Fistula-in-Ano with Broomsticks: An Unusual Etiology.

ABSTRACT: Fistula-in-ano is caused by idiopathic infection of the cryptoglands located in the anal intersphincteric plane when the resultant cryptoglandular abscess drains internally and externally. It is a common surgical disease that responds well to surgical intervention. In cases of recurrent non-healing fistula-in-ano, an underlying cause should be suspected and searched for. We present a 29-year-old man who had recurrent complex fistula-in-ano caused by broomsticks of an unknown source. Fistulotomy, tactile wound exploration, extraction of the broomsticks, and wound debridement were done. The wound healed well by secondary intention. Few cases of recurrent complex fistula-in-ano had been reported in the literature. However, this is the first time to the best of our knowledge that broomsticks causing non-healing, complex fistula-in-ano that is being reported. We suggest the use of a bending machine instead of mashing broom bunch in the preparation of Ewedu soup which is a delicacy for the Yoruba tribe in Nigeria to eliminate the chances of inadvertent ingestion of broomsticks when eating Ewedu soup.

Fatal Spontaneous Subarachnoid Haemorrhage- A Report of Three Unusual Causes.

PURPOSE: To report three rare causes of fatal spontaneous subarachnoid haemorrhage (SAH) and to discuss the clinical presentations, neuroimaging findings of the patients, and a brief review of the literature on these unusual causes of SAH. CASE REPORTS: Anomalous branches of the internal carotid artery (ICA) are remarkably rare and multiple aneurysms associated with these aberrant arteries a rarer phenomenon still. A case of multiple proximal and distal aneurysms of the main trunk of an aberrant ICA branch, which resulted in a World Federation of Neurosurgical Societies (WFNS) grade V SAH, was presented. This abnormal vessel had an arterial fenestration, another rare occurrence. The second patient had a craniocervical junction (CCJ) arteriovenous fistula, which was associated with a distal aneurysm extending to the upper cervical spinal canal. The patient presented with recurrent SAH which had been misdiagnosed multiple times in the past. The third case presentation is that of a WFNS grade IV SAH, which occurred secondary to a ruptured giant fusiform aneurysm of the supraclinoid segment of the left ICA. The first two cases manifested with multiple episodes of Fisher grade IV SAH, and all cases proved fatal. CONCLUSION: It is crucial for clinicians to ensure prompt angiographic studies in patients presenting with spontaneous subarachnoid haemorrrhage, as delay in the definitive diagnosis/intervention can be lethal. In particular, a high index of suspicion for a vascular brain lesion should be entertained in cases of repetitive SAH.

BUT: Pour signaler trois causes rares d'hémorragies sousarachnoïdiennes spontanées mortelles (HSA) et discuter des présentations cliniques, les résultats de la neuro-imagerie des patients et une évaluation de la littérature concernant des causes inhabituelles de HSA. ETUDES DE CAS: Les vaisseaux anormaux de l'artère carotide interne (ACI) sont remarquablement rares et multiples anévrismes associés à ces vaisseaux aberrants est encore phénomène rare. Un cas de multiples anévrismes proximaux et distaux du tronc principal d'un navire ACI aberrant, à l'issue de WFNS grade V HSA a été présenté. Ce vaisseau anormal a eu une fenestration artérielle, qui est une autre occurrence rare. Le deuxième patient avait une charnière craniorachidienne (CCR), les fistules artério-veineuse, qui était associée à un anévrisme distal qui s'étend à la partie supérieure du col canal rachidien. Le patient avec une HSA récurrente qui avait été diagnostiquée plusieurs fois dans le passé. La troisième présentation de cas c'est celle d'un WFNS de grade IV du HSA, qui est le secondaire à un anévrisme fusiforme géant rompu du segment supra-clinoïde de l'ACI du gauche. Le les premiers deux cas se sont manifestés par de multiples épisodes d'HSA de niveau IV de Fisher, et tous les cas c'était avéré fatal. CONCLUSION: Il est cruciale que les cliniciens garantissent des examens angiographiques rapides chez les patients présentant une hémorragie sous-arachnoïdienne spontanée, car un retard dans le diagnostic définitif/l'intervention peut être mortel. En particulier, un indice élevé de suspicion d'une lésion cérébrale vasculaire doit être envisagé en cas d'HSA répétitive. MOTS CLÉS: Anomalie vaisseaux, Fistules artérioveineuse, Anévrismes fusiforme, Fenestration artérielle, Hémorragie subarachnoïde.

