Outcome of Nonoperative Management of Selected Cases of Acute Traumatic Intracranial Hematomas in a Rural Neurosurgical Service of a Developing Country.

OBJECTIVE: In resource-limited settings, the standard of care prescribed in developed countries for either operative or nonoperative management of traumatic intracranial hematomas (TICHs) frequently has to be adapted to the economic and infrastructural realities. This study aims to present the outcome of selected cases of TICHs managed nonoperatively without routine intensive care unit admission, repeated cranial computed tomography (CT) scan or intracranial pressure monitoring at a rural neurosurgical service in a developing country. METHODS: This was a retrospective analysis of a cohort of our patients with cranial CT-confirmed TICHs selected for nonoperative treatment from our prospective head injury (HI) register over a 42-month period. RESULTS: There were 67 patients (51 males) in this study with a mean age of 38.6 (standard deviation, 17.6) years, having mild HI in >half, (55.2%, 37/67) and anisocoria in 22.4% (15/67). Road traffic accident was the most common (50/67, 74.7%) trauma etiology. Isolated acute-subdural hematoma, intracerebral hemorrhage, and epidural hematoma occurred in 29.9%, 25.4%, and 22.4% of the patients respectively. Only 2 of 8 patients in whom intensive care unit admission was deemed necessary could afford admission. Repeat cranial CT scan was requested in 8 patients (8/67, 11.9%); only 5 of these could afford the investigation. The outcome of care was good in 82.1% patients (55/67). Increasing severity of the HI (P < 0.01) and presence of pupillary abnormality (P = 0.03) were significant predictors of poor outcome. CONCLUSIONS: In a Nigerian rural neurosurgery practice, nonoperative management of a well-selected cohort of TICHs was attended by acceptable level of favorable outcome.

Clinical profile and outcome of surgical management of intramedullary spinal cord tumours: A single center study in a developing country.

Objective: There is as yet a paucity of data on intramedullary spinal cord tumours (IMSCTs) in sub-Saharan Africa. This study aims to define the clinical profile and outcome of management of IMSCTs in a Nigerian tertiary hospital. Methods: This is a retrospective study of all the patients who had surgery for IMSCTs in our hospital over a 14 year period. Results: There were 20 patients, 9 males, 11 females, in this study. The median age was 33 years (range = 7-78 years). The median duration of symptoms was 12 months (range = 1-120 months). Motor deficit was present in all but one (95%) of our patients. Only 25% of the patients presented in good functional status (McCormick grades I and II). The tumours were confined to the thoracic region in 10 patients (50%), while tumours in the thoracic region extending to the adjoining cervical and lumbar regions were seen in 6 patients (30%). Gross total tumour resection was achieved in 60% of the patients and subtotal resection in the remaining 40%. Astrocytoma and ependymoma were the most common tumours, each occurring in 35% of the cases. Six patients (30.0%) improved, 12 patients (60.0%) remained neurologically the same, while 2 patients (10.0%) deteriorated at the time of last follow up. The mortality rate was 15%. The preoperative functional status was a significant predictor of postoperative outcome (p = 0.03). Conclusion: Astrocytoma and ependymoma were the most common histological tumour types among our patients. Late presentation and poor pre-operative functional status were prominent features of our patients' cohort.

Efficacy of 48 hours dose of phenytoin in prevention of early post-traumatic seizure.

Background: Antiseizure medications, such as phenytoin sodium, have been shown in some reports to reduce the incidence of early post-traumatic seizure. These medications, however, are not without side effects which may be dose related or duration related. The risks associated with short-term therapy are minimal and often dose related (and hence avoidable). This study intends to determine the efficacy of a short-course (48-hour dose) of phenytoin in prevention of early post-traumatic seizure. Methods: This was a prospective randomised double-blind clinical intervention study. Head injured patients presenting within the first 24 hours were randomly assigned to either 48-hour dose of phenytoin or control groups, and were observed for clinical seizure over a week. The difference in the incidences of early post-traumatic seizure between the two groups was determined by χ2 test. A p<0.05 was considered as statistically significant. Results: A total of 94 patients were included in the study, 47 each in the control group and the phenytoin group. There were 77 males and 17 female (M:F 4.5:1). Both groups had similar demographic and clinical profile. The incidence of seizure was 21.3% in the control but 2.1% in the treatment arm (p<0.01). All seizures occurred within 24 hours of trauma in the control, while the only episode of seizure in the treatment group occurred later. Conclusion: A short-course (48-hour dose) of phenytoin might be an effective prophylactic treatment to reduce the incidence of early post-traumatic seizure.

