Assessment of childhood intracranial pressure: a comparative study of transcranial Doppler ultrasound indices and findings at ventriculoperitoneal shunt.

PURPOSE: This study compares transcranial Doppler (TCD) Pulsatility Index (PI) and Resistivity Index (RI) with intra-operative CSF opening pressure measured by manometric technique during ventriculoperitoneal (V-P) shunt in children with hydrocephalus. METHODS: It was a prospective, hospital-based study performed among patients diagnosed with hydrocephalus. Patients had TCD ultrasonography before V-P shunt. The TCD sonography was repeated within 1 week post-op, and at 1 month post-op. The PI and RI were retrieved after insonating the middle cerebral artery. Ventricular CSF opening pressure was measured. Associations between TCD indices and CSF pressure were determined using the t-test and the Wilcoxon rank /Mann-Whitney tests where the normality test failed. A p-value of < 0.05 was considered significant for associations. RESULTS: Fifty-two patients were enrolled with a mean age of 9.9 ± 11.5 months. Of these, 41 (78.8%) were aged ≤ 12 months. The mean CSF opening pressure was 21.4 ± 9.0. When raised, ICP was defined as opening pressure > 15 cm of H2O, high PI (≥ 1.19), and high RI (> 0.8) diagnosed it with a sensitivity of 55% and 50%, respectively. The mean pre-operative PI (1.17 ± 0.56) reduced to 0.96 (Z = - 2.032, p = 0.042), while that of RI (0.66 ± 0.17) also decreased to 0.58 (t = 2.906, p = 0.044) after V-P shunt surgery. A strong positive correlation exists between a reduction in PI and RI after V-P shunt (r = 0.743, p = 0.014). CONCLUSION: Both PI and RI significantly decrease following V-P shunt, but a single reading has a poor sensitivity in predicting ICP.

Pilot application of Lecture-Panel-Discussion Model (LPDM) in global collaborative neurosurgical education: a novel training paradigm innovated by the Swedish African Neurosurgery Collaboration.

BACKGROUND: Disruptions in global surgery educational routines by the COVID-19 pandemic have elicited demands for alternative formats for rendering qualitative neurosurgical education. This study presents application of a novel model of online neurosurgical course, the Lecture-Panel-Discussion Model (LPDM). METHODS: This is a cross-sectional survey of participants who attended the Swedish African Neurosurgery Collaboration (SANC)-100A course. Participants evaluated the course through an online self-administered questionnaire using a 5-point Likert scale ranging from very poor-1, poor-2, average (fair)-3, good-4, to excellent-5. SANC-100A comprises a tripod of Lectures, Panel review, and interactive case Discussion. This model (LPDM) was innovated by SANC and applied at the Enugu International Neurosurgery course in February 2021. RESULTS: There were 71 attendees, 19 were course faculty, while 52 were participants. Thirty-five attended from Nigeria, 11 from Sweden, 3 from Malawi, 2 from Senegal, and 1 from the UK. Among 44 participants who completed the questionnaire, there were 9 fellows and 35 residents. The overall median course Likert rating was 4.65 ± 0.1. The median overall rating for course events was similar between day 1 (Likert score = 4.45) and day 2 (Likert score = 4.55), U = 55, Z score = 1.10, P = 0.27. The median rating for lectures was 4.50 ± 0.2 and varied from 4.40 on day 1 to 4.55 on day 2. The median rating for panel review was 4.60 ± 0.1 and varied from 4.55 on day 1 to 4.65 on day 2. Interactive case discussions were rated 4.80 on both course days. There was a significant variability in the rating profiles of the course tripod: U = 24.5, P = 0.03. Fifty-one (98%) participants believe LPDM was COVID-19-compliant, while 90% believe the course was beneficial to training and practice. CONCLUSION: Initial application of LPDM is rewarded with both high acceptance and high rating among participants.

Correlation of palpation anterior fontanometry and cerebrospinal fluid opening pressure in early childhood hydrocephalus.

