Fatal Spontaneous Subarachnoid Haemorrhage- A Report of Three Unusual Causes.

PURPOSE: To report three rare causes of fatal spontaneous subarachnoid haemorrhage (SAH) and to discuss the clinical presentations, neuroimaging findings of the patients, and a brief review of the literature on these unusual causes of SAH. CASE REPORTS: Anomalous branches of the internal carotid artery (ICA) are remarkably rare and multiple aneurysms associated with these aberrant arteries a rarer phenomenon still. A case of multiple proximal and distal aneurysms of the main trunk of an aberrant ICA branch, which resulted in a World Federation of Neurosurgical Societies (WFNS) grade V SAH, was presented. This abnormal vessel had an arterial fenestration, another rare occurrence. The second patient had a craniocervical junction (CCJ) arteriovenous fistula, which was associated with a distal aneurysm extending to the upper cervical spinal canal. The patient presented with recurrent SAH which had been misdiagnosed multiple times in the past. The third case presentation is that of a WFNS grade IV SAH, which occurred secondary to a ruptured giant fusiform aneurysm of the supraclinoid segment of the left ICA. The first two cases manifested with multiple episodes of Fisher grade IV SAH, and all cases proved fatal. CONCLUSION: It is crucial for clinicians to ensure prompt angiographic studies in patients presenting with spontaneous subarachnoid haemorrrhage, as delay in the definitive diagnosis/intervention can be lethal. In particular, a high index of suspicion for a vascular brain lesion should be entertained in cases of repetitive SAH.

BUT: Pour signaler trois causes rares d'hémorragies sousarachnoïdiennes spontanées mortelles (HSA) et discuter des présentations cliniques, les résultats de la neuro-imagerie des patients et une évaluation de la littérature concernant des causes inhabituelles de HSA. ETUDES DE CAS: Les vaisseaux anormaux de l'artère carotide interne (ACI) sont remarquablement rares et multiples anévrismes associés à ces vaisseaux aberrants est encore phénomène rare. Un cas de multiples anévrismes proximaux et distaux du tronc principal d'un navire ACI aberrant, à l'issue de WFNS grade V HSA a été présenté. Ce vaisseau anormal a eu une fenestration artérielle, qui est une autre occurrence rare. Le deuxième patient avait une charnière craniorachidienne (CCR), les fistules artério-veineuse, qui était associée à un anévrisme distal qui s'étend à la partie supérieure du col canal rachidien. Le patient avec une HSA récurrente qui avait été diagnostiquée plusieurs fois dans le passé. La troisième présentation de cas c'est celle d'un WFNS de grade IV du HSA, qui est le secondaire à un anévrisme fusiforme géant rompu du segment supra-clinoïde de l'ACI du gauche. Le les premiers deux cas se sont manifestés par de multiples épisodes d'HSA de niveau IV de Fisher, et tous les cas c'était avéré fatal. CONCLUSION: Il est cruciale que les cliniciens garantissent des examens angiographiques rapides chez les patients présentant une hémorragie sous-arachnoïdienne spontanée, car un retard dans le diagnostic définitif/l'intervention peut être mortel. En particulier, un indice élevé de suspicion d'une lésion cérébrale vasculaire doit être envisagé en cas d'HSA répétitive. MOTS CLÉS: Anomalie vaisseaux, Fistules artérioveineuse, Anévrismes fusiforme, Fenestration artérielle, Hémorragie subarachnoïde.

Deficits of Learning and Spatial Memory are Associated with Increased Pyknosis of Pyramidal Neurons of the Hippocampus of Adult Rats with Chronic Hydrocephalus.

