Spinal ganglioneuroma with extension to the brachial plexus. The challenges for total surgical excision, a case report.

INTRODUCTION: Ganglioneuromas are benign neurogenic tumors that arise from the sympathetic ganglia. They are less aggressive compared to the more immature neuroblastomas and ganglioneuroblastomas but can grow to exert mass effect on surrounding tissues. PRESENTATION OF CASE: A 7 years old girl who presented with progressive quadriplegia for 4 months. On examination, she had a right supra-clavicular mass with reduced power in the right hand than the left. Power in the lower limbs was also reduced with hyper-reflexia, clonus and Babinski positive. Laboratory investigations were unremarkable and Chest X-Ray showed a widened mediastinum. Magnetic Resonance Imaging (MRI) scan revealed an extra-medullary spinal tumor at C6/C7 extending laterally on the right through the C6/7 neuro-foramen to the para-spinal tissue and brachial plexus. A C6/7 laminectomy with Spinal cord decompression by partial resection of the tumor was done. Histology of the resected tissue showed ganglioneuroma. DISCUSSION: The presentation of Ganglioneuromas is usually asymptomatic until they are huge enough to exert mass effect on surrounding tissue. Most are located in the posterior mediastinum, retro-peritoneum and neck. Due to this, it may be very challenging to achieve total resection especially when they surround major vessels or nerves. A multi-disciplinary approach is needed for the best surgical outcomes but this is not always realized in our setting. CONCLUSION: In resource limited settings, more collaboration and training is needed to realize appropriate management of complex surgical conditions. Although complications are not uncommon, total surgical excision is necessary to prevent recurrence and progression of Ganglioneuromas.

Global Neurosurgery: A Retrospective Cohort Study to Compare the Effectiveness of Two Training Methods in Resource-Poor Settings.

BACKGROUND AND OBJECTIVES: Many low- and middle-income countries are experiencing profound health care workforce shortages. Surgical subspecialists generally practice in large urban centers but are in high demand in rural areas. These subspecialists must be trained through sustainable programs to address this disparity. We quantitatively compared the relative effectiveness of 2 unique training models to advance neurosurgical skills in resource-poor settings where formally trained neurosurgeons are unavailable. METHODS: Neurosurgical procedure data were collected from 2 hospitals in Tanzania (Haydom Lutheran Hospital [HLH] and Bugando Medical Centre [BMC]), where 2 distinct training models ("Train Forward" and "Back-to-Back," respectively) were incorporated between 2005 and 2012. RESULTS: The most common procedures performed were ventriculoperitoneal shunt (BMC: 559, HLH: 72), spina bifida repair (BMC: 187, HLH: 54), craniotomy (BMC: 61, HLH: 19), bone elevation (BMC: 42, HLH: 32), and craniotomy and evacuation (BMC: 18, HLH: 34). The number of annual procedures at BMC increased from 148 in 2008 to 357 in 2012; at HLH, they increased from 18 in 2005 to 80 in 2010. Postoperative complications over time decreased or did not significantly change at both sites as the diversity of procedures increased. CONCLUSION: The Train Forward and Back-to-Back training models were associated with increased surgical volume and complexity without increased complications. However, only the Train Forward model resulted in local, autonomous training of surgical subspecialists after completion of the initial training period. Incorporating the Train Forward method into existing training programs in low- and middle-income countries may provide unique benefits over historic training practices.

Outcomes of traumatic brain injury patients with acute epidural and subdural hematoma who underwent burr hole surgery: A two-year study at Kilimanjaro Christian Medical Centre, Tanzania.

Background: Traumatic brain injury is a leading cause of mortality and morbidity in Africa. Craniotomy is the surgical standard for acute extra-axial hematomas that is not realistic in LMIC due to deficient human and operative resources. Burr hole surgery may be an alternative in resource-limited settings. This study aimed at determining outcomes and factors associated with burr hole surgery as definitive management of traumatic extra-axial hematomas. Methods: Hospital-based cross-sectional study of patients with acute traumatic extra-axial hematomas who underwent burr hole surgery. Data were extracted from the patient's medical records after confirmation of the surgery and CT scan findings. The data were entered to SPSS 25 for analysis where a bivariate analysis was done. Results: 156 participants were enrolled; 149 (95.5 %) were males. The mean age of the participants was 35.33 (SD 15.37) years. The mean arrival GCS was 11.76 ± 3.59. Most participants had mild, followed by severe then moderate (55.8 %, 24.4 %, and 19.9 % respectively) TBI. 118 (75.6 %) participants had good outcomes and the overall in-hospital mortality was 18.6 %. 109 (69.9 %) had epidural hematomas mostly (21 %) in the parietal lobe. 30 (19.2 %) had brain herniation syndromes. Poor outcomes were associated with age above 50 years, severe TBI, motor response <4, abnormal pupil size, other injuries, ICU admission, SDH, midline shift >10 mm, cerebral edema, and brain herniation syndromes. Surgical site infection and hemostasis by packing were associated with a long length of hospital stay. Conclusion: Burr hole surgery is still a safe, effective, and simple life-saving procedure in patients with acute hematomas in resource-constrained areas.

