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BACKGROUND/OBJECTIVE: Neuroendoscopic surgeries require specialized equipment, which may not be universally available or equitably distributed in most neurosurgical units of resource-limited healthcare systems. This review reports on the use of locally available resources to perform safe ventricular endoscopic surgeries in patients with hydrocephalus and cystic craniopharyngioma, in a resource-limited health care system. METHODS: This study, described the use of locally available resources to perform intraventricular endoscopic surgeries, and retrospectively reviewed a three-year outcome of these surgeries, The authors, used a 24Fr, 2-way Foley's catheter, that served as an endoscopic working sheet. A transparent 9mm naso-tracheal tube, that served as a retractor and a peel-away sheet. An intravenous fluid (IVF) giving set, was used for irrigation, and a metallic stylet of External ventricular drain(EVD) was used for third ventricular floor or cyst wall fenestration. RESULTS: Twenty-one intraventricular endoscopic surgeries were performed, consisting; of endoscopic third ventriculostomy (ETV), septostomies, cystostomies, and intraventricular biopsies. Mortality occurred in four patients, with one of the mortality, directly related to intraoperative hemorrhage. Most (3/21) of the complications were post-operative CSF leakage and partial wound dehiscence. Of the 17 surviving patients, the ETV success rate was 82.4% (14/17). Logistic regression analysis revealed that the patient's age, etiology, ETV success score (ETVSS) and procedure performed were not predictive of ETV success or mortality. CONCLUSIONS: Patients accessing neurosurgical care in resource-limited healthcare systems can benefit from safe and successful intraventricular endoscopy. However, this may require the innovative use of locally available resources that can be adapted to local neurosurgical needs.
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Meningomyelocele is one of the most severe forms of neural tube defects (NTDs) and the most frequent structural birth defect of the central nervous system. We assembled the Spina Bifida Sequencing Consortium to identify causes. Exome and genome sequencing of 715 parent-offspring trios identified six patients with chromosomal 22q11.2 deletions, suggesting a 23-fold increased risk compared with the general population. Furthermore, analysis of a separate 22q11.2 deletion cohort suggested a 12- to 15-fold increased NTD risk of meningomyelocele. The loss of Crkl, one of several neural tube-expressed genes within the minimal deletion interval, was sufficient to replicate NTDs in mice, where both penetrance and expressivity were exacerbated by maternal folate deficiency. Thus, the common 22q11.2 deletion confers substantial meningomyelocele risk, which is partially alleviated by folate supplementation.
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Deleción Cromosómica , Cromosomas Humanos Par 22 , Meningomielocele , Animales , Femenino , Humanos , Masculino , Ratones , Cromosomas Humanos Par 22/genética , Síndrome de DiGeorge/genética , Secuenciación del Exoma , Ácido Fólico/administración & dosificación , Deficiencia de Ácido Fólico/complicaciones , Deficiencia de Ácido Fólico/genética , Meningomielocele/epidemiología , Meningomielocele/genética , Penetrancia , Disrafia Espinal/genética , Riesgo , Proteínas Adaptadoras Transductoras de Señales/genéticaRESUMEN
OBJECTIVE: Trauma is a leading causes of death and disability in all ages. The aim of this study was to describe the demography and characteristics of paediatric head trauma in our institution and examine the predictors of outcome and incidence of injury related mortality. METHODS: We examined our institutional Trauma Registry over a 2 year period. RESULTS: A total of 1100 trauma patients were seen over the study period. Of the 579 patients who had head injury 99 were in the paediatric age group. Of the paediatric head trauma patients 79 had documented Glasgow coma score (GCS), 38 (48.1%), 17 (21.5%) and 24 (30.4%) had mild, moderate and severe head injury respectively. The percentage mortality of head injury in the paediatric age group was 6.06% (6/99). There is an association between mortality and GCS (p=0.008), necessity for intensive care unit (ICU) admission (p=0.0001), associated burns (p=0.0001) and complications such as aspiration pneumonia (p=0.0001). The significant predictors of outcome are aspiration (p=0.004), the need for ICU admission (p=0.0001) and associated burns (p=0.005) using logistic binary regression. During the study period 46 children underwent surgical intervention with extradural haematoma 16 (34.8%), depressed skull fracture 14 (30.4%) and chronic subdural haematoma five (10.9%) being the commonest indication for surgeries. CONCLUSION: Paediatric head injury accounted for 9.0% (99/1100) of all trauma admissions. Majority of patients had mild or moderate injuries. Burns, aspiration pneumonitis and the need for ICU admission were important predictors of outcome in children with traumatic brain injury.
