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.

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.

Head injury: correlation of brain morphology on cranial CT with head injury severity using a new (computed tomography-head injury severity assessment) grading scale--a pilot study.

Eighty two (82) consecutive patients who presented with mechanical brain injury to the Accident and Emergency department of our hospital and were assessed with cranial Computerized Tomographic Scan between November 2005 and April 2006 were included in the study. Demographic data were obtained at admission. Clinical severity of head injury was assessed by the Glasgow Coma Scale Score just before cranial CT while morphologic severity was assessed using features on the same post-resuscitation cranial CTwith which theTCDB (Traumatic Coma Databank) grade and CT-HISAS (computerizedTomographic-Head injury Severity Assessment Scale) score were assessed. Both the TCDB and CT-HISAS scores were correlated with short-term outcomes using the Glasgow outcome score. Pearson's correlation coefficient, ANOVA and regression models were used as appropriate for statistical tests of significance.The age range of Patients was between 3 months and 86 years with a mean of 26.8 years and median of 25.9 years +/- 1.9 years (95% CL). There were more males (74.4%) than females (25.6%). There was a negative correlation between Post resuscitation GCS and CT-HISA score (p = -0.0141). However, although patients with non-functional outcome based on Glasgow Outcome score had higher CT-HISA scores, this relationship was not statistically significant. From our study, brain morphology on cranial CT using the CT-HISA Scale predicts clinical severity and outcome.We believe this study that CT-HISA may find useful application in assessment of teleradiologically transferred CT images of patients as well as research in mechanical brain trauma.

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.

Pediatric brain tumors in Nigeria: clinical profile, management strategies, and outcome.

INTRODUCTION: Although modern neuroimaging has facilitated early care of brain tumors in children worldwide, there are, however, few published reports on clinical profile, treatment, and outcome of brain tumors in children from our subregion. PURPOSE: We aimed to retrospectively study the clinical profile and outcome of pediatric brain tumors in a tertiary referral center from a developing country. METHODS: Forty pediatric patients with histologically verified brain tumors managed by the authors over a 13-year period (May 1994-April 2006) were studied. Patients' data from clinical, radiological, and pathology records were analyzed using the statistical package for social sciences version 16. RESULTS: The mean age was 9.75 years (range 1-15 years). Twenty-two males, 18 females. Common presenting symptoms were headaches (23 patients, 57.5%) and seizures (15 patients, 37.5%). Hyperreflexia (72.5%) and focal motor deficits (62.5%) were the most common neurologic signs. The mean interval from onset of symptoms to neurosurgical diagnosis was 13.4 months (95% CI). All patients had tumor resection, while 11 (27.5%) patients received adjuvant radiotherapy. Hydrocephalus occurred in 19 (47.5%) patients and was associated with early presentation (X2 = 10.65, p < 0.01). Low-grade astrocytoma (25%) and medulloblastoma (25%) were the most common tumors. Survival at 1 and 5 years were 56 and 47%, respectively. CONCLUSION: Focal motor signs and elevated intracranial pressure are the salient presenting features of brain tumors in children seen in Nigeria. Those of them with hydrocephalus are likely to present early. The outcome for pediatric brain tumors remains poor.

Surgical anatomy of the vertebrobasilar territory and posterior circle of Willis.

BACKGROUND: In the present era of microscopic and neuroendoscopic procedures, the surgical anatomy of the skull base vessels has gained increased significance. The pattern of the vertebrobasilar arterial complex and the posterior circle of Willis (COW) in Nigerians has not been previously reported despite various variants of these complexes existing in different populations. OBJECTIVE: To review and document the size, distribution and anomalies of the vertebrobasilar territory and posterior COW pattern in a Nigerian set of brains. METHODS: The target population for this study was a group of Nigerian adults 18 years and above. Specimens from patients with an ante-mortem or post-mortem evidence of meningitis or atherosclerosis were excluded. The size, distribution and anomalies of the vertebrobasilar artery, its branches, and the posterior COW were defined in 50 brains. RESULTS: The male: female ratio was 1.9:1 and a mean age of 44 years. Statistical analysis showed significant differences between the sizes of posterior inferior cerebellar arteries and anterior inferior cerebellar arteries (Student's t=-30.189; p-value= 0.000). Fifty-six percent of the brains had no anomalies. Thirty anomalies were noted in posterior COW compared with six in the vertebrobasilar territory. There were no aneurysms in all the specimens studied. CONCLUSION: Anomalies in the region of the posterior COW are commoner than the vertebrobasilar territory and the region of the posterior communicating artery is the most common site of anomalies in the posterior COW territory. These variations should be taken into account during skull base and carotid surgeries, and cerebral angiography.

