Demographic Profile and Outcome in Surgically Managed Patients with Chronic Subdural Haematoma: A 9-Year Retrospective Cohort Study

BACKGROUND

Chronic subdural hematoma (CSDH) is achronic inflammatory and angiogenic condition that is potentially fatal and common among the elderly with a probability of gender, racial and ethnic differences. As our population ages due to increase in our life expectancy, a closer look at this disease in our environment is therefore justified.

OBJECTIVES

Our objective is to evaluate the epidemiology, relationship of demography, procedure type and mode of anaesthesia on outcome in the patients.

METHODS

Retrospective analyses of patients with CSDHs treated by single burrhole, over a 9-year period was performed. Patients' biodata, type of surgery, mode of anaesthesia and discharge outcome were noted. Data were analysed with chisquare, independent t test and multivariate binary regression. Values of p < 0.05 were considered statistical significance.

RESULTS

Two hundred and sixty-four patients were managed during the study period. The male-to-female ratio was 2:1 with mean age of 61.4 years. The peak age range was in the seventh decade. Recurrence and mortality rates were 2.7% and 6.8% respectively. Age was significantly associated with mortality.

CONCLUSION

The study showed a male preponderance. Age was significantly associated with mortality. Recurrence of CSDH was not related to patients' age, gender or mode of anaesthesia.

Evaluating the health risk of metals (Zn, Cr, Cd, Ni, Pb) in staple foods from Lagos and Ogun States, Southwestern Nigeria

The study evaluated the health risk of metals in commonly consumed staple foods from Lagos and Ogun states, southwestern Nigeria. One hundred and thirty-three food samples were collected and analyzed for Zn, Cr, Cd, Ni, and Pb using atomic absorption spectrophotometric method. Data collected were analyzed for simple descriptive and inferential statistics using SPSS for Windows. The health risk of metals in staple foods was assessed for average daily dose (ADD), hazard quotient (HQ), hazard index (HI), and cancer risk (CR). Results showed the highest concentrations of Zn (18.99 ± 13.62 mg kg^-1) and Ni (0.21 ± 0.10 mg kg^-1) in beans, while the highest amount of Cr (2.04 ± 1.44 mg kg^-1) was obtained in rice. Cd concentrations in staple foodstuffs ranged from < 0.01 to 0.30 mg kg^-1, while Pb was below the detection limit. The average levels of Zn in beans and maize were higher than the recommended dietary allowance (9.5 mg kg^-1) of the Institute of Medicine. The mean concentrations of Cr and Cd (except for rice) in staple food samples were also higher than the permissible standards. The health risk data revealed HQ value greater than 1.0 for Cr in the food samples, indicating non-carcinogenic adverse health effects. The HI value greater than 1.0 in staple foods established cumulative adverse effects of metals. The carcinogenic evaluation of Cr (in all the food samples) and Ni (in beans) showed CR values greater than the acceptable limit of 1.0 × 10^-4, thereby demonstrating possible development of cancer through consumption of the staple foodstuffs.

Neurotrauma burden in a tropical urban conurbation level I trauma centre

BACKGROUND

Neurotrauma is a preventable public health problem whose quantum is said to be increasing in Third-World countries. This evaluation was performed to collate data which is needed to guide in designing, implementing, and evaluating public health prevention programmes with respect to neurotrauma.

METHODS

A single institution prospective study was carried out. Data was collected at the surgical emergency (SE) room over a year period (1st October 2012-30th September 2013). These included patients' demographics, cause of injury, region of the body involved, Glasgow coma scale score, and outcome. The patients were further divided into patients with traumatic brain (TBI) and spine injury (TSI). Analysis of the variables was by simple proportion, percentages, Chi-square and analysis of variance was used to determine the differences between group means. A probability (p) of less than 0.05 was considered statistically significant.

RESULTS

A total of 2149 neurotrauma cases (38.8%) out of a total of 5541 surgical trauma cases were seen within the study period at our SE unit. Of the neurotrauma cases, 1621 were males, giving a male:female ratio of 3.1:1. The mean age was 31 years (median 30 years). The most common age group was 20-29 (29.6%) and 30-39 years (29.6%). Assault was the cause of neurotrauma in 903 patients (42%), closely followed by road traffic injury in 744 patients (34.6%). Brain and spine injury separately occurred in 93.2% and 5.3% of cases, respectively. Five hundred patients (23.3%) were resuscitated and referred to other centres due to lack of bed space. Forty (1.9%) patients were dead on arrival, while twenty-six (1.2%) died while on treatment at the emergency room.