Background: The anterior fontanelle (AF) tension has been a traditional clinical method of indirect assessment of intracranial pressure (ICP). How does this time-tested bedside assessment technique compare with an objective ventricular cerebrospinal fluid (CSF) opening pressure? Objective: To determine the correlation of palpation anterior fontanometry and CSF opening pressure in early childhood hydrocephalus. Materials and Methods: Children diagnosed with hydrocephalus who were planned for CSF diversion using ventriculo-peritoneal (V-P) shunt were prospectively studied over 18 months. The AF tension was assessed by palpation preoperatively and graded. The CSF opening pressure was measured using sterile disposable plastic manometers after ventricular cannulation intraoperatively. Statistical Analysis: Data obtained were analysed using SPSS version 21. Student's t-test, Mann-Whitney U test and ANOVA were used to determine associations based on normality tests. A P < 0.05 was considered significant for associations. Results: Fifty-two children were operated on with AF patency rate of 88.5%. Their age ranged between 2 weeks and 18 months with a mean age of 7.1 ± 5.1 months. The fontanelle tension was tense, full and normal in 63.0%, 26.1% and 10.9% of patients, respectively. The mean CSF opening pressure of 20.5 ± 8.5 cm of H2O was higher than the expected ICP for the age group (t-test 4.754, P = 0.000). All 28 patients with CSF opening pressure >15 cm of H2O had a tense fontanelle, but 10.9% of children with raised ICP have normal AF tension. Conclusion: The mean ICP increases as palpation AF tension increases, but a normal AF tension does not rule out raised ICP.

Pediatric brain tumor care in a Sub-Saharan setting: current poise of a precariously loaded dice.

OBJECTIVE: To evaluate the current status of pediatric brain tumor (PBT) care and identify determinants and profiles of survival and school attendance. METHODS: An 8-year institution-based prospective longitudinal study. All cases investigated with neuroimaging and treated were enrolled. Data was analyzed with SPSS (Inc) Chicago IL, USA version 23. Chi Square test, One-way ANOVA and confidence limits were used to evaluate associations at the 95% level of significance. Ethical approval for our study was obtained Health Research Ethics Committee of our hospital. RESULTS: Among 103 patients enrolled, 92 satisfied our study criteria. There were 45 males and 39 females, M: F = 0.8. The mean age was 9.5 ± 2.1 years 95%CI with a range of 7 months to 16 years. The most common symptom was headache for supratentorial lesions (73%) and gait disturbance (80.2%) for infratentorial lesions. More tumors were supratentorial in location 51 (55.4%), 35 (38.1%) were infratentorial and 6 (6.5%) were transtentorial. Craniopharyngiomas (n = 23), medulloblastomas (n = 22) and astrocytomas (n = 15) were the most common tumors. Hemoglobin genotype (AA and AS) had some influence on tumor phenotype FT, P = 0.033. 76 cases were microsurgically resected while 16 patients were treated with radiotherapy alone. The 30-day mortality for operated cases is 7.2 ± 0.7%. Overall 1-year and 5-year survival was 66.7 and 52.3%, respectively. School attendance, performance and outcome varied among treatment subgroups. CONCLUSION: Survival profile in this series suggests some improvement in comparison to previous studies from our region, Hemoglobin genotype profiles may signature paediatric brain tumor phenotypes in our setting.

Endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) in non-communicating hydrocephalus (NCH): comparison of outcome profiles in Nigerian children.

BACKGROUND: Endoscopic third ventriculostomy (ETV) and ventriculo-peritoneal shunt (VPS) although recognized surgical options for non-communicating hydrocephalus have debatable applications. OBJECTIVE: We analysed a prospective cohort of age-matched children with non-tumor, non-communicating hydrocephalus treated with the two surgical modalities using clinically measurable parameters. METHODS: A single institution analysis of age-matched patients with non-communicating hydrocephalus treated with VPS or ETV over a 3-year period. Occipitofrontal circumference (OFC), milestone, shunt independence as well as complication profiles of patients were recorded and analysed. Mean follow-up period was 1.27 ± 0.19 years 95%CI). Data analysis were performed using SPSS version 15, Chicago, IL. Statistical tests were set at 95% significance level. RESULTS: Fifty-five patients were enrolled, 25 patients had ETV, while 30 had VPS. Mean age was 2.3 ± 0.7 years (95% CI) with a range of 3 months to 4.5 years. Aqueductal stenosis was the most common indication. OFC profile decline was significant among the VPS group when compared with ETV group at 3 months follow-up (χ2 = 7.59, df = 1, p < 0.05). There was no difference among the two treatment groups χ2 = 2.47, df = 1, p > 0.05) in milestone profile. Thirteen percent of VPS, compared to (4%) ETV patients, had sepsis (χ2 = 4.59, df = 1 p < 0.05). Ninety-two percent of ETV patients remained shunt free, while 80% of shunted patients achieved ETV independence. Two patients died among the VPS group compared to one patient in the ETV group. CONCLUSION: VPS compared to ETV is associated with an earlier milestone and OFC response. ETV is associated with lower rates of sepsis and mortality.

