Spinal Malignant Peripheral Nerve Sheath Tumours in Nigerians.

BACKGROUND: Spinal Malignant peripheral nerve sheath tumours (MPNSTs) are very rare aggressive tumours with poor prognosis. Little is known about these tumours in sub-saharan Africa. OBJECTIVES: This study aims to evaluate the clinical profile and outcome of management of these tumours in a resource limited country. METHODS: We retrospectively analysed data from the records of patients who had surgery for spinal MPNSTs at our center between January 2004 and December 2018. RESULTS: There were four patients in this study (M:F= 1:1). The ages ranged from 27-53 years with a mean of 43.25 ± 11.84 years. The tumour was located in the thoracic region in 2 of the patients (50%), the lumbar region in one (25%) and thoracolumbar in the 4th patient. Three patients (75%) presented with back pain while limb weakness, sensory deficit and sphincteric dysfunction were present in all patients at presentation. The duration of symptoms were 2 months in 2 patients (50%) and 3 months in the other 2. None of the patients had neurofibromatosis. Gross total tumour excision was achieved in 2 patients (50%) and subtotal resection in the other 2. The tumours were high grade in three patients (75%) and low grade in one. Two patients had adjuvant radiotherapy. Two of the patients were dead within 6 months of the diagnosis, another one within 18 months while one patient is still alive 3 years after. CONCLUSIONS: MPNSTs are very rare in our practice. Most of the tumours were high grade tumours and ran an aggressive course.

Pericallosal artery aneurysm - Case report, literature review and management outcome.

INTRODUCTION: Pericallosal artery aneurysms are rare. Very few cases of this vascular anomaly have been published from West Africa. We report the first case of a ruptured pericallosal artery (PCA) aneurysm managed in a Nigerian neurosurgical facility, with the aim to add to the limited documentation on vascular brain lesions in our sub-region. The management outcome of the index patient and a literature review on these unusual aneurysms were also discussed. CASE REPORT: A middle-aged known hypertensive woman who presented with clinical features of a WFNS grade I subarachnoid hemorrhage (SAH). A plain cranial computerized tomography (CT) scan revealed SAH, a supracallosal intracerebral hematoma and intraventricular hemorrhage. Cranial computerized tomography angiography (CTA) showed a small right pericallosal artery aneurysm, which was treated (with clipping via an interhemispheric approach) in a resource-constrained neurosurgical facility. The patient has remained well over a six-year follow-up period. DISCUSSION: PCA aneurysms have a high tendency to bleed compared with other supratentorial intracranial aneurysms in spite of their small size. Microsurgical approach, although difficult, is an effective treatment option for these rare aneurysms. CONCLUSION: Surgical clipping remains a safe and useful treatment option for pericallosal artery aneurysms in a low-resource neurosurgical facility.

Brainstem Glioma: Clinical Profile and Challenges of Management in a Developing Country.

BACKGROUND AND OBJECTIVES: Brainstem gliomas are relatively rare tumours of the central nervous system which have varying presentations and clinical course. This study aims to analyse the clinical profile and challenges of management of these tumours in a resource-limited country. METHIODS: We retrospectively analysed the data from the records of the patients managed for briainstem glioma between January 2010 and July 2017. RESULTS: There were 11 patients in the study (7 males and 4 females). The median age at diagnosis was 9 years. Eight of the patients were less than 15 years. The duration of symptoms ranged from 1 month to 2 years. All the patients had cranial nerve deficits at presentation, while 7 patients had cerebellar signs. Hydrocephalus was present in 4 patients. The lesion was pontine in 9 patients and tectal in 2. Three of the patients with hydrocephalus had ventriculoperitoneal shunt insertion while one patient refused surgery. Only one of the patients had radiotherapy. None of the patients received chemotherapy. A patient was dishcarged against medical advice. One patient is still alive after 4 years while another patient is alive after 2 years. The other 9 patients are dead with a mean survival period of 6 months. CONCCLUSION: Most of the tumours in this series were located in the pons and ran aggressive courses. Majority of our patients did not have access to radiotherapy while none had chemotherapy.

THE PROFILE AND SURGICAL TREATMENT OF SYRINGOMYELIA IN NIGERIAN PATIENTS.

