictable among those 60 years or older, those in unhealthy BMI categories. There is the need for the reinforcement and intensification of educational campaigns on the consumption of iodized dietary salt as well as the consumption of foods rich in iodine content, particularly among older individuals.

Contrast Medium Use in Computed Tomography for Patients Presenting with Headache: 4-year Retrospective Two-Center Study in Central and Western Regions of Ghana.

Background: Contrast medium (CM) administration during computed tomography (CT) enhances the accuracy in the detection and interpretation of abnormalities. Evidence from literature also validate the essence of CM in imaging studies. CT, by virtue of its ubiquity, ease of use, speed, and lower financial footprint, is usually the first investigation in cases of headache. Through a multicenter retrospective analysis, we compared findings of contrast-enhanced CT (CECT) to noncontrast-enhanced CT (NCECT) head examinations among patients presenting with headache. Methods: A multicenter retrospective analysis of four years' CT head examination data at two radiology centers located in Central and Western Regions of Ghana were reviewed. Records of patients who presented with headache as principal complaint between January 2017 and December 2020 were reviewed. A total of 477 records of patients with headache were identified, retrieved and evaluated. A Chi-square test and Fisher exact test were used to compare the CECT and NCECT groups. Binary logistic regression analysis was computed to assess association between CECT and each CT findings. Statistical significance was considered at p < 0.05 with a 95% confidence interval. Results: A significant proportion of the patients was females (51.8% in CECT and 60% in NCECT). The NCECT group (40.06 ± 14.76 years) was relatively older than the CECT group (38.43 ± 17.64 years). There was a significant difference between the CECT and NCECT in terms of age (p=0.002) and facility CT was performed (p < 0.0001). The rate of abnormalities was higher in CECT (43.5%, 166/382) compared NCECT (37.9%, 36/95). There was no significant association between CT head findings and contrast enhancement. Conclusion: CECT examination accounted for 5.6% increase in the detection of head abnormalities. Efforts required to establish local standard operation procedures (SOPs) for contrast medium use especially in CT head examinations. Further studies to improve the knowledge of agents, mechanism of action, and safety of contrast media used among practitioners in Ghana is recommended.

A case report of a teenager with hepatitis B surface antigen-positive multifocal hepatocellular carcinoma in a noncirrhotic liver.

Hepatitis B virus is a known carcinogen for hepatocellular carcinoma, which is rare in the pediatric population. We report a 13-year-old patient with hepatitis B surface antigen-positive multifocal hepatocellular carcinoma in a noncirrhotic liver. Her APRI score was 0.24. Her BCLC stage was C, and her caregiver opted for palliative care.

Audit of Radiology Request Form for Completion and Usefulness of Clinical History: Teaching Hospital Experience, Ghana.

BACKGROUND: The role of the "traditional" radiologist has shifted from imaging centered to patient focus, which underscores the utmost importance of the clinical radiologist in the multidisciplinary team in patient management. For the clinical radiologist to effectively play this key role, the referring clinician must provide adequate and useful patient information to assist the radiologist in making a diagnosis or provide differential diagnosis. The objectives were to assess the level of completion of the radiology request form and to determine whether the clinical history provided aided in the final impression/diagnosis. Materials and Method. We conducted a prospective review of 500 radiology request forms at the Cape Coast Teaching Hospital (CCTH) between September and October 2018. The forms were consecutively sampled and reviewed for each field/area such as patient's name, age, and clinical history. Data were analyzed descriptively for the level of completeness and usefulness of clinical history entered by the clinician. RESULTS: No request form was completed in full. All the request forms did not have X-ray serial number and previous examination details documented. The proportions of forms with various fields completed were as follows: more than 90% of the forms had patient's name, investigation required, date of the request, doctor's name, and clinical history fields filled. The patient's age, patient's ward/address, and doctor's address were filled in 88%, 75%, and 18.4%, respectively. Twenty percent of the request forms were not useful to the radiologist in the final diagnosis. CONCLUSION: A significant proportion of radiology request forms are incompletely filled and therefore denies the radiologist, the critical information needed to make a diagnosis, or narrow differential diagnosis.

Ketamine Use in Hysterosalpingography (the Jimah Procedure): A Follow-Up of Bilateral Tubal Evaluation of 27 Infertile Women at a Teaching Hospital, Ghana.