CONCLUSION

Neurotrauma is one of the most common form of trauma at our surgical emergency. Assault and road traffic injury (RTI) were the most common cause of TBI and TSI respectively, with RTI being the most common cause of moderate and severe TBI. The incidence and aetiology of TBI varies according to age and gender.

Visual function in infants with congenital hydrocephalus with and without myelomeningocoele

OBJECTIVES

Congenital hydrocephalus without or with associated myelomeningocoele has impaired visual function as a potential complication. The present study was embarked on to determine the frequency of optic nerve deficits and refractive errors in this group of children and document any relationship to neuroradiological measurements.

MATERIALS AND METHODS

All infants with congenital hydrocephalus associated with myelomeningocoele (MHC) and congenital hydrocephalus without myelomeningocoele (HC) were prospectively studied. The children underwent clinical neuro-ophthalmological evaluation and neuroimaging. Radiological confirmation and severity of hydrocephalus was by Evans ratio (frontal and occipital) and third ventricular diameter.

RESULTS

There were 50 children (27 boys and 23 girls, median and mean age of 6 and 5.4 months, respectively) included in the study. Eighteen patients (36%) had no or poor visual tracking and fixation, while nine (18%) patients had optic atrophy. Optic atrophy was significantly associated with the HC group (p = 0.007), while the MHC group was significantly associated with a lower Evans ratio (occipital ratio, p = 0.000; frontal ratio, p = 0.000). Forty-nine patients had anisometropia. The refractive errors were more commonly hypermetropia (46 patients). This was not significantly associated with HC or MHC (0.309).

CONCLUSION

Optic atrophy rarity in MHC is probably due to early presentation of the patients and lower Evans ratio (occipital and frontal). Evans ratio is a good predictive index for optic atrophy in infantile congenital hydrocephalus. Refractive errors frequency is not dependent on an association of myelomeningocoele with or without hydrocephalus.

Posterior spinal decompression, stabilization and arthrodesis in Nigerian adults: Profile and outcome

Background:

The availability of intraoperative fluoroscopy and improved access to varieties of spinal titanium implants has revived posterior spinal stabilization techniques with their distinct advantages. Our aim is to describe the profile of various spine pathologies requiring subaxial posterior spinal decompression, stabilization (using titanium implants), and arthrodesis, and to determine the rate of postoperative complications and factors affecting outcome.

Materials and Methods:

This is a prospective single institution study of consecutive adult patients seen during the study period. Data collected included the patients’ demographics, radiological findings, indication for surgery, surgical procedure, operation time, intraoperative blood loss, and postoperative complications.

Results:

There were 26 patients (15 males and 11 females). Their ages ranged between 24 and 78 years (median = 42 years). The most common indications for surgery were spinal trauma and degenerative spine disease (24 patients). The region that was most commonly stabilized was the lumbar- 12 cases (46.2%). No patients experienced neural or vascular injury as a result of screw position; likewise no patient had screw loosening. There was a case each of superficial surgical site infection and transient cerebrospinal fluid leak but no case of implant failure was encountered. The outcome was significantly associated with the etiology (0.030) of the indication for surgery and preoperative power grade (0.000).

Conclusion:

Spinal trauma and degenerative spine disease are the two most common indications for posterior spinal decompression, stabilization and fusion in our center. It is associated with acceptable postoperative complication rate when done under fluoroscopic guidance. Outcome is related more to the preoperative neurological deficit and etiology of the indication for surgical stabilization.

Surgical congenital central nervous system anomalies in a tropical teaching hospital

BACKGROUND

Surgical congenital malformations of the central nervous system (CNS) are structural defects with potential for morbidity and mortality more so if intervention is delayed.

AIM

To determine the frequency and pattern of surgical CNS anomalies in our region.

METHODS

We carried out a hospital-based prospective observational study of all consecutive children who presented to our unit over a 2-year period. Brain computerised tomography and/or magnetic resonance imaging was performed on all patients suspected of having cranial CNS abnormalities.

RESULTS

There were 94 children with surgical congenital anomalies of the CNS during the study period, with a male to female ratio of 1:1.1. There was no parental consanguinity in all the cases neither were there any history of preconception use of folic acid in all the mothers of the patients. Prenatal ultrasound was done after the first trimester in 91 cases (97%), but anomaly was noted in only 23 cases (25.3%). Eighty-six percent of the patients presented after the first month of life. Though there was a general delay in presentation, patients with neural tube defect tended to present much earlier compared to others (p = 0.005). Likewise, patients with spinal anomalies tend to be seen much earlier.