BACKGROUND: Syringomyelia is an often progressive disorder of the spinal cord. There is a dearth of reports in the African population. AIMS AND OBJECTIVES: This study describes the profile and the outcome of treatment in our population of patients. DESIGN OF THE STUDY: A retrospective review of patients surgically treated for syringomyelia over a ten year period. SETTING: Department of Neurological Surgery, University College Hospital, Ibadan, Nigeria. MATERIALS AND METHODS: Eight patients were surgically treated for Syringomyelia over the period 2004-2014. We extracted data on their gender, age, aetiology, syrinx location, diagnosis, operative procedure and outcome. Simple statistical analysis was done. RESULTS: There were five males and three females. The mean age was 31.6(SD15.3) years (median: 32.5 years). The causes of the syrinx were: Chiari malformation (3), intramedullary spinal tumour (2), foramen magnum tumour (1), post-traumatic (1), and iatrogenic chemical arachnoiditis (1). The syrinx location was: cervical region (4), cervicothoracic region (2) and multi-level (2). The operative procedures were posterior fossa decompression (2), sub-occipital craniectomy with laminectomy and tumour excision (2), laminectomy and syringomyelotomy (2), laminectomy and tumour excision (1), and ventriculoperitoneal shunting (1). The duration of follow up was 2 weeks to 35 months. Outcome was satisfactory in six patients. A child who had initial ventriculoperitoneal shunting died at home before definitive surgery, and an adult male died of respiratory insufficiency post operatively. CONCLUSION: Syringomyelia is rare in our population. It affects young patients, typically in the cervico-thoracic region. The aetiologies are similar to those from previous reports. The outcome of surgical treatment in our small group of patients is satisfactory.

Outcome of surgery for upper cervical spine injuries in Nigerians.

AIMS AND OBJECTIVES: . This is a review of the initial experience with surgical management of upper cervical spine injuries. MATERIALS AND METHODS: The clinical case notes of patients surgically managed for UCSI were analysed for aetiology, presentation, duration of symptoms before presentation and surgery, pre- and post-operative Frankel grading, nature of injury and type of surgery. RESULTS: Eleven male and one female patients (mean age; 41.8 years; range 22-58 years) with UCSI were managed surgically. All the patients were involved in road traffic crashes. The case distribution were odontoid peg fracture [type II] alone (2 cases), hangman fracture alone (5 cases), both C1/2 subluxation and odontoid peg fracture (4 cases) and complex C2 injury (1 case). The surgical management includes C1 posterior ring excision and occipitocervical fusion [C0 - C4] (one patient), modified Gallie fusion alone (six patients), combined modified Gallie fusion and Rogers interspinous wiring (three patients). One patient each had C1/C2 interspinous wiring and combined modified Gallie fusion and occipito-cervical fusion [C0 - C4]. Post-operatively, two patients improved from Frankel C to D, 2 patients from C to E and one patient from D to E. The other patients with Frankel D and E injuries pre-operatively remained in status quo post-operatively. Eleven of the patients were discharged home on progressive ambulation with one having neck stiffness and one patient died 7 weeks post- surgery. CONCLUSION: Odontoid peg and hangman fractures were the most common indications for upper cervical spine surgery for trauma in our unit, and the post- operative outcome appears satisfactory.

Initial experience with spinal stabilisation with pedicle screws and rods in Nigerians: indications and outcome of surgery.