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Background/Objectives: Spinal cord injury is a devastating condition and has been recognised so since antiquity with evolving pattern of presentation and outcome. This study aimed to review the clinical profile and determinants of early outcome in patients with traumatic spinal cord injury (TSCI) in Jos, Nigeria. Materials and Methods: This retrospective cohort study, reviewed the health records of all patients with TSCI that were managed, based on the neurosurgical unit protocol for the management of TSCI in our institution from 2011 to 2021. Relevant data were retrieved into a preformed pro forma, analysis was done for determinants of outcome using SPSS and presented in tables and figure. Results: A total of 296 patients, aged 20-39 years, with male to female ratio of 5.2:1 were studied. The median time from injury to presentation was 96 h, and the cervical spine was the most (139, 47.0%) affected region. Most of the patients (183, 61.8%) had complete injury (ASIA A) at presentation, the average, first week mean arterial blood pressure (MAP) of 89.98 ± 8.86. Mortality was 73 (24.7%) at 6 weeks post injury and complete TSCI, cervical spinal cord segment and the average "first week" MAP were, independent predictors of mortality. The admission ASIA impairment scale (AIS) and injury to presentation interval were predictive of AIS improvement at 6 weeks and length of hospital stay (LOHs). Conclusions: We also found that AIS at admission, level of spinal cord affected and the average first week MAP were early predictors of mortality, while the injury to presentation interval and admission AIS, predicted improvement of AIS at 6 weeks. The LOHs was seen more in patients with severe AIS at admission and those who had delayed presentation.
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Background and Objective: Intramedullary tuberculoma (IMT) of the conus medullaris is an extremely rare tumour that constitutes a diagnostic and management challenge in a resource-limited setting. We report a case of conus medullaris, IMT in a young immunocompetent, patient with no prior clinical features of pulmonary or extra-pulmonary tuberculosis. Case Summary: The patient presented with six months history of progressive and persistent mid back pain and slight weakness of both lower limbs of 3 months duration. Physical examination revealed a well-nourished man with power of 3/5 and hyperreflexia on both lower limbs. Chest radiograph and other investigations for tuberculosis were negative. Magnetic resonance imaging (MRI) of the lumbosacral spine showed fusiform expansion of the conus medullaris, with a well circumscribed, ring enhancing, intramedullary mass straddle between T12 and L1. Patient had gross total resection with no intraoperative monitoring assistance and no post-operative worsening of neurological function. Histology showed granulomatous lesion with central caseation in keeping with a tuberculoma. Patient was commenced on post-operative anti-tuberculous therapy with physiotherapy, with full motor recovery at six months post-surgical intervention and anti-tuberculous therapy. Conclusion: Intramedullary tuberculoma can be considered as one of the differential diagnoses of intradural, intramedullary tumour of the conus, even in immunocompetent individual with no clinical features of tuberculosis.
