Immunohistochemical Patterns of Pituitary Adenomas in Southeastern Nigeria, a 10-year Histopathologic Review.

Introduction: Pituitary adenomas [PAs] constitute the third most common primary intracranial tumours, with a wide prevalence rate of 1% to 40%. Histologic (H & E) classification into acidophilic, basophilic and chromophobic adenomas have little clinical relevance but WHO recommended immunohistochemical subclassification has both therapeutic and prognostic significance. This immunohistochemical subclassification has not been done in our environment, making it imperative for us to evaluate the patterns in our environment.Aim: To determine the immunohistochemical patterns of PAs in Southeastern Nigeria.Materials and Methods: This was a 10-year retrospective review of all PA biopsies received at University of Nigeria Teaching Hospital Enugu, Memphys Hospital for Neurosurgery Enugu and Grace Pathology Consults Enugu, Nigeria. The age, sex, histologic, immunohistochemical subtypes and biopsy size of all diagnosed PAs were analyzed using Statistical Package for Social Sciences (SPSS) version 20 (New York: IBM Inc.) and the results were expressed in descriptive statistics.Results: One hundred cases of PAs were identified in this study constituting 19.6% of all primary intracranial tumors received at our study centers during the period under review. There were 45 (45.0%) females and 55 (55.0%) males giving a female to male ratio of 1:1.2, and a mean age of 45.3 years. The commonest histologic type was acidophilic adenoma (49.0%), followed by basophilic (40.0%) and chromophobic (11.0%) adenomas. Null cell adenomas were the most common immunohistochemical subtype (44.0%), followed by PRL-secreting adenomas (27.0%). Others were Luteinizing hormone (LH) - 13 (13.0%), follicle stimulating hormone (FSH) - 7 (7.0%), growth hormone (GH) - 3(3.0%), TSH - 2(2.0%) and ACTH - 1(1.0%) adenomas.Conclusion: PAs predominate amongst males, occurring mostly in the middle age groups in Southeastern Nigeria. Null cell adenoma is the commonest immunohistochemical subtype followed by PRL-secreting adenomas. Routine immunohistochemical characterization is required for accurate diagnosis and optimal patient care.

Global neurosurgery over a 60-year period: Conceptual foundations, time reference, emerging Co-ordinates and prospects for collaborative interventions in low and middle income countries.

Introduction: We evaluated salient initiatives invested in global neurosurgery over a 60-year period. Research question: What are the Phases, Achievements, Challenges, and Lessons of Global Neurosurgery. Methods: A 60-year retrospective study from 1960 to 2020 analyzing the major phases, lessons, and progress notes. We reviewed the foundational need questions and innovated tools used to answer them. Results: Three phases defining our study period were identified. In the early phase, birthing academic units and the onset of individual volunteerism were dominant concepts. The 2nd phase is summarized by the rise of volunteerism and surgical camps.The third phase is heralded by advocacy and strategies for achieving care equity. The defining moment is the Lancet commission for global surgery summit in 2015. Lessons include the need for evaluation of the resources of recipient and donor locations using novel global surgery tools. Conclusion: Global neurosurgery over the 60-year study period is summarized by indelible touchstones of personal and group efforts as well as triumphs derived from innovations in the face of formidable challenges.

Neurophthalmic manifestations of giant sellar tumors in adults: Relationship between endocrine status and visual acuity profile pre and postsurgical treatment: A prospective cohort study.

OBJECTIVE: To evaluate the relationship between visual acuity (VA) and endocrine status among patients with giant sellar tumors pre and postsurgical treatment. METHODS: A 7-year single institution prospective cohort study of patients with giant sellar tumors treated by pterional transylvian microsurgical resection. Patients were evaluated and followed-up by a collaborative team of ophthalmologists and neurosurgeons. RESULTS: Sellar tumors represent 25% of our brain tumors cases (n = 257). Giant sellar tumors were 61 (23.7%) cases. Pituitary adenomas occurred in 40 patients and in 24 of these, the tumor was a functional adenoma. The age range was 16 to 75 years with a mean of 43.7 ± 3.3 years. Visual impairment (n = 60), headache (n = 55), and endocrinopathy (24) were among the common manifestations. VA and visual field defects were experienced by 59 and 39 patients, respectively. For both eyes, endocrine active tumors presented with poorer preoperative VA profile using mean logMAR VA [(χ2 = 10.3, P = 0.002 OD) and (χ2 = 8.9, P = 0.003 OS)]. Postoperatively, the mean logMAR VA profiles of endocrine active tumors showed a significantly better response when compared to endocrine inactive tumors in both eyes [(χ2 = 5.53, P = 0.029 OD) and (χ2 = 6.77, P = 0.037 OS)]. CONCLUSION: Visual acuity defects are almost invariable in patients with giant sellar tumor and may be associated with an endocrine profile. Surgical resection with normalization of hormone status is rewarded with VA improvement.