Traumatic Spinal Cord Injury in Children: Clinical Profile and Management Outcome in a Developing Country's Rural Neurosurgery Practice.

BACKGROUND: There is paucity of data-driven study on pediatric traumatic spinal cord injury (SCI) in the developing countries. This study aims to define the clinical profile of pediatric traumatic SCI in a rural tertiary hospital in a sub-Saharan African country. METHODS: This was a prospective observational study of all children with spinal cord injury managed at our center over a 42-month period. RESULTS: There were 20 patients, comprising 13 males and 7 females with a mean age of 11.5 years. Road traffic crash was the cause in 70% of the cases (motorcycle accident = 45%), and fall from height in 25%. Pedestrians were the victims of the road traffic crash in 42.9% (6/14) of the cases, while 21.4% (3/14) and 28.6% (4/14) were passengers on motorcycles and in motor vehicles, respectively. The cervical spine was the most common location of injury, occurring in 90% of the cases (18/20). Seventy-five percent of the patients (15/20) had transient deficits, but were grossly normal neurologically on examination (American Spinal Cord Injury Association [ASIA] grade E); 2 patients had ASIA D, while 1 patient each had ASIA C, B, and A injuries. All patients were managed nonoperatively. The patients with incomplete deficits improved, while those with complete injury did not make any motor or sensory gain. CONCLUSION: Road traffic accident, mostly motorcycle crash, was the most common etiology of pediatric SCI in this series, and most of the injuries were located in the cervical spine. Disabling injury constituted a small proportion of pediatric SCI in our practice.

Spinal meningioma: clinical profile and outcome of surgical management.

Spinal meningiomas are relatively rare tumours with often favourable surgical outcomes. There is paucity of data on spinal meningiomas in the Nigerian literature. This study was designed to evaluate the incidence, the anatomical distribution and outcome of surgical treatment of spinal meningiomas in our center. This was a retrospective study of patients who had surgery for spinal meningioma at our center during the study period. We obtain data from case note, operation and pathology registers. Univariate analysis was performed using SPSS version 15 (SPSS Science Inc; Chicago, IL, USA). There were 11 patients in the study all of whom were females with age range of 26-65 years. All the patients had motor deficit at presentation. Four patients (36.4%) presented within 6 months of onset of symptoms while the duration of symptoms was more than a year in 5 patients (45.5%). The preoperative functional grading was Frankel A in 2 patients (18.2%), Frankel D in 1 patient (9.1%), Frankel B and C each in 4 patients (36.4%). The tumours were located in the thoracic region in six patients (54.5%), cervical region in 2 patients (18.2%) while the tumours were cervicothoracic in the other 3 patients (27.3%). All the patients had gross total tumour resection. Post-operative neurological improvement occurred in 7 patients (63.6%) while 4 patients (36.4%) remained neurologically the same. All the patients in this study were women. Gross total tumour resection was achieved in all the cases with satisfactory functional outcome.

Paediatric Spinal Tumours: Profile and Treatment Outcome in a Nigerian Tertiary Institution.

INTRODUCTION: Paediatric spinal tumours are rare, accounting for 1-10% of all childhood central nervous system tumours. There is a paucity of information on spinal tumours in Sub-Saharan Africa. This is particularly so in the Nigerian paediatric population where neuro-oncologic data are limited. Indeed, there is no previously published work on paediatric spinal tumours in the Nigerian neurosurgical literature. The authors aim to document the profile of paediatric spinal tumours in a Nigerian tertiary institution and to contribute to the available data on paediatric central nervous system tumours in West Africa. METHODS: We retrospectively evaluated data on paediatric patients who underwent surgery for spine tumours over a 20-year period at our institution. RESULTS: A total of 12 patients were managed for paediatric spine tumours during the study period. These had a male:female ratio of 1:1.4, and their ages ranged between 3 and 18 years (mean: 12.83 ± 4.75 years). The highest incidence (6/12) was seen in the 15-18 years age group. The mean duration of symptoms was 10.2 months. More than half (7/12) of the patients presented with symptoms with duration of at least 6 months. Motor deficit was present in all patients at presentation. Two-thirds of the tumours were in the thoracic region, 1 was located in the cervical region, while the remaining 3 tumours were cervicothoracic. The tumour was extradural in location in 8 of our patients and intramedullary in the remaining 4. Astrocytoma, intramedullary in all cases, was the most predominant histological tumour type (3/12) in our series. Postoperative neurological improvement occurred in 7 of the patients while 5 remained the same. There was no permanent postoperative neurological deterioration or perioperative mortality. CONCLUSION: Paediatric spinal tumours mostly affected older children in our study group and were predominantly astrocytic in nature. The most common tumour location was extradural, involving mostly the thoracic spinal level. The preoperative neurological status correlates with the postoperative functional outcome. Therefore, the need for early diagnosis and treatment of these tumours cannot be overemphasized.

