Seasonal trend in the occurrence of myelomeningocele in nigeria: a hypothesis of climate-induced oxidative stress.

PURPOSE: Myelomeningocele is the most severe birth defect compatible with long-term survival. It accounts for 5.7% of neurological surgeries in Nigeria. However, the exact cause of this neural tube defect remains unidentified. This study aims to determine if seasonal variation is a potential environmental contributor. METHOD: This study prospectively recruited 242 children diagnosed with myelomeningocele at the University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria, between January 2010 and December 2022. Our primary outcome was the seasonal occurrence of myelomeningocele, while covariates included gender, birth order, maternal folic acid supplementation (FAS), and parental age. The estimated month of conception was derived from the mother's last menstrual period (LMP), and the occurrence of myelomeningocele across the various seasons in which these babies were conceived was assessed using the Lorenz curve and the Gini coefficient. RESULTS: 242 patients were studied with a male-to-female ratio of 1.26. The majority of cases were lumbosacral (93.4%), and none of the mothers commenced FAS before conception. The highest proportion of cases (39.7%) occurred during the hottest period of the dry season (January-March), while the lowest proportion (15.7%) occurred during the early wet season (April-June). The Gini index of 0.29, and the Gini coefficient derived from 100,000 Monte Carlo simulations of 0.24, indicate a significant variation in the distribution of myelomeningocele cases across different seasons of conception. CONCLUSION: The seasonal occurrence of myelomeningocele with a peak in January-March suggests a potential association with environmental factors including oxidative stress induced by solar radiation.

Pilot application of Lecture-Panel-Discussion Model (LPDM) in global collaborative neurosurgical education: a novel training paradigm innovated by the Swedish African Neurosurgery Collaboration.

BACKGROUND: Disruptions in global surgery educational routines by the COVID-19 pandemic have elicited demands for alternative formats for rendering qualitative neurosurgical education. This study presents application of a novel model of online neurosurgical course, the Lecture-Panel-Discussion Model (LPDM). METHODS: This is a cross-sectional survey of participants who attended the Swedish African Neurosurgery Collaboration (SANC)-100A course. Participants evaluated the course through an online self-administered questionnaire using a 5-point Likert scale ranging from very poor-1, poor-2, average (fair)-3, good-4, to excellent-5. SANC-100A comprises a tripod of Lectures, Panel review, and interactive case Discussion. This model (LPDM) was innovated by SANC and applied at the Enugu International Neurosurgery course in February 2021. RESULTS: There were 71 attendees, 19 were course faculty, while 52 were participants. Thirty-five attended from Nigeria, 11 from Sweden, 3 from Malawi, 2 from Senegal, and 1 from the UK. Among 44 participants who completed the questionnaire, there were 9 fellows and 35 residents. The overall median course Likert rating was 4.65 ± 0.1. The median overall rating for course events was similar between day 1 (Likert score = 4.45) and day 2 (Likert score = 4.55), U = 55, Z score = 1.10, P = 0.27. The median rating for lectures was 4.50 ± 0.2 and varied from 4.40 on day 1 to 4.55 on day 2. The median rating for panel review was 4.60 ± 0.1 and varied from 4.55 on day 1 to 4.65 on day 2. Interactive case discussions were rated 4.80 on both course days. There was a significant variability in the rating profiles of the course tripod: U = 24.5, P = 0.03. Fifty-one (98%) participants believe LPDM was COVID-19-compliant, while 90% believe the course was beneficial to training and practice. CONCLUSION: Initial application of LPDM is rewarded with both high acceptance and high rating among participants.

Improving capacity and access to neurosurgery in sub-Saharan Africa using a twinning paradigm pioneered by the Swedish African Neurosurgical Collaboration.

BACKGROUND: The unmet need for neurosurgery in sub-Saharan Africa is staggering. Resolving this requires strategies that synergize salient local resources with tailored foreign help. This study is a trial of a twinning model adopted by the Swedish African Neurosurgical Collaboration (SANC). METHODS: A multi-step neurosurgical twinning technique, International Neurosurgical Twinning Modeled for Africa (INTIMA), developed through a collaboration between African and Swedish neurosurgical teams was adopted for a neurosurgical mission in March 2019. The pioneering steps are evaluated together with data of treated patients prospectively acquired using SPSS Chicago Inc., Version 23. Associations were analyzed using chi-square tests, while inferences were evaluated at 95% level of significance. RESULTS: The SANC global neurosurgery mission targeted microsurgical brain tumor resection. Fifty-five patients were operated on during the mission and subsequent 3 months. Patients' ages ranged from 3 months to 69 years with a mean of 30.6 ± 2.1 years 95% CL. Seven cases were performed during the first mission, while 48 were performed after the mission. Compared to 3 months before SANC when only 9 brain tumors were resected, more tumors were resected (n = 25) within the 3 consecutive months from the mission (X2 = 14.2, DF = 1, P = 0.000). Thirty-day mortality following tumor resection was also lower, X2 = 4.8, DF = 1, P = 0.028. CONCLUSION: Improvements in capacity and short-term outcome define our initial pioneering application of a neurosurgical twinning paradigm pioneered by SANC.

Endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) in non-communicating hydrocephalus (NCH): comparison of outcome profiles in Nigerian children.

BACKGROUND: Endoscopic third ventriculostomy (ETV) and ventriculo-peritoneal shunt (VPS) although recognized surgical options for non-communicating hydrocephalus have debatable applications. OBJECTIVE: We analysed a prospective cohort of age-matched children with non-tumor, non-communicating hydrocephalus treated with the two surgical modalities using clinically measurable parameters. METHODS: A single institution analysis of age-matched patients with non-communicating hydrocephalus treated with VPS or ETV over a 3-year period. Occipitofrontal circumference (OFC), milestone, shunt independence as well as complication profiles of patients were recorded and analysed. Mean follow-up period was 1.27 ± 0.19 years 95%CI). Data analysis were performed using SPSS version 15, Chicago, IL. Statistical tests were set at 95% significance level. RESULTS: Fifty-five patients were enrolled, 25 patients had ETV, while 30 had VPS. Mean age was 2.3 ± 0.7 years (95% CI) with a range of 3 months to 4.5 years. Aqueductal stenosis was the most common indication. OFC profile decline was significant among the VPS group when compared with ETV group at 3 months follow-up (χ2 = 7.59, df = 1, p < 0.05). There was no difference among the two treatment groups χ2 = 2.47, df = 1, p > 0.05) in milestone profile. Thirteen percent of VPS, compared to (4%) ETV patients, had sepsis (χ2 = 4.59, df = 1 p < 0.05). Ninety-two percent of ETV patients remained shunt free, while 80% of shunted patients achieved ETV independence. Two patients died among the VPS group compared to one patient in the ETV group. CONCLUSION: VPS compared to ETV is associated with an earlier milestone and OFC response. ETV is associated with lower rates of sepsis and mortality.

Correlation of the transorbital ultrasonographic optic nerve sheath diameter with intracranial pressure measured intraoperatively in infants with hydrocephalus.

OBJECTIVE: Hydrocephalus is a highly significant global public health concern. In infants, it may be associated with a potentially deleterious increase in intracranial pressure (ICP). Currently, the gold standard for accurate monitoring of ICP is an intraventricular ICP monitor, but this method is invasive and expensive. Transorbital ultrasound measurement of the optic nerve sheath diameter (ONSD) may provide a noninvasive and cost-effective alternative method for monitoring ICP. The goal of the study was to determine the extent of the correlation between ultrasonographic ONSD and ICP in infants. METHODS: A prospective observational study of 47 children with hydrocephalus aged ≤ 18 months was performed. The ONSD was measured with a transorbital ultrasound scan, while the intraventricular CSF opening pressure was assessed using a manometer during ventriculoperitoneal shunt insertion. Data were analyzed using SPSS software. The ONSD and ICP measurements were correlated, the receiver operating characteristic (ROC) curve was evaluated, and a sensitivity analysis was performed. Inferences were made using the 0.05 alpha level of significance. RESULTS: The mean age of the study cohort was 4.8 ± 4.3 months, and 93.6% of patients were infants. The mean ONSD was 4.5 ± 0.7 mm (range 2.9-6.0 mm), and the mean ICP was 19.9 ± 6.5 mm Hg (range 5.2-32.4 mm Hg). Both ONSD and ICP increased with increasing age. The Pearson correlation coefficient revealed a strong positive correlation between ONSD and ICP (r = 0.77, p < 0.001). The ONSD cutoff points were 3.2 mm, 4.0 mm, and 4.6 mm for patients with ICPs of 10 mm Hg, 15 mm Hg, and ≥ 20 mm Hg, respectively. The sensitivity of ONSD was 97.7% (area under the ROC curve 0.99), and for every 14.3-mm Hg increase in ICP, the ONSD increased by 1.0 mm holding age constant. CONCLUSIONS: ONSD has a strong positive correlation with ICP. Correspondingly, ONSD is highly sensitive in estimating ICP.

