Characterizing hepatitis B virus infection in children in the Democratic Republic of Congo to inform elimination efforts.

Objective: Despite global reductions in hepatitis B virus (HBV) prevalence, an estimated 6.2 million children are infected, two-thirds of whom live in the WHO Africa region. We sought to characterize childhood HBV to inform elimination efforts in the Democratic Republic of Congo (DRC), one of the largest and most populous African countries. Methods: Using the most recent (2013-14) nationally representative Demographic and Health Survey in the DRC, we analyzed HBV surface antigen (HBsAg) on dried blood spots and associated survey data from children aged 6-59 months. We estimated HBsAg-positivity prevalence nationally, regionally, and by potential correlates of infection. We evaluated spatial variation in HBsAg-positivity prevalence, overall and by age, sex, and vaccination status. Findings: Using data from 5,679 children, we found national HBsAg-positivity prevalence was 1.3% (95% CI: 0.9%-1.7%), but ranged from 0.0% in DRC's capital city province, Kinshasa, to 5.6% in northwestern Sud-Ubangi Province. Prevalence among boys (1.8%, 95% CI: 1.2%-2.7%) was double that among girls (0.7%, 95%CI: 0.4%-1.3%). Tetanus antibody-negativity, rurality, and lower household wealth were also significantly associated with higher HBsAg-positivity prevalence. We observed no difference in prevalence by age. Children had higher HBsAg-positivity odds if living with ≥1 HBsAg-positive adult household member (OR: 2.3, 95%CI: 0.7-7.8), particularly an HBsAg-positive mother (OR: 7.2, 95%CI:1.6-32.2). Conclusion: In the largest national survey of HBV among children and household contacts in the DRC, we found that childhood HBV prevalence was 10-60 times the global target of 0.1%. We highlight specific regions and populations for further investigation and focused prevention efforts.

Postoperative Complications of Transsphenoidal Pituitary Adenectomy: A Single Institution Based Experience.

Background Inside a cranium, pituitary gland seats in an area of complex anatomical construct. Further it holds a very important physiological role to maintain all bodily function. Pituitary adenoma being one of the commonest tumors of that intricate area is preferably tackled with transsphenoidal approach. However, as in any surgery, it is also not without postoperative complications. Objective To examine and categorize all the postoperative complications that we have encountered in our center after pituitary surgery. Method A retrospective study of patients who had undergone transsphenoidal pituitary adenectomy in past five years was conducted at a tertiary level neurosurgical center and various postoperative complications during hospital stay were noted and analyzed. Result In our series of 53 patients, we met different postoperative complications, out of which diabetes insipidus (DI) was the commonest. Other electrolyte abnormalities excluding diabetes insipidus was the second most common followed by Cerebrospinal fluid leak. Post-operative hematoma requiring re-exploration, panhypopituitarism, seizure and meningitis were among the rare complications. No statistically significant association was noted between tumor size, patient age and sex with surgical complications. Conclusion Postoperative complications should be anticipated in transsphenoidal pituitary surgery even though it is considered to be a relatively safe undertaking. Knowing about these complications is the first step in preventing them.

Cheiro-Oral Syndrome.

Cheiro-Oral Syndrome (COS) is a very rare neurological syndrome associated with varied etiology. We report a 53-year-old man presented with left sided perioral and ipsilateral hand/fingers burning sensation for a one-month duration. On examination, he had hypesthesia over left perioral and distal palmar aspect of all five fingers. MRI revealed subacute infarct in the posterior limb of right internal capsule adjacent to and minimally involving thalamus. He was diagnosed as CheiroOral Syndrome as a result of ischemic stroke and managed.

Cerebral Venous Sinus Thrombosis during Everest Expedition: A Case Report and Review of the Literature.

Cerebral venous sinus thrombosis (CVST) is a rare but serious disorder that is associated with a poor clinical outcome. We report a 35-year-old man who had a severe headache and diplopia while climbing Mount Everest. His MR venography showed right transverse and right sigmoid sinus thrombosis. He improved on anticoagulant and symptomatic measures. Cerebral venous sinus thrombosis at high altitude is discussed.

