Split cord malformation associated with congenital dermoid cyst and myeloschisis - case-based literature review on possible embryonic derivation and implications.

Split cord malformation co-existing with either congenital dermoid or myeloschisis has been previously reported. Theories exist which explain the underlying embryopathy behind the occurrence of each of these anomalies in conjunction with split cord malformation. However, the occurrence of all three anomalies in the same patient, to the best of our knowledge, has not yet been reported in the literature. We report two cases on the co-existence of congenital dermoid cyst with both myeloschisis and split cord malformation and review the literature on previous postulations of mechanisms that could possibly explain the simultaneous occurrence of all three distinct anomalies. They involve all three primary germ layers and therefore share a common embryonic origin from the epiblast. We try to explain their co-existence based on the theory of notochordal splitting and endomesechymal tract formation consequent on endodermal-ectodermal adhesion as postulated by Beardmore and Wigglesworth and discuss on implications in terms of treatment paradigms. The unusual combination of all three anomalies in both patients probably highlights a need for further research on their pathogenesis despite these previous theories. These cases demonstrate the fact that currently accepted embryological explanations of most pathologies especially outliers still fall short with much remaining to be understood.

Intracranial abscesses in children at Ile-Ife, Nigeria: a case series and review of literature.

PURPOSE: Central nervous system (CNS) infections are significant causes of morbidities and mortalities in children with some being prone to the development of abscesses which can either be within the brain parenchyma or located in extracranial structures. We aimed to describe the clinical profile and outcome of children with cranial abscesses at the Obafemi Awolowo University Teaching Hospital Complex (OAUTHC). METHODS: Consecutive cases presenting at the Children Emergency Ward of OAUTHC Ile-Ife were recruited. The pattern of presentation, predisposing factors and outcome of these children were studied. RESULTS: Among the 641 children admitted within a 6-month period, six were diagnosed with cranial abscess giving a hospital prevalence of 0.9%. The mean duration of symptom prior to presentation was 12.7 ± 13.4 days. Five (83.3%) of the patients had intracranial abscesses which were multiple in two (33.3%) children. One patient had Pott's puffy tumour following frontal sinusitis. Surgical management was done for two (33.3%), and this was by craniotomy and evacuation. Two of the patients died with a case fatality rate of 33.3%. CONCLUSION: Though uncommon, cranial abscesses remain life threatening in children especially in resource-poor settings. Early presentation and early treatment of local infections will improve outcome.

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.

Single-stage deformity correction in children with neurogenic kyphoscoliosis: nuances and a proposal for risk stratification.

OBJECTIVE Neurogenic kyphoscoliosis in pediatric patients has varied causes and diverse management options. The most common management strategy is to stage the orthopedic and neurosurgical aspects of the correction at an interval of 3-6 months from each other. The aim of this study was to report the authors' experience with correction of deformity in children with associated neurological abnormalities requiring intervention as a single-stage surgical treatment. METHODS Of 591 pediatric patients with scoliosis treated at the Amrita Institute of Medical Sciences and Research Centre between January 2001 and January 2011, the authors identified all patients with neurogenic kyphoscoliosis who underwent deformity correction and a neurosurgical procedure in the same surgical session when they were younger than 15 years. Data regarding the demographic details, preoperative Cobb angle/kyphotic angle, surgical details, postoperative complications, cost of the procedure, and long-term neurological outcome were collected for each case and analyzed. Based on the results of this analysis, the authors propose a 2-category risk stratification system for the timing of deformity correction depending on the primary neurogenic etiology. RESULTS Ten cases involving patients with neurogenic kyphoscoliosis requiring both deformity correction and neurosurgical procedure met the criteria and were included in the analysis. All 10 patients were younger than 15 years; their mean age was 10.8 years. The average Cobb angle was 59.5°. Five patients underwent foramen magnum decompression, 5 patients underwent spinal cord detethering, and 1 patient had intraspinal intradural tumor excision. The mean estimated blood loss was 1177 ml (range 700-1550 ml), and the mean operative time was 4.4 hours (range 3-5.5 hours). There were no intraoperative complications. None of the patients had any new postoperative neurological deficits. The mean postoperative Cobb angle of the main thoracic curve was 12.6°. CONCLUSIONS Simultaneous deformity correction along with a definitive neurosurgical procedure in patients with neurogenic kyphoscoliosis can be performed without added morbidity and avoids both the added costs and the risk of complications associated with a second surgery. The risk stratification system proposed in this paper may serve as a guideline for case selection and help to optimize outcome.