AIMS AND OBJECTIVES: To provide an initial experience in performing the procedure of the use of pedicle screws and rods for stabilisation of the spinal column in Nigerians with highlights on indications and outcome of surgery. MATERIALS AND METHODS: The hospital records of all the patients who had the procedure were retrieved. Biodata, presentation, neuroimaging findings, surgical procedure and postoperative outcome were extracted from records. Evidence of recurrent spinal instability, change in neurological status, wound infection and implant related complications postoperatively were used as outcome measures. RESULTS: Twenty seven procedures were performed in 26 patients [male: female was 1:1]. The age range was 26 to 77 years (mean=52.9, SD=13.7). Seventeen (65.4%) patients had degenerative spinal disease, while 9 (34.6%) had trauma. Five patients (19.2%) had thoracic spinal lesions and these were secondary to trauma, while there were 21 (80.8%) patients with lumbar spinal lesions. The indications for surgery were spinal instability in trauma cases and/or anticipated instability for degenerative cases. Two spinal segments were fused during 11 (40.7%) procedures, 3 in 10 (37.4%), 4 in 4 (14.8%) and 5 segments in 2 (7.4%) procedures. Post operatively, the Frankel grading improved in 6 (23.1%) patients, while it remained the same in 20 (76.9%). Back pain resolved in all but 1 (96.2%) patient. One (3.9%) patient each had screw fracture, recurrent instability and symptomatic redundant rod length while 2 (7.7%) peri-operative mortalities occurred due to cardiac events. CONCLUSION: The most common indication for posterior spinal stabilisation with pedicle screws and rods in this study is established or anticipated instability from degenerative lumbar spinal disease.Immediate stabilisation was achieved in majority of the patients without postoperative neurological deterioration.

Factors influencing the immediate postoperative outcome in operated head injured patients in Ibadan, Nigeria.

INTRODUCTION: The injured brain is subjected to anaesthetic agents and various intravenous fluids which may exacerbate haemodynamic instability, increase cerebral blood volume and intracranial pressure. OBJECTIVE: The study examined factors that influenced the immediate postoperative outcome in head injured patients who underwent general anaesthesia in a tertiary health care facility. METHODS: The demographic and outcome data of all head injured patients who had neurosurgical procedures under general anaesthesia in our centre between January and December 2010 were compiled prospectively. Outcome was measured using the Glasgow Coma Scale (GCS), good outcome was defined as an improvement in the GCS/recovery while poor outcome as worsening of GCS / mortality post operatively. The data were analyzed using SPSS 16.0 and p value was set at 0.05. RESULTS: Ninety nine patients were recruited. The patients' median age was 37.0 years and 81.8% were males. The most affected age group was 17-49 years. Indications for surgery were compound depressed skull fracture 28.3%, intracerebral haematoma 17.2%, subdural 35.4% and extradural haematoma 13.1% and impacted intracranial foreign body 6%. Eighty six percent of the patients had their head injury following road traffic accident. Fatality rate was 16.2%. Outcome was poor in patients with severe head injury (13%) compared with patients with mild (1.1%) and moderate head injury (2%) p = 0.001, and poor in American Society of Anaesthesiologist's (ASA) 3 (9%) and 4 (6%) classification compared to ASA 2 (1%) (p = 0.0069). Outcome was also poor in patients with intracerebral haematoma (9%) and acute subdural haematoma (2%) compared to that of depressed skull fracture (1%) (P=0.002) and in patients with intraoperative hypotension (13.1%) compared with those with normal blood pressure (1%) (p = 0.001). CONCLUSION: Road traffic accident is the leading cause of head injury, increasing ASA, decreasing GCS, type of cranial lesion and intraoperative hypotension are some of the factors affecting outcome in operated head injuries. Efforts should be made to reduce the incidence of intra operative hypotension to increase good outcome in operated head injured patients.

A prospective study of two methods of closing surgical scalp wounds.

BACKGROUND AND OBJECTIVE: Scalp wounds are commonly closed in two layers, although single layer closure is feasible. This study prospectively compared the two methods of closing scalp wounds. METHODOLOGY: Patients with non-traumatic scalp wounds were allocated to either the single layer closure group or the multilayer closure group. We obtained relevant data from the patients. The primary outcome measures were wound edge related complications, rate of suturing and cost of sutures used for suturing. RESULTS: Thirty-one wounds were in the single layer closure group and 30 were in the multilayer closure group. Age range was 1-80 years. The most common indication for making a scalp incision was subdural hematoma, representing 27.8% of all the indications. The most common surgery was burr hole drainage of subdural hematoma. Polyglactin acid suture was used for the inner layer and polyamide -00- for the final layer in the multilayer closure group. Only the latter suture was used for the single layer closure method. Total cost of suturing per wound in the single layer closure group was N= 100 (0.70USD) and N= 800 (5.30USD) in the multilayer group. The mean rate of closure was 0.39 ± 1.89 mm/sec for single layer closure and 0.23 ± 0.89 mm/sec in multilayer closure. The difference was statistically significant. Wound edge related complication rate was 19.35% in the single layer closure group and 16.67% in the multilayer closure method group. The difference was not statistically significant (z: 0.00, p value: 1.000; Pearson chi-squared (DF = 1)= 0.0075, p = 0.0785). CONCLUSION: The study shows that closing the scalp in one layer is much faster and more cost effective compared to the multilayer closure method. We did not observe significant difference in the complication rates in the two methods of closure. Long-term outcome, especially cosmetic outcome, remains to be determined in this preliminary study.