Administrative and policy implementation for cancer treatment and prevention programs.

Proper policy implementation is the building block of every group, organization and society. Like every edifice, it requires proper, clear and distinct purpose, plan, materials and masons, to borrow a leaf from Aristotle's four causes. There are always challenges associated with this very important endeavour, but there are peculiarities to it in the context of Nigeria as a developing nation and with respect to cancer prevention and management as a complex and sophisticated activity. This work seeks to clarify and comment on the concepts of policy, administration, cancer treatment and prevention, and then highlight challenges to successful implementation of cancer treatment and prevention policy in Nigeria and propose some solutions.

Raffia hookeri Ethanolic Pulp Extract Ameliorated Neuronal Damage and Brain Oxidative Stress Following Mechanical-Induced Traumatic Brain Injury in Rats.

Traumatic brain injury (TBI) is a complex process resulting into structural brain damage and functional deficits as a result of an external mechanical force. This study aimed to investigate the possible ameliorative effect of Raphia hookeri ethanol extract (RHEE) on induced acute traumatic brain injury in rats. The choice of the plant was based on its reported anti-oxidative property. Thirty-six female Wistar rats were divided into six groups of six animals each. I: CONTROL - distilled water orally; II: RHEE - 100 mg/kg RHEE; III: Sharp trauma brain injury (STBI); IV: STBI+RHEE; V: Blunt trauma brain injury (BTBI); VI: BTBI+RHEE.  Brain injury was inflicted using modified weight drop technique on experimental day 1 while RHEE was given orally by gavage for 7 days post-injury. Blood was collected serially 24hrs, 72hrs and 7 days post-trauma for full blood count and differentials of the white blood cells. On day nine, rats were euthanized and brain harvested for biochemical and histological analyses. Trauma significantly (p<0.05) reduced the relative brain weight of rats compared with the control. Lymphocyte count increased while neutrophils reduced in all traumatized rats compared with control group. Both BTBI and STBI significantly (p<0.05) elevated MDA and significantly (p<0.05) reduced the level of GSH, the activities of SOD and CAT enzymes compared with control group. Histologically, the extent of haemorrhage into the subarachnoid and brain parenchyma in STBI and BTBI groups was reduced in the BTBI+RHEE and STBI+RHEE groups. Administration of RHEE reduced oxidative damage and ameliorated neuronal damage in sharp and blunt brain injuries.

Determinants of outcome in operative treatment of traumatic extradural haematoma.

BACKGROUND: Traumatic extradural haematoma is a rare condition and treatment in a majority of cases is by operative evacuation. Outcome from treatment is influenced by several factors. OBJECTIVE: To evaluate the operative treatment of traumatic extradural haematoma in our centre and assess the impact on outcome of some of the historical factors. METHODS: A retrospective study of cases managed January 1993-February 2004 using records from the Emergency Room, Wards, Theatre and Radiology Unit. Only the cases definitively diagnosed as extradural haematoma resulting from trauma and had operative evacuation, were recruited. The Glasgow Coma Scale was used to measure the severity of injury; whereas postoperative outcome was considered good in those with minimal or no neurological deficits. Collated data were analyzed and the patients were divided into 3 groups--good, moderate and fatal (poor) based on the outcome; the impact of the various historical factors was compared among the groups. Statistical analysis was done using the chi-square test and p-value of 0.05 or less was considered significant. RESULTS: Majority of the patients were young, with mild head injury and good outcome, and a surprisingly long mean preoperative time lag of 123.1 hours. Outcome was good in 24 (64.9%), moderate 6 (16.2%) and fatal 7 (18.9%). There were skull fractures in 26 (70.3%), but there was no significant difference in outcome among those with and those without fractures. CONCLUSION: Age of the patient and severity of head injury (a reflection of concomitant brain injuries), more than other factors appear to dominantly prognosticate outcome from operative evacuation in our service.