Social Determinants of Health Impact Spinal Cord Injury Outcomes in Low- and Middle-Income Countries: A Meta-Epidemiological Study.

BACKGROUND AND OBJECTIVES: Traumatic spinal cord injuries (SCI), which disproportionally occur in low- and middle-income countries (LMICs), pose a significant global health challenge. Despite the prevalence and severity of SCI in these settings, access to appropriate surgical care and barriers to treatment remain poorly understood on a global scale, with data from LMICs being particularly scarce and underreported. This study sought to examine the impact of social determinants of health (SDoH) on the pooled in-hospital and follow-up mortality, and neurological outcomes, after SCI in LMICs. METHODS: A systematic review was conducted in adherence to the Preferred Reporting in Systematic Review and Meta-Analysis-guidelines. Multivariable analysis was performed by multivariable linear regression, investigating the impact of the parameters of interest (patient demographics, country SDoH characteristics) on major patient outcomes (in-hospital/follow-up mortality, neurological dysfunction). RESULTS: Forty-five (N = 45) studies were included for analysis, representing 13 individual countries and 18 134 total patients. The aggregate pooled in-hospital mortality rate was 6.46% and 17.29% at follow-up. The in-hospital severe neurological dysfunction rate was 97.64% and 57.36% at follow-up. Patients with rural injury had a nearly 4 times greater rate of severe in-hospital neurological deficits than patients in urban areas. The Gini index, reflective of income inequality, was associated with a 23.8% increase in in-hospital mortality, a 20.1% decrease in neurological dysfunction at follow-up, and a 12.9% increase in mortality at follow-up. CONCLUSION: This study demonstrates the prevalence of injury and impact of SDoH on major patient outcomes after SCI in LMICs. Future initiatives may use these findings to design global solutions for more equitable care of patients with SCI.

A case report of atypical presentation of a solitary brain metastasis from a primary lung cancer in a low resource setting.

INTRODUCTION AND IMPORTANCE: Brain metastasis is the most common associated consequence of primary lung cancers, and it has a major detrimental influence on patients' survival and quality of life. Modern imaging modalities such as brain MRIs and PET scans are preferred for assessing these lesions. Complete surgical resections have been shown to enhance survival. CASE PRESENTATION: We present the case of a 59-year-old male patient who had a history of progressive left-sided weakness and right-sided headaches with no respiratory symptoms. A solitary brain lesion was noticed, prompting a surgical resection. Histology findings confirmed brain metastases, and a thoracic CT scan revealed a primary lung tumour. The patient was scheduled for chemotherapy. DISCUSSION: Primary lung tumors often disseminate to the brain. The brain metastatic lesions in advanced lung cancer are often numerous and smaller in size, based on MRI imaging. The patient's symptomatology obscured the existence of an underlying lung tumour, delaying focused therapy. The early symptomatology and scans of our patient indicated the probability of a solitary brain tumour, necessitating a surgical excision. CONCLUSION: Prompt management of brain metastatic lesions is crucial. Yet, some patients emerge with atypical characteristics of the lesions that hint to a primary brain lesion and conceal the presence of a lung tumour. Enhancing these patients' prognoses necessitates a targeted therapy that includes a comprehensive examination, radiological imaging, and recognition of the distinctive brain patterns in patients with lung cancer. The merits of complete or incomplete resections for multiple brain metastatic lesions might be a fascinating subject of discussion.

Isolated cerebellar tuberculoma mimicking a malignant posterior cranial fossa tumor in a healthy child: A rare case report from Tanzania.

INTRODUCTION: Tuberculosis (TB) is one of the leading causes of mortality and morbidity in the world, especially in developing countries that account for 98 % deaths among TB cases. Although TB is primarily a disease of the lungs, extrapulmonary manifestations have been reported. Although CNS tuberculoma mostly affects immunocompromised people, it also affects healthy people at extremes of age. Imaging of intracranial tuberculoma may look like neurocysticercosis, and other ring-enhancing lesions hence imposing a diagnosis dilemma. CASE PRESENTATION: A 13-year-old female presented with headache, convulsions, blurry vision, and gait disturbance for six months. Brain imaging showed a left cerebellar lesion with obstructive hydrocephalus. She underwent ventriculoperitoneal shunting on admission, then sub-occipital craniotomy with tumor resection one week later. Histology confirmed a diagnosis of tuberculoma. She was given anti-tuberculosis medications and she was discharged home healthy without any of the symptoms she had on admission. DISCUSSION: Although only about 1 % of active tuberculosis cases presents as CNS TB, 5-10 % of intracranial space-occupying lesions in developing countries are tuberculomas. Provisional diagnosis of tuberculoma can be made through clinical history, examination, and neuroimaging. However, it is challenging because neurocysticercosis also appears as a ring-enhancing lesion in the brain and has almost similar prevalence in low-income settings. Being immunocompetent with no history of tuberculosis or constitutional symptoms, a diagnosis of tuberculoma was only confirmed by histology. CONCLUSION: A high index of suspicion for CNS tuberculomas in TB endemic areas should be kept in patients presenting with features of intracranial space-occupying lesions regardless of the absence of risk factors.