Feasibility and efficacy of thrombolysis in acute ischemic stroke: A study from National Institute of Neurological and Allied Sciences, Kathmandu, Nepal.

BACKGROUND: Stroke is the major cause of morbidity and mortality worldwide. The number of stroke patients receiving recombinant tissue plasminogen activator (rt-PA), also known as Alteplase, in the developing world is extremely low. We aim to study the feasibility and efficacy of thrombolysis for the 1(st) time in our country. MATERIALS AND METHODS: In this retrospective study (July 2012-August 2015), acute ischemic stroke patients who were thrombolyzed within 3 h of stroke onset were included. Their demographic profiles, clinical profiles, risk factors, type of thrombolytic used, and outcomes were systematically recorded and analyzed. RESULTS: A total of 9 patients were thrombolyzed. The mean time from the onset of stroke symptoms to first dose of rt-PA (onset to treatment) was 1.2 h. Six patients had good neurological outcome as measured by modified Rankin Scale (mRS). The median mRS at discharge was 3. Thrombolysis-related post treatment complication was noted in 44.4%, of which nonfatal intracranial bleed occurred only in 2 patients (22.2%). None of the patients receiving intravenous tenecteplase had thrombolysis-related complications, and none of the patients had fatal intracranial bleed. CONCLUSION: This study clearly demonstrates the beginning of a feasible and effective thrombolysis in the treatment of acute ischemic stroke in Nepal.

Outcome of head injury patients undergoing surgical management: a tertiary level experience.

BACKGROUND: Head injury is the major cause of death in a neurosurgical patient. OBJECTIVE: To find the outcome, and treatment modality affecting the outcome in patients with head injury. METHODS: Nine hundred eighty seven patients presenting to National Institute of Neurological and Allied Sciences, Kathmandu, with head injury from September 2009 to October 2010 were included in the study. Patients were categorized according to post resuscitation Glasgow Coma Score. Outcome was assessed at discharge using Glasgow Outcome Score and analyzed for any correlation with modality of treatment and severity of injury. RESULTS: Among 987 patients with head injury,152 (15.4%) had severe, 126 (12.8%) had moderate and 709 (71.8%) had mild head injuries. Three hundred twelve (31.6%) patients required definitive and supportive surgical intervention. One hundred eighty two required cranial surgical intervention. Overall mortality was 10% (99), 137 patients (13.9%) had unfavorable outcome and 850 (86.1%) had favorable Glasgow Outcome Score of 4 and 5. Mortality was 53.2%, 9.5% and 0.8% in severe, moderate and mild head injury group respectively. Mortality rate was significantly higher (64.6%) in severe head injury group managed conservatively than those in same group treated with supportive and definite surgical intervention (44.8%) (p=0.016). CONCLUSION: Mortality in head injury patients depend upon severity of injury. Mortality in severe head injury group can be reduced by supportive and definite surgical intervention.

Traumatic brain injury in children.

This article provides a clinical overview of traumatic brain injury in children. It concentrates on the current management guidelines from initial assessment in the accident and emergency department through to specialist critical care.

Hearing preservation in 2.7 cm vestibular schwannoma.

Hearing preservation is exceedingly difficult in vestibular schwannoma surgery, especially with increasing tumor size. We herein report a case of hearing preservation in a 2.7 cm vestibular schwannoma, where the patient maintained her pre-operative hearing threshold of 55 dB till a year after surgery. Hence, it appears that an attempt at hearing preservation is worth pursuing.

Role of repeat CT scan head in initially inoperable cases of traumatic head injury.