Pedicled Radial Forearm Flap in Reconstruction of Complex Defects in the Craniofacial Region.

The radial forearm flap is a fasciocutaneous flap that has been used for reconstructing defects in the craniofacial region, either as a free flap or a pedicled flap. The pedicled radial forearm flap is a reliable option for reconstructing scalp defects. Microvascular free tissue transfer has, however, remained the preferred choice in the reconstruction of most complex scalp defects in the craniofacial region. We present the cases of a 37-year-old woman with an ulcerated malignant lesion on the forehead and a 40-year-old woman with a large malignant tumor on the scalp. Excision of both lesions, which turned out to be squamous cell carcinomas, resulted in complex defects that were reconstructed with pedicled radial forearm flaps. Both patients had satisfactory results and were counseled for radiotherapy.

Aetiology and diagnostics of paediatric hydrocephalus across Africa: a systematic review and meta-analysis.

BACKGROUND: We aimed to identify the aetiological distribution and the diagnostic methods for paediatric hydrocephalus across Africa, for which there is currently scarce evidence. METHODS: In this systematic review and meta-analysis, we searched MEDLINE (Ovid), the Cochrane Database of Systematic Reviews (Wiley), Embase (Ovid), Global Health (Ovid), Maternity & Infant Care (Ovid), Scopus, African Index Medicus (Global Index Medicus, WHO) and Africa-Wide Information (EBSCO) from inception to Nov 29, 2021. We included studies from any African country reporting on the distribution of hydrocephalus aetiology in children aged 18 years and younger, with no language restrictions. Hydrocephalus was defined as radiological evidence of ventriculomegaly or associated clinical symptoms and signs of the disorder, or surgical treatment for hydrocephalus. Exclusion criteria were studies only reporting on one specific subgroup or one specific cause of hydrocephalus. We also excluded conference and meetings abstracts, grey literature, editorials, commentaries, historical reviews, systematic reviews, case reports and clinical guidelines, as well as studies on non-humans, fetuses, or post-mortem reports. The proportions of postinfectious hydrocephalus, non-postinfectious hydrocephalus, and hydrocephalus related to spinal dysraphism were calculated using a random-effects model. Additionally, we included a category for unclear cases. Diagnostic methods were described qualitatively. To assess methodological study quality, we applied critical appraisal checklists provided by the Joanna Briggs Institute. The study was registered in Prospero (CRD42020219038). FINDINGS: Our search yielded 3783 results, of which 1880 (49·7%) were duplicates and were removed. The remaining 1903 abstracts were screened and 122 (6·4%) full articles were sought for retrieval; of these, we included 38 studies from 18 African countries that studied a total of 6565 children. The pooled proportion of postinfectious hydrocephalus was 28% (95% CI 22-36), non-postinfectious hydrocephalus was 21% (95% CI 13-30), and of spinal dysraphism was 16% (95% CI 12-20), with substantial heterogeneity. The pooled proportion of hydrocephalus of unclear aetiology was 20% (95% CI 13-28). INTERPRETATION: Our findings suggest that postinfectious hydrocephalus is the single most common cause of paediatric hydrocephalus in Africa. For targeted investments to be optimal, there is a need for consensus regarding the aetiological classification of hydrocephalus and improved access to diagnostic services. FUNDING: Rikshospitalet, Oslo University Hospital, Oslo, Norway.

Application of blended integrated revision course in clinical surgery in West Africa in response to Covid-19 pandemic: perception of trainee surgeons.

Background/Objective: This study assessed the surgery residents' evaluation of blended delivery of the 2020 Integrated Revision Course in Clinical Surgery (IRCCS) of the West African College of Surgeons undertaken as a result of COVID-19 pandemic. Methods: We performed a cross-sectional survey of 234 participants of the 2020 IRCCS using self-administered questionnaire. The survey assessed the previous traditional course and various aspects of the novel blended course using 5-point Likert scale. Results: Overall, 186 (79.5%) responded. The blended course had overall mean rating of 4.92 (on a 5-point scale) compared to 4.05 for the previous traditional course. Of the virtual aspect of the blended course, didactic lectures had the best mean rating of 4.32, while unmanned OSCE had the least with mean rating of 3.30. Aspects of the multicentre component of the blended course were rated highly with conduct of manned OSCE receiving the best mean rating of 4.26. The major challenge of the blended course format was poor internet connectivity (n =102; 54.8%). Conclusion: Blended format of surgical training course is well rated by the surgery residents, and may be an effective means of delivery of clinical and non-clinical course contents during periods of disruption.