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OBJECTIVE: Encephalocele is a common congenital malformation of the central nervous system; however, giant encephaloceles are rare. The use of folic acid supplementation and termination of pregnancies, which are prenatally diagnosed with encephaloceles and other congenital malformation of the central nervous system, has significantly reduced the occurrence of this type of congenital malformation, especially in developed countries. METHODS: This was a retrospective review over a 5-year period from January 2006 to December 2010 at the Department of Neurosurgery, Regional Centre for Neurosurgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria. The records of patients with giant encephalocele were retrieved from the case notes of patients who had excision and repair for encephalocele. RESULTS: Seventy-three patients had excision and repair of encephalocele over the study period. However, the records of only 50 patients were retrieved. Fourteen (28%) of the 50 whose records were retrieved had giant encephalocele. There were 4 male and 10 female patients (1:2.5). Thirteen (92.9%) had the lesion located in the occipital region, whereas in 1 patient (7.1%) the lesion was at the vertex. Three (21%) of the cases had microcephaly, 1 (7.1%) had macrocephaly, and 1 (7.1%) developed postoperative hydrocephalus. The average size of defect was 2.43 cm, and the size of the lesion ranged from 12 × 6 cm to 40 × 50 cm. The average maternal age was 20.3 years (n = 6), and the paternal age was 29 years (n = 4). Four out of 7 (57%) mothers had febrile illness in early pregnancy. Seven out of 10 patients (70%) did not have antenatal care. CONCLUSIONS: This condition is more common in children conceived during the period when farm products are yet to be harvested, and whose mothers did not attend antenatal care visits. It is recommended that mothers should be educated on the necessity of preconception folic acid. Implementation of a national strategy on food fortification is also advised. We recommend surgery after the first month of life to reduce poor early postoperative outcomes. In developing countries and centers with suboptimal pediatric intensive care units, surgical intervention is preferred after the first month of life with good temperature control, adequate fluid replacement following rupture of the sac, blood transfusion availability, and, only if necessary, complex cranial reconstruction.
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Fontanelas Craneales , Hidrocefalia , Niño , Encefalocele , Femenino , Humanos , Masculino , Nigeria , Embarazo , Estudios RetrospectivosRESUMEN
BACKGROUND: Mastery of the microsurgical anastomosis is an indispensable component of neurosurgical training. However, in many resource-limited countries, the training, materials, and equipment to obtain these surgical and decision making skills are severely lacking. This study aimed to compare different suturing techniques for microvascular anastomosis and to complete a comparative assessment of the performance of a young neurosurgeon when using the various techniques. METHODS: We compared 3 end-to-end suturing techniques for microvascular anastomosis: interrupted suturing, continuous suturing, and a 2-octyl-cyanoacrylate-based lid technique using an umbilical artery model. We assessed the subjective difficulty of the suturing technique, the time needed to perform the procedure, and the flow rate and leakage of the vessel after each technique. This study was designed to use materials that would be available in developing countries. Surgical apparatus used, such as operating microscopes, were first-generation technology, and testing procedures were designed for neurosurgical residents in developing countries. RESULTS: The mean times to complete the anastomosis were 20.7 ± 7.7 minutes for the interrupted technique, 26.4 ± 7.7 minutes for the continuous technique, and 12.5 ± 2.5 minutes for the lid technique; these values were significantly different (P < 0.01). The differences among the 3 techniques in leakage and flow rates and subjective difficulty in performance were not significant. CONCLUSIONS: Suturing time was the only statistically significant difference among the 3 anastomotic techniques, with the lid technique apparently the quickest to perform. Such techniques can be designed to assess microsurgical abilities and help neurosurgery residents in developing countries improve their surgical skills and techniques.