Review of skull base surgery in a Nigerian teaching hospital.

BACKGROUND AND OBJECTIVES: There is dearth of information on skull base surgery in Nigerians. This study was conducted to determine types of skull base lesions describe surgical approaches to the lesions and determine outcome of surgical management of the lesions over the study period. METHODS: We retrospectively reviewed the case notes of the patients who underwent skull base neurosurgical procedures between January 2001 and June 2007 in our centre. We obtained information on demography, clinical presentation, diagnosis, cranial computerised tomography findings, type of surgery, intraoperative findings and outcome of surgical management at the time of discharge from the hospital. RESULTS: Brain tumours were diagnosed in 28 patients, head injuries in 9 patients and one patient each had anterior encephalocele and frontal sinus mucocele. Eighteen patients had frontal craniotomy, three patients had temporal craniotomy and two patients had lateral rhinotomy in addition to bifrontal craniotomy. Two patients had frontoorbitotomy while retrosigmoid craniectomy was performed in one patient. Thirty three patients showed significant postoperative improvement at discharge. CONCLUSION: Brain tumour was the most common indication for skull base surgery in our centre. These tumours were mainly located in the anterior cranial fossa. Frontal craniotomy was the most common surgical approach. Non-availability of modern neurosurgical facilities confined us to the use of mainly traditional approaches. The availability of these facilities will assist in improving our management outcome in the future.

Pattern of death in a Nigerian teaching hospital; 3-decade analysis.

BACKGROUND: In developing countries such as Nigeria, limited resources require that health priorities be selected wisely and death-related research is clearly warranted. The aim of this study is to provide a comprehensive report on the various causes of death in our center from 1978 to 2006. METHODS: This was a descriptive, retrospective study of all deaths recorded at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile - Ife, Osun State in Southwest Nigeria from 1978 to 2006. RESULT: A total number of 9,947 deaths were recorded during the study period and there were 6,277 male deaths (63.1%) and 3,670 female deaths (36.9%) with a female to male ratio of 1:1.5. The age ranged from birth to 100 years with a median of 25 years. Infection (2,594 patients; 26.1%) was the most common cause of death and this was followed closely by trauma death (2,028 patients; 20.4%) and neonatal death (1,074 patients; 10.8%). Death from infectious disease and trauma reduced from 1,048 and 1,441 in the first decade (1977 - 1986) to 478 and 133 in the last decade respectively. While death from neoplasia increased from 112 in the first decade to 354 in the last decade of the study period. CONCLUSION: Our study shows that death from infectious disease in the present decade has reduced to almost half that was recorded in first decade. Similarly death from trauma has also reduced compared to the first decade of the study. Death from neoplasia is however higher in the last decade.

Intraoperative magnetic resonance imaging and meningioma surgery.

OBJECTIVE: To determine if intraoperative magnetic resonance imaging improves surgical resection and postoperative outcome of intracranial meningioma. STUDY DESIGN: Prospective, non-randomized, cohort study. METHOD: Intraoperative Magnetic Resonance Imaging (iMRI) was used to evaluate patients with meningioma undergoing surgery. Images were obtained after induction of anaesthesia and at various stages of tumour resection. Extent of surgical resection was graded using Simpson grading system for meningioma. The images were reviewed together with histopathology and early outcome. Primary outcome measure was determined by finding unexpected tumur in interdissection images. Secondary outcome measures were determined by postoperative complications including infections and mortalities. RESULTS: There were 39 procedures in 38 patients from January 1998 to December 2002. Surgical-planning images helped to optimize craniotomy placement. Interdissection images revealed unexpected residual tumour in only 1 patient. Complete resection (Simpson grades 1-3) was achieved in 33 procedures. The average follow up period was 16.4 months. Tumour recurrence has been observed in three patients. Two of these patients had anaplastic meningioma. There was no mortality in the 30-day postoperative period. CONCLUSION: Intraoperative MRI was beneficial in siting the craniotomy in addition to providing anatomical relationships between the tumour and adjacent structures in lesions located at the skull base though the full benefit of these is yet to be determined. The low morbidity and zero mortality recorded in the study may be related to all these factors.