BACKGROUND: Pain, anxiety, and distress are common in radiological investigations including hysterosalpingogram (HSG). Studies suggest that sedation allows patients to better tolerate diagnostic imaging and image-guided procedures by relieving anxiety, discomfort, and pain. This study aimed at assessing the safety and effectiveness of ketamine use in HSG and the proportion of true positive bilateral tubal blockage during HSG using the Jimah Procedure. METHODS: We performed repeated HSG workup under IV ketamine (20-40 mg/mL) sedation for 27 infertile women at the Cape Coast Teaching Hospital. The exclusion criteria included unilateral tubular blockage, acute infection of the vagina or cervix, active vaginal bleeding, glaucoma, and high blood pressure at the time of the study. Data were entered with Microsoft Excel and analyzed using SPSS version 21. RESULTS: A total of 27 patients (age range: 25-48 years) previously diagnosed of bilateral tubal blockage or spasm were enrolled for the repeat HSG procedure. The median age was 34 years (IQR: 32-37), while secondary infertility (20) (74.1%) was the commonest indication. None of the patients reported of pain or distress during or after the procedure. Two (7.4%) women vomited after HSG. Twelve patients (44.4%) had bilateral tubal blockage (true positive), while tubal patency was seen in 15 (55.6%) patients on HSG under ketamine sedation. CONCLUSION: This study found IV ketamine sedation produces profound anesthesia and analgesia and eliminates tubal spasm. We recommend that radiologists in developing countries should consider sedating patients during HSG and documenting observations and patients' feedback to help assess safety and effectiveness in local settings.

Prenatal Diagnosis of Skeletal Dysplasia and Review of the Literature.

INTRODUCTION: Obstetric ultrasonography is routinely used to screen for fetal anomalies. Thanatophoric dysplasia (TD) is one of the common though rare lethal skeletal dysplasia, detected during routine ultrasound scan. TD is caused by a mutation in FGFR3 gene. Characteristic features include shortening of limbs, macrocephaly and platyspondyly. In our local setting, it is common to miss the diagnosis in the early scans due to lack of expertise of the sonographers. To the best of our knowledge, this is the first publication from Ghana. Case Presentation. We present the case of a 33-year-old woman who was referred to the facility on account of ultrasound scan report suggestive of thanatophoric dysplasia type 1 at 34 weeks of a female baby. The diagnosis was not made despite the mother being a regular antenatal attendant, until a fifth scan done at 34 weeks reported features suggestive of thanatophoric dysplasia. The ultrasound scan features included a biparietal diameter of 37weeks, femur length-24weeks, narrowed thoracic cage with hypoplastic lungs and short ribs. The liquor volume was increased with amniotic fluid index (AFI) of 38.4 cm. The femur, tibia, fibula, humerus, ulna, and radius were shortened (micromelia). The diagnosis of thanatophoric dysplasia type 1 was confirmed on autopsy. CONCLUSION: This report was aimed to highlight the potential contribution of ultrasound scan in the diagnosis of thanatophoric dysplasia in our setting.

Hysterosalpingography Findings and Jimah Ratio of the Uterine Cavity in Women with Infertility in Central Region, Ghana.

BACKGROUND: Infertility affects from 1.3% to 25.7% of couples worldwide and, especially, from 14.5% to 16.4% in Africa. Hysterosalpingography (HSG) is a diagnostic modality that is considered both common and efficient. It is used to investigate abnormalities of the uterine cavity and fallopian tubes. This study assessed the spectrum of findings on HSG among women with infertility in the Central Region (Ghana). METHODS: We conducted a prospective cross-sectional study to examine 203 infertile women undergoing HSG work-up at the Cape Coast Teaching Hospital. The exclusion criteria were acute infection of the vagina or cervix and active vaginal bleeding or pregnancy. Data were entered with Microsoft Excel and analyzed using SPSS version 21. RESULTS: A total of 203 women were enrolled, and eighty-five (41.87%) of the women had at least one or more abnormalities. The mean age was 32.9 years with majority of the women within 30-39 years (61.08%). More than half (50.74%) of the women presented with secondary infertility, while age of women (p=0.004) and duration of infertility (0.034) were found to be in association with the type of infertility. Uterine findings were predominantly capacious uterine cavity (45.1%) and uterine fibroids (33.3%), while fallopian tube findings included bilateral blockage (24.2%), right unilateral proximal blockage (17.7%), loculated spillage (16.1%), and left unilateral proximal blockage (16.1%). The range of normal uterine cavity size, measured as ratio (Jimah ratio) of intercornual diameter to interiliac diameter was 0.2-0.45, with a mean of 0.36. CONCLUSION: Secondary infertility was the commonest indication for HSG in the study, and a significant proportion of infertile women had abnormalities. Abnormalities were higher in the fallopian tubes than the uterus, while capacious uterine cavity, uterine fibroid, and bilaterally blocked tubes were the top three abnormalities found.