Outcome of management of elevated skull fractures in Enugu, South-East Nigeria.

INTRODUCTION: Elevated skull fractures, previously thought of as a very rare variety of fractures, are no longer very uncommon. They are expectedly gradually finding a slowly growing list of references in neurosurgical literature. They are mostly posttraumatic compound fractures due to the mechanism of injury. Outcome of operative neurosurgical care is generally rewarding. MATERIALS AND METHODS: A 4-year retrospective study of case notes, operation registers, and radiology records of patients diagnosed with elevated skull fractures who had neurosurgical care at the University of Nigeria Teaching Hospital, Enugu, Nigeria, between 2012 and 2015, was done. Only patients with evidence of elevated skull fracture on head computed tomography scan were included. The presenting Glasgow Coma Score and Extended Glasgow Outcome Score (GOSE) at the time of discharge from the hospital and 6 months thereafter were analyzed. RESULTS: Out of 209 patients managed with skull fractures over the study period, eight met the inclusion criteria. Seven (87.5%) were males. The latency to presentation was 6 h in one case and> 8 h in the other cases. All the patients had operative care involving debridement, duroplasty, and bone-fragment realignment (cranioplasty) either primarily or on an interval basis. The GOSE at 6 months was at least 7 in 87.5% of the patients. CONCLUSIONS: Despite the grotesque appearance at presentation, outcome of properly managed elevated skull fractures is good.

Challenges and outcome of cranial neuroendoscopic surgery in a resource constrained developing African country.

BACKGROUND: Cranial neuroendoscopy has been safely applied to the surgical treatment of different lesions of the brain in our center since its introduction in September 2009. This article summarizes our experience with neuroendoscopy, highlighting the salient challenges and outcome. METHODS: A single institution, retrospective analysis of prospectively acquired cases over a 2.5-year period (September 2010 to February 2013). Challenges experienced during the course of patient care as well as complications and outcomes were recorded and analyzed using SPSS (SPSS Inc. Chicago IL, USA) version 17. Tests of statistical significance were set at 95% level. RESULTS: Of the 291 cranial procedures performed during the study period, 37 (12.7%) were neuroendoscopic interventions. Patients were between the ages of 0.25 years and 25 years with a mean of 5.7 ± 1.5 years (95% confidence interval (CI)). Aqueductal stenosis was the most common indication for endoscopic intervention in 22 (59.5%) patients. Endoscopic third ventriculostomy was the most commonly performed neuroendoscopic procedure in 21 patients (56.7%). Major challenges experienced were patient dependent in 28 ± 1.0 patients (95% CL), learning curve related in 21 ± 0.4 patients, and poor endoscopy support infrastructure in 15 ± 0.5 patients. Complications were significantly more common in the first 6 months of neuroendoscopy (χ2= 7.57, df = 1, P< 0.05). Overall, 30 (81.1%) patients in our study experienced a positive outcome. The permanent morbidity and mortality rates in our series were 2.7% and 8.5%, respectively. CONCLUSION: Highlighted are the myriad obstacles which interface the successful set up of neuroendoscopy service especially in resource-constrained settings. Endoscopic procedures become safer with experience and complications reduce significantly after a steep learning curve.

Skull traction for cervical spinal injury in Enugu: A 5-year retrospective multicenter analysis of the clinical outcomes of patients treated with two common devices.

BACKGROUND: Treatment of cervical spine injury is the most challenging of all the injuries of the spine, and there is yet no agreement on the best method of care. OBJECTIVE: We studied the complications and outcome of two skull traction devices used to treat cases of cervical spine injury in three centers in Enugu, South East Nigeria. PATIENTS AND METHODS: A retrospective analysis of patients with cervical spine injury managed with skull traction as the definitive treatment using either Crutchfield or Gardner-Wells tongs over a 5-year period (April 2008-March 2013). The traction was applied for 6 weeks, and the patient was subsequently mobilized with either hard cervical collar or Minerva jacket for another 6 weeks. RESULTS: One hundred and five patients with complete records out of 127 cervical spinal injured patients treated were studied. Forty-one had the American Spinal Injury Association (ASIA) Grade A whereas 64 had incomplete cord injury of ASIA Grades B-E. Forty-eight had Crutchfield traction whereas 57 had Gardner-Wells traction. At the end of treatment, no patient improved among those with ASIA Grades A and B. All the 12 cases of mortality were recorded as well among ASIA A (n = 9) and B (n = 3) Grades. Over 50% of ASIA Grades C and D patients improved to Grade E. The complication profile varied significantly between the traction subgroups with those treated using Crutchfield tongs experiencing more events (χ2 = 6.5, df = 1, P< 0.05). However, there was no significant statistical difference in the Association Impairment Scale (AIS) outcome (P = 0.55) as well as mortality rates (χ2 = 0.97, DF = 1, P> 0.05) between those treated with Crutchfield and Gardner-Well traction. CONCLUSION: Crutch field tong traction may be associated with more complications when compared with Gardner-Wells traction. However, from our study, the final American Spinal Injury AIS outcome, as well as the overall mortality rates associated with the two traction techniques, did not vary significantly.