An Analysis of Outcome of Endoscopic Fenestration of Cavum Septum Pellucidum Cyst - More Grey than Black and White?

BACKGROUND: Cavum septum pellucidum (CSP) and cavum vergae are actually fluid-filled, generally communicating midline cavities located between the third ventricle and corpus callosum. There have been various reports of their association with many behavioral and psychiatric disorders. Infrequently, they have been associated with an obstructive hydrocephalus-like picture. Although the structure and management of CSP has long been known, it has been an enigma as far as functional significance and management indications are concerned. The authors of this article try to analyze the significance of a persistent cavum and involvement of the same entity in varied presentations ranging from an incidental imaging finding to acute hydrocephalus, and propose a possible implication on the present surgical intervention paradigm. PURPOSE: To assess the surgical outcome of fenestration of a CSP cyst. METHODS: Retrospective analysis of 3 patients who underwent endoscopic fenestration for CSP with obstructive hydrocephalus between 2012 and 2014 was done, and data were analyzed for symptomatic clinical improvement in particular behavior. RESULTS: Pre- and postoperative brain MRI showed a significant decrease in the size of the cyst as well as the ventricles. There were no recurrences during follow-up. All of the patients improved. CONCLUSIONS: (1) Endoscopic fenestration of symptomatic CSP cysts is a safe treatment option. (2) Neurocognitive assessment is essential in the evaluation and outcome assessment of CSP.

The debate on most ideal technique for managing recurrent lumbar disc herniation: a short review.

BACKGROUND: Though different techniques have been successfully employed in the treatment of recurrent lumbar disc herniation, the one which should be considered most ideal has remained a controversy, particularly since there are currently no generally accepted guidelines for surgical care. OBJECTIVE: To review previous publications comparing the available operative options, with the aim of determining if any of the available interventions gives better outcomes compared to others. METHODS: A systematic literature review of previous publications comparing various techniques employed in the surgical treatment of recurrent disc herniation. RESULTS: All publications investigated in this review clearly demonstrated quite comparable outcomes, with no superiority of one method over the other. CONCLUSION: In view of the currently available data and evidence, minimally invasive techniques for revision of recurrent disc herniation do not really appear to be superior to the conventional open surgical approaches and vice-versa. We suggest the management strategy for surgical treatment of each case of recurrence to be simply based on the experience of the surgeon, the available facilities and equipment. Fusion should not be undertaken in all recurrences but should only be considered as an option for revision when spinal instability, spinal deformity or associated radiculopathy is present.

Customizable rigid head fixation for infants: technical note.

INTRODUCTION: The need and advantages of rigid fixation of the head in cranial surgeries are well documented (Berryhill et al., Otolaryngol Head Neck Surg 121:269-273, 1999). Head fixation for neurosurgical procedures in infants and in early years has been a challenge and is fraught with risk. Despite the fact that pediatric pins are designed, rigid head fixation involving direct application of pins to the head of infants and slightly older children is still generally not safe (Agrawal and Steinbok, Childs Nerv Syst 22:1473-1474, 2006). Yet, there are some surgeries in which some form of rigid fixation is required (Agrawal and Steinbok, Childs Nerv Syst 22:1473-1474, 2006). We describe a simple technique to achieve rigid fixation of the head in infants for neurosurgical procedures. TECHNICAL NOTE: This involves applying a head band made of Plaster of Paris (POP) around the head and then applying the fixation pins of the fixation frame directly on to the POP. CONCLUSION: We have used this technique of head fixation successfully for infants with no complications.

Beckwith-Wiedemann syndrome and Chiari I malformation--a case-based review of central nervous system involvement in hemihypertrophy syndromes.