Pattern and factors affecting management outcome of spina bifida cystica in Ile-Ife, Nigeria.

BACKGROUND AND OBJECTIVE: There is paucity of data on the pattern and factors affecting the management outcome of patients with spina bifida cystica in the Ife-Ijesa zone, Nigeria. This study was designed to address this research question. METHOD: One hundred and six consecutive cases of spina bifida cystica who presented in our hospital from January 1990 to December 2004 were reviewed. We obtained information on sociodemographic factors, medical history and management as well as clinical outcome. SPSS was used to analyze the data. RESULT: Males constituted 54.7% and females 45.2% of cases. Mortality was high in those presented after the 4th week of life (p = 0.04). The malformation occurred in the lumbar and lumbosacral regions in 77.4%. Myelomeningocele was the most common type (86.8%). Hydrocephalus was recorded in 53.8% of patients. Surgical closure was done for 91.5% of the patients. About 77% of all the patients were discharged while 22.7% died. This was significantly related to age at presentation (p = 0.04) and infection before surgery (p = 0.045). Postoperative complications were more frequent in patients with ruptured lesions (p = 0.025), a larger size of defect (p = 0.028) and a lower birth weight (p = 0.006). CONCLUSION: Myelomeningocele is the most common type of spina bifida cystica in our environment. Late presentation and preoperative infection are associated with high mortality in our patients.

Cranial computed tomographic (CT) findings in HIV-positive Nigerian patients presenting for neurosurgical evaluation.

INTRODUCTION: The central nervous system (CNS) is an important site of HIV infection. As many as one quarter of AIDS patients present with neurological symptoms and up to 75% of the patients may have CNS abnormalities at autopsy. Under these circumstances therefore, differential diagnoses in HIV-positive patients with neurological symptoms constitute a management challenge. OBJECTIVE: To describe the pattern of cranial computed tomographic (CT) findings in neurosurgical patients with HIV infection. STUDY DESIGN: Retrospective analysis. PATIENTS AND METHOD: A total of 1907 patients were admitted from October 1996 to October 2001. Sixteen patients were positive for HIV using the Western blot. We reviewed their biodata, clinical features and cranial CT findings. RESULTS: There were 10 male and 6 female patients. Twelve patients had cranial CT. Four patients had lesions that could be attributed to direct infection by HIV virus. Two patients had lesions that suggested immunosuppression from HIV infection. Diffuse breakdown in blood brain barrier (BBB) with contrast enhancement as well as mass effect that was disproportional to the enhancing lesion were common findings in three patients. The other lesions seen on cranial CT could not be directly linked to HIV infection. CONCLUSION: Apart from the diffuse breakdown in blood brain barrier with disproportional mass effect, our findings were similar to previous reports. Further study with a larger population of patients and, especially, biopsy of the CNS lesion will be needed to confirm our findings.

Solitary intracranial tuberculoma in patients without immuno-suppression: a report of three cases.

BACKGROUND AND OBJECTIVE: Poverty, drug resistance and the advent of human immunodeficiency virus infection (HIV) have led to a recent upsurge in the incidence of tuberculosis including intracranial tuberculosis. In this article, we report 3 patients who had solitary brain tuberculomas and were otherwise healthy to underscore the importance of continuing vigilance for this disease. CASE REPORTS: Three patients (57 years, female; 52 years, male; 7 years male) presented to our unit with features of intracranial tumours. They were all HIV negative with no previous history of tuberculosis. Cranial computed tomography scans demonstrated uniformly contrast enhancing falcine supratentorial masses in the adult patients and a cerebellar hemispheric lesion with peripheral contrast enhancement in the paediatric patient INTERVENTION: All the patients had gross total tumour excision. The histology confirmed a tuberculoma. They all had antituberculous therapy after histological confirmation. The outcome was good in all the patients. CONCLUSION: Intracranial tuberculoma can occur in otherwise healthy individuals and should always be considered in the differential diagnosis of solitary intracranial mass lesions in sub-Saharan Africans so that minimally invasive procedures can be used to establish the correct diagnosis.