Smartphone Ocular Fundal Photography in the Diagnosis of Raised Intracranial Pressure: A Novel Adaptation to Neurosurgical Practice.

Background Consistently raised intracranial pressure (ICP) is a common final pathway to morbidity/mortality in many neurosurgical conditions. This underscores the need for early diagnosis and prompt management of raised ICP. This study aims to determine whether smartphone fundal photography features of raised ICP can accurately predict the computed tomography (CT) findings suggestive of elevated ICP in neurosurgery patients. Methods Dilated ocular fundal photography examinations using an ophthalmoscope adapter mounted on a smartphone were done on 82 patients with clinical suspicion of raised ICP. Fundal photography findings were recorded as pictures/videos for disc analysis. Patients subsequently had neuroimaging with results analyzed for radiological features of raised ICP. These were correlated with fundal photography findings. Results A total of 82 adult patients participated in this study. Chi-square analysis showed a relationship between radiological signs of raised ICP and the absence of spontaneous retinal venous pulsation (SRVP) (p=0.001). There was no relationship observed between papilledema and radiological signs of raised ICP. However, when the fundal photography signs were aggregated, there was a significant relationship between the fundal signs of raised ICP and radiological signs of raised ICP (p=0.004). The sensitivity and specificity of smartphone-fundoscopy-detected papilledema in predicting radiological signs of raised ICP were 43.2% and 100%, respectively, while those of absent SRVP were 100% and 92.6%, respectively. Conclusion Smartphone ophthalmoscopy is a reliable screening tool for evaluating ICP in neurosurgical patients. It should be introduced into the neurosurgeon's tools for prompt evaluation of raised ICP, especially in developing/resource-poor settings where CT or magnetic resonance imaging is not readily available.

Predictors of Outcome Following Interventions for Ruptured Intracranial Aneurysms in an Emerging Health Institution in West Bengal: A 6-Year Experience.

BACKGROUND: Microsurgical clipping and endovascular coiling have remained over the past half-century, the main options for definitive treatment of ruptured intracranial aneurysms. However, recent advances in endovascular techniques have broadened their application stimulating much debate regarding the usefulness of microsurgical options. For locations with limited capacity or evolving endovascular service, however, microsurgical treatment offers not only cost-effective and durable options but also oftentimes the only option available for most patients. MATERIALS AND METHODS: This was a single institution questionnaire-based retrospective study from West Bengal India. It was performed on patients with aneurysmal rupture managed from June 2010 to October 2016. Data analysis was performed with SPSS for Windows, version 21. RESULTS: One hundred and ten patients were studied. The mean age was 50.8 years (standard deviation [SD] ±13.5) for females and 50.2 (SD ± 12.4) for males (P = 0.8112, t-test). Ninety (81.8%) patients received microsurgical clipping. Microsurgical options such as wrapping, bypass, and excision were performed for 9 (8.2%) patients. Coiling was performed for 11 (10%) patients. ACOM was the most common site for ruptured aneurysm. Ictus-intervention interval (χ2 = 10.034, P = 0.007) and multiple surgical procedures (χ2 = 8.9341, P = 0.003) were the significant outcome determinants. Overall, 72.7% of those treated had a good outcome (Glasgow Outcome Score of 4 and 5). The good outcome was higher among microsurgery groups (73.7%) compared to the coiling group (63.6%) but this difference did not achieve statistical significance (χ2 = 0.46 P = 0.4976). CONCLUSION: Microsurgical options achieved good outcomes in the management of ruptured aneurysms in our series. Their availability makes them first-line options for low-income settings.

The Ebb and Flow of Neurosurgery in a Re-Emerging Sub-Saharan Center. Lessons from 1025 Consecutive Operated Cases and Progress Models. A Prospective Observational Cohort Study.