CONCLUSIONS

Late presentation of CNS anomalies is still the norm in our region. The result makes a case for an aggressive approach to periconceptional folic acid supplementation for our women and policy to encourage fortification of a staple food with folic acid. A nationwide effort to fully clarify the epidemiology is needed so as to indicate where the community and governmental resources, including educational efforts should be directed.

Outcome of endoscopic third ventriculostomy and Chhabra shunt system in noncommunicating non-tumor childhood hydrocephalus

Background:

Endoscopic third ventriculostomy (ETV) the main alternative to ventriculoperitoneal shunt (VPS) is just beginning to have a foothold in West Africa. It provides a great opportunity for a hydrocephalic child to be shunt free. The purpose of this paper is to compare outcome following ETV and VPS (using the cheap Chhabra shunt) in children with noncommunicating non-tumoral hydrocephalus in an environment where late presentation is the norm.

Materials and Methods:

Sixty-three pediatric patients (< 6 years) with hydrocephalus who underwent a VPS or ETV at our hospital were included in this study. The study period was of 30 months (January 2006 till June 2008). Clinically successful outcome was defined as no event occurring during or after surgery that resulted in an alternate surgical procedure, or significant post-operative complication that includes death. All complications related to the procedures were also analyzed.

Results:

The outcome of surgical intervention was not significantly related to the gender, age of the patient at surgery, or type of surgery. The post-operative complication rate was similar in both groups.

Conclusions:

The clinical outcome of ETV is comparable to that of VPS, with the added benefit of no shunt-related problems; and being a short procedure, patient anesthesia and operation time, hospital stay, and cost are significantly reduced. We consider ETV to be the procedure of choice for the treatment of noncommunicating nontumoral hydrocephalus in the pediatric population.

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.

Hydrocephalus and subdural effusion with extracranial extension complicating meningitis

Post-meningitic subdural effusion does not extend extracranially. To our knowledge, the association of hydrocephalus and extracranial extension of a subdural effusion has not been previously reported. We present a case of an 8-year-old boy who presented with progressive head enlargement and worsening pulsatile peri-orbital swelling of 1 year duration. Cranial computerized tomographic scan confirmed communicating hydrocephalus and bilateral subdural effusion worse on the right side. The patient had a ventriculo-peritoneal shunt, with resolution of the subdural effusion and his hydrocephalus.

Dimensions, septation, and pattern of pneumatization of the sphenoidal sinus

The endoscopic endonasal transsphenoidal approach (EEA) to treat sellar, parasellar, and suprasellar tumours continues to gain increased significance. Due to the close proximity of the sphenoid sinus to the carotid artery and the optic canal, it is very important for surgeons to know the anatomical features and variations of the sphenoid sinus as relevant to EEA. A prospective study of the sphenoid sinus morphology was carried out on the cranial tomographic (CT) scan images of 60 Nigerian adult patients. The CTs were reviewed regarding the different anatomical variations of the sphenoid sinus: dimensions, septation, and pattern of pneumatisation. There were 37 males and 23 females. The patients' ages ranged from 18 years to 85 years, with a mean of 47.2 years. There was a main single intersphenoid septum in most patients (95%). The insertion of the septum was usually to the right posteriorly (38%) and in the midline anterior (65%). Although there is usually a main septum, the septa present were multiple in 29 of the sinuses studied. There was no gender difference with respect to the attachment of the main sphenoid sinus septum. The sphenoid anterior, posterior, and transverse dimensions were not significantly dependent on age, but they were longer in males than in females. Sellar pneumatization was present in the majority of the patients (83%), with 4 patients having postsellar pneumatization (6.7%) and 3 patients having presellar pneumatization (5%). There were no cases with conchal pneumatization or lateral pneumatization of the greater wing of the sphenoid. The present study provides anatomical information about the sphenoid sinus dimensions morphology that is essential for avoiding complications in performing an endoscopic sphenoidotomy.