BACKGROUND: The hippocampus is the brain's centre for the consolidation of short-term and spatial memory that enables navigation. Hippocampal injury occurs in hydrocephalus and is associated with loss of memory. OBJECTIVE: We assessed pyknotic changes in kaolin-induced chronic hydrocephalus in adult rats using qualitative and quantitative means, and related these to memory deficits in the rats. METHODS: Adult rats were randomly divided into control and experimental groups. Hydrocephalus was induced by intracisternal injection of 0.1ml sterile kaolin suspension for 6weeks. Control rats received sham injections. Spatial memory was assessed with the Morris water maze test. Coronal sections of the brains were grouped into either mild or moderate hydrocephalus and then stained with H&E and cresyl violet stains. Thus, there were three groups: control, mild hydrocephalus and moderate hydrocephalus (n=10), respectively. RESULTS: Shrinking and thinning of the hippocampal tissue, distortion of the pyramidal layer and pyknotic cells were observed in the CA1 and CA3 regions of the hydrocephalic rats. The pyknotic indices in the mild hydrocephalic rat (Cornus Ammonis, CA) CA1, CA2, CA3 (54.30±1.38; 27.62±0.83; 57.61±0.74) and moderate hydrocephalic rat CA1, CA2, CA3 (48.18±0.67; 32.00±0.84; 42.41±1.19) regions were significantly increased compared to the controls' CA1, CA2, CA3 (12.14±0.56; 9.21±0.36; 13.04±0.59). CONCLUSION: Chronic hydrocephalus in adult rats was associated with cell death in all the regions of the hippocampus, irrespective of the degree of ventricular enlargement. The extent of cell death corresponded with the severity of learning and memory deficits. CONTEXTE: L'hippocampe est le centre du cerveau pour la consolidation de la mémoire à court terme et de la mémoire spatiale qui permet la navigation. Une lésion de l'hippocampe se produit dans l'hydrocéphalie et est associée à la perte de mémoire. OBJECTIF: Nous avons évalué les changements pyknotiques dans l'hydrocéphalie chronique induite par le kaolin chez des rats adultes en utilisant des moyens qualitatifs et quantitatifs, et nous les avons reliés aux déficits de mémoire chez les rats. MÉTHODES: Des rats adultes ont été répartis au hasard en groupes témoins et expérimentaux. L'hydrocéphalie a été induite par injection intracisternale de 0,1 ml de suspension stérile de kaolin pendant 6 semaines. Les rats témoins ont reçu des injections simulées. La mémoire spatiale a été évaluée par le test du labyrinthe aquatique de Morris. Les sections coronales des cerveaux ont été regroupées en hydrocéphalie légère ou modérée, puis colorées au H&E et au crésyl violet. Il y avait donc trois groupes : contrôle, hydrocéphalie légère et hydrocéphalie modérée (n=10), respectivement. RÉSULTATS: Un rétrécissement et un amincissement du tissu hippocampique, une distorsion de la couche pyramidale et des cellules pyknotiques ont été observés dans les régions CA1 et CA3 des rats hydrocéphales. Les indices pyknotiques dans les régions CA1, CA2 et CA3 des rats hydrocéphales légers (Cornus Ammonis, CA) (54,30±1,38 ; 27,62±0,83 ; 57,61±0,74) et des rats hydrocéphales modérés CA1, CA2 et CA3 (48. 18±0.67 ; 32.00±0.84 ; 42.41±1.19) ont été significativement augmentées par rapport aux régions CA1, CA2, CA3 des témoins (12.14±0.56 ; 9.21±0.36 ; 13.04±0.59). CONCLUSION: L'hydrocéphalie chronique chez les rats adultes était associée à la mort cellulaire dans toutes les régions de l'hippocampe, quel que soit le degré d'élargissement ventriculaire. L'étendue de la mort cellulaire correspondait à la sévérité des déficits d'apprentissage et de mémoire. MOTS CLÉS: Hydrocéphalie chronique, hippocampe, rats adultes, mémoire, cellules pyknotiques.

Pyramidal cell morphology and cell death in the hippocampus of adult mice with experimentally induced hydrocephalus

Background: Hippocampus is a neural structure in the temporal lobe that plays a crucial role in learning and memory. Cognitive impairment with learning disabilities is a common feature in hydrocephalus and is more prominent in adult-onset hydrocephalus. The aim of this study is to describe the morphological alterations in the pyramidal cells of the hippocampus of adult hydrocephalic mice. Method: Hydrocephalus was induced in adult albino mice by intra-cisternal injection of kaolin suspension (250 mg/ml in sterile water). They were sacrificed 7, 14 and 21 days post-induction. Morphological analysis was carried out on hematoxylin and eosin stained coronal sections of the hippocampus: the pyramidal neurons (normal and pyknotic) in the CA1 and CA3 subregions were counted and the pyknotic index (PI) was calculated. The somatic and dendritic features of Golgi stained pyramidal neurons were examined by light microscopy in both hydrocephalic and control mice. Result: The PI was significantly greater in the CA1 region of the hippocampus in the hydrocephalic groups compared to the age matched controls. The dendritic processes of pyramidal neurons in the CA1 region were fewer with shorter terminal branches in the hydrocephalic mice than in controls; this was pronounced at 7 days post-induction. In the CA3 region, there was no difference in dendritic arborization between hydrocephalic and control mice. Conclusion: Acute adult-onset hydrocephalus was associated with increased pyknosis and reduced dendritic arborization in hippocampal pyramidal cells in the CA1 but not CA3 region

Assessment of the Holistic Model of Neurosurgical Patient Care at the University College Hospital (UCH), Ibadan.