BACKGROUND: The evolution of neurosurgery in our center comprises 2 active phases separated by a decade-long latent phase. This study evaluates our experience in the renaissance phase using 1025 cases. We identify paradigms that predict progress under existing practice conditions. METHODS: A prospective observational study was undertaken of all freshly operated patients from 2009 to 2016. Ethical approval was obtained from the hospital institutional review board. Data of enrolled patients were acquired and analyzed using SPSS software for Windows version 21. Inferences were evaluated using a 95% level of significance. Major and intermediate cases were included, whereas bedside cases as well as patients operated on elsewhere were excluded. RESULTS: Of 5132 patients treated, 3033 had surgical lesions, 1129 (33.2 ± 2.7% confidence limit [CL]) were operated on, and 1025 satisfied the study criteria. The unmet surgical load (66.1%) was significant (χ2 = 10.9; degree of freedom = 1; P = 0.001). The most common diseases treated were neurotrauma in 438 patients, congenital malformations in 268, and tumors in 170. The mean annual operative rate was 125 ± 5.7 patients (95% CL). Cases showed significant variability using 1-way analysis of variance (F = 13.77; P = 0.03). Residency training was a positive influence on surgeons' operative rate (χ2 = 7.59; P = 0.02). The mean complication rate was 10.3% ± 2.9%, and the mortality was 5.5% ± 1.7%. CONCLUSIONS: We found a large unmet neurosurgical load. To resolve this situation, we recommend an increase in the number of training programs for neurosurgery residency. As neurosurgery units evolve, their progress may be evaluated using the NESCAPE (Neurosurgery Care Phase Evolution) paradigm.

Civilian Penetrating Gunshot Injury to the Neurocranium in Enugu.

INTRODUCTION: Civilian penetrating gunshot injuries to the neurocranium are no longer uncommon in Nigeria. Such injuries are however poorly reported. They are associated with poor outcome and, at close range, are frequently fatal, especially when inflicted by high-velocity weapons. Prompt transfer to neurosurgical service and urgent intervention may improve outcome in those that are not mortally wounded. MATERIALS AND METHODS: Fifty-two patients with civilian penetrating gunshot wounds seen over a 10-year period (2004-2014) at the University of Nigeria Teaching Hospital and Memfys Hospital for Neurosurgery Enugu were reviewed retrospectively, and their data were analyzed to evaluate factors that impacted on outcome. Only patients with clinical and imaging evidence of cranial gunshot injuries who reached hospital alive were included in the study. The overall mortality and Glasgow outcome score were analyzed. RESULTS: Fifty-two patients with isolated civilian penetrating gunshot wounds were identified (M:F = 7.7:1); mean (standard deviation) age was 32.8 (11.9) years. There was a high correlation (0.983) between the sex of the patients and the outcome. The overall mortality was 30.8%, whereas the mortality for patients with postresuscitation Glasgow coma scale (GCS) score ≤8 was 57%, as against 12.9% in those in whom postresuscitation GCS was >8; meaning that 87.1% of patients in whom postresuscitation GCS was >8 survived. Thirty-one patients (59.6%) had papillary abnormalities. Majority of patients with monohemispheric lesions survived while all those with diencephalic, transventricular, and posterior fossa involvement had 100% mortality. CONCLUSIONS: Admitting GCS and bullet trajectory were predictive of outcome.

Civilian penetrating gunshot injury to the neurocranium in Enugu

Introduction: Civilian penetrating gunshot injuries to the neurocranium are no longer uncommon in Nigeria. Such injuries are however poorly reported. They are associated with poor outcome and, at close range, are frequently fatal, especially when inflicted by high-velocity weapons. Prompt transfer to neurosurgical service and urgent intervention may improve outcome in those that are not mortally wounded. Materials and Methods: Fifty-two patients with civilian penetrating gunshot wounds seen over a 10-year period (2004­2014) at the University of Nigeria Teaching Hospital and Memfys Hospital for Neurosurgery Enugu were reviewed retrospectively, and their data were analyzed to evaluate factors that impacted on outcome. Only patients with clinical and imaging evidence of cranial gunshot injuries who reached hospital alive were included in the study. The overall mortality and Glasgow outcome score were analyzed. Results: Fifty-two patients with isolated civilian penetrating gunshot wounds were identified (M:F = 7.7:1); mean (standard deviation) age was 32.8 (11.9) years. There was a high correlation (0.983) between the sex of the patients and the outcome. The overall mortality was 30.8%, whereas the mortality for patients with postresuscitation Glasgow coma scale (GCS) score ≤8 was 57%, as against 12.9% in those in whom postresuscitation GCS was >8; meaning that 87.1% of patients in whom postresuscitation GCS was >8 survived. Thirty-one patients (59.6%) had papillary abnormalities. Majority of patients with monohemispheric lesions survived while all those with diencephalic, transventricular, and posterior fossa involvement had 100% mortality. Conclusions: Admitting GCS and bullet trajectory were predictive of outcome