Review of Neurosurgery in the Democratic Republic of Congo: Historical Approach of a Local Context.

Neurosurgical practice in the Democratic Republic of Congo (DRC) is challenged by limited resources and infrastructure. The DRC has 16 local residing neurosurgeons for 95 million inhabitants, a ratio of 1 neurosurgeon per 5.9 million Congolese citizens. This is attributable to decades of political unrest and a loosely regulated health care system. Understanding the role of neurosurgery in a historical context is necessary to appreciate and overcome current challenges in the delivery of neurosurgical care. We describe past and present political, social, and economic challenges surrounding the development of neurosurgical practice and training. Highlights of early innovators, current challenges, and a suggested framework to guide future advances in neurosurgical practice are provided. Interviews with Dr. Antoine Beltchika Kalubye, the oldest living neurosurgeon in the DRC, and Dr. Jean-Pierre Kalala Okito, current president of the Congolese Society of Neurosurgery, provide a detailed account of events. Firsthand narrative was supplemented via literature review and collaboration with registrars in the DRC to review current neurosurgery programs. Our discussions revealed that decades of political unrest and inconsistent management of health care resources are responsible for the current state of healthcare, including the dearth of local neurosurgeons. The neurosurgery workforce deficit in the DRC remains substantial. It is essential to understand local neurosurgical history, in its present state and breadth of challenges, to inform future development of neurosurgical care and to secure equitable partnerships between local stakeholders and the international community.

Comparison of the CRASH Score-Predicted and Real Outcome of Traumatic Brain Injury in a Retrospective Analysis of 417 Patients.

OBJECTIVE: The aim of this retrospective study was to externally validate the CRASH (Corticosteroid Randomisation After Significant Head Injury) clinical calculator as a prognostic tool. Mortality at 14 days and an unfavorable outcome (i.e., Glasgow Outcome Scale score <4) after 6 months were the primary endpoints. METHODS: The study included adult patients admitted to the emergency department of Ghent University Hospital during 2010-2014 with traumatic brain injury. The CRASH score was calculated for every patient and compared with real-life outcome at 14 days and 6 months. Researchers were blinded for each other's results, and each observer either calculated the CRASH score or obtained clinical outcome. Receiver operating characteristic analysis was used to validate the CRASH calculator. The prognostic value of other variables was tested using logistic regression (P < 0.05 was significant). RESULTS: Of 417 included patients with traumatic brain injury, 94.7% were still alive at 14 days, and 65% had a Glasgow Outcome Scale score ≥4 at 6 months. Receiver operating characteristic analysis showed an area under the curve of 92.1% at 14 days and 90.7% at 6 months (P < 0.05). Calculated cutoff value for the CRASH score at 14 days was 31.50% (sensitivity 0.823, specificity 0.895). At 6 months, calculated cutoff value was 55.75% (sensitivity 0.793, specificity 0.830). CONCLUSIONS: The CRASH calculator is a good predictor of outcome in traumatic brain injury at 14 days and 6 months with high sensitivity and specificity. It does not replace clinical judgment of the physician treating the patient in the emergency department, but it constitutes a useful additional tool.

Adjuvant therapeutic potential of tonabersat in the standard treatment of glioblastoma: A preclinical F98 glioblastoma rat model study.

PURPOSE: Even with an optimal treatment protocol, the median survival of glioblastoma (GB) patients is only 12-15 months. Hence, there is need for novel effective therapies that improve survival outcomes. Recent evidence suggests an important role for connexin (Cx) proteins (especially Cx43) in the microenvironment of malignant glioma. Cx43-mediated gap junctional communication has been observed between tumor cells, between astrocytes and between tumor cells and astrocytes. Therefore, gap junction directed therapy using a pharmacological suppressor or modulator, such as tonabersat, could be a promising target in the treatment of GB. In this preclinical study, we evaluated the possible therapeutic potential of tonabersat in the F98 model. PROCEDURES: Female Fischer rats were inoculated with ± 25.000 F98 tumor cells in the right frontal lobe. Eight days post-inoculation contrast-enhanced T1-weighted (CE-T1w) magnetic resonance (MR) images were acquired to confirm tumor growth in the brain. After tumor confirmation, rats were randomized into a Control Group, a Connexin Modulation Group (CM), a Standard Medical Treatment Group (ST), and a Standard Medical Treatment with adjuvant Connexin Modulation Group (STCM). To evaluate therapy response, T2-weighted (T2w) and CE-T1w sequences were acquired at several time points. Tumor volume analysis was performed on CE-T1w images and statistical analysis was performed using a linear mixed model. RESULTS: Significant differences in estimated geometric mean tumor volumes were found between the ST Group and the Control Group and also between the STCM Group and the Control Group. In addition, significant differences in estimated geometric mean tumor volumes between the ST Group and the STCM Group were demonstrated. No significant differences in estimated geometric mean tumor volumes were found between the Control Group and the CM Group. CONCLUSION: Our results demonstrate a therapeutic potential of tonabersat for the treatment of GB when used in combination with radiotherapy and temozolomide chemotherapy.

The use of the trendelenburg position in the surgical treatment of extreme cerebellar slump.