Delay in presentation and diagnosis of adult primary intracranial neoplasms in a tropical teaching hospital: a pilot study

Sixty-three adult patients with intracranial neoplasms were studied prospectively over a 2 year period. The various factors related to pre-presentation symptoms interval (PSI) and pre-diagnostic interval (PI) were noted. The mean age at presentation for all patients was 46.8 years (range 18-72 years, median 46 years). Meningiomas (30%), Pituitary tumours (18%), High-grade gliomas (14%) and craniopharyngiomas (8%) were the most common brain tumours. The median PSI of all patients was 2 year (range 2 months-5 years) with a PI of 4 weeks (range 0-8 months). The PSI and PI were longer for women with a statistical significance between the PSI and gender (p=0.016). The tumour grade was significantly correlated with PSI (p=0.000) and PI (p=0.043). Late presentation and diagnosis were due to cultural and religious beliefs compounded by self medication and financial constraint. There is the need for widespread mass enlightenment, improvement in accessibility and affordability of neuroimaging facilities coupled with subsidization of treatment.

Outcome of myelomeningocoele repair in sub-Saharan Africa: the Nigerian experience

OBJECTIVE

Early repair of myelomeningocoele (MM) is associated with decreased morbidity and mortality. In sub-Saharan Africa, the peculiar harsh economic and social realities make late presentation, malnutrition and sepsis at presentation prevalent. As these factors may affect surgical repair, the aim of this study was to review the outcome of repair of MM in this peculiar patient population.

MATERIALS AND METHODS

A prospective study of patients with MM who presented at the Lagos State University Teaching Hospital, Lagos, Nigeria over a 12 month period was studied. Follow up ranged from 8 weeks to 1 year.

RESULTS

Five patients died while awaiting surgery. Thirty-six patients, 24 males and 12 female infants with MM were operated on during the study period. Majority of the patients were operated on or after the seventh day of life. The median age at surgery was 11th day of life (range second day-2 years). The mean surface area of the myelomeningocoele was 26.4 cm(2) (range 12.6-62.9 cm(2)). The post-operative morbidity and mortality was five and one, respectively.

CONCLUSIONS

Intracranial sepsis is the main cause of death in MM patients who are not operated on time. The patients we are seeing are probably those that survived to present at the hospital; by that time primary closure is usual without the need for complex plastic procedures. Delay in presentation even with associated malnutrition and local sepsis seems not to significantly affect the outcome of MM repair.

Non-operative management of benign intracranial hypertension presenting with complete visual loss and deafness

Benign intracranial hypertension (BIH) may lead to blindness and rarely deafness. We describe the case of a rapidly deteriorating 14-year-old African girl who presented with headaches associated with complete visual and hearing loss due to BIH. This was managed non-operatively with lumbar cerebrospinal fluid tap, weight reduction, nicotinic acid and acetazolamide. Response to treatment was quite dramatic with resolution of severe headaches and regaining of light perception 8 days after commencing treatment. By 3 months hearing recovered to normal and there was resolution of vision. This to the best of our knowledge is the first reported case of complete visual and hearing loss occurring in a patient with BIH, which was managed successfully non-operatively. When indicated, non-operative management is an effective treatment option even in malignant BIH.

The jugular foramen -- a morphometric study

The jugular foramen (JF) varies in shape and size from side to side in the same cranium, and in different crania, racial groups and sexes. Side dominance is also said to be common. The foramen's irregular shape, its formation by two bones and the numerous nerves and venous channels that pass through it further compound its anatomy. A morphometric study of 20 (40 JF) adult male Nigerian dry skulls was carried out. A bony bridge completely partitioned the JF in 3 (7.5%) of the JF. There was no tripartite JF. The JF mean length on the right and left were 13.90 mm (11.6-17.0 mm) and 14.11 mm (9.2-20.2 mm), while their widths measured 10.22 mm (6.8 -14.4 mm) and 9.57 mm (7.4-12.8 mm) on the right and left respectively. The mean JF area on the right was 437.49 mm (265.35-669.54 mm) and that on the left was 419.48 mm (276.46-634.60 mm). Side predominance of one of the JF appeared in 80% of cases. When present, the predominance of the right side was 55%, with 25% on the left. There was a difference in the length and width on each side but no significant difference in the length, width and area of the JF between the two sides. There was a positive correlation between skull width/ length and height/length ratio and JF area and length on each side. In conclusion, complete bony subdivision of the JF was not common among our study population and although the JF was generally larger on the right in our population, this is not statistically significant. A higher skull width/length and height/length ratio is associated with a greater JF length and area.