Could Parkinsonism complicate craniotomy and excision of convexity meningioma? A case report.

Parkinsonism is a neurodegenerative clinical disorder characterized by varying combinations and degrees of rest tremor, rigidity, slowing of voluntary movements and postural instability. Amongst the aetiologic factors, massive post-craniotormy haematoma has not been previously considered. This report is to arouse the suspicion that vascular displacement in the midbrain resulting from a massive unilateral intracranial haematoma could lead to the unusual complication of Parkinsonism. This is the report of a 55-year old retired male banker, without any previously identifiable risk factor except for his age, who developed Parkinsonism following a huge acute extradural haematoma that complicated a craniotomy for the excision of a haemorrhagic convexity meningioma. The patient was placed on medical treatment resulting in a slow but progressive neurological improvement. Reports of Parkinsonism following post-tumour excision are probably, very rare. We, hereby, report a case of Parkinsonism complicating a gross total excision of a convexity meningioma.

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.

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.

Concomitant craniospinal injuries with maxillofacial trauma--a review of 266 cases.

Maxillofacial injuries are fairly common and they are usually found in association with multiple injuries. The proximity of the face to the craniospinal axis results in significant association between maxillofacial trauma and craniospinal injuries. Previous studies have enumerated this association but the injury types, classifications and influences of the concomitant injuries on the outcome of management are sketchy. In this study, road traffic accident was the commonest cause of maxillofacial and concomitant c raniospinal injuries: mild closed head injuries was the commonest concomitant injury occurring in almost 60% of the cases whilst mandibular fracture was the maxillofacial injury frequently encountered. The average duration of hospitalization in patients with maxillofacial trauma and concomitant mild head injury was 19 days but it was much higher (average 34.9 days) in patients with concomitant spinal injuries. The high incidence of head injury would suggest that maxillofacial units are best cited in hospitals with functional neurosurgical services.

Malignant schwannoma of the nasal cavity and paranasal sinuses in a Nigerian.

An unusual case of malignant schwannoma with involvement of the forehead, external nose, right nasal cavity, paranasal sinus system (bilateral frontal sinus, right ethmoidal sinus), right orbit and anterior cranial fossa is reported in a Nigerian. Malignant schwannomas of the paranasal sinus are extremely rare, as only 20 well-documented cases have been previously published in English literature. No report in black Africans has been found in extant literature. The clinical features of this tumour are presented with detailed management. The patient had a wide surgical resection of the lesion with reconstruction of the resultant fronto-nasal defect using forehead musculofascial flap plus full thickness skin graft and adjuvant radiotherapy with satisfactory outcome. The good result of combined surgery and radiation regimens in this case demonstrates the usefulness of adjuvant radiation therapy in this condition.

An unusual faciocerebellar arrow injury: successful surgical removal in a peasant Nigerian: a case report.

INTRODUCTION: Reports of penetrating injuries of the cranium have been mainly craniocerebral or faciocerebral, craniocerebellar projectiles are few. CASE: We present a case of a 23 year old Nigerian with a craniofacial penetrating injury by a hunting arrow. The trajectory of the arrow through the facial skeleton across the craniocervical junction into the posterior fossa makes this unique in the literature. Successful operative retrieval by a joint team of neurosurgeons and otorhinolaryngologists, problems of delayed presentation and inadequate diagnostic facilities are highlighted. CONCLUSION: The morbidity-free outcome of surgical removal despite the delay in presentation and management in our practice setting with limited facilities are the salient points of this presentation.

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.

Intradural spinal arteriovenous malformation of the glomus type: a case report.

Spinal arteriovenous malformations (AVMs) being even rarer than cranial ones, constitute 3 - 4% of all spinal tumours, with an overall male:female ratio of 4:1. We report the case of a 24-year old female Youth Corps member who presented with an apoplectic onset of a left hemiparesis, progressively deteriorating to an incomplete quadriplegia with motor power of 2 and 0 in the right and left lower limb muscle groups, respectively. Magnetic resonance imaging (MRI) showed a vascular malformation whose precise nature was indeterminate; the definitive diagnosis of a Glomus AVM was only made intra-operatively. Laminectomy with complete surgical excision was done and she gradually improved to ambulate with minimal support. The experience in our unit tends to support the observation in literature that spinal arteriovenous malformations could be very rare, and depending on the location, could be amenable to complete surgical excision and recovery of neurological function.