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.

Assessment of the Holistic Model of Neurosurgical Patient Care at the University College Hospital (UCH), Ibadan.

BACKGROUND: Holistic ward round (HWR) is a polyadic, multiphasic, holistic model of neurosurgical patient care. It is a multidisciplinary ward round where all healthcare providers involved in patients care, the patients, the relations, as well as clergymen (depending on the patients' faith and need) collectively work to review patient's condition and make decisions in the patient's best interest. OBJECTIVES: The study assessed the effectiveness of the holistic model of care and identified the challenges facing this model of healthcare delivery. METHODS: The study was qualitative in design and In-depth Interviews (IDIs) were conducted with eighteen (18) participants who were purposively selected. They include neurosurgeons, nurses, medical social workers and physiotherapists. The data were thematically content analysed with the help of ATLAS.ti (v.7) software. RESULTS: The study found that patients and relations have immensely benefitted from the model of care through psychosocial support. The major challenges facing HWR were logistic, timing and common problems found in the Nigerian healthcare system. CONCLUSION: It was concluded that for HWR to effectively help spinal cord injured patients further, the healthcare providers, patients and their families require support in different forms from outside the hospital.

WHITE CEREBELLUM SIGN AS A DARK PROGNOSTIC INDICATOR OF CEREBRAL INJURY: A CASE REPORT.

Introduction: The white cerebellum sign (WCS) is a classical but rare radiological finding usually associated with irreversible diffuse hypoxic-ischemic cerebral injury. Very few cases exist in the literature globally, especially from the West African region, as a potential hallmark of poor prognostic outcome. We describe the white cerebellum sign in a Nigerian pediatric patient, managed for severe head injury. Case Presentation: A fourteen-year old boy presented to our emergency department with loss of consciousness following a pedestrian road traffic accident. Physical examination revealed a critically ill boy with fever, hypotension, tachycardia, gasping respiration, GCS 3, bilateral dilated unreactive pupils, absent corneal, gag and oculocephalic reflexes. He was thus diagnosed of severe traumatic brain injury and brainstem dysfunction. He had endotracheal intubation, ventilatory and inotropic support. Cranial computerized tomography scan of the patient showed radiological features in keeping with the WCS. His clinical status remained poor until he suffered a cardiac arrest about twelve hours after admission. Conclusion: WCS has been reported in relation to child abuse, anoxic-ischemic brain injury, inflammatory and metabolic brain disorders and trauma. It is a classical radiological description of diffuse cerebral edema alongside relatively normal cerebellar hemispheres and brainstem. Management of this pathology is symptomatic, and aims to ameliorate the associated raised intracranial pressure, control seizures and prevent cerebral infarction. The index patient, who presented 24 hours after severe head injury with associated early post-traumatic seizures, respiratory failure and brainstem dysfunction, had an unfavourable outcome consistent with previous reports of WCS. We have reported the rare but classical white cerebellum sign. It remains a grave prognosticator of cerebral injury and should be sought for in the neuroimaging of patients with acute brain insults.

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.

CERVICAL SPINAL CORD INJURY FROM A VEHICULAR ACCIDENTAL NEAR HANGING INJURY AND NECK MANIPULATIONS.

Spinal cord injury is a global problem. It is a devastating life altering condition that is associated with permanent disability and reduced life expectancy. Road traffic accident has been described in global literature as the commonest aetiology and second to it is falls. Identifying these factors have led to development of policies and advocacy to reduce these causes of spinal cord injuries. We present three cases of spinal cord injuries from unusual aetiologies viz-a-viz an accidental hanging which resulted in a C4 traumatic myelopathy Frankel A in a 30-year old artisan, playful neck manipulation in a 23-year old male student, resulting in Brown-Sequard syndrome, which resolved with non-operative spinal cord injury management protocol over six weeks and a C4 traumatic myelopathy Frankel D with a 50% anterior listhesis of C4 on C5 in a 50-year old man who sustained injuries from a choke hold 10 weeks prior to presentation. He recovered fully on non-operative management and discharged home Frankel E.

UPPER LUMBAR DISC PROLAPSE.