Predictors of Outcome Following Interventions for Ruptured Intracranial Aneurysms in an Emerging Health Institution in West Bengal: A 6-Year Experience.

BACKGROUND: Microsurgical clipping and endovascular coiling have remained over the past half-century, the main options for definitive treatment of ruptured intracranial aneurysms. However, recent advances in endovascular techniques have broadened their application stimulating much debate regarding the usefulness of microsurgical options. For locations with limited capacity or evolving endovascular service, however, microsurgical treatment offers not only cost-effective and durable options but also oftentimes the only option available for most patients. MATERIALS AND METHODS: This was a single institution questionnaire-based retrospective study from West Bengal India. It was performed on patients with aneurysmal rupture managed from June 2010 to October 2016. Data analysis was performed with SPSS for Windows, version 21. RESULTS: One hundred and ten patients were studied. The mean age was 50.8 years (standard deviation [SD] ±13.5) for females and 50.2 (SD ± 12.4) for males (P = 0.8112, t-test). Ninety (81.8%) patients received microsurgical clipping. Microsurgical options such as wrapping, bypass, and excision were performed for 9 (8.2%) patients. Coiling was performed for 11 (10%) patients. ACOM was the most common site for ruptured aneurysm. Ictus-intervention interval (χ2 = 10.034, P = 0.007) and multiple surgical procedures (χ2 = 8.9341, P = 0.003) were the significant outcome determinants. Overall, 72.7% of those treated had a good outcome (Glasgow Outcome Score of 4 and 5). The good outcome was higher among microsurgery groups (73.7%) compared to the coiling group (63.6%) but this difference did not achieve statistical significance (χ2 = 0.46 P = 0.4976). CONCLUSION: Microsurgical options achieved good outcomes in the management of ruptured aneurysms in our series. Their availability makes them first-line options for low-income settings.

Scaling Up Global Collaborations for Neurosurgical Education and Care Capacity Development in West Africa: Are There Low-Hanging Fruits Where It Tolls?

BACKGROUND: Six decades after birth, the path to sustainable neurosurgical education and care in West Africa remains slow paced. We highlight plain sailing local attributes and global interventions for accelerated progress. METHODS: This was a 20-year study of neurosurgical practice and training status from 1999 to 2018. We prospectively evaluated development of neurosurgical units between 2009 and 2018 and compared with retrospective data both from 1999 to 2018 and from the origin of West African neurosurgery in 1962. RESULTS: The number of neurosurgeons rose from 1 in 1962 to 221 in 2018 with a mean of 3.95 neurosurgeons per year. Between 1998 and 2018, the subregional annual neurosurgeon birthrate varied significantly between 0.72 and 3.95. In 1998, 7 countries contributed to a neurosurgeon population of 26. In 2018, 13 countries contributed to a total of 221 neurosurgeons. The period 2009-2018 recorded the highest growth of neurosurgeons with a neurosurgeon birthrate of 7.5. Nigeria accounts for 51.6% (200.9 million) of the West African population and has 57% (11) of the 19 fully accredited training centers, while Ghana and Senegal account for 7.7% and 4.3% of the West African population, respectively, and each has 11% of the training centers. The 10-year unit procreativity index for the period 2009-2018 was 1.3, with Nigeria accounting for 0.7 (53.8%). CONCLUSIONS: The low unit procreativity index across West Africa, a major cause of the low neurosurgeon birthrate, can be resolved using tailored kindling and procreative strategies.

Epidemiology of congenital anomalies of the central nervous system in children in Enugu, Nigeria: A retrospective study.