Gross morphological studies on the effect of cyanide on the developing cerebellum of wistar rat (rattus novegicus).

The teratogenic effect of maternal cyanide consumption on the gross morphology of the post-natal phase of the developing rat cerebellum was studied. Twenty pregnant female rats weighing between 170 g and 190 g were separated into control and experimental groups. The control animals were fed a standard diet of mice cubes, while the experimental animals were fed 500 ppm potassium cyanide, mixed with the standard diet. The diets were fed to the animals and their litters in separate cages and water provided ad libitum during gestation and to the offspring after birth. After birth, the offspring (five per group) of days 1, 9, 14, 21, 28 and 50 were weighed, killed by cervical dislocation and the gross parameters studied. In the experimental animals, no significant differences were observed in the studied parameters between the control and experimental animals on day 1. A significant reduction in body weight was observed on day 14 (P < 0.05). The brain weight was significantly reduced on day 9 (P < 0.05). Similarly, the cerebellar weight was significantly reduced on days 14,21 and 28 (P < 0.05). The maximum vermal length was significantly reduced on day 50 (P < 0.05), and the maximum side-to-side dimension of the cerebellum was also reduced on day 28 (P < 0.05). There was no reduction in the thickness (anteroposterior dimension) of the cerebellum in the experimental group (P > 0.05). From the result, it is inferred that maternal consumption of 500 ppm cyanide causes reduction in the cerebellar weight, vermal length and side-to-side dimension of the developing cerebellum in postnatal life in rats.

The effect of dexamethasone, metronidazole and ascorbic acid on the morphological changes induced by gamma rays on the spinal cord of Wistar rats.

We studied the effects of dexamethasone, ascorbic acid, and metronidazole on the irradiated spinal cord of Wistar rats. Thirty adult Wistar rats were randomly assigned into 3 groups. Five rats served as the control group. Another group of 5 rats were irradiated in the neural axis with 2.5 Gy of gamma rays. The last group of 20 rats were irradiated and then divided into four subgroups of 5 rats each: one subgroup was administered dexamethasone alone, a second subgroup had metronidazole alone, a third subgroup was treated with dexamethasone and metronidazole combined, and a fourth subgroup had ascorbic acid alone, given intraperitoneally for 7 days before exposure to radiation, and also for 5 days after-irradiation. All irradiated animals demonstrated similar vascular changes in form of splitting of the smooth muscle layers of the arterioles of the anterior spinal arteries. Similarly, all the irradiated spinal cord demonstrated shrinkages as noted in the diminution of the neuronal sizes measured by a microscope with a micrometer embedded in the eye-piece objective. The drugs did not individually protect neurons from damage at the level of our investigation. However, the combination of dexamethasone and metronidazole produced a reduction of the degenerative effect of radiation on the neurons when the post-irradiation diameters of the neurons were compared with the control and those of the other experimental groups. We conclude that gamma ray induced damage in the spinal cord may be ameliorated by combining dexamethasone with metronidazole but not by individual treatment with any of the three drugs.

Conservative management of third trimester cervical spinal cord injury using Gardner-Wells tongs traction.

Spinal cord injury, though an important cause of morbidity appears to be uncommon in pregnant women or perhaps, has not been accurately documented among them. Superimposed on the many impairments resulting from spinal cord injury is the presence of the foetus in the womb which in itself normally brings about intense physiological alterations in the patient. Despite the complexities, neither the pregnancy nor the spinal cord injury needs jeopardize the optimal care of the other as long as the standard protocols are followed. In the past 10 years, the University college Hospital, Ibadan, Nigeria treated approximately 900 spinal cord injury patients, and only 3 of these were pregnant-an incident of 0.30 per 90 patients per year, or 0.33%. We report here, the conservative management of one of these pregnant patients using the Gardner-Wells' tongs traction, resulting in normal parturition and full neurological recovery.