BACKGROUND: Beckwith-Wiedemann syndrome (BWS) is an unusual complex of abnormalities that includes mainly omphalocele, macroglossia, gigantism, visceromegaly, and neonatal hypoglycemia. Type I Chiari malformation, on the other hand, is defined as ectopia of the cerebellar tonsils below the plane of the foramen magnum. Only one case of association of BWS with Chiari I malformation has been previously reported in the literature. DISCUSSION: Several conditions involving congenital hemihypertrophy have been previously reported in association with Type I Chiari malformation. The pathophysiological mechanism for most of these associations is thought to be quite complex and still remains unclear. However, the presence of tonsillar herniation in BWS has been explained by Tubbs and Oakes in the only one existing case report of BWS with Type I Chiari malformation in the literature, to be due to associated hemihypertrophy of the skull base. We additionally suggest that cerebellar hypertrophy may also contribute to the tonsillar herniation and fourth ventricular outlet obstruction. ILLUSTRATIVE CASE: We now report our recent experience on this association following a review of the literature on association of other hemihypertrophy syndromes with the central nervous system anomalies. CONCLUSION: We believe that a common pathogenesis of Type I Chiari malformation occurs in conditions of hemihypertrophy including BWS, probably secondary to dysmorphology involving the posterior cranial fossa, and is not just an associated finding.

Neurocysticercosis in a Nigerian woman -missed diagnosis of a neglected disease and surgical management.

Neurocysticercosis is a rarely diagnosed but significant clinical problem from infestation with taenia solium. It occurs as a result of ingestion of infested pork and the mode of transmission is usually feco-oral. It is commonly associated with non-specific neurologic manifestations expected of intracranial space-occupying lesions with its most common neurological presentation being seizures. However, its diagnosis without seizure is rarely reported. We report a recent experience in this regard and outcome of this disease which was inadvertently managed surgically. A good history and high index of suspicion especially in developing and low socioeconomic region is helpful for diagnosis in the presence of appropriate radiological findings. Prognosis is good when treatment is tailored to well selected cases. Treatment options include medical with or without surgical removal of encapsulated cyst. A high index of suspicion will be helpful in making appropriate diagnosis and proper management of this disease.

A Geospatial Analysis of the Availability, Distribution, and Accessibility of Neurosurgical Facilities, Workforce, and Infrastructure in Nigeria; and Projection Towards 2050.

OBJECTIVE: There has been a modest but progressive increase in the neurosurgical workforce, training, and service delivery in Nigeria in the last 2 decades. However, these resources are unevenly distributed. This study aimed to quantitatively assess the availability and distribution of neurosurgical resources in Nigeria while projecting the needed workforce capacity up to 2050. METHODS: An online survey of Nigerian neurosurgeons and residents assessed the country's neurosurgical infrastructure, workforce, and resources. The results were analyzed descriptively, and geospatial analysis was used to map their distribution. A projection model was fitted to predict workforce targets for 2022-2050. RESULTS: Out of 86 neurosurgery-capable health facilities, 65.1% were public hospitals, with only 17.4% accredited for residency training. Dedicated hospital beds and operating rooms for neurosurgery make up only 4.0% and 15.4% of the total, respectively. The population disease burden is estimated at 50.2 per 100,000, while the operative coverage was 153.2 cases per neurosurgeon. There are currently 132 neurosurgeons and 114 neurosurgery residents for a population of 218 million (ratio 1:1.65 million). There is an annual growth rate of 8.3%, resulting in a projected deficit of 1113 neurosurgeons by 2030 and 1104 by 2050. Timely access to neurosurgical care ranges from 21.6% to 86.7% of the population within different timeframes. CONCLUSIONS: Collaborative interventions are needed to address gaps in Nigeria's neurosurgical capacity. Investments in training, infrastructure, and funding are necessary for sustainable development and optimized outcomes.

Assessing the Neurosurgical Capacity in Nigeria Using the Modified Neuro-PIPES Tool.

