Amos O. Adeleye

Central nervous system congenital malformations in a developing country: issues and challenges against their prevention.

BackgroundLittle efforts are geared towards prevention of CNS anomalies in the developing countries.MethodsA 1-year prospective cross-sectional analysis of the cases of CNS congenital anomalies seen in a Nigerian neurosurgical unit. This included both the children’s and parents’ sociodemographics, the profiles of the CNS anomalies, and the maternal obstetric health behaviors toward primary and/or secondary prevention of the anomalies. Statistical analysis was done with the Pearson’s chi-square (or Fishers’ exact) test. Level of significance set at Pu2009<u20090.05.ResultsThere were 54 cases of cranial and spinal gross CNS anomalies, including 32 neural tube defects; two thirds of the parents were low-income earners, and half had only basic education. Thirty percent of the pregnancies were unbooked; the mean gestational age (GA) at booking and commencement of obstetric micronutrient supplementation was 4.6xa0months. No case had periconceptional folic acid supplementation. Obstetric ultrasonography was performed late in pregnancy (mean GA 6xa0months), made positive diagnosis of CNS anomaly in only 14%, and was performed mainly in unsupervised private clinic settings in 98%.ConclusionsLittle or no attention is currently paid to the prevention of CNS congenital anomalies in much of the low- and middle-income countries of the world. There is a great need to regulate the practice of obstetric ultrasonography in Nigeria. There is even a much greater, more fiercely urgent need to ensure periconceptional folic acid supplementation for all women of childbearing age through appropriate food fortification in these societies.

Skull Base Surgery in a Large, Resource-Poor, Developing Country with Few Neurosurgeons: Prospects, Challenges, and Needs

BACKGROUNDnUpon returning home to Nigeria from postresidency fellowship training in skull base surgery, using expertise gained overseas, we applied appropriate treatment to various skull base pathologies. This is an audit of our initial experience.nnnMETHODSnThis is a prospective, descriptive survey of all the skull base pathologies operated on during 30 months. Clinical-demographic data, surgical procedures, and the postoperative outcome are presented statistically. Simple inferential statistics was performed for associations deemed significant at P≤0.05.nnnRESULTSnFifty-one individuals (27 men and 24 women, mean age 32 years) were operated on for skull base pathologies. Clinical presentation had a mean symptom duration of 22 months and a poor clinical status in more than 60% of the patients. Congenital, infective, traumatic, and neoplastic lesions were encountered, including craniofacial malignancies operated on jointly with other craniofacial surgeons. Other intracranial neurosurgical pathologies like jugular foramen and brain stem tumors, and meningiomas of various skull base corridors, including the cavernous sinus and the foramen magnum, were encountered. Our skull base dissections were craniofacial in 23.5% of cases, anterolateral in 33.3%, midbasal in 15.7%, and posterior fossa in 27.5% of patients. Surgery was successful in 86.3%. The patients status improved on hospital discharge in 70.6% of cases. The postoperative outcome was significantly worse (P=0.03) in those patients with postbasal lesions with poor clinical performance index preoperatively.nnnCONCLUSIONSnIn spite of the many inherent challenges of a typical developing country health system, there are great prospects for skull base surgical practice in Nigerian neurological surgery.

Prevention of myelomeningocele: African perspectives

BackgroundThe prevention of neural tube defects (NTDs) is now an issue of major public health concern. Myelomeningocele, the most common NTD, often results in severe disabilities and may be life threatening. In Africa, there is little awareness of the NTDs, and most African countries lag behind in the global efforts at preventing them.PurposeFollowing a review of global literature, we discuss the burden of myelomeningocele on the society and the current state of its prevention with an emphasis on Africa within the global context. The realization that folate supplementation reduces the occurrence of NTDs by as much as 85xa0% offers an opportunity to promote global reduction in the incidence of NTDs through (1) effective folate supplementation strategies combined with (2) secondary prevention using prenatal detection and termination of NTD pregnancies within respective national legal frameworks. We call attention to the poor state of understanding of NTDs in Africa and the alarming rarity of policies to prevent the condition in the continent.ConclusionsThe understanding of the contributions of folate deficiency to the causation of NTDs has enabled appropriate, though still inadequate, preventive measures to be taken in several countries. We call on African governments and the international community to rapidly promote policies aimed at making fortification of wheat (and or other substitute staple foods) with folic acid universally available.

Cerebral pleomorphic xanthoastrocytoma associated with NF1: an updated review with a rare atypical case from Africa

The occurrence of cerebral pleomorphic xanthoastrocytoma (PXA) in individuals with neurofibromatosis type 1 (NF1) is very rare. We present a 10-year-old Nigerian boy with NF1 who was found to harbor a thalamic-lateral ventricular solid mass lesion whose histologic and immunohistochemical findings were in keeping with PXA. We also carried out an updated review of the PXA-NF1 literature and found only eight previous reports of this clinical disease association. These reports have been limited to only certain regions of the world, with none yet reported from Africa, South America, Australia, and Eastern Europe. As far as we know, this might be the first such report from Africa. The case we present, in addition, demonstrated some other unique clinical, radiological, and histopathologic characteristics which have been highlighted in this review.

