Subdural actinomycoma presenting as recurrent chronic subdural hematoma.

Actimomycosis is a rare chronic bacterial infection of the central nervous system, and subdural actinomycoma is extremely rare. This case report brings to bear an uncommon association between subdural actinomycosis with chronic subdural hematoma. Subdural actinomycoma may present as a diagnostic conundrum and could be mistaken radiologically for either a subdural hematoma or an empyaema.

Using the head as a mould for cranioplasty with methylmethacrylate.

Methacrylate is a valuable tool to the neurosurgeon, even though it is currently being replaced by custom bone. During cranioplasty in the absence of custom bone, which is preformed based on the patients imaging, one has to make a cast to cover the cranial defect with or without the use of a mould. A good artificial skull outline is necessary for prevention of implant extrusion and acceptable cosmetic outcome. Using the patients head as a mould is a simple, cheap, and useful technique. An incision is made, and either a craniectomy or an attempt at skull elevation or separation of the scalp from dura is done based on the indication for the cranioplasty. The methacrylate monomer is mixed with its solvent. It is placed in between a sliced glove and then thinned out. Several layers of drapes are placed on the patients head, the acrylate which is in between the gloves is then placed on the drapes. As soon as it starts setting and the required shape obtained, it is removed and place on the sterile tray. It is then anchored and the wound closed. This technique produces good cosmetic outcome. However, the head must be properly protected from the risk of burns from the exothermic reaction. The technique is described in a 40-year-old driver who had a compound depressed skull fracture. He had a methylmethacrylate cranioplasty in the 9(th) week post trauma after allowing for wound healing. We recommend that this technique may be used in centers where custom bone is either too expensive or not available during cranioplasty in order to obtain a good outcome.

Combined transfacial and transcranial approach for tumours of the nose and paranasal sinuses with intracranial extension.

OBJECTIVES: To describe the importance of craniofacial approach in extensive tumours of the nose and paranasal sinuses with intracranial extension. MATERIALS AND METHODS: This is a retrospective study and descriptive analysis of craniofacial approaches to extensive tumors of the nose and paranasal sinuses that were carried at Usmanu Danfodiyo university teaching Hospital Sokoto Nigeria over a nine year period (July 1999 to June 2008). RESULTS: Out of 111 patients seen with tumours of the nose and paranasal sinuses during the period, 29(26.1%) were radiologically reported through computerised tomographic scan to have intracranial extension. Twenty-four (82.8%) were males while 5 (17.2%) were females. Twenty five (86.2%) patients underwent transfacial approach ( modified lateral rhinotomy). Intraoperative findings in these cases only warranted the repair of dural tear in 6 cases through the transfacial approach who had anterior skull base invovlement while 4 had combined transcranial and transfacial approaches (anterior craniofacial resection). Therefore only 10 (34.5%) patients of all the radiologically reported cases of intracranial extension were confirmed intraoperatively to have intracranial extension (5 males, 5 females) with an age range of 1 1/2 to 60 years and mean age of 34.1 years. One patient had orbital exenteration also carried out. Four out of 10 patients are alive after a minimum period of 2 years follow up due to extensive intracranial spread and late presentation of the patient. CONCLUSION: Extensive tumours of the nose and paranasal sinuses with suspected intracranial extension requires not only computerized tomographic scans to assess the extent of the tumour but also a combined transfacial and transcranial approach to successfully resect the tumour.

Combined transfacial and transcranial approach for tumours of the nose and paranasal sinuses with intracranial extension.