Surgical management of tuberculum sellae meningioma in a patient with a twin pregnancy: case report

BACKGROUND

Meningioma in twin pregnancy is rare. The tumor has an accelerated growth during the pregnancy and may enlarge or become symptomatic during this period. This relationship makes management of patients with this tumor quite challenging.

CASE DESCRIPTION

We describe a case of a rapidly deteriorating 35-year-old woman harboring an extensive tuberculum sellae meningioma who underwent craniotomy during the 24th week of pregnancy because of rapid deterioration. The surgical procedure and postoperative period were relatively uneventful.

CONCLUSION

To the best of our knowledge, this is the first reported case of surgical management of a meningioma in a patient carrying a twin pregnancy (one missed abortus). When indicated, craniotomy is a safe and effective treatment option for huge frontobasal tumors during the second trimester of pregnancy.

Hip fractures in a tropical teaching hospital

The pattern of hip fractures, treatment, outcome of treatment, and complications of forty-four consecutive patients treated over a five-year period were retrospectively studied. This represents 3.5% of the hospitalised patients in orthopaedic services. The male:female ratio was 1:1.3. Seventy percent of the fractures occurred in those over 65 years of age. The fractures were the result of low energy trauma in 81.8% of patients. Intracapsular (cervical) fractures accounted for 79.5% of the total cases. Only two patients had associated injuries on admission. Austin Moore hemiarthroplasty was the choice of hip replacement for intracapsular fractures, while ORIF (Open reduction and internal fixation using fixed angle blade plate) was done for patients with (extracapsular) trochanteric fractures. Anaesthesia (general or regional) was uneventful. Non-fatal pulmonary embolism occurred in one patient post-hemiarthroplasty while in the hospital. This study shows that hip fractures are not uncommon in our environment although far less common than what obtains in the Caucasians.

Traumatic dislocation of the hip joint--pattern and management in a tropical African population

Traumatic dislocation of the hip is an orthopaedic emergency for which early reduction is indicated. This article describe our experience of the pattern and choice of management of traumatic dislocation of the hip joint in a tropical African population. Majority of the dislocation (87%) were Thompson and Epstein's grades I and II which were easily managed by closed reduction following the administration of titrated intravenous analgesic and intravenous diazepam. This treatment option is cheap and readily administrable to avoid undue delays in the management of this orthopaedic emergency. All the close reduction were carried out in the accident and emergency room except for one patient with bilateral posterior hip dislocation who had his reduction on the ward. Early diagnosis and treatment of traumatic hip dislocation are essential to reduce the morbidities that are commonly associated with delay in reduction.

Size, course, distribution and anomalies of the middle cerebral artery in adult Nigerians

OBJECTIVE

To determine the size, course, distribution and anomalies of the middle cerebral artery in adult Nigerians.

DESIGN

A retrospective study.

SETTING

Department of pathology, University College Hospital, Ibadan between April and September 1999.

SUBJECTS

One hundred middle cerebral arteries from patients' asymptomatic for central nervous system lesions, obtained at autopsy from fifty adult Nigerians were examined.

RESULTS

The MCA arose as the wider of the two terminal branches of the internal carotid artery (ICA). Its mean diameter was 3.49 mm (CI = 3.39-3.59 mm), while the mean pre-division length was 15.43 mm (CI = 14.59-16.27 mm). In 92% of specimens, the first branches were perforators. The early branches were destined solely to the temporal lobe pole in most hemispheres (85%). In most specimens, (81%) the main trunk bifurcated while in 13% it trifurcated. One accessory MCA, and the early branches were given off before the perforators in two middle cerebral arteries, making an incidence of anomalies of 3%. There was no aneurysm.

CONCLUSION

These results are similar to what has been described in the literature for Caucasians. It buttresses the assertion that anatomical anomalies of the MCA are rare. The rarity at autopsy of aneurysms of the MCA in asymptomatic Nigerian Africans is not explained by the gross morphology of this vessel.

Biological therapy in cancer

The current therapeutic modalities for the treatment of patients with cancer are surgery, radiotherapy, chemotherapy, immunotherapy and hormonal therapy. The spontaneous regression of advanced disease in immunogenic tumours and the discovery of several gene classes involved in carcinogenesis has opened new avenues for exploring the control of cellular growth in cancer by biological therapy. There is gradual and steady improvement and refinement in immunotherapy while gene manipulation is becoming easier. Though many ethical and technical obstacles remain, the rapid rate of advancement in recombinant deoxyribonucleic acid (DNA) technology may lead to a major breakthrough in gene therapy in the nearest future.