The CT scan has become popular in cases of head injury. In this study 71 cases (M:48; 68.0% and F:23; 32.0%) with traumatic head injury admitted and initially managed conservatively at National Neurosurgical Referral Centre, Bir hospital starting from May 2005 to April 2006. The most common cause of injury was road accidents (43 cases) with motorcycle and bus injuries as the leading causes. Nausea and vomiting were the most common symptom in 41 (57.0%) cases, followed by headache in 31 (43.0%). Contusions were the most common radiological findings in 84.0% followed by extradural haematoma in 8.0% and pneumocephalus in 7.0%. Out of these the most common location for contusion was frontal (16 cases), followed by parietal (12 cases) and then bilateral contusions. The mean volume was 12 ml, 9 ml and 9 ml for frontal, parietal and temporal contusions, respectively. Repeat scan showed increase in volume of contusion in 31 cases (44.0%), no change in 28 cases (40.0%) and decrease in 12 cases (16.0%). The increase was mainly due to edema in 20 cases (64.0%) and due to actual increase in contusion in only 11 cases (35.0%). Only 5 (7.0%) cases needed operative intervention. It is concluded that routine use of repeat scan in mild to moderate head injury has no role unless there is clinical deterioration.

Single burr hole drainage for chronic subdural haematoma.

Chronic subdural haematoma is a common neurosurgical condition and surprisingly surgical treatment ranges from twist drill craniostomy to more radical membranectomy. However, the outcome is generally favourable with appropriate therapy. This retrospective study is aimed at analyzing the result of single burr hole drainage of such haematoma under local anaesthesia over a period of fifteen years. There were a total of 365 patients ranging from 6 months to 89 years with the mean age of 60 years. Recurrence of haematoma was noted in 17 (4.6%) patients and majority of them (65.0%) were managed by aspiration through the previous burr hole. Favorable outcome was noted in 98.6% patients. Those with adverse outcome were in coma preoperatively. This study suggests that single burr hole drainage under local anaesthesia is sufficient in the majority of patients and outcome was favorable even in the elderly provided they presented before lapsing into coma.

Result of surgery for ruptured intracranial aneurysms in Nepal.

Although aneurysmal subarachnoid haemorrhage appears to be fairly common in the developing countries, the data on the results of management appear to be relatively sparse. This is a retrospective study of 40 patients with 44 intracranial aneurysms operated upon at the National Neurosurgical Referral Centre in Kathmandu, Nepal from 1991 to 1999. The female male ratio was 1.5:1. Age ranged from 16 to 69 years with a mean of 43.2. In location, 18 (41%) were anterior communicating, 10 (23%) posterior communicating, nine (20%) middle cerebral, five (11%) internal carotid other than posterior communicating, two (5%) distal anterior cerebral and one (2%) posterior circulation. Multiple aneurysms were present in four (10%) and giant in three (8%). The timing of surgery ranged from 3 days to 3 months from the day of bleeding. Microsurgical clipping was possible in 37 (93%) and wrapping had to be done in three (7%). Overall mortality was four (10%), two (5%) had a surgery-related death and a further two (5%) died later due to pulmonary embolism. The remaining (90%) made a good recovery. The results compare favourably with that of the International Cooperative Study. Further reduction in mortality will have to await the introduction of endovascular techniques.

The management of brain abscess in a developing country: are the results any different?

A retrospective study of 57 surgically-managed brain abscesses at the Neurosurgical Unit, Bir Hospital during a 6-year period from October 1990 is presented. Detailed hospital case notes could be traced in only 37 cases, consisting of 25 males and 12 females with age range from 5 months to 60 years. Cryptogenic abscess was the commonest category followed by abscess caused by chronic ear infection. The diagnosis was made with enhanced computed tomography (CT) in all the cases. Positive bacteriology was found in only nine cases. The treatment consisted of 6 weeks of intensive intravenous antibiotics and emergency surgical drainage of the abscess. Five out of the total cases died (13.5%). These patients were all in an extremely poor condition at the time of presentation. All the survivors made a good recovery. With timely CT diagnosis, surgical drainage and antibiotics, good results can be achieved even in a developing country.

An anterior intradural neurenteric cyst of the cervical spine: complete excision through central corpectomy approach--case report.

The case of a cervical intraspinal neurenteric cyst in a 6-year-old boy is reported. The anterior intradural location of the cyst was confirmed by preoperative magnetic resonance imaging. Complete excision of the cyst was achieved through the anterior central corpectomy approach. The vertebral defect was reconstructed with autogenous fibular graft. The child made a complete neurological recovery without a mechanical problem either at the neck or at the graft donor site.