OBJECTIVES: To describe the importance of craniofacial approach in extensive tumours of the nose and paranasal sinuses with intracranial extension. MATERIALS AND METHODS: This is a retrospective study and descriptive analysis of craniofacial approaches to extensive tumors of the nose and paranasal sinuses that were carried at Usmanu Danfodiyo University Teaching Hospital, Sokoto Nigeria over a nine year period (July 1999 to June 2008). RESULTS: Out of 111 patients seen with tumours of the nose and paranasal sinuses during the period, 29(26.1%) were radiologically reported through computerised tomographic scan to have intracranial extension. Twenty-four (82.8%) were males while 5 (17.2%) were females. Twenty-five (86.2%) patients underwent transfacial approach (modified lateral rhinotomy). Intraoperative findings in these cases only warranted the repair of dural tear in 6 cases through the transfacial approach who had anterior skull base invovlement while 4 had combined transcranial and transfacial approaches (anterior craniofacial resection). Therefore only 10 (34.5%) patients of all the radiologically reported cases of intracranial extension were confirmed intraoperatively to have intracranial extension (5 males, 5 females) with an age range of 1 1/2 to 60 years and mean age of 34.1 years. One patient had orbital exenteration also carried out. Four out of 10 patients are alive after a minimum period of 2 years follow up due to extensive intracranial spread and late presentation of the patient. CONCLUSION: Extensive tumours of the nose and paranasal sinuses with suspected intracranial extension requires not only computerized tomographic scans to assess the extent of the tumour but also a combined transfacial and transcranial approach to successfully resect the tumour.

Fetal head injury from intentional penetrating abdominal trauma in pregnancy.

A male fetus was extruded from the uterus following multiple lower abdominal stab wounds to the mother. He was brought to the emergency room at 8 hours of age. He had sustained a compound skull fracture with brain contusion. There was no neurological deficit. Debridement and primary wound closure were undertaken. His mother had multiple lacerations to the uterus and a laceration of the fundus of the bladder. Following resuscitation, she had repair of the uterus and bladder and made an uneventful recovery. At 3 years of age, the boy is developing normally.

Solitary giant neurofibroma of the scalp with calvarial defect in a child.

Neurofibroma of the scalp are mostly multiple as part of neurofibromatosis or other phakomatosis. De novo solitary types are less common and rarely erode the skull, unlike the intracranial counterpart. Skull erosion has been reported in adults with longstanding plexiform neurofibromas. We report a giant neurofibroma on the scalp of a five-year-old boy, managed in our center. Although this condition is a rare entity, it should be anticipated and the treatment strategy should include repair of the skull defect.

Pott's puffy tumour: a case report.

A 10-year-old girl presented with an episode of seizure following oste omyelitis of the frontal bone and subperiosteal abscess due to frontal sinusitis. CT scan confirmed osteomeyelitis of the frontal bone and subperiosteal abscess. At surgery, the subperiosteal abscess and contiguous subdural abscess was drained and sequestrectomy of the affected frontal bone done. Broad spectrum antibiotics and anticonvulsant were given for 4 weeks. The patient recovered without residual problems and has remained well at 5 years of follow up. Pott's puffy tumor is now relatively uncommon and associated seizure is unusual. Early diagnosis and prompt treatment is necessary to avoid severe neurological complications and sequelae.

Carotid occlusion and cerebral infarction from camel bite: case report.

A 30-year-old farmer was bitten by his camel on the left side of the neck. He suffered immediate loss of consciousness but recovered three days later with right-sided hemiplegia and complete aphasia. He bled minimally from the neck. CT scan of the brain and carotid Doppler ultrasonography confirmed left parietal lobe infarction and partial occlusion of the left carotid artery respectively. He was managed conservatively with physiotherapy and low dose aspirin. At six months of follow up, his speech remains slurred but comprehensible and is able to walk with a walking stick.

Management of pneumocephalus in a resource limited environment: review from sub-Saharan Africa.

