Smartphone Ocular Fundal Photography in the Diagnosis of Raised Intracranial Pressure: A Novel Adaptation to Neurosurgical Practice.

Background Consistently raised intracranial pressure (ICP) is a common final pathway to morbidity/mortality in many neurosurgical conditions. This underscores the need for early diagnosis and prompt management of raised ICP. This study aims to determine whether smartphone fundal photography features of raised ICP can accurately predict the computed tomography (CT) findings suggestive of elevated ICP in neurosurgery patients. Methods Dilated ocular fundal photography examinations using an ophthalmoscope adapter mounted on a smartphone were done on 82 patients with clinical suspicion of raised ICP. Fundal photography findings were recorded as pictures/videos for disc analysis. Patients subsequently had neuroimaging with results analyzed for radiological features of raised ICP. These were correlated with fundal photography findings. Results A total of 82 adult patients participated in this study. Chi-square analysis showed a relationship between radiological signs of raised ICP and the absence of spontaneous retinal venous pulsation (SRVP) (p=0.001). There was no relationship observed between papilledema and radiological signs of raised ICP. However, when the fundal photography signs were aggregated, there was a significant relationship between the fundal signs of raised ICP and radiological signs of raised ICP (p=0.004). The sensitivity and specificity of smartphone-fundoscopy-detected papilledema in predicting radiological signs of raised ICP were 43.2% and 100%, respectively, while those of absent SRVP were 100% and 92.6%, respectively. Conclusion Smartphone ophthalmoscopy is a reliable screening tool for evaluating ICP in neurosurgical patients. It should be introduced into the neurosurgeon's tools for prompt evaluation of raised ICP, especially in developing/resource-poor settings where CT or magnetic resonance imaging is not readily available.

Developing a Guideline for Neurotrauma in Nigeria.

BACKGROUND: The Nigerian Academy of Neurological Surgeons in 2019 resolved to standardize the practice of neurosurgery in Nigeria. It set up committees to standardize the various aspects of neurosurgery, such as neurotrauma, pediatrics, functional, vascular, skull base, brain tumor, and spine. The Committee on Neurotrauma convened and resolved to study most of the available protocols and guidelines in use in different parts of the world. OBJECTIVE: To formulate a standard protocol for the practice of neurotrauma care within the Nigerian locality. METHODS: The Committee split its membership into 3 subcommittees to cover the various aspects of the Neurotrauma Guidelines, such as neurotrauma curriculum, standard neurotrauma management protocols, and neurotrauma registry. Each subcommittee was to research on available models and formulate a draft for Nigerian neurotrauma. RESULTS: All the 3 subcommittees had their reports ready on schedule. Each concurred that neurotrauma is a major public health challenge in Nigeria. They produced 3 different drafts on the 3 thematic areas of the project. The subcommittees are: 1. Subcommittee on Fellowship, Training and Research Curriculum; 2. Subcommittee on Standard Protocols and Management Guidelines; and 3. Subcommittee of the Nigerian Neurotrauma Registry. CONCLUSION: The committee concluded that a formal protocol for neurotrauma care is long overdue in Nigeria for the standardization of all aspects of neurotrauma. It then recommended the adoption of these guidelines by all institutions offering services in Nigeria using the management protocols, opening a registry, and mounting researches on the various aspects of neurotrauma.

A Case of Retroperitoneal Malignant Triton Tumor in a Nigerian Boy.

Malignant peripheral nerve sheath tumor is a rare tumor occurring in 5%-10% of all malignant soft tissues sarcomas and triton tumor arising from neurofibromatosis type 1 (NF-1) is even rarer with associated high rate of mortality. No case of triton tumor has been reported in Nigeria to the best of our knowledge. We seek to report a case of lately detected retroperitoneal triton tumor presenting in a 12-year-old Nigerian child who was brought with bilateral lower limb weaknesses, weight loss, and a right lumbar mass. There were multiple café au lait spots on the body. Abdominal computerized tomographic scan revealed a huge right retroperitoneal mass crossing the midline, compressing adjacent structures with multilevel intraspinal extensions. Core needle biopsy performed and both histology and immunohistochemical studies confirmed the diagnosis, but patient demised in the course of care. The aim is to heighten suspicion of this extremely very rare malignant tumor in children with NF-1.

Does Improvised Waterbed Reduce the Incidence of Pressure Ulcers in Patients with Spinal Injury?