Pattern of congenital anomalies among pediatric surgical patients in a tertiary care hospital in northern Tanzania.

Background: Congenital anomalies are major causes of morbidity and mortality in children under 5 years of age and make a significant contribution to the surgical burden of diseases. Most anomalies have multifactorial causes and commonly affect the central nervous, cardiovascular, gastrointestinal and musculoskeletal systems. Countries with improved pediatric surgical care have shown dramatic reductions in morbidity and mortality rates. The aim of this study was to analyze the pattern of congenital anomalies presenting in our surgical departments in patients under 5 years of age. Methods: A retrospective descriptive study was done. Data were obtained from clinical records of patients under 5 years of age, who underwent surgical correction of their congenital anomalies between 2017 and 2021. Analysis was done to identify the proportion of congenital anomalies managed in our setting. Results: Congenital anomalies contributed 4.6% of overall surgical burden. Totally, 822 patients with congenital anomalies were included for analysis. The most commonly diagnosed congenital anomaly was inguinal hernia, followed by hydrocephalus, neural tube defects and cleft lips. The most commonly affected system was the central nervous system, anterior abdominal wall, orofacial and digestive system in decreasing order of frequency. Most of our patients presented outside the neonatal period (84.4%), and few (16.1%) had more than one system affected. Male children comprised 64%. Conclusions: Delayed presentation of children with congenital anomalies is still a significant problem in our area. Prevention through nutritional supplementation and antenatal screening is crucial. The true epidemiology of congenital anomalies in northern Tanzania is still obscure.

The pattern of prognostic and risk indicators among women with breast cancer undergoing modified radical mastectomy in Dar es Salaam, Tanzania.

BACKGROUND: Breast cancer is the commonest female malignancy globally and the second (after uterine cervix) in sub-Saharan Africa including Tanzania. Prognostic indicators reportedly influence post-mastectomy adjuvant therapy by predicting risks on survival and recurrence although in Tanzania this data is lacking. Here, we evaluate the pattern of prognostic and risk indicators among women with breast cancer undergoing modified-radical-mastectomy (MRM) at Muhimbili National Hospital (MNH) and Tumaini Hospital (TH), Dar es Salaam, Tanzania. METHODS: This hospital-based prospective cross-sectional study included female patients undergoing MRM from April 2011 to January 2012. Clinical stage I-III patients were enrolled after being scheduled for mastectomy. Patients with evidence of distant metastasis (stage IV) were excluded. Mastectomy and axillary lymph nodes biopsies were submitted to the Histopathology laboratory for grade, type, nodal and margins status. Data was collected using a structured questionnaire and analyzed using SPSS. RESULTS: A total of 348 patients were admitted with breast cancer including 86 patients (with 16 from TH having similar demography and presentation) meeting inclusion criteria. Age-range at diagnosis was 28-79 years, mean 52.1 years. Most (89 %) attained menarche after 11 years. About 56 % were postmenopausal. The majority (78 %) were multiparous with positive family history in 14.1 and 37.6 % used hormonal contraceptives. About 27.1 % were social alcohol drinkers. The majority (61 %) had T4b disease, 75.6 % had positive axillary nodes including 42.7 % with 4-9 involved nodes (N2). The commonest (91.9 %) histological type was invasive ductal carcinoma. Lobular, medullary and mucinous carcinomas were rare. Most (83.7 %) of our patients presented with stage III and the rest stage II. Intermediate- and high-grade tumors accounted for 73.5 %. Following MRM, 25 % of our patients had positive surgical margins and similarly for the base. CONCLUSIONS: Most of our breast cancer patients present with frequent risks including younger age, multiparity, hormonal contraceptives use, alcohol use and family history. Unfavourable prognostic indicators including late stages, large primary tumor size, skin infiltration, positive surgical margins, positive axillary lymph nodes and a high histological grade were associated. A sustainable screening program by self-examination to allow early diagnosis is needed to reduce morbidity and mortality from this cancer.