Cranioplasty (CP) after decompressive craniectomy (DC) for trauma is a neurosurgical procedure that aims to restore esthesis, improve cerebrospinal fluid (CSF) dynamics, and provide cerebral ...protection. In turn, this can facilitate neurological rehabilitation and potentially enhance neurological recovery. However, CP can be associated with significant morbidity. Multiple aspects of CP must be considered to optimize its outcomes. Those aspects range from the intricacies of the surgical dissection/reconstruction during the procedure of CP, the types of materials used for the reconstruction, as well as the timing of the CP in relation to the DC. This article is a narrative mini-review that discusses the current evidence base and suggests that no consensus has been reached about several issues, such as an agreement on the best material for use in CP, the appropriate timing of CP after DC, and the optimal management of hydrocephalus in patients who need cranial reconstruction. Moreover, the protocol-driven standards of care for traumatic brain injury (TBI) patients in high-resource settings are virtually out of reach for low-income countries, including those pertaining to CP. Thus, there is a need to design appropriate prospective studies to provide context-specific solid recommendations regarding this topic.
Background
Spinal cord damage (SCD) is rare in children, hence the paucity of literature on the subject, particularly in developing countries. This study aims to define the clinical epidemiology of ...paediatric SCD in a Nigerian tertiary health facility.
Methods
A retrospective review of a 42-month long prospectively collected clinical data on paediatric SCD in a rural neurosurgery unit.
Results
There were 37 children (20 males) accounting for about 12% of the paediatric neurosurgical patients we managed during the study period. The mean age was 6.9 years (peak = 0–4 years, 43.2%). Traumatic spinal cord injury (SCI) was the cause of SCD in 54.1% (20/37) of the cases, spinal bifida in 37.8%, spinal cord tumour in 5.4%, and spinal tuberculosis in 2.7%. The mean age of patients with traumatic SCI was 11.5 years, while the median age for spinal bifida was 3 days. Traumatic SCI was caused by road traffic accident in 70% (14/20), and falls in 25%. The cervical spinal cord was the location of the spinal cord damage in 51.4% of all the cases in this study, lumbosacral in 24.3%, and sacral in 10.8%. Traumatic SCI was predominantly located in the cervical region in (90%, 18/20) while spinal bifida was most commonly lumbosacral (64.3%, 9/14).
Conclusion
Spinal cord damage accounted for more than a tenth (12.1%) of our paediatric neurosurgical workload in this rural neurosurgery, and are mostly due to traumatic SCI and spinal bifida.
In order to identify targets for primary preventive strategies, we explored possible predictors of periconceptional folic acid (pFA) intake in a Nigerian population of reproductively active women.
A ...cross sectional study of mothers attending immunization clinics at two hospitals was conducted between May and November 2012. Information obtained included sociodemographic and obstetric details and periconceptional usage of FA. Independent variables were analysed as predictors of pFA intake using chi-square statistical test and multinomial logistic regression.
The study involved 602 mothers aged 17 to 42 years; 23% had a university degree and 66% were in the working class. Preconceptional usage was proven in only 15 (2.5%). Periconceptional usage was more likely among professionals (X2=41.194, p<0.001), have university degree (X2=53.089, p<0.001), be primigravid (X2=18.415, p<0.001) and early antenatal clinic attendees (X2=355.9, p<0.001). Women were less likely to know that FA could prevent birth defects if in the working class (1.7% vs. 11.1%, X2=25.593, p<0.001), less educated (0.5 vs. 10.9%, X2=38.083, p<0.001) or booked late for antenatal care (2.0 vs. 5.9%, X2=5.767, p=0.016). The determinants of late commencement of FA were low social class (OR=4.29, 95% CI: 1.59, 11.31), lack of university education (OR=4.58, 95% CI: 3.06, 6.87) and late booking (OR=104.27, 95% CI: 53.09, 204.76).
In this population of reproductively active women, pFA intake and knowledge of its health benefits are poor amongst mothers--in working class, with limited education, and who present late for antenatal care.
•Preventable death from head injury are remains a feature in developing countries.•This is a report of two such occurrence.•We report two fatalities from scalp laceration in rural Nigeria.