Mannitol Dosing Error during Pre-neurosurgical Care of Head Injury: A Neurosurgical In-Hospital Survey from Ibadan, Nigeria.

Objectives Inappropriate use of mannitol is a medical error seen frequently in pre-neurosurgical head injury (HI) care that may result in serious adverse effects. This study explored this medical error amongst HI patients in a Nigerian neurosurgery unit. Methods We performed a cross-sectional analysis of a prospective cohort of HI patients who were administered mannitol by their initial non-neurosurgical health care givers before referral to our center over a 22-month period. Statistical Analysis A statistical software was used for the analysis with which an α value of <0.05 was deemed clinically significant. Results Seventy-one patients were recruited: 17 (23.9%) from private hospitals, 13 (18.3%) from primary health facilities (PHFs), 20 (28.2%) from secondary health facilities (SHFs), and 21 (29.6%) from tertiary health facilities (THFs). Thirteen patients (18.3%) had mild HI; 29 (40.8%) each had moderate and severe HI, respectively. Pupillary abnormalities were documented in five patients (7.04%) with severe HI and neurological deterioration in two with mild HI. Mannitol administration was deemed appropriate in only 43.7% (31/71). Data on mannitol dosing in 60.6% (43/71) of the patients showed 8/43 (18.6%) receiving continuous 10% mannitol infusion. The remaining 35/43 received mannitol as a 20% solution but also showing dosing error in 62.9% (22/35): overdosing in 7/35 (20%), and nonbolus administration in 15/35 (42.9%). The distribution of the dosing error among the referring health facilities (all the 13 [100%] patients from private hospitals, 66.7% from PHF, 60% from SHF, and 45.5% from THF) showed a trend of better performance ( p = 0.002) by the THFs. Conclusion Mannitol use is apparently fraught with an understudied medical error in the pre-neurosurgical care of the head injured.

Bedside single burr hole craniostomy drainage of chronic subdural hematoma in the emergency room: A useful option in resource challenged settings.

BACKGROUND: In resource challenged environments, the standard treatment of chronic subdural hematoma (CSDH) in the theater may be delayed because of the endemic financial constraint and logistic problems with consequent negative impact on the outcome. An emergency bedside burr hole craniostomy with a local anesthetic at the accident and emergency ward may be lifesaving in patients presenting in extreme neurological conditions in these settings. CASE DESCRIPTION: We presented three patients (one male and two females) with CSDH who presented at our service in poor neurological condition. The patients were between 49 and 70 years. The Glasgow Coma Score ranged from 3 to 6. The three patients had respiratory and pupillary abnormalities at presentation. They all had bedside single frontal burr hole craniostomy drainage of the hematoma under local anesthesia at the accident and emergency unit of the hospital. Surgery was done within 1 h of review by the neurosurgical team in all cases. The duration of hospital stay ranged from 8 to 24 days. The outcome was good in all cases. CONCLUSION: Bedside single burr hole craniostomy at the accident and emergency unit may be lifesaving in patients with CSDH who present in extreme neurological condition but in whom prompt standard surgical treatment in the theater is not feasible.

Determinants of discharge against medical advice from a rural neurosurgical service in a developing country: A prospective observational study.