Symptomatic pleural effusion without intrathoracic migration of ventriculoperitoneal shunt catheter.

BACKGROUND: Symptomatic pleural effusion following ventriculoperitoneal (VP) shunt insertion is very rare. The patient was an 8-year-old girl who had VP shunt for hydrocephalus as a result of aqueductal stenosis. Six weeks after surgery, she presented with headache, vomiting and drowsiness. She developed respiratory distress with pain in the right lower chest region and right hypochondrium on admission. METHODS: Chest X-ray confirmed right hydrothorax and showed the tip of the peritoneal catheter in the right suprahepatic subphrenic space. Her symptoms abated after the catheter was repositioned from the subphrenic region to the general peritoneal cavity. Repeat chest X-ray confirmed the resolution of the hydrothorax. DISCUSSION: Shunt review without thoracocentesis or thoracostomy is an effective treatment of symptomatic hydrothorax following VP shunt, especially when there is no intrathoracic shunt migration.

Gun burner injury: a peculiar accidental self-inflicted missile head injury.

The objective of this study was to report the pattern of unusual accidental missile head injuries from the use of the locally-manufactured Dane gun, which presented at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria. Six illustrative patients are presented, each with a peculiar injury. All the patients except one, who died prior to surgery, had wound debridement and elevation of associated fractures with removal of the metallic foreign body. With the exception of the patient that died prior to surgical intervention, all did well without noticeable neurological deficits. Missile injury to the head is increasing. Firearm-related death is also on the increase and our environment is not exempted. Accidental injuries from stray bullets are fairly common; however, self-inflicted injuries are usually due to the improper handling of firearms, particularly by novices, suicide attempts and faulty technology of locally made firearms.

Encephalocele and associated skull defects.

Encephalocele is a common congenital problem in the practice of Neurosurgery worldwide, with varying sizes of the underlying skull defects. This study was carried out to determine the size of the problem; to assess whether the skull defects are being under-managed or not; and also to determine those patients that will benefit from cranioplasty. The case notes of the patients with encephalocele managed over a 5 year period were reviewed and the relevant data obtained. Seventy-six percent of the patients had occipital encephalocele. The average diameter of the skull defect was 1.8 cm. Only 2 (9.5%) of the patients had cranioplasty. Cosmesis was acceptable to all the patients. No recurrence was noted in the series studied. We therefore concluded that the skull defects are not being under-managed, however large anteriorly based lesions with wide skull defects (i.e >2.5 cm) will require cranioplasty.

Acute isovolaemic haemodilution in two Jehovah's Witnesses presenting for major intracranial surgery.

The Jehovah's Witnesses (JWS) is a religious sect with strong convictions against acceptance of blood and its products for medical care, including surgery. We present two cases of JWS, aged 24 and 19 years old, who had craniectomy for trauma and craniotomy for tumour excision, respectively. A team approach was employed in the care of both patients. During exhaustive preoperative discussions they re-affirmed their religious convictions but agreed to some modifications. Both patients accepted Acute Isovolaemic Haemodilution (AIH). However one of them insisted on non-discontinuation of the line used in collecting the blood from the vein, as that would constitute blood storage. The preoperative Packed Cell Volume (PCV) was 45% and 41% for the trauma and the tumour patients respectively. Two units of blood (1000 ml) were collected from each patient resulting in post donation PCV of 40% and 33%. The intraoperative blood loss was 300 ml and 2000 ml, respectively, and the units and crystalloid fluids were transfused for replacement. Postoperative PCV were 42% and 25%. The latter improved to 30% over the following two weeks with oral haematinics. The two cases are discussed in the light of the experience gained.