BACKGROUND: Like many low- and-middle-income countries in Africa, documented assessment of the neurosurgical workforce, equipment, infrastructure, and scope of service delivery in Nigeria is lacking. This study aimed to assess the capacity for the delivery of neurosurgical services in Nigeria. METHODS: An 83-question survey was disseminated to neurosurgeons and residents in Nigeria. We report the findings from the capacity assessment section of the survey, which used the modified neurological-PIPES (personnel, infrastructure, procedures, equipment, and supplies) (MN-PIPES) tool to evaluate the availability of neurosurgical personnel, infrastructure, procedures, equipment, and supplies. A comparative analysis was done using the domain and total MN-PIPES scores and MN-PIPES index. RESULTS: The national average MN-PIPES score and index were 176.4 and 9.8, respectively. Overall, the southwest and northwest regions had the highest scores and frequently had high subscores. The survey respondents reported that the main challenges impeding neurosurgery service delivery were a lack of adjunctive supplies (75.2%), a dearth of diagnostic and interventional equipment (72.4%), and an absence of a dedicated intensive care unit (72.4%). CONCLUSIONS: The availability of workforce, infrastructure, equipment, and supplies needed to provide optimal neurosurgical care is uneven in many institutions in Nigeria. Although major strides have been made in recent years, targeted collaborative interventions at local, national, regional, and international levels will further improve neurosurgical service delivery in Nigeria and will have positive ripple effects on the rest of the healthcare system.

Women in Nigerian Neurosurgery: A Cross-Sectional Survey.

BACKGROUND: Although women have made remarkable strides in several medical specialties in Sub-Saharan Africa, their presence and contribution to the development of neurosurgery remain limited. We sought to study the gender differences within Nigerian neurosurgery, identify challenges resulting from these differences, and recommend how African female neurosurgeons can maximize their effects in neurosurgery. METHODS: A structured online survey captured data on neurosurgical infrastructural capacity, workforce, and training from neurosurgical consultants and residents in neurosurgical centers in Nigeria. All the collected data were coded and analyzed. RESULTS: Altogether, 82 neurosurgical consultants and 67 neurosurgical residents from 50 primary medical institutions in Nigeria completed the online survey. Only 8 of the respondents (5.4%) were women, comprising 3 consultants, 2 senior residents, and 3 junior residents. Although 40.2% of the respondents did not believe that being female affected the decision of whether to specialize in neurosurgery, 46.3% believed that being female was a disadvantage. Most did not believe that being female affected admission (57.8%), completion of a neurosurgery residency (58.5%), or life working as a neurosurgeon after graduation (63.4%). The most common challenges women face while navigating through neurosurgery training and practice are erosion of family and social life, lack of female mentors, and lack of a work-life balance. CONCLUSIONS: There is a deficit of both female consultants and trainees among Nigerian neurosurgeons. Identifying female medical students with a strong interest in neurosurgery and providing early mentorship might increase the number of female neurosurgeons.

Sellar brain tumour co-existing with a left posterior communicating aneurysm causing ptosis: lessons learnt (case report).

Posterior communicating aneurysm (PCOM) commonly presents with ptosis of the eye. This is so also with space occupying lesion compressing the oculomotor nerve. It is quite uncommon for a patient to have both lesions at the same anatomical space concurrently causing ptosis. If undiagnosed before surgical intervention, surgical complications from such a complex neurosurgical problem can be extremely devastating. We share our recent experience with confusing clinical presentation and subsequent treatment of a sellar brain mass co-existing with a left posterior communicating artery aneurysm at the same location in a 48 years old woman who was successfully managed with left pterional craniotomy and clipping of the PCOM aneurysm followed by gross total excision of the lesion. She improved with full resolution of left ptosis within 2 months. The histology revealed WHO Grade 1 psammomatous meningioma. Although similar sorts of pathologies occurring together have been described in the literature, this unique experience underscores the importance of thoroughly evaluating neurosurgical cases clinically irrespective of findings from radiologic investigations in order to prevent unexpected intra-operative disasters and embarrassment. Moreso, this is important particularly in Africa where advanced investigations to easily identify such complex pathologies are not readily available.

Proposal of a Novel Anatomic Guide to the Sphenoid Sinus.