BACKGROUND: In low-resource regions of the world, discharge against medical advice (DAMA) is one empiric contributory factor to poor in-hospital outcome that is not often mentioned. This study aims to investigate the determinants of DAMA from a rural neurosurgical service in a developing country. METHODS: This was a prospective observational study of all patients who discharged against medical advice in our service between November 2018 and October 2019. RESULTS: There were 88 patients, 67 (76.1%) males, in the study, (M:F = 3.2:1), representing 17.4% of our patient population in the study period. The peak incidence was in the 20-29 years age group which accounted for 37.5% of the cases. About 55% of the patients presented directly to our center; 31.8% were referred from other hospitals, while 3.4% came from traditional caregivers and 1.1% from religious homes. Head injury was the most common indication for presentation (76.1% of the cases). The duration of hospital stay ranged from 2 h to 14 days. Majority of the patients (87.5%) left the hospital within 8 h of presentation. The reason for DAMA was financial constraints in 50% of cases, inadequate health literacy in 20.5%, financial constraints and poor health literacy together in 12.5%, religious misgivings in 4.5%, and traditional belief in 2.3%. Neurotrauma was predictive of early DAMA (P = 0.001). CONCLUSION: The rate of DAMA was high in our study. Financial constraints with other socioeconomic limitations were the most common causes of DAMA in our environment.

Extensive vertebral scalloping in a thoracolumbar junction spinal schwannoma.

Severe vertebral scalloping in spinal schwannoma is very rare. When present, extensive scalloping of the vertebral bodies possesses significant treatment challenges in patients with spinal tumors. We present the computed tomography scan and magnetic resonance images of spinal schwannoma with marked vertebral scalloping in a 40-year-old Nigerian.

The Burden of Neurosurgical Diseases in a Rural Southwestern Nigeria Setting.

BACKGROUND: Most of the few neurosurgeons in Nigeria are clustered in the urban centers. Consequently, a large proportion of the population who live in the rural areas have no direct access to neurosurgical care. This study aims to describe the burden of neurosurgical diseases in a rural neurosurgical service in Nigeria. METHODS: This was a prospective observational study of all neurosurgical patients managed at our center between August 2018 and July 2019. Data were analyzed with SPSS version 20 (IBM, Armonk, New York, USA). RESULTS: The study cohort comprised 379 patients, including 267 males and 112 females (male:female ratio 2.4:1). The mean age was 35.71 ± 20.08 years (range, 35 hours to 100 years). More than one-half of the patients (55.6%) were age 20-49 years. Head injury was the most common presentation, occurring alone in 256 patients (67.55%) and in combination with spinal cord injury in 30 patients (7.92%). Brain tumors were present in 19 patients (5.01%), spinal cord injury in 15 patients (3.96%), degenerative spine disease in 9 patients (2.38%), and hydrocephalus in 5 patients (1.32%). Surgical intervention was performed in 21 patients (5.54%). The outcome of treatment was good in 251 patients (66.22%); 34 patients (8.97%) were referred to other facilities, 43 patients (11.35%) were discharged against medical advice, mostly because of economic reasons and poor medical insight, and 31 patients (8.18%) died. CONCLUSIONS: Trauma is the most common indication for neurosurgical care in our service. Poverty and poor medical insight remain formidable obstacles to maximizing the benefits of available neurosurgical care in developing countries.

Determinants of Timing of Presentation of Neurotrauma Patients to a Neurosurgical Center in a Developing Country.

BACKGROUND: A major goal in neurotrauma management is the prevention of secondary neuronal injuries. This goal is time bound as neurological deficits once established are usually irreversible. Late presentation is the norm in most neurotrauma patients in developing countries. AIMS: The aim of the study was to review the timing of presentation of neurotrauma patients and the possible causes of their late presentation for neurosurgical care in our practice. METHODS: A cross-sectional study of a 4-month prospective database of neurotrauma patients presenting to the University College Hospital, Ibadan, was done. The participants' biodata, injury characteristics, initial-care details before referral, and information on timing and causes of delay were analyzed. RESULTS: The study subjects included 111 patients, 80.2% (89/111) were males, and 52.8% aged 21-40 years. Head injury (HI), spinal cord injury (SCI), and combined HI and SCI occurred, respectively, in 80.2%, 14.4%, and 5.4%. Road accidents followed by falls were seen in 73.9% and 14.4% (16), respectively. Just 46.8% (52/111) cases presented within 12 h of injury and only 37 (33.3%) within 4 h. Majority, 83.8% (93/111) were referrals from primary care. These referrals were delayed in 81.7% (76/93) of these. The referring health facilities were located intracity with our center in 54%. Other causes of delayed presentation of these study participants included long-distance travel to our center, lack of funds, or a combination of the above factors. Eighty-nine patients (80.2%) were brought in by family members and the remaining minority by passers-by and road safety personnel. CONCLUSIONS: Delayed referral from primary care features prominently in timing of presentation of neurotrauma patients in Nigeria. There is a need for collaboration as well as continuing medical education between the neurotrauma specialists and primary care physicians.