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.

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.

Collaborative International Neurosurgery Education for Africa-The Journey So Far and the Way Forward.

OBJECTIVE: Lack of standard neurosurgical training has long been a major factor limiting the availability of neurosurgical services in most parts of Africa. International collaborative efforts have however, to a large extent, resolved this challenge. METHODS: A review of previous international collaborative programs and educational initiatives in Africa along with their outcomes and accomplishments was conducted. We make a few recommendations on how these programs could be further improved upon toward more productivity and better output with the few available facilities in Africa. RESULTS: Various international collaborative programs focusing on neurosurgery education and training currently exist in East Africa with well-documented advancements in achieving their goals and especially include Neurosurgery Education and Development Foundation, the Weill Cornell Tanzania Neurosurgery project, Duke East Africa Neurosurgery Program, Duke Global Neurosurgery and Neurosciences, and CURE Hydrocephalus Program. In West Africa, they include the Swedish African Neurosurgical Collaboration and the Association of West African Neurosurgeons. CONCLUSIONS: So far, collaborative neurosurgical education and training has been an effective approach in efficiently and progressively increasing capacity in Africa. To further improve the quality of neurosurgical care in Africa in the face of difficult economic circumstances and significant neurosurgical disease burden, implementation of the suggested recommendations will enhance the capacity and sustainability of these existing programs with the few available facilities and equipment and would go a long way in further reducing the burden in Africa.

Cervical Decompression for Myelopathy in a Resource-Poor Region: Initial Experience.

BACKGROUND: The aim of this study was to document the initial experience and challenges of cervical decompression in a resource-poor region. METHODS: Forty-three patients with cervical myelopathy who had surgery were included in the study. Details including evaluations pre- and postoperative (at 6 weeks and 6 months) using the Nurick score were recorded prospectively. Details of surgery were also documented. RESULTS: The mean age at surgery was 58.0 years. There were 37 men and 6 women. Surgeries performed were anterior cervical decompression and fusion (51.2%), cervical laminectomy (32.6%), corpectomy and occipitocervical fixation (2.3% each), and decompression with lateral mass fixation (11.6%). Four patients presented within 3 months of onset of symptoms (early), whereas 39 after 3 months (late). The Nurick grade significantly improved in 41 patients (97.6%) following surgery (P < 0.001). The average Nurick preoperative score was 3.2, and postoperative it was 2.12 and 1.14 at 6 weeks and 6 months, respectively. In the early presentation group, scores improved from an average preoperative of 2.5-0.5 at 6 months, whereas in the late presentation group, score improved from an average of 3.3 preoperative to 1.2 at 6 months postoperative. CONCLUSIONS: Despite the challenges of poverty, late presentation, and lack of basic standard instruments and equipment, patients with cervical myelopathy in the resource-poor setting had outcomes similar to other well-established centers after surgical decompression. We infer that challenges in setting up a spine unit in a resource-poor region can be circumvented safely.

Infantile supratentorial subdural empyema managed by percutaneous aspiration: an outcome study in a Nigerian city.

Subdural empyema (SDE), a common neurosurgical emergency in the developing countries, accounts for 15%-20% of localised paediatric intracranial infections. In regions where modern diagnostic tools are scarce and inaccessible, detection of SDE may be delayed with subsequent poor outcome. Percutaneous subdural aspiration in patients with open anterior fontanel may be the only surgical option in resource-poor regions of the world. This review focuses on the management outcome, including neurological outcome of these children. Clinical charts of children with SDE and treated by percutaneous subdural tap between February 2006 and August 2014 were reviewed. Demographic, clinical, radiological, bacteriological parameters and outcome data were analysed. Forty-five children with a mean age of 10.6 ± 6.2 months (range: 2-17 months) and followed up for a median duration of 16.4 months were included. The most frequent clinical features were enlarged head circumference, fever, focal neurologic deficits and altered level of consciousness. Diagnosis of SDE was confirmed using trans-fontanel ultrasound scan in 32 (71.1%) children, computerised tomography in 12 (26.7%) children and magnetic resonance imaging in one (2.2%) child. SDE was unilateral in 73.3% and bilateral in 26.7%. In 23 (51.1%) children with a positive culture, Staphylococcus aureus (n = 10), anaerobes (n = 7), Escherishia coli and Haemophilus influenza (n = 6 each) were the most common organisms. Forty-three children (95.6%) survived, 36 of which had good Glasgow outcome score. Seven children still had moderate deficits at 3 months. Treatment of SDE in young children with patent fontanel using percutaneous subdural tap has good therapeutic and neurological outcome.

Proposal of modification in management strategy for intracranial hemorrhage in low- and middle-income countries.

This brief communication describes the challenges faced by neurosurgeons in Low- or middle-income countries to treat neurosurgical emergencies from intracranial bleeds (whether traumatic or spontaneous). The authors point out that in low- or middle-income countries and Africa in particular, resources, facilities, and personnel are lacking to follow the guidelines proposed for treating these conditions in high-income countries. The proposal offered here is to move to early surgical intervention because algorithms to monitor patients under conservative management guidelines are often not possible.

Early outcome of combined endoscopic third ventriculostomy and choroid plexus cauterization in childhood hydrocephalus.

OBJECT: Although shunts have been the mainstay in treating hydrocephalus over the past 5 decades, the use of endoscopic techniques in addressing this disorder in children offers both the neurosurgeon and the patient a unique opportunity to avoid shunting and its attendant complications. The combination of endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) remains uncommon in most centers despite its potential promise. The authors sought to investigate the efficacy of combining ETV and CPC (ETV+CPC) in treating childhood hydrocephalus in Nigeria. Infection and spina bifida contribute a high percentage of the cases of hydrocephalus in Nigeria. METHODS: Over a 2-year period, all children 0-18 years of age who had endoscopic treatment for hydrocephalus were prospectively evaluated to determine the need for subsequent treatment. Children who had the combination of ETV+CPC were identified as a subcategory and form the basis of this retrospective study. RESULTS: Twenty-two of 38 endoscopically treated children had undergone the combination of ETV+CPC for hydrocephalus of varied etiology. There was a male preponderance (2.5:1), and 90% of the patients were infants. The overall success rate was 75%, with the best outcome in children with spina bifida. One child required a repeat ETV. CONCLUSIONS: The combination of ETV+CPC is useful in treating children with hydrocephalus of varied etiology. The complication profile is acceptable, and the overall success rate is comparable to that associated with shunt insertion.