BACKGROUND: Although pneumocephalus is not uncommon, most reports from Africa are of single or few cases. METHODS: A retrospective review of 20 patients with pneumocephalus managed in 4 years was done. There were 19 males and one female aged 22-45 years (median 35 years). The cause of pneumocephalus was head trauma in 18 patients and spontaneous in 2. The commonest symptoms were headache 19 and CSF rhinorrhoea 11. Skull radiographs and brain CT scan were used to confirm the diagnosis in all the patients. Eight patients had surgery while 12 were managed non-operatively. RESULTS: Of the eight that had surgery; six recovered fully, one had residual neurologic deficit and one died from meningitis. Nine patients that were managed non-operatively recovered fully; one died also from meningitis and one refused treatment and left the hospital against advice. CONCLUSIONS: Air in the cranial cavity behaves like any space-occupying lesion; a high index of suspicion is needed to make a diagnosis, prompt treatment and control of infection will prevent unwanted morbidity and mortality.

Delayed presentation of penetrating craniocerebral injury caused by a nail.

A 38-year-old woman presented after 2 weeks with penetrating craniocerebral injury from a six inch nail. She had aphasia and right hemiplegia. Brain CT scan showed no significant cerebral injury. The nail track was infected. Craniectomy and extraction of the nail along with broad spectrum antibiotics was effective. She had no residual neurologic deficit.

Cervicothoracic arachnoid cyst in a patient with neurofibromatosis: case report.

Intradural cervicothoracic arachnoid cysts are not common. They may be congenital, or secondary to trauma, surgery, haemorrhage, or inflammation. This is a report of a 39-year-old man who presented with cutaneous neurofibromatosis and cervicothoracic arachnoid cyst causing gradual quadriparesis. Magnetic resonance imaging showed an intradural extramedullary anterior cystic lesion at C5-T2 level. Laminectomy and mersupialisation of the cyst was performed. Histology confirmed the diagnosis of arachnoid cyst. The patient recovered without neurological deficit.

Necrotising fasciitis: experience with 32 children.

BACKGROUND: Necrotising fasciitis (NF) in children is rare, rapidly progressive and potentially fatal. A satisfactory outcome depends on early diagnosis and aggressive surgical debridement, along with appropriate antibiotic therapy. AIM: The aim was to describe the various presentations of NF and evaluate outcome of treatment. PATIENTS AND METHODS: This was a 4-year prospective, descriptive study of all consecutive cases of NF aged 15 years and under treated at Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria from January 2001 to December 2004. RESULTS: Thirty-two children were treated during the study period. The male:female ratio was 1.7:1. Ages ranged from 6 days to 12 years (mean 2 yrs). The commonest predisposing factors were malnutrition (40.6%), boils (37.5%) and intravenous canulation (9.4%). Duration of symptoms ranged from 3 to 19 days (mean 6.4) and the total body surface areas involved ranged from 2% to 16% (mean 5.9%). Half of the patients presented with involvement of the trunk, followed by head/neck (28.1%), upper limbs (21.9%), lower limbs (6.3%) and perineum (6.3%). Most patients had polymicrobial infection, but the organism most commonly isolated was Staphylococcus aureus (71.9%). All patients were resuscitated and had surgical wound debridement, antibiotics and wound care. Final wound resurfacing was by secondary intention (46.9%), direct suturing (6.3%), split thickness skin grafting (21.9%) and local flap reconstruction (12.5%). Septicaemia was the commonest complication (71.9%). The mortality rate was 9.4%. Duration of hospital stay ranged from 14 to 96 days (mean 27.6). Follow-up ranged from 3 weeks to 6 months (mean 52.4 days). CONCLUSION: NF in children is not uncommon in Nigeria. It is associated with significant morbidity, but mortality can be reduced remarkably by early diagnosis and aggressive treatment.

Blindness following ventriculoperitoneal shunt block in a child with spinal dysraphism: case report.

A six-year-old boy presented with a week history of increasing headache, visual loss and convulsions. He had repair of myelomeningocele early in life and later had insertion of a ventriculoperitoneal shunt for hydrocephalus after the repair. He was treated for meningitis at the referring hospital without improvement. Computed tomography scan of the brain showed ventricular enlargement. The shunt was found to be broken and blocked and was revised. This was followed by rapid improvement but vision was never regained. Shunt malfunction in patients with spinal dysraphism can lead to visual loss but the features may mimic those of meningitis, and delayed referral and treatment. Early shunt revision should prevent this complication.