BACKGROUND: Landmarks for transsphenoidal surgery have been described to facilitate resection for pituitary lesions. However, carrying out sphenoidotomy for access to the sellar floor could still be challenging, especially for young surgeons during the steep learning curve. OBJECTIVE: We describe the LUTH (Lagos University Teaching Hospital) line as a simple anatomic guide to avoid missing the trajectory to the sella during anterior sphenoidotomy in microscopic transsphenoidal pituitary surgery. METHODS: We identified this line as an impression on the floor of the sphenoid sinus across the point at which the floor of the anterior cranial fossa and the bony projection from the clivus meet. We carried out a literature review of articles describing landmarks for anterior sphenoidotomy using data obtained from PubMed and Ovid MEDLINE databases according to PRISMA guidelines. RESULTS: A total of 80 patients were operated using the LUTH line as a guide for anterior sphenoidotomy during microscopic transsphenoidal pituitary. We did not find any previous description of this anatomic landmark over the anterior sphenoid sinus in the literature. The LUTH line was clearly identified in all 80 cases. The line was used as a bony landmark to the sphenoid sinus in all cases and was found to be consistently accurate. CONCLUSIONS: The LUTH line is a consistent and easy-to-identify landmark that could be useful in preventing potential complications of access to the pituitary sella through the sphenoid sinus. We believe it to be useful in the absence of intraoperative guidance, especially for young surgeons who are just starting off their career in pituitary surgery.

Surgical management of Aneurysmal Subarachnoid Haemorrhage in a resource-constrained region: A Nigerian regional experience.

Background: Aneurysmal Subarachnoid Haemorrhage (aSAH) is a vascular injury with significantly high mortality, especially when poorly managed. This study seeks to outline the experiences in setting up a neurovascular service in Lagos, Nigeria. Methods: A series of 45 patients were operated after aSAH over a period of 10 years. Patients consecutively were recruited following computed tomography angiography (CTA) diagnosis of aSAH. Clinical data were recorded on a predesigned form after obtaining informed consent; aSAH was classified using the WFNS classification, intraoperative findings were documented. Challenges in the management were analysed in a post-operative root cause analysis (RCA) review. Outcomes and factors responsible for the observed outcomes and actions taken were recorded. Results: Forty-five patients were operated after aSAH was confirmed; there were 29 females and 16 males. (M:F 1:1.8), the age ranged from 14 to 76 years (mean 49.1±13.58). All the aneurysms were on the anterior circle of Willis, mainly on Anterior Communicating Artery aneurysm (18/48).Thirty-eight patients (84.4%) survived and were discharged within an average of 10 days after surgery. Lower GCS at presentation was associated with poor prognosis (p = 0.026); however, data analysis demonstrated that other factors (financial issues, lack of appropriate instrumentation and equipment, experience of the surgeon) played a significant role in determining the outcome. Conclusions: Aneurysmal Subarachnoid Haemorrhage (aSAH) is a challenging pathology and its management may be further burdened in resource constrained countries, as shown by the data analysed in this study from Lagos, Nigeria. Specialized and well-funded Neurovascular centres are needed to overcome the challenges faced and to improve care for aSAH patients in Nigeria.

The status of specialist neurosurgical training in Nigeria: A survey of practitioners, trainers, and trainees.

OBJECTIVE: Despite the well-known neurosurgical workforce deficit in Sub-Saharan Africa, there remains a low number of neurosurgical training programs in Nigeria. This study sought to re-assess the current status of specialist neurosurgical training in the country. METHODS: An electronic survey was distributed to all consultant neurosurgeons and neurosurgery residents in Nigeria. Demographic information and questions relating to the content, process, strengths, and challenges of neurosurgical training were explored as part of a broader survey assessing neurosurgical capacity. Descriptive statistics were used for analysis. RESULTS: Respondents identified 15 neurosurgical training centers in Nigeria. All 15 are accredited by the West African College of Surgeons (WACS), and 6 by the National Postgraduate Medical College of Nigeria (NPMCN). The average duration of core neurosurgical training was 5 years. Some identified strengths of Nigerian neurosurgical training included learning opportunities provided to residents, recent growth in the neurosurgical training capacity, and satisfaction with training. Challenges included a continued low number of training programs compared to the population density, lack of subspecialty training programs, and inadequate training infrastructure. CONCLUSION: Despite the high number of neurosurgery training centers in Nigeria, compared to other West African countries, the programs are still limited in number and capacity. Although this study shows apparent trainee satisfaction with the training process and contents, multiple challenges exist. Efforts at improving training capacity should focus on continuing the development and expansion of current programs, commencing subspecialty training, driving health insurance to improve funding, and increasing available infrastructure for training.