While ...outcome of head injury has improved over the years in the advanced world, the developing countries with their less than the desired health systems lag behind. In these settings, deaths often result from trivial causes including scalp laceration.
We present two cases of such fatalities from mere scalp lacerations seen in a new rural neurosurgery practice in Nigeria. Both patients had no other source of significant blood loss. These patients had been to some peripheral hospitals but were merely referred for ‘expert neurosurgical care’without any attention to the scalp lacerations. Both patients arrived at the accident and emergency department of our health facility hours after the trauma in extreme conditions and subsequently died within minutes of arrival before they could be fully resuscitated.
Though eminently treatable and complications preventable, scalp lacerations remain a highly preventable cause of death in rural health services of developing countries.
There is paucity of data-driven scientific reports from sub-Saharan Africa on the burden of spontaneous intracerebral hemorrhage (sICH). We have maintained a prospective consecutive in-hospital ...database of cases of sICH referred for neurosurgical intervention over a 5-year period.
This is a cross-sectional descriptive study of the clinical epidemiology and brain computed tomography (CT) characterization of sICH from the database in this region in the current era.
There were 63 subjects, 38 (60.3%) males, aged 28-85 years, mean 55.7 (SD, 12.7), the modal age distribution being the sixth decade. Uncontrolled hypertension was the main predisposition in the study: present, premorbid, in 79%, but uncontrolled in 88% of these known cases, and exhibited malignant derangements of blood pressure in more than half. The clinical ictus to in-hospital presentation was delayed, median 72 h; was in severe clinical state in 70%, 57% was comatose; and was complicated with fever in 57% and respiratory morbidity in 55.6%. The main clinical symptomatology was hemiparesis, headache, vomiting, and aphasia. The sICH was supratentorial on brain CT in 90.5%, ganglionic in 50.8%, and thalamic in 58.3% of the latter. The bleed had CT evidence of mass effect and intraventricular extension (IVH) in more than half. Twenty-three patients (36.5%) underwent operative interventions.
In this patient population, sICH is mainly ganglionic and thalamic in location with significant rate of associated IVH. In-hospital clinical presentation is delayed, and in a critical state, the bleeding is uncontrolled hypertension related in >95%.
Abstract
Background Chronic subdural hematoma (CSDH) is not a totally benign disease in the elderly patients, especially those aged 70 years and above. Hence, the surgical treatment of CSDH in aged ...patients needs to be as minimally disruptive as possible.
Methods An annotated description of the surgical technique of single frontal burr-hole craniostomy performed under local anesthesia and without closed tube drainage for evacuating CSDH in the septuagenarians and older adults is given. We also review the outcome of the procedure on a prospective consecutive cohort of patients in our service
Results Thirty patients, 25 males, aged 70 years and above successfully underwent this surgical procedure. Their mean age was 76.5 years (standard deviation, 4.3). The CSDH was bilateral in 30% (9/30), and more left sided in the rest, the unilateral cases, and was of mixed density radiologically, in most cases (73%, 22/30). Clinical presentation was mainly gait impairment, cognitive decline, and headache, and 57% (17/30) presented with coma or stupor as assessed by the Markwalder grading scale.
The surgery was successfully executed in all, median duration 45.0 minutes (interquartile range 37.3–60.0), and solely under local anesthesia in 77% (23/30) or with momentary short-acting sedation in the rest. The outcome was very good in 90.0% (27/30) using the modified Rankin Scale (mRS) including two-third (20/30) completely asymptomatic (mRS 0) and 7/30 with only slight symptoms/disability, mRS ≤ 2. Three patients died perioperatively, all presenting in coma.
Conclusion This surgical technique appears very effectual for CSDH, is executed at a comparatively low cost, and, being much less disruptive than other traditional methods, may be a more homeostatic operative treatment in geriatric patients at least.