BACKGROUND: Pressure ulcers are lesions caused by unrelieved pressure over bony prominences, resulting in damage to underlying tissues. The etiology is multifactorial including prolonged immobility. They usually complicate spinal cord injuries with long periods of bed confinement. The use of bed replacements markedly reduces the incidence of pressure ulcers, but the unaffordability of these replacements in low-income countries has necessitated the need to explore cheaper alternatives. AIM AND OBJECTIVE: The aim of this study was to ascertain whether the use of our cheap and locally improvised waterbeds would reduce the incidence of pressure ulcers in patients on prolonged bed confinement due to spinal injury. METHODOLOGY: Over a 16-month period, 51 patients (age range 1-80 years) with spinal injuries were managed conservatively in our service using improvised waterbeds in 21 (41.2%), while using the regular hospital bed/foam in 30 (58.8%). Biodata, the time interval between injury and presentation to the hospital, nature of the injury, use of improvised waterbed and development of pressure ulcer, were collected, collated, and analyzed. Statistical significance was calculated with the Chi-square test. RESULTS: Most were males (98%), in the age range of 21-30 years (25.5%), and due to fall from heights (35.3%). Of 21 patients who were managed on improvised waterbeds, 6 (28.6%) had pressure ulcers, and of the 30 who did not use the waterbed, 17 (56.7%) developed ulcers. The χ(2) = 3.9381, while P = 0.0472. This difference was statistically significant. CONCLUSION: The improvised waterbed, which is much cheaper than the standard waterbed, was observed to have significantly reduced the incidence of pressure ulcers among our patients. Nonetheless, further studies would still be needed to confirm this observation.

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.

Differential diagnoses of cerebral hemiatrophy in childhood: a review of literature with illustrative report of two cases.

Childhood cerebral hemiatrophy is an uncommon clinical entity. Its aetiologies are diverse but can generally be grouped into congenital and acquired. The congenital type is intrauterine in origin while the acquired type occurs early in life, usually before two year of life. When childhood cerebral hemiatrophy occurs, it evokes a spectrum of compensatory calvarial sequlae. These include ipsilateral calvarial thickening, diploe widening, hyper-pneumatization of paranasal sinues/ mastoids, elevation of petrous bone and small middle cranial fossa. MRI is very effective in high lightening brain atrophy, associated parenchymal changes and even the above enumerated skull changes. Our two case reports of left hemi-cerebral atrophy in male Cameroonian children seen in our MRI practice aptly demonstrated some of the aforementioned radiological features of childhood cerebral hemiatrophy noted in literature review.

Peculiarities in cases of spina bifida cystica managed recently in south-east Nigeria: could antimalarial drugs be a major but unrecognized etiologic factor?

BACKGROUND: Spina bifida is a long-known disease arising from the incomplete fusion of the caudal neuropore in the first month of intrauterine life. It is thought to have a multifactorial etiology, the most important of which is folic acid deficiency. In evaluating its etiology, the role of antifolate agents like antimalarial drugs is rarely given a strong mention. METHODS/PATIENTS: This is a 44-month prospective study of consecutive cases of spina bifida cystica presenting to the Neurosurgery Unit of Nnamdi Azikiwe University Teaching Hospital, Nnewi, South-East Nigeria. Data collection was with a structured proforma from presentation, and collation done with Microsoft Excel broadsheet and data analysis with SPSS and χ2 test. RESULTS: A total of 41 cases of spina bifida were attended to within the period, with 92.7% cases of spina bifida cystica. Most presented by >12-24 months, with a consistent history of maternal ingestion of antimalarial drugs during the first trimester of pregnancy. CONCLUSION: Spina bifida cystica was diagnosed mostly in children whose mothers ingested antimalarial drugs during the first trimester of gestation. There may be a need to critically evaluate the contribution of antimalarial drugs to the etiopathogenesis of this malformation and develop safer antimalarial treatment in pregnancy.

Diagnostic dilemma; report of a bizarre case of advanced scalp and face angiosarcoma and literature review.

A 36-year-old male painter presented to our service in 2007 with an ulcerated solitary scalp swelling of 8 months' duration. The mass was a dormant, painless, pea-sized growth, which he had had since childhood and which he bruised in a passenger motorcycle road traffic accident 8 months prior to presentation. The accident caused it to flare up and progressively increase in size, with associated pain, contact bleeding, and ulceration. A work-up for excision biopsy was proposed, but the patient defaulted and presented 2 years later with an increased number of lesions all around the scalp and face and in an obviously deteriorating clinical status with regional lymph node involvement at this stage. An incisional biopsy was then carried out and the histological reports came out with three different diagnoses of glioblastoma multiforme, poorly differentiated angiosarcoma, and squamous cell carcinoma, constituting a major diagnostic dilemma for our service.

Combating complications following ventriculoperitoneal shunting in a new centre.

BACKGROUND: Over the years, different approaches to the treatment of hydrocephalus have evolved across all age groups; however, ventriculoperitoneal shunting (VPS) remains the most widely used procedure, albeit with many complications. AIMS: The aim of our study is to prospectively look at the incidence of complications following VPS in our centre, and to suggest ways of minimizing these complications. PATIENTS AND METHODS: Between April 2006 and March 2008, all patients who had VPS in our centre were recruited for the study using a structured protocol from the time of admission to the time of discharge; data were augmented with case notes along with clinic and theatre records. Our centre is located in south-east Nigeria, and we commenced neurosurgical services in April 2006. RESULTS: Within this 2-year period, 49 patients were definitively diagnosed with hydrocephalus and 32 underwent VPS, following which 9 (28%) had various complications - with shunt infection being the most common (n = 3; 9.3%). CONCLUSION: VPS is the definitive treatment modality for hydrocephalus in our centre, and shunt infection (as reported by several other authors) is the most common complication we encounter. Adopting a strict protocol for the prevention of perioperative contamination, as well as educating caregivers, is advocated to reduce this complication in any new neurosurgical centre.