Competency in Chest Radiography Interpretation by Junior Doctors and Final Year Medical Students at a Teaching Hospital.

BACKGROUND: Chest radiography (CXR) is a widely used imaging technique for assessing various chest conditions; however, little is known on the medical doctors' and medical students' level of skills to interpret the CXRs. This study assessed the residents, medical officers, house officers, and final year medical students' competency in CXRs interpretation and how the patient's clinical history influences the interpretation. METHODS: We conducted a cross-sectional study in the Cape Coast Teaching Hospital in the Central Region of Ghana among 99 nonradiologists, comprising 10 doctors in residency programmes, 18 medical officers, 33 house officers, and 38 final year medical students. The data collection was done with a semistructured questionnaire in two phases. In phase 1, ten CXRs were presented without patient's clinical history. Phase 2 involved the same ten CXRs presented in the same order alongside the patient's clinical history. Participants were given 3 minutes to interpret each image. Median and interquartile ranges were used to describe continuous variables, while frequencies and percentages were used to describe categorical variables. Test of significant difference and association was conducted using a Wilcoxon rank-sum test/Kruskal-Wallis test and chi-square (X 2) test, respectively. RESULTS: The average score for interpreting CXRs was 7.0 (IQR = 5-8) and 4.0 (IQR = 3-4), when CXRs were, respectively, presented with and without clinical history. No significant difference was seen in average scores regarding the levels of formal training. Without clinical history, only 40.0% of residents, 22.2% of medical officers, 24.2% of house officers, and 13.2% of medical students correctly interpreted CXRs, while more than 75% each of all categories correctly interpreted CXRs when presented with clinical history. However, all participants had difficulties in identifying CXR with pneumothorax (27.3% vs. 30.3%), pneumomediastinum or left rib fracture (8.1% vs. 33.3%), and lung collapse (37.4% vs. 37.4%) in both situations, with and without patient clinical history. CONCLUSION: The patient's clinical history was found to greatly influence doctors' competence in interpreting CXRs. We found a gap in doctors' and medical students' ability to interpret CXRs; hence, the development of this skill should be improved at all levels of medical training.

A community-based ultrasound determination of normal thyroid volumes in the adult population, Assin North District, Ghana.

INTRODUCTION: the purpose of this study was to measure thyroid volumes among normal sub-population of Ghanaians using ultrasonography in order to help provide preliminary local thyroid gland volume reference data for use in Ghana. METHODS: this was a cross-sectional study in which the thyroid glands of 320 normal adults aged 18 to 95 years from six (6) communities in the Assin North District of Ghana were examined using ultrasonography. The volumes of the left and right lobes were summed to constitute the total thyroid volume. Information on socio-demographic characteristics and anthropometric parameters of subjects were also collected. The data were summarized using mean, standard deviation and proportions, whilst inferential analysis was done using the T-test, ANOVA test and Pearson correlation. RESULTS: of the 320 adults examined, 284 (88.8%) were found to have normal thyroid glands. This consisted of 164 females and 120 males whose mean ages were 42.3 (±15.9) years and 45.4 (±15.9) years respectively. The overall mean total thyroid volume (MTTV) was 6.8±2.5 mL. This was greater in the males (7.1±2.7 mL) than in the females (6.6±2.2 mL). The MTTVs for three age groups; 30-39 years (7.1±2.1), 40-49 years (7.3±2.8 mL) and 50-59 years (7.1±3.0 mL) were greater than the overall MTTV. Thyroid volume had a positive correlation with body surface area (BSA) (r=0.119, p=0.046), but not with body mass index (BMI) (r=-0.021, p=0.719). CONCLUSION: this study estimated local reference values much lower than the WHO/ICCIDD thyroid volume reference values. This calls for the need for nationally representative studies to inform the establishment of standard local reference values for Ghana.