Neuroendoscopy in Jamaica / Neuroendoscopía en Jamaica

This retrospective, descriptive study reviewed the patient profile, disease spectrum, indications for and results of treatment and complications of all 27 patients who had neuroendoscopy at the University Hospital of the West Indies (UHWI) over the three-year period between November 2000, when the service was first introduced, and November 2003. Nineteen (67.9) were males and eight were females. Their mean age was 27.5 +/- 21.4 years with a range of four months to 70 years. Of the entire group, 20 had hydrocephalus with raised intracranial pressure, of which 15 had endoscopic third ventriculostomy (ETV) for the treatment of obstructive hydrocephalus, using two different techniques for ventricular floor fenestration. There was no demonstrable difference in outcome between the water jet and blunt forceps techniques. Three procedures failed to relieve the hydrocephalus, requiring subsequent ventriculo-peritoneal shunts. Three patients had successful cyst fenestrations. Six patients had endoscope assisted trans-sphenoidal resection for pituitary tumours. There were five complications and no deaths. Mean hospital stay was 18.4 +/- 16.7 days and mean follow-up was 29 weeks. There were no late failures. Neuroendoscopy is the treatment of choice for obstructive hydrocephalus due to aqueduct stenosis or posterior fossa tumours and has the advantage of avoiding shunt related complications. It is safe and effective for the majority of patients and has a significant role in the management of neurosurgical patients in the Caribbean

Este estudio retrospectivo y descriptivo, examinó el perfil del paciente, el espectro de la enfermedad, las indicaciones y resultados del tratamiento, así como las complicaciones de un total de 27 pacientes sometidos a neuroendoscopía en el Hospital Universitario de West Indies (UHWI) por un período de tres años, de noviembre de 2000 de noviembre - cuando se introdujo el servicio por primera vez - hasta noviembre de 2003. Diecinueve (67.9%) eran hombres y ocho mujeres. Su edad promedio fue de 27.5 ± 21.4 años con un rango de cuatro meses a 70 años. De la totalidad del grupo, 20 presentaban hidrocéfalo con presión intracraneal alta, y de ellos 15 tuvieron ventriculostomía endoscópica del tercer ventrículo (VET) para el tratamiento de hidrocéfalo obstructivo, usando dos técnicas diferentes para la fenestración del piso ventricular. No hubo diferencia demostrable en cuanto a resultados, entre la técnica de chorro de agua y la de fórceps romos. Tres procedimientos no lograron aliviar el hidrocéfalo, haciéndose necesarios subsiguientes derivaciones ventrículo-peritoneales. Tres pacientes tuvieron fenestraciones de quiste exitosas. Seis pacientes fueron sometidos a resección trans-esfenoidal con asistencia endoscópica para los tumores pituitarios. Se presentaron cinco complicaciones y no hubo muertes. La estancia promedio en el hospital fue de 18.4±16.7 días y el seguimiento medio fue de 29 semanas. No hubo ningún fallo a última hora. La neuroendoscopía es el tratamiento elegido para el hidrocéfalo obstructivo debido a estenosis del acueducto o tumores en la fosa posterior, y tiene la ventaja de evitar complicaciones relacionadas con las derivaciones. La neuroendoscopía es segura y efectiva para la mayoría de los pacientes, y desempeña un papel significativo en el tratamiento de los pacientes neuroquirúrgicos en el Caribe

Infections in neurosurgical patients admitted to the intensive care unit at the University Hospital of the West Indies

Patients admitted to the Intensive Care Unit (ICU) are at risk of developing life-threatening nosocomial infections, especially with organisms resistant to commonly used antibiotics. Neurosurgical patients are particularly vulnerable because of the serious nature of their illness, the frequency of associated trauma and the presence of invasive devices. Of 120 neurosurgical patients admitted to the ICU of the University Hospital of the West Indies (UHWI) between September 1995 and December 1999, the records of 73 patients were available for analysis. All had prophylactic antibiotics. Twenty-one of these 73 patients (28.8) developed 22 infections after a mean of five days in the ICU: nine with chest infection, seven with urinary tract infection, four with central nervous system (CNS) infection and one each with wound and skin infection. This is an incidence of 11.6/1000 patient-days. The responsible organisms included Pseudomonas (7/21), Acinetobacter (3/21), E. coli 2/21, Enterobacter (2/21), and Klebsiella (2/21), and one each with Staphylococcus aureus, methicillin resistant Staphylococcus aureus, coagulase negative Staphylococcus, group D Streptococcus and bacteroides (1/21). Infection was significantly related to length of hospital stay, length of ICU stay, duration of intubation, duration of ventilation and the presence of diabetes mellitus. All patients who had surgery after ICU admission developed infection, seven with chest infection, two with urinary tract infection, two with CNS and one with skin infection. The three patients who were admitted with intracranial infections all developed other infections. Infected patients had a significantly longer hospital stay. Five patients died, none directly attributable to infection, while 55 (75.5) made a good recovery. The problem of ICU infection may be expected to escalate with the increased use of intensive care, increasingly more complex surgical procedures and the growing problem of antibiotic resistance. Since infection is related to the length of ICU stay, earlier discharge of neurosurgical patients to an appropriately staffed high dependency unit is likely to result in reduction of the infection rate. Reinforcement of infection control strategies within the ICU may be expected to further minimize the infection rate

Brain Abscess at the University Hospital of the West Indies

Surgical infections of the central nervous system are still attended by high rates of morbidity and mortality, although substantial progress has been made since the advent of computed tomography (CT) scanning technology. In this retrospective review of 25 surgically treated patients with either brain abscess of subdural empyema at the University Hospital of the West Indies, the majority of patients were male and between the ages of 10 and 30 years with a mean age of 16.9 years. Almost half the patients had a hemiparesis on presentation while 60 percent had fever. Subdural empyema was more common than a localised intracerebral abscess which was most frequently located in the frontal lobe. The most common predisposing factors were sinusitis and congenital heart disease. Streptococci spp and Staphylococci spp were the most frequently isolated organisms. All patients underwent CT scanning and surgical intervention. The mortality rate was 20 percent, and 21 percent of the survivors had late seizures. There must be a high index of clinical suspicion and early referral to specialist centres where neuroradiological investigation and prompt neurosurgical intervention can be carried out to minimise morbidity and mortality.

Spinal Injuries at the University Hospital of the West Indies

Acute spinal damage forms a small percentage of total trauma injury but it has tremendous significance because of the resultant disability, poor prognosis, economic and social cost and the burden on victims, family, taxpayers and health workers. Of fifty-five patients admitted to the University Hospital of the West Indies (UHWI), Mona, Jamaica, over a seven-year period, forty form the basis of this report. Young males accounted for most victims and 85 percent of the injuries were non-intentional. The cervical spine, most commonly C6, was the region most frequently injured, followed by the lumbar and the thoracic regions. On admission, the mean Glasgow Coma Score was 14.6 and the mean Modified Injury Severity Score 12.7. Five patients were admitted in Frankel Grade A, complete paraplegia. Of eighteen patients treated with steroids, only eleven had methylprednisolone and only six of these appropriately. Nine patients had surgery after a mean time of 10.1 days. The average length of hospital stay was 18.2 days. Of 35 patients whose outcomes were known, eleven improved; two patients died in hospital. With the modernisation of the management of this condition, we recommend that attention be focused on prevention, pre-hospital immobilisation and transport, prompt resuscitation, the standardisation of written protocols and early operative intervention. Also essential is the continuing medical education of all levels of personnel and the formalisation of a well-coordinated and rehearsed Spine team.