Cervical spine injury: a ten-year multicenter analysis of evolution of care and risk factors for poor outcome in southeast Nigeria.

STUDY DESIGN: Retrospective study. OBJECTIVE: To describe the evolution of care and risk factors for poor outcome in patients with cervical spine injury (CSI) treated at three centers in southeast Nigeria. SETTING: Nigeria, southeast. MATERIALS AND METHODS: A 10-year retrospective multicenter analysis of patients with CSI, managed at three centers in southeast Nigeria, from January 2003 to December 2012. RESULTS: Two hundred and seven patients (55%) had CSI out of 377 spinal injury cases in the three study centers, but 195 cases had complete records and were studied. There were 148 males and 47 females. The age range was 3-74 years with a mean of 32.6 (± 1.9) years 95% CI. Most injuries (149 cases) resulted from motor vehicular accidents (MVA). The C5 spinal level was involved in 75 (38%) cases One hundred and seventeen patients (60%) presented with American Spinal Injury Association A (ASIA A) injury. CSI care evolved from the application of a Minerva jacket or cervical traction only to cervical traction and spinal fusion resulting in a reduction in hospital stay (F = 52.5, DF (2, 3) P < 0.05). When compared to 51 patients with incomplete injuries, who improved in neurologic al status at discharge, only three patients with ASIA grade A experienced some improvement. The mortality rate from our series is 16% (32 patients). Those who died were more likely to have a complete injury (25 patients) or a high cervical injury (X² = 61.2, P < 0.05) among other factors. CONCLUSION: The cervical spine is the most commonly injured spinal segment in southeast Nigeria. Although treatment evolution has resulted in reduction of hospital stay, the associated mortality risk still remains high.

Cervical Spine Injury: A Ten-Year Multicenter Analysis of Evolution of Care and Risk Factors for Poor Outcome in Southeast Nigeria

Study Design: Retrospective study. Objective: To describe the evolution of care and risk factors for poor outcome in patients with cervical spine injury (CSI) treated at three centers in southeast Nigeria. Setting: Nigeria; southeast. Materials and Methods: A 10-year retrospective multicenter analysis of patients with CSI; managed at three centers in southeast Nigeria; from January 2003 to December 2012. Results: Two hundred and seven patients (55) had CSI out of 377 spinal injury cases in the three study centers; but 195 cases had complete records and were studied. There were 148 males and 47 females. The age range was 3-74 years with a mean of 32.6 (?1.9) years 95) cases One hundred and seventeen patients (60 CI. Most injuries (149 cases) resulted from motor vehicular accidents (MVA). The C5 spinal level was involved in 75 (38) presented with American Spinal Injury Association A (ASIA A) injury. CSI care evolved from the application of a Minerva jacket or cervical traction only to cervical traction and spinal fusion resulting in a reduction in hospital stay (F = 52.5; DF (2; 3) P 0.05). When compared to 51 patients with incomplete injuries; who improved in neurologic al status at discharge; only three patients with ASIA grade A experienced some improvement. The mortality rate from our series is 16 (32 patients). Those who died were more likely to have a complete injury (25 patients) or a high cervical injury (X 2

Head injury: correlation of brain morphology on cranial CT with head injury severity using a new (computed tomography-head injury severity assessment) grading scale--a pilot study.