BACKGROUND: Congenital anomalies, including those of the central nervous system (CNS), are among the leading causes of morbidity, mortality, and fetal loss. OBJECTIVE: To determine the prevalence and associated factors of CNS congenital anomalies in children. METHODS: A cross-sectional retrospective study of children managed with CNS anomalies was undertaken. Relevant clinical data of identified cases based on standard case definitions were retrieved from their case record files. Data were analyzed using SPSS 20.0 while the level of statistical significance was set at P < 0.05. RESULTS: Seventy-two cases of CNS anomalies were identified over the period under review; out of 7329 total pediatric admissions giving a prevalence of 0.98%. Spina bifida cystica, 49 (68.0%) was the most common of the five anomalies seen followed by congenital hydrocephalus 11 (15.3%). Fifty-seven (79.2%) of the mothers did not take periconceptional folic acid supplementation (P < 0.05) whereas 25 (34.7%), 6 (8.3%), and 1 (1.4%) reported history of febrile illness in the first trimester of pregnancy, alcohol use, and diabetes mellitus in pregnancy, respectively. Majority of the cases of spina bifida cystica (30 [61.2%]) seen had corrective surgeries while the overall case fatality rate was 1 (1.4%). CONCLUSIONS: Spina bifida cystica was the most common anomaly of the CNS seen in this study and majority of the mothers of affected children did not take periconceptional folic acid supplementation (P < 0.05). Efforts should be made to create awareness and apply adequate preventive health education models including the use of periconceptional folic acid supplementation as well as the provision of access to standard prenatal care to at risk mothers.

Validation of Siriraj Stroke Score in southeast Nigeria.

The aim of the study is to validate the use of Siriraj Stroke Score (SSS) in the diagnosis of acute hemorrhagic and acute ischemic stroke in southeast Nigeria. This was a prospective study on validity of SSS in the diagnosis of stroke types in southeast Nigeria. Subjects diagnosed with stroke for whom brain computerized tomography (CT) scan was performed on admission were recruited during the study period. SSS was calculated for each subject, and the SSS diagnosis was compared with brain CT scan-based diagnosis. A total of 2,307 patients were admitted in the hospital medical wards during the study period, of whom 360 (15.6%) were stroke patients and of these, 113 (31.4%) adult subjects met the inclusion criteria. The mean age of the subjects was 66.5±2.6 years. The mean interval between ictus and presentation was 2.5±0.4 days. Ischemic stroke was confirmed by CT in 74 subjects; however, SSS predicted 60 (81.1%) of these subjects correctly (P<0.05). Hemorrhagic stroke was confirmed by CT in 39 subjects, and SSS predicted 36 (92.3%) of them correctly (P<0.05). In acute ischemic stroke, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of SSS were 92%, 94%, 97%, 86%, and 93%, respectively, while in patients with hemorrhagic stroke, the corresponding percentages were 94%, 92%, 86%, 97%, and 93%, respectively. SSS is not reliable enough to clinically differentiate stroke types in southeast Nigeria to warrant interventions like thrombolysis in acute ischemic stroke.

The challenges of managing acute extradural hematoma in a Nigerian neurosurgical center--still a long way to go.

BACKGROUND: Acute extradural hematoma (EDH) is the collection of blood in the potential space between the dura mater and endocranium within 3 days of an incident. It is usually, but not always, a neurosurgical emergency, and early treatment reduces morbidity and mortality, although the outcome is still affected by some other determinants. In Nigeria, the National Health Insurance Scheme does not cover neurosurgical cases, and patients have to pay for all of their treatment regardless of the emergency status. We evaluate epidemiologic patterns, management protocols, and outcome, especially in relation to timely operative intervention, in patients with acute extradural hematoma who presented to our recently established neurosurgical service. METHODS: This prospective study comprised cases managed in our center from May 2006 to July 2013. Data of all patients with acute EDH were collected on Microsoft Excel software and complemented with hospital charts and operative records. Demographic data, etiologic factors, time interval from injury to presentation in our service, time interval from presentation to definitive treatment, and outcome were collected and analyzed. RESULTS: Within the 86-month study period, 1648 patients presented to our service with head injuries. Acute EDH constituted 3.03%, with a mean of 7.14 cases per year. Among the cases of acute EDH, 92% involved male patients (male-to-female ratio, 11.5:1). Peak age incidence (42%) was 21-30 years (mean, 23 years), and motorcycle road traffic accident was the most common etiologic factor (72%). Operative treatment was performed in 84% of the cases (in 57.1%, operative treatment occurred within 1 week of presentation). Conservative management was employed in 10% of cases. Mortality was 14.9%; most (10%) had severe head injury, although 2.1% had mild injury known to be associated with 0% mortality. CONCLUSIONS: Acute EDH is a potentially fatal condition that is easily treatable if presentation, diagnosis, and treatment occur promptly. Our outcomes could be improved if the present logistics associated with the cash-and-carry health care delivery system in Nigeria could be reduced or obviated.