BACKGROUND: Holistic ward round (HWR) is a polyadic, multiphasic, holistic model of neurosurgical patient care. It is a multidisciplinary ward round where all healthcare providers involved in patients care, the patients, the relations, as well as clergymen (depending on the patients' faith and need) collectively work to review patient's condition and make decisions in the patient's best interest. OBJECTIVES: The study assessed the effectiveness of the holistic model of care and identified the challenges facing this model of healthcare delivery. METHODS: The study was qualitative in design and In-depth Interviews (IDIs) were conducted with eighteen (18) participants who were purposively selected. They include neurosurgeons, nurses, medical social workers and physiotherapists. The data were thematically content analysed with the help of ATLAS.ti (v.7) software. RESULTS: The study found that patients and relations have immensely benefitted from the model of care through psychosocial support. The major challenges facing HWR were logistic, timing and common problems found in the Nigerian healthcare system. CONCLUSION: It was concluded that for HWR to effectively help spinal cord injured patients further, the healthcare providers, patients and their families require support in different forms from outside the hospital.

Brainstem Glioma: Clinical Profile and Challenges of Management in a Developing Country.

BACKGROUND AND OBJECTIVES: Brainstem gliomas are relatively rare tumours of the central nervous system which have varying presentations and clinical course. This study aims to analyse the clinical profile and challenges of management of these tumours in a resource-limited country. METHIODS: We retrospectively analysed the data from the records of the patients managed for briainstem glioma between January 2010 and July 2017. RESULTS: There were 11 patients in the study (7 males and 4 females). The median age at diagnosis was 9 years. Eight of the patients were less than 15 years. The duration of symptoms ranged from 1 month to 2 years. All the patients had cranial nerve deficits at presentation, while 7 patients had cerebellar signs. Hydrocephalus was present in 4 patients. The lesion was pontine in 9 patients and tectal in 2. Three of the patients with hydrocephalus had ventriculoperitoneal shunt insertion while one patient refused surgery. Only one of the patients had radiotherapy. None of the patients received chemotherapy. A patient was dishcarged against medical advice. One patient is still alive after 4 years while another patient is alive after 2 years. The other 9 patients are dead with a mean survival period of 6 months. CONCCLUSION: Most of the tumours in this series were located in the pons and ran aggressive courses. Majority of our patients did not have access to radiotherapy while none had chemotherapy.

The Cephalometry of the Yoruba Ethnic Group of Southwestern Nigeria.

Cephalometry of an ethnic population is determined by sex, diet, geographic location and genetics. Quantitative facial morphometry is necessary in today's contemporary society because of the globalization of crime and justice. The objective of this study is to determine Yoruba ethnic population's cephalofacial uniqueness for gender identification. A total of 222 adults (155 females and 67 males) participants from 10 local government areas in 5 states of the South-west Nigeria were randomly selected. Pre-defined set of cephalometric parameters were measured using standard requirement for anthropometry. Statistical analysis was calculated for gender differences using SPSS 20. Overall, gender differences (male vs female) was exhibited in head length, head width, upper facial height, lower facial height and facial width. Sexual differences were also exhibited in head modulus index (41.43±1.72 cm Vs 42.87±2.18 cm) and the index of the size of head (2361.89±444.53 cm3 vs 2147.78±316.13 cm3). Both genders exhibited dolichocephalic/mesocephalic type. Gender identification in this ethnic group may concentrate on five facial morphometry.

THE PROFILE AND SURGICAL TREATMENT OF SYRINGOMYELIA IN NIGERIAN PATIENTS.