Eighty two (82) consecutive patients who presented with mechanical brain injury to the Accident and Emergency department of our hospital and were assessed with cranial Computerized Tomographic Scan between November 2005 and April 2006 were included in the study. Demographic data were obtained at admission. Clinical severity of head injury was assessed by the Glasgow Coma Scale Score just before cranial CT while morphologic severity was assessed using features on the same post-resuscitation cranial CTwith which theTCDB (Traumatic Coma Databank) grade and CT-HISAS (computerizedTomographic-Head injury Severity Assessment Scale) score were assessed. Both the TCDB and CT-HISAS scores were correlated with short-term outcomes using the Glasgow outcome score. Pearson's correlation coefficient, ANOVA and regression models were used as appropriate for statistical tests of significance.The age range of Patients was between 3 months and 86 years with a mean of 26.8 years and median of 25.9 years +/- 1.9 years (95% CL). There were more males (74.4%) than females (25.6%). There was a negative correlation between Post resuscitation GCS and CT-HISA score (p = -0.0141). However, although patients with non-functional outcome based on Glasgow Outcome score had higher CT-HISA scores, this relationship was not statistically significant. From our study, brain morphology on cranial CT using the CT-HISA Scale predicts clinical severity and outcome.We believe this study that CT-HISA may find useful application in assessment of teleradiologically transferred CT images of patients as well as research in mechanical brain trauma.

Neonatal head injury unrelated to birth trauma in South-East Nigeria.

BACKGROUND: Neonatal head trauma resulting from causes other than birth trauma has rarely been the focus of many a research theme in the literature. AIM/OBJECTIVE: To highlight the occurrence of non-birth trauma related neonatal head injury, and evaluate the causes and outcome of treatment. METHODS: A 3 year retrospective review of neonatal patients with head injury from two tertiary hospitals in South-East Nigeria between July 2009 and June 2012 (n-37). Data was collected from patients' birth and medical records. Data was analyzed using the SPSS version 15. RESULT: Among the one hundred and seventy-six cases (11.78)% pediatric head injury cases seen, thirty seven (2.48)% occurred in neonatal patients. The most common cause of head injury was fall 22 cases [59.5%]. Children of mothers with low educational qualification were more likely to sustain falls 22 cases (59.5%). Road traffic accident (n = 15) was associated with more severe injuries and poorer outcome. Operative treatment was associated with increased mortality (two of three cases). The mortality rate in our series is 8.10%. CONCLUSION: Reduction of neonatal head trauma could be achieved through improved maternal education.

Pediatric brain tumors in Nigeria: clinical profile, management strategies, and outcome.

INTRODUCTION: Although modern neuroimaging has facilitated early care of brain tumors in children worldwide, there are, however, few published reports on clinical profile, treatment, and outcome of brain tumors in children from our subregion. PURPOSE: We aimed to retrospectively study the clinical profile and outcome of pediatric brain tumors in a tertiary referral center from a developing country. METHODS: Forty pediatric patients with histologically verified brain tumors managed by the authors over a 13-year period (May 1994-April 2006) were studied. Patients' data from clinical, radiological, and pathology records were analyzed using the statistical package for social sciences version 16. RESULTS: The mean age was 9.75 years (range 1-15 years). Twenty-two males, 18 females. Common presenting symptoms were headaches (23 patients, 57.5%) and seizures (15 patients, 37.5%). Hyperreflexia (72.5%) and focal motor deficits (62.5%) were the most common neurologic signs. The mean interval from onset of symptoms to neurosurgical diagnosis was 13.4 months (95% CI). All patients had tumor resection, while 11 (27.5%) patients received adjuvant radiotherapy. Hydrocephalus occurred in 19 (47.5%) patients and was associated with early presentation (X2 = 10.65, p < 0.01). Low-grade astrocytoma (25%) and medulloblastoma (25%) were the most common tumors. Survival at 1 and 5 years were 56 and 47%, respectively. CONCLUSION: Focal motor signs and elevated intracranial pressure are the salient presenting features of brain tumors in children seen in Nigeria. Those of them with hydrocephalus are likely to present early. The outcome for pediatric brain tumors remains poor.

Epidemiological and treatment profiles of spinal cord injury in southeast Nigeria.

STUDY DESIGN: Retrospective study. OBJECTIVE: To evaluate the epidemiology and treatment outcome of spinal cord injuries (SCIs) at three tertiary care centres within southeast Nigeria. SETTING: Southeast Nigeria. METHODS: Causes, seasonal variation, transportation to hospital, severity of injury, treatment and outcome of patients with SCIs treated by the authors at three study locations from September 2009 to August 2012 were studied. RESULTS: Eighty-five patients with SCI had been admitted during that period to the three hospitals and were qualified for the study. The age range was 2-75 years with a mean of 36.13 years. The 31-45 years age group is the most frequently affected. Altogether, 69 male and 16 female individuals were involved. Motor vehicle accident (MVA) (47, 55.3%) was the most frequent cause of injury. Falls from palm trees (3.5%) were markedly reduced from what they were inferred to be (40.2%) from a similar study in our area in 1988. Injury peaks were observed during major festivities. Only three patients (0.035%) were transported to care centres with an ambulance. Forty patients were classified as being affected by ASIA grade A injury, whereas 45 patients had various ASIA grades of incomplete injury. Sixty-eight patients were managed conservatively; 23 of them improved from their grades, 35 remained the same, 1 worsened, while 9 died. Of 17 patients treated operatively, 9 improved, 5 remained the same, 2 worsened and 1 died. CONCLUSION: Currently, SCIs reported in the three main hospitals located in southeast Nigeria are caused mainly by MVAs. SCI affects mainly male individuals and peak frequencies are observed during festivities.