BACKGROUND: State-of-the-art treatment for Chiari Malformation I (CM-I) consists of decompression by posterior fossa craniectomy. A rare but severe complication that develops over months to years after this procedure is cerebellar slump. Treatment options for this condition are limited. We present a new and promising approach to treat this rare condition. METHODS: The patients were placed in the Trendelenburg position to facilitate ascent of the cerebellum. After almost complete dissolution of neurologic symptoms, surgical reconstruction was performed by tonsillar resection and the creation of a new structural support using a bone graft. RESULTS: Both patients experienced good clinical and morphological outcomes immediately after surgery, and for two years thereafter. CONCLUSIONS: Neurological symptoms related to cerebellar or brainstem slump can be adequately reversed by placing the patient in the Trendelenburg position. After uneventful gravitational reversal of the slump, safe surgical reconstruction of the cerebellar support can be performed to securely preserve the anatomical reversal.

Endoscopic Treatment of Temporal Arachnoid Cysts in 34 Patients.

INTRODUCTION: Arachnoid cysts are lesions present in 1% of the population and usually found in the temporal fossa. Clinical and radiologic presentations can differ greatly. Despite intensive research, it is still debatable which patients will benefit from surgery. OBJECTIVE: This study aims to investigate the pretreatment parameters influencing the outcome after neuroendoscopic treatment of temporal arachnoid cysts. MATERIALS AND METHODS: A retrospective analysis of 34 patients who underwent an endoscopic fenestration of a temporal arachnoid cyst between July 1991 and December 2013 was performed. RESULTS: In symptomatic patients, there was a clinical improvement in 76.4% of cases. The best results were found in treating symptoms related to intracranial hypertension, acute neurologic defects, and macrocrania. Patients with temporal lobe epilepsy improved after cyst fenestration in 33.3% of cases. Behavioral problems and psychomotor retardation remained largely unchanged. Patients with a complex neurologic presentation, often from a congenital syndrome and combined with an intellectual disability, had the least benefit from endoscopic surgery. Radiologic follow-up showed a cyst volume decrease in 91.2% of cases. Complications were present in 29.4%, but were mostly minor and transient. CONCLUSION: This study demonstrates that patients with symptoms related to intracranial hypertension, acute neurologic deficits, and macrocrania have the best postoperative outcome. Also, patients with ipsilateral temporal lobe epilepsy seem to be good candidates for endoscopic arachnoid cyst fenestrations. In complex neurologic disorders without one of the previously mentioned symptoms, endoscopy remains less successful.

A novel design for steerable instruments based on laser-cut nitinol.

OBJECTIVE: Omnidirectional articulated instruments enhance dexterity. In neurosurgery, for example, the simultaneous use of 2 instruments through the same endoscopic shaft remains a difficult feat. It is, however, very challenging to manufacture steerable instruments of the requisite small diameter. We present a new technique to produce such instruments by means of laser cutting. Only 3 coaxial tubes are used. The middle tube has a cutting pattern that allows the steering forces to be transmitted from the proximal to the distal end. In this way the steering part is concealed in the wall of the tube. Large diameter articulated instruments such as for laparoscopy might benefit from the excellent tip stability provided by the same economical technology. METHOD: Coaxial nitinol tubes are laser-cut with a Rofin Stent Cutter in a specific pattern. The 3 tubes are assembled by sliding them over one another, forming a single composite tube. In a surgical simulator, the neurosurgical microinstruments and laparoscopic needle drivers were evaluated on surgical convenience. RESULTS: Simultaneous use of 2 neurosurgical instruments (1.5 mm diameter) through the same endoscopic shaft proved to be very intuitive. The tip of the steerable laparoscopic instruments (10 mm diameter) could resist a lateral force of more than 20 N. The angle of motion for either instrument was at least 70° in any direction. CONCLUSIONS: A new design for steerable endoscopic instruments is presented. It allows the construction in a range from microinstruments to 10-mm laparoscopic devices with excellent tip stability.

Transarterial embolization with ONYX for treatment of intracranial non-cavernous dural arteriovenous fistula with or without cortical venous reflux.

BACKGROUND AND PURPOSE: To report our experience with transarterial ONYX embolization of intracranial non-cavernous dural arteriovenous fistulas (DAVFs) with or without cortical venous reflux. MATERIALS AND METHODS: Retrospective analysis of transarterial ONYX embolization in 20 patients with 21 DAVFs, presenting with intracranial hemorrhage (n=7), pulsatile bruit (n=7), vertigo (n=3), non-pulsatile bruit (n=1), headache (n=1) and epilepsy (n=1). Risk grading of DAVFs was Borden type I (n=6), type II (n=4) and type III (n=11). RESULTS: 18 of 21 (85.7%) DAVFs were angiographically occluded immediately after embolization, with ONYX embolization only, in either one (n=12) or two sessions (n=2); with a combination of ONYX and glue or transvenous coiling in a single session (n=2) or in two sessions (n=1); or after previous transvenous coiling/glue embolization (n=1). At the 6 (4-14) month control digital subtraction angiography (DSA), available in 14 of 18 occluded DAVFs, one patient showed a small residual fistula (17/21 or 81% occluded). Mid-term DSA was not available because of early death (n=2) or patients were awaiting the examination (n=2). In three cases, treatment was incomplete. Of six Borden type I DAVFs, four were cured and two partially occluded with resolution of symptoms. In two DAVFs, neurosurgical access to the feeding artery allowed distal microcatheterization and successful embolization. CONCLUSION: Transarterial ONYX embolization offers an effective and safe treatment for all non-cavernous DAVFs, whether with or without cortical venous reflux.