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Anastomosis Quirúrgica/métodos , Cianoacrilatos/uso terapéutico , Técnicas de Sutura , Adhesivos Tisulares/uso terapéutico , Humanos , Procedimientos NeuroquirúrgicosRESUMEN
OBJECTIVE Revascularization is indicated in the management of moyamoya disease (MMD), with options that include direct and indirect techniques. Indirect bypass is popular in young children because the diminutive caliber of donors and recipients makes direct bypass difficult. The authors reviewed a series of patients treated with direct superficial temporal artery (STA)tomiddle cerebral artery (MCA) bypass in combination with encephalomyosynangiosis (EMS) in children 3 years or younger to demonstrate feasibility and safety. METHODS A retrospective review of all surgeries for MMD over a 19-year period identified 11 procedures in 6 patients. Surgical results, angiographic outcomes, and clinical outcomes were analyzed. RESULTS Patients had a mean age of 22.4 months. The symptomatic hemisphere was revascularized first, and the contralateral hemisphere was revascularized on average 2.8 months later in 5 patients. All direct bypasses were patent postoperatively and remained patent at late follow-up (mean 4.1 years), with both STA and MCA diameters increasing significantly (n = 5, p < 0.03). At last follow-up (mean follow-up duration, 5.0 years), favorable outcomes (modified Rankin Scale scores 02) were observed in 5 of the 6 patients (83%), with 1 dependent patient remaining unchanged postoperatively. CONCLUSIONS Direct STA-MCA bypass in combination with EMS for MMD is feasible and safe in patients 3 years or younger, based on favorable clinical and radiological outcomes in this patient cohort. Direct bypass should be considered when immediate revascularization is needed, without the biological delay associated with indirect bypass. ABBREVIATIONS EDAS = encephaloduroarteriosynangiosis; EMS = encephalomyosynangiosis; MCA = middle cerebral artery; MMD = moyamoya disease; mRS = modified Rankin Scale; STA = superficial temporal artery; TIA = transient ischemic attack.
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Revascularización Cerebral/métodos , Arteria Cerebral Media/cirugía , Enfermedad de Moyamoya/cirugía , Arterias Temporales/cirugía , Anastomosis Quirúrgica/efectos adversos , Anastomosis Quirúrgica/métodos , Revascularización Cerebral/efectos adversos , Preescolar , Estudios de Factibilidad , Femenino , Humanos , Lactante , Masculino , Enfermedad de Moyamoya/diagnóstico por imagen , Complicaciones Posoperatorias , Estudios RetrospectivosRESUMEN
Cavum septum pellucidum (CSP) cysts are relatively rare. The most common presenting symptom is headache, which is thought to be secondary to elevated intracranial pressure. Many CSP cysts are treated surgically; conservative treatment is seldom recommended. The authors describe 3 cases of pediatric CSP cysts that were managed without surgery. The patients ranged in age from 5 months to 8 years old. Two presented with headaches, which were associated with mild ventricular enlargement in 1 case. Over the course of 5-15 months, 2 cysts became markedly reduced in size, and in one of these 2 cases a substantial reduction in ventricle size was also observed. At last follow-up, all 3 children were asymptomatic. The authors note that CSP cysts are often associated with headaches. In the absence of hydrocephalus, they recommend conservative management with clinical and radiological follow-up.
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Quistes del Sistema Nervioso Central/patología , Quistes del Sistema Nervioso Central/terapia , Tabique Pelúcido , Quistes del Sistema Nervioso Central/complicaciones , Quistes del Sistema Nervioso Central/cirugía , Niño , Preescolar , Femenino , Humanos , Hidrocefalia/etiología , Lactante , Hipertensión Intracraneal/etiología , Imagen por Resonancia Magnética , Masculino , Tabique Pelúcido/patología , VentriculostomíaRESUMEN
Nasogastric intubation is one of the most common routine nonoperative procedures available for the hospital care of patients. The insertion and removal of this tube is associated with many complications. The complications include trauma, nasal septal abscess and inadvertent entry into the cranial cavity and trachea, ulceration, bleeding from varices and perforation. Knotting of the nasogastric tube is one of the very rare complications of nasogastric intubation particularly in children. To the best of our knowledge there are very few reported cases in children. The technique used in the patient was the application of a steady tug which allows the lower oesophageal sphincter to open, therefore enabling the removal of the nasogastric tube. The possible predispositions to knotting of a nasogastric tube include small bore tubes, excess tube length and gastric surgery. We postulate that reduced gastric tone is another possible predisposing factor with head injury being the most likely reason in the index patient. We also challenge the fact that the small sized stomach is a risk factor for knotting of a feeding tube if the functional status and tone are normal, because of the rarity in children.