Determinants and outcomes of ventriculoperitoneal shunt infections in Enugu, Nigeria.

BACKGROUND: To evaluate the determinants and outcomes of shunt infection (SI). METHODS: One hundred ninety-eight pediatric hydrocephalic patients treated with a ventriculoperitoneal (VP) shunt between January 2008 and August 2012 were retrospectively studied. Patients with SI were compared to those without SI in terms of the occurrence of risk factors and outcomes. Data was analyzed using Statistical Package for the Social Sciences software (version 15). RESULTS: The age range was 2 weeks to 13 years, with a mean age of 3.1 ± 0.19 years for the SI group versus 2.7 ± 0.2 years for those without SI. One hundred and twelve patients were female and 86 were male. SI was recorded in 17 (8.6%) patients. Postinfective hydrocephalus (n = 6) was the most common cause of hydrocephalus in the SI group. Individuals in the SI group, compared to those without infection, were more likely to be underweight (χ2 = 23.4, p < 0.01). The mean interval between VP shunt placement and SI was 1.83 ± 1.25 months. Coagulase-negative Staphylococcus (29.4%) was the most common pathogen. The mortality rate in our series was 21.4% in patients with SI compared to 2.7% in those without SI. CONCLUSION: Coagulase-negative Staphylococcus is currently the most common cause of SI and underweight children appear have a higher risk.

Intensive care unit admissions in Federal Medical Centre Umuahia south east Nigeria.

BACKGROUND: The Federal Medical Centre Umuahia (FMCU) is a tertiary referral centre in Abia state, southeast Nigeria serving a catchment area made of Abia state and environs. An intensive care unit (ICU) was established in the hospital in December 2009 to improve healthcare delivery to critically ill patients. OBJECTIVE: To determine the admission patterns and report the initial experience in the intensive care of patients in the FMCU. METHODS: This is a retrospective study ofthepatients admitted into the ICU of FMCU from December 2009 to March 2011. Data retrieved from the patients ICU records included demographics, indication for admission, length of stay in ICU, and outcome of stay The cost of ICU care was extracted from the financial records of the patient following discharge or demise. Data acquisition and analysis was performed using the statistical package for social sciences (SPSS) version 15. RESULTS: A total of 87 patients were studied consisting of 59 males and 28 females. The ages ranged from 2 days to 87 years with a mean age of 41 +/- 2.34 years. There were 11 patients within the pediatric age range (12.6%). Post-operative surgical patients (51) accounted for the majority of the admissions (58.6%). There were also 21 non-operated trauma cases (24.1%), 7 medical cases (8.1%), 8 obstetrics and gynecological cases (9.2%). Post-operative admissions were mainly emergencies--39 cases (76.5%) cases while 12 (23.5%) were elective. Most post-operative ICU admissions followed abdominal surgery -31 cases (58.8%) while neurological trauma accounted for most non-operated trauma 17cases (81%). The cost of stay per patient ranged from N2745.65 to N238123.4 ($82.23 to $1536.28) with an average cost per day of N19506.75 ($125.85). The cost per day for mortality cases was N28598, 74 ($184.51). The modal length of ICU stay was 2 days with a mean of 3.63 +/- 0.34 days and a range of one to sixteen days. About 68.4% of the patients spent = 3 days (38.3% of total ICU days), while 31.6% spent > 3 days (61.7% of total ICU days). Of the 87 patients, 57 (65.5%) were discharged from ICU to the wards, 28 (32.2%) died in ICU while 2 (2.3%) were referred to bigger centers. Twelve mortalities (42.8%) were among the emergency postoperative patients and 10 (35.8%) non-operated trauma patients (80% of which are neurological trauma). CONCLUSION: From our study, most ICU admissions and is comparable to other studies in Africa. The cost of stay is very high when compared with annual per capita income in Nigeria of $1190.