ABSTRACT
This is a prospective observational study on the profile of central nervous system (CNS) anomalies in a neurosurgical unit in Ikeja, Nigeria. All cases of CNS anomalies seen by the authors ...in 1 year, January to December 2005, were analyzed. Descriptive variables include some demographics of the patients and their parents; profiles of CNS anomalies, cranial or spinal, neural tube defects (NTD) or others; presence of associated anomalies; and rate of surgical correction of these anomalies. Sixty‐one cases were recorded, approximately 64% of our total pediatric neurosurgical output. Forty‐one cases were males, 20 females, with a male to female ratio of approximately 2 to 1. The age at presentation ranged from 2 days to 60 months (mean 5.6 months) and the majority of the parents were young (the mean ages of the fathers and mothers were 35 years and 28 years, respectively), and low income earners (70%). The cases comprised cranial (61%) and spinal (39%) anomalies, or 54% of NTD versus others. The cranial lesions were mainly congenital primary hydrocephalus in 44% of cases, encephalocele in 28%, and microcephaly in 17%. The spinal lesions were spinal dysraphism in more than 90%; all in the lumbosacral region. Seventy percent of the NTD had associated cranial or other system anomalies, mainly secondary hydrocephalus in 65%. The surgical correction rate of all of these cases was 38%. NTD were significantly more likely to present early, be associated with other anomalies and undergo surgical correction in this series (P < 0.001). CNS congenital anomalies are under‐reported in Nigeria and other developing countries. A call is made for the establishment of nationwide efforts to fully clarify the epidemiology of this silent epidemic.
In resource-limited settings, the standard of care prescribed in developed countries for either operative or nonoperative management of traumatic intracranial hematomas (TICHs) frequently has to be ...adapted to the economic and infrastructural realities. This study aims to present the outcome of selected cases of TICHs managed nonoperatively without routine intensive care unit admission, repeated cranial computed tomography (CT) scan or intracranial pressure monitoring at a rural neurosurgical service in a developing country.
This was a retrospective analysis of a cohort of our patients with cranial CT-confirmed TICHs selected for nonoperative treatment from our prospective head injury (HI) register over a 42-month period.
There were 67 patients (51 males) in this study with a mean age of 38.6 (standard deviation, 17.6) years, having mild HI in >half, (55.2%, 37/67) and anisocoria in 22.4% (15/67). Road traffic accident was the most common (50/67, 74.7%) trauma etiology. Isolated acute-subdural hematoma, intracerebral hemorrhage, and epidural hematoma occurred in 29.9%, 25.4%, and 22.4% of the patients respectively. Only 2 of 8 patients in whom intensive care unit admission was deemed necessary could afford admission. Repeat cranial CT scan was requested in 8 patients (8/67, 11.9%); only 5 of these could afford the investigation. The outcome of care was good in 82.1% patients (55/67). Increasing severity of the HI (P < 0.01) and presence of pupillary abnormality (P = 0.03) were significant predictors of poor outcome.
In a Nigerian rural neurosurgery practice, nonoperative management of a well-selected cohort of TICHs was attended by acceptable level of favorable outcome.
Breaking of medical bad news is anecdotally deemed culturally unacceptable, even intolerable, to native Africans. We explored this hypothesis among a cohort of relatives of patients who had difficult ...neurosurgical diagnoses in an indigenous practice.
A semi-structured, interviewer-administered questionnaire was used in a cross-sectional survey among a consecutive cohort of surrogates/relatives of concerned patients. Their opinion and preferences regarding the full disclosure of the grave neurosurgical diagnoses, and prognoses, of their wards were analyzed.
A total of 114 patients' relatives, 83 (72.8%) females, were sampled. They were mainly young adults, mean age 40.2 (SD 14.2) years; 57% had only basic literacy education; but the majority, 97%, declared themselves to have serious religious commitments. Ninety nine percent of the study participants deemed it desirable that either they or the patients concerned be told the bad news; 80.7% felt that this is best done with both patients and relations in attendance; 3.5% felt only the patients need be told. These preferences are similar to those expressed by the patients themselves in an earlier study. But a nearly significant greater proportion of patients' relatives (15 vs 5%, p = 0.06) would rather be the only ones to be told the patients' bad news.
This data-driven study showed that contrary to anecdotal belief about them, a cohort of native Nigerian-African surrogates of neurosurgical patients was well disposed to receiving, and appeared able to handle well, the full disclosure of difficult medical diagnostic/prognostic information.
PDF