Malignant peripheral nerve sheath tumour associated with von Recklinghausen's disease: case report.

Only a few cases of malignant peripheral nerve sheath tumour (MPNST) associated with Von Recklinghausen's disease or type I neurofibromatosis (NF-1) have so far been reported worldwide, yet the primary disease (NF-I ) does not seem rare even in Africa. We present a case of a 40 year old woman with MPNST of the left thigh associated with NF-1. The diagnosis was based on clinical, radiological and histopathological evidence. She presented with a 25 year history of painless, multiple, generalized skin nodules and hyperpigmented spots. She also noticed a gradually progressive, painless, redundant mass on the left side of the forehead 16 years prior to presentation. Four months before presentation, she noticed another mass at the back of the left thigh, which increased rapidly in size. Examination revealed a middle aged woman with generalized subcutaneous nodules of various sizes (3mm - 2.5cm), multiple café-au-lait spots (2cm-4.5cm), a plexiform neurofibroma on the left side of the forehead measuring 6cm x 5cm x 5cm. There was a firm, non-pulsatile and non-tender mass (11.5cm x 9cm x 5cm) on the posterior aspect of the left upper thigh. The mass was more mobile longitudinally than transversely and was attached to the overlying skin at the summit, the regional Iymph nodes were not enlarged. Most investigations were essentially normal except a plain radiograph, which revealed a soft tissue mass on the left thigh without bony involvement. At surgery, a well localized soft tissue tumour, abutting on the sciatic nerve was widely resected without neural damage to the nerve. Histologic sections of a tru cut as well as the surgical specimens showed a tumour consisting of closely packed serpentine cells arranged in palisades; marked nuclear and cellular pleomorphism and hyperchromatism, many bizarre tumour giant cells, mitotic figures and foci of necroses. The patient received six courses of cytotoxic therapy and is well eleven months after surgery. It is presented to highlight the clinical and pathological features of NF-1 complicated with malignant transformation.

Acute ileus following ventriculoperitoneal shunt: case report.

A three month old girl with progressive hydrocephalus from birth had a ventriculoperitoneal (VP) shunt, during which the cerebrospinal fluid (CSF) was found to be xanthochromic. She developed acute ileus four hours post-operatively and continued to deteriorate. The shunt was exteriorised as an external ventricular drain. She did well and another VP shunt was inserted later. Acute ileus following VP shunt is not common, but can occur in the presence of xanthochromic CSF. It is advisable that when such CSF is encountered during VP shunt, the initial management should be external ventricular drainage, followed later by VP shunt when the CSF becomes clear. This can be life saving.

Managing scalp defects in sub-Saharan Africa.

OBJECTIVES: To determine the common aetiological factors of scalp defects, and outcome of management. DESIGN: A two year prospective study. SETTING: Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria. SUBJECTS: All consecutive patients with scalp defect from January 2001 to December 2002. MAIN OUTCOME MEASURES: Size of defect, associated bone loss, osteomyelitis, type of surgery, duration of hospital stay and complications of surgery. INTERVENTIONS: Patients went through a simple management protocol involving history, clinical examination, relevant tests and appropriate treatment, including surgery. RESULTS: A total of 27 patients were studied out of which 15 were males and 12 females, giving a male to female ratio of 1.25:1. The age range was seven months-42 years (mean = 13.9 years). Road Traffic Accidents (RTAs) was the commonest cause of scalp defects (81.5%). The temporo-parietal area was involved in over 50% of patients. Chronicity and osteomyelitis were common complications of the defects. Over 50% of the patients had local flap reconstruction. CONCLUSIONS: Management of scalp defects remains a major challenge in our environment. The importance of continuing education of colleagues and other health workers in peripheral health units on the importance of proper initial wound debridement and early referral cannot be overemphasised.