BACKGROUND: Syringomyelia is an often progressive disorder of the spinal cord. There is a dearth of reports in the African population. AIMS AND OBJECTIVES: This study describes the profile and the outcome of treatment in our population of patients. DESIGN OF THE STUDY: A retrospective review of patients surgically treated for syringomyelia over a ten year period. SETTING: Department of Neurological Surgery, University College Hospital, Ibadan, Nigeria. MATERIALS AND METHODS: Eight patients were surgically treated for Syringomyelia over the period 2004-2014. We extracted data on their gender, age, aetiology, syrinx location, diagnosis, operative procedure and outcome. Simple statistical analysis was done. RESULTS: There were five males and three females. The mean age was 31.6(SD15.3) years (median: 32.5 years). The causes of the syrinx were: Chiari malformation (3), intramedullary spinal tumour (2), foramen magnum tumour (1), post-traumatic (1), and iatrogenic chemical arachnoiditis (1). The syrinx location was: cervical region (4), cervicothoracic region (2) and multi-level (2). The operative procedures were posterior fossa decompression (2), sub-occipital craniectomy with laminectomy and tumour excision (2), laminectomy and syringomyelotomy (2), laminectomy and tumour excision (1), and ventriculoperitoneal shunting (1). The duration of follow up was 2 weeks to 35 months. Outcome was satisfactory in six patients. A child who had initial ventriculoperitoneal shunting died at home before definitive surgery, and an adult male died of respiratory insufficiency post operatively. CONCLUSION: Syringomyelia is rare in our population. It affects young patients, typically in the cervico-thoracic region. The aetiologies are similar to those from previous reports. The outcome of surgical treatment in our small group of patients is satisfactory.

UPPER LUMBAR DISC PROLAPSE.

Upper lumbar disc prolapse (ULDP) is a rare and a unique clinical entity which has a potentially devastating clinical outcome. It may manifest with low back or anterior thigh pain, polyradiculopathies (from spinal cord or cauda equina compression) and/or degenerative kyphoscoliosis. Its diagnosis is often difficult and may be missed because of the lack of specific root signs. Magnetic resonance imaging is the diagnostic modality of choice. Anterior, posterior and endoscopic approaches have been explored in the treatment of this pathology. However, the treatment outcome for ULDP has been found to be poorer compared to that of similar herniations at lower spinal levels. We report this case to draw attention to the need for a high index of suspicion to make the correct diagnosis.

Thyroid Hormone Profile in a Population of Nigerian Patients with Traumatic Brain Injury.

Traumatic brain injury (T.B.I.) has an annual incidence of 200/100000. There is little or no information onneuroendocrine sequelae following T.B.I. in the Nigerian population. The purpose of the study is to evaluate the effect ofT.B.I on the thyroid axis and relate it to outcome by outlining the change in thyroid axis of head injured patients. One hundredand fifteen patients were recruited with 85% male and 15% female. Of these patients, 71.7% presented within 24 hours ofinjury. The head injury was mild in 53%, moderate in 16% and severe in 31% of the patients. Serum T3 was high in 52.2%,low in 7.8% and normal in 40%. Serum T4 was high in 4.3%, low in 68.7%, and normal in 27%. Serum TSH was high in16.5% TSH levels, low in 6.1% and normal in 77.4%. There was no correlation between the severity of head injury measuredby the Glasgow coma score and patterns observed in the thyroid function test. With respect to outcome of head injury, serumT4 was low in patients who died or had persistent vegetative state (p=0.012). Traumatic brain injury in Nigerian patients isassociated with an elevation of T3, low levels of T4 and normal TSH values. Death and persistent vegetative state wereassociated with low T4.

Neurobehavioral Deficits in Progressive Experimental Hydrocephalus in Neonatal Rats.

Hydrocephalus is usually associated with functional deficits which can be assessed by neurobehavioral tests. This study characterizes the neurobehavioral deficits occurring with increasing duration and severity of ventriculomegaly in an experimental neonatal hydrocephalic rat model. Hydrocephalus was induced in three weeks old albino rats by intracisternal injection of kaolin while controls received sterile water injection. They were sacrificed in batches at one, four and eight weeks post-injection after neurobehavioral tests (forelimb grip strength, open field and Morris water maze tests) were performed. The hydrocephalic rats were also categorized into mild, moderate and severe hydrocephalus based on ventricular size. The indices of muscular strength and vertical movements in severely hydrocephalic rats were 28.05 ± 5.19 seconds and 7.29 ± 2.71 rearings respectively, compared to controls (75.68 ± 8.58 seconds and 17.09 ± 1.25 rearings respectively). At eight weeks, vertical movements were significantly reduced in hydrocephalic rats compared to controls (3.14 ± 1.3 vs 13 ± 4.11 rearings). At one week, indices of learning and memory were significantly reduced in hydrocephalic rats, compared to controls (0.89±0.31 vs 3.88±1.01 crossings), but at 8 weeks, the indices were similar (2.56 ± 0.41 vs 3.33 ± 0.71 crossings). Untreated hydrocephalus is accompanied by decline in motor functions which increase with duration and severity of ventriculomegaly. However, cognitive deficits appear to partially recover.