The role of international collaborations in sustainable neurosurgical development in Nigeria.

OBJECTIVE: Despite six decades of existence, neurosurgery is still in the developing stages in Nigeria. In this era of collaborative health system capacity-building in low- and middle-income countries, this article reviews past efforts and future prospects for collaborative neurosurgical development in Nigeria. METHODS: A bibliometric review of the Nigerian neurosurgical literature and data from a structured survey of Nigerian neurosurgeons and residents provided details of current local and international collaborations for neurosurgical research, service delivery, training, and capacity building. These were analyzed to provide an overview of the role of collaborations in sustainable neurosurgical development in Nigeria and to recommend approaches to enhance neurosurgical capacity. RESULTS: In 1023 peer-reviewed neurosurgery publications from Nigeria, there were 4618 authors with 3688 from 98 Nigerian institutions and 930 from 296 foreign institutions in 70 countries. While there were significant research collaborations amongst Nigerian institutions, the most common were with institutions in the US, UK, and Cameroon. From the survey, 62 of 149 respondents (41.6%) from 32 health facilities noted their institution's involvement in capacity-building neurosurgical collaborations. These collaborations involved 22 Nigerian institutions and 13 foreign institutions in 9 countries and were mostly for training and workforce development (78.1%), and research and data management (59.4%). The majority of foreign institutions were from the US and UK. CONCLUSION: Current and previous neurosurgical collaborations have led to sustainable progress in Nigeria. Further local, regional, and international collaborations would enhance the capacity to address the needs and challenges affecting neurosurgery in Nigeria.

Review of pharmacological treatment of depression in patients with primary brain tumour and proposal of modification in management strategy.

This brief paper describes the challenges with treatment of depression in brain tumour patients particularly in the absence of any currently accepted guidelines for treating this perculiar subset of patients. The proposal offered here is to move to pharmacologic treatment with other modalities in a methodical pattern only after surgical intervention. This is because simply treating with medications based on physician / patient choice as currently recommended may not achieve optimal results in majority of cases in view of the multiple aetiological factors that interplay. A flowchart treatment plan is presented to guide management in a streamlined fashion.

Strategies for Treatment of Multiple Brain Aneurysms Without Intraoperative Adjuncts.

BACKGROUND: Although fairly rare, multiple brain aneurysms are well known to occur in certain conditions such as arteriovenous malformations, coarctation of the aorta, renal artery stenosis, adult type 3 polycystic kidney disease, as well as connective tissue disorders (such as Ehlers-Danlos syndrome, Marfan syndrome, and fibromuscular dysplasia). Increased incidence of complications of surgery in such situations is expected to be more likely than in surgery for a single aneurysm, particularly in the absence of intraoperative guidance with adjuncts. METHODS: We report a case of an anterior communicating artery aneurysm, a right middle cerebral artery aneurysm, and a right pericallosal aneurysm in a 70-year-old man. All 3 aneurysms were clipped through a single-stage approach without the aid of any adjuncts such as micro-Doppler ultrasonography, indocyanine green videoangiography, or intraoperative digital subtraction angiography. We carried out a literature review for past publications on similar reports. RESULTS: The patient made a complete postoperative recovery and sustained no neurologic deficits. Out of 388 publications from the literature search, only 1 case report described clipping of 2 tandem aneurysms in a 60-year-old woman without mentioning any intraoperative adjuncts. CONCLUSIONS: This case illustrates that multiple aneurysms can actually be safely operated with adequate planning in the absence of these adjuncts, especially in resource-poor regions. This is particularly crucial in Africa and most low-and-middle-income countries, where such facilities and equipment are not common.