Upper lumbar disc prolapse (ULDP) is a rare and a unique clinical entity which has a potentially devastating clinical outcome. It may manifest with low back or anterior thigh pain, polyradiculopathies (from spinal cord or cauda equina compression) and/or degenerative kyphoscoliosis. Its diagnosis is often difficult and may be missed because of the lack of specific root signs. Magnetic resonance imaging is the diagnostic modality of choice. Anterior, posterior and endoscopic approaches have been explored in the treatment of this pathology. However, the treatment outcome for ULDP has been found to be poorer compared to that of similar herniations at lower spinal levels. We report this case to draw attention to the need for a high index of suspicion to make the correct diagnosis.

Ectopic lesion of schistosomiasis of the penis simulating an early carcinoma.

A case of ectopic lesion of Schistosoma haematobium of the penis with extensive tissue destruction, simulating an early carcinoma of the penis and almost resulting in an autoamputation of the crown of the penis, is presented. The penis was surgically repaired and the patient treated with ambilhar. In schistosoma endemic area, it is important to think of ectopic schistosoma lesion by such a presentation. Existing theories to explain the presence of schistosoma eggs in locations outside the portal-caval system were reviewed and another one was advanced: its being sexually transmitted.

Vanishing penis syndrome: the Ife experience.

Twenty-five cases of vanishing penis syndrome as a rare cause of mechanical impotence seen over a nine year period in Ile-Ife are presented. Local aetiological factors some distinct from those earlier recorded in literature are highlighted. The prominent role which surgery can play in the management of this form of physical and mental handicap, loss of sexual function let alone becoming a social out cast is stressed.

Prognostic determinants in the management of prostatic cancer in Ife.

Sixty-two patients diagnosed as early and advanced cancer of the prostate gland were studied under three categories. The survival rate of those diagnosed early was 80% in the first five years while the overall survival rate in the series was 19.23%. The prognostic determinants in all categories while under therapy was, however, similar. The study confirmed that poor prognostic features were body weight of about 40 kg, haematocrit below 20%, Urea level of 10 mmol/lit and above, raised white cell count, raised erythrocytes sedimentation rate and total confinement to bed. The paper concluded that these findings, in a local pilot study, are of significance and sufficient value to merit further study and clinical evaluation.

The effect of urethral stricture on male fertility in Ife.

Twenty patients with Urethral stricture disease presenting with difficulty in micturition, azoospermia, and oligospermia were studied. Only 5% of our patients could firmly claim to be fertile at the time of presentation with a rise to 80% fertility rate at the end of management. Fifteen percent did not notice any change in their status. Surgical approach claimed better result over conservative management because of other complications following gonococcal infections. The need for a close forensic analysis in the determination of paternity in all cases of Urethral strictures was stressed while a treatment protocol of graft urethroplasty in all cases of traumatic rupture and dilatation in cases following inflammatory lesions of the urethra was established.

Ureteric injuries associated with gynecologic surgery.

We conducted a review of eight ureteric injuries associated with major gynecologic surgery in seven patients over an 11-year period. Our low incidence of 0.36% is comparable with other reports. Diagnosis was made either intra-operatively or postoperatively. Immediate ureteric repair is advocated for all injuries discovered intra-operatively. Attention to preventive measures both before and during gynecological operations will reduce the incidence of ureteric injuries.

Essential thrombocythaemia associated with priapism: a case report.

A case of priapism complicating essential thrombocythaemia in a 45-year old Nigerian gardener is described. His platelet counts ranged from 1.2-1.6 x 10(12)/L, haematocrit from 0.25-0.33 L/L and leucocytes from 23.4-30.6 x 10(9)/L. There was a splenomegaly of 5cm. He had bilateral cavernostomy but is yet to regain penile erection 3(1)-2 months after surgery.

Management of recurrent hernias with two parallel rows of four-layer fascioplasty.

A hundred and fifty-two patients with recurrent inguinal hernias, 10 females and 142 males seen over a ten-year period have been reported. The patients, none of whom were earlier seen or operated on by the author were managed with two parallel rows of four-layer fascioplasty held with nonabsorbable Astralen sutures. The complications which may arise from the method applied were reviewed. The recurrence rate in advanced countries ranges between 7% and 30% for all types of inguinal hernias, but in Nigeria is higher. The author does not claim that recurrence cannot occur with this method but he has not recorded any. The technique has also alleviated the fears of many and removed the social problems of having just one testis, an important factor in this environment.