Magnetic resonance imaging: Clinical experience with an open low-field-strength scanner in a resource challenged African state

Introduction: Despite the fact that an magnetic resonance imaging (MRI) has been in clinical use for over 20 years, its use and availability in Nigeria, a West African state, is still extremely low. Hence, only few publications are available on the clinical experience with MRI from Nigeria. We set out to evaluate our initial clinical experience with a low-field-strength MRI in a Nigerias foremost university hospital. Materials and Methods: A retrospective review of all studies, performed with an open 0.2 Tesla MAGNETOM Concerto (Siemens Medical) MRI scanner over a 5-year period (2006 - 2010) was conducted. All patients with complete records were evaluated for their clinical and demographic characteristics. Results: The records of 799 MRI studies were available. Patients’ ages ranged from 1 day to 90 years, with a mean of 40.1 years (± 20.7 SD). There were 463 (57.9%) males and 336 (42.1%) females. Over 90% of the studies were requested to evaluate brain or spine lesions. Low back pain represented the commonest (161/799, 20.7%) clinical indication for MRI. The largest number of patients was referred by physicians from surgical specialties (65.6%). Conclusion: The awareness and competence for proper use of MRI in Nigeria appears high. Low back pain is the commonest indication for MRI in our institution, and surgeons make a greater use of the facility. The provision of high-signal strength MRI may be beneficial in making a wider range of applications available to clinicians.

Estimating the global incidence of traumatic brain injury

OBJECTIVETraumatic brain injury (TBI)-the silent epidemic-contributes to worldwide death and disability more than any other traumatic insult. Yet, TBI incidence and distribution across regions and socioeconomic divides remain unknown. In an effort to promote advocacy, understanding, and targeted intervention, the authors sought to quantify the case burden of TBI across World Health Organization (WHO) regions and World Bank (WB) income groups.METHODSOpen-source epidemiological data on road traffic injuries (RTIs) were used to model the incidence of TBI using literature-derived ratios. First, a systematic review on the proportion of RTIs resulting in TBI was conducted, and a meta-analysis of study-derived proportions was performed. Next, a separate systematic review identified primary source studies describing mechanisms of injury contributing to TBI, and an additional meta-analysis yielded a proportion of TBI that is secondary to the mechanism of RTI. Then, the incidence of RTI as published by the Global Burden of Disease Study 2015 was applied to these two ratios to generate the incidence and estimated case volume of TBI for each WHO region and WB income group.RESULTSRelevant articles and registries were identified via systematic review; study quality was higher in the high-income countries (HICs) than in the low- and middle-income countries (LMICs). Sixty-nine million (95% CI 64-74 million) individuals worldwide are estimated to sustain a TBI each year. The proportion of TBIs resulting from road traffic collisions was greatest in Africa and Southeast Asia (both 56%) and lowest in North America (25%). The incidence of RTI was similar in Southeast Asia (1.5% of the population per year) and Europe (1.2%). The overall incidence of TBI per 100,000 people was greatest in North America (1299 cases, 95% CI 650-1947) and Europe (1012 cases, 95% CI 911-1113) and least in Africa (801 cases, 95% CI 732-871) and the Eastern Mediterranean (897 cases, 95% CI 771-1023). The LMICs experience nearly 3 times more cases of TBI proportionally than HICs.CONCLUSIONSSixty-nine million (95% CI 64-74 million) individuals are estimated to suffer TBI from all causes each year, with the Southeast Asian and Western Pacific regions experiencing the greatest overall burden of disease. Head injury following road traffic collision is more common in LMICs, and the proportion of TBIs secondary to road traffic collision is likewise greatest in these countries. Meanwhile, the estimated incidence of TBI is highest in regions with higher-quality data, specifically in North America and Europe.

Targeting a zero blood transfusion rate in the repair of craniospinal dysraphism: outcome of a surgical technique for developing countries.

Abstract Objectives: In Africa and other developing countries, the financial cost of the in-hospital acute surgical treatment of children with open neural tube defects (NTD) is often beyond the reach of the parents. Surgery-related blood transfusion requirements sometimes add to the concerns. Here, we present a surgical technique used in our practice to mitigate the blood transfusion issue. Methods: First, we present the technical report of our near-bloodless technique for targeting zero blood transfusion rate during the surgical repair of open cranial and spinal dysraphism. The technique is based on the generous use of the Bovie electrocautery in the initial phase of the surgical dissection. We also carried out an outcome analysis of its use in a prospective consecutive cohort of patients operated on over a 24-month period. Results: There were 48 NTDs in children aged 2–372 days. The widest diameter of the dysraphic lesions ranged from 3 to 14 cm (mean 5·8 ± 2·6); six were occipital encephalocoeles and the rest were spinal dysraphisms, 79·2% lumbosacral. The operative time ranged from 25 to 105 minutes (mean 59·6 ± 20·4); surgical blood loss was <10% of calculated total blood volume in 92% of the children, and none needed blood replacement. With only few minor wound issues recorded, healing of the surgical wound was by primary intention in 92%. There was no other unusual occurrence of postoperative neurological limb or sphincteric deficits. Conclusion: This surgical technique greatly reduces the need for operative blood replacement in the surgical repair of open craniospinal dysraphisms, and has acceptable rates of postoperative wound and neurological complications.

Non-operative treatment of chronic subdural hematoma: Case report

The literature on the non-operative treatment of chronic subdural hematoma is scanty indeed as it appears that many neurosurgeons take surgical evacuation for granted as its key management principle. We here present the case of a 61-year-old man with a severe, troublesome headache of 4 days duration following a minor trauma. He had been involved in another minor trauma 2 months before the index admission. Cranial computed tomography (CT) scanning showed a left frontoparietal chronic subdural hematoma with notable mass effects. He declined surgery for personal reasons and was thus treated non-operatively on a short course of low dose dexamethasone. Clinical improvement was dramatic within 5 days into treatment and repeat CT 5 weeks later showed nearly complete resolution of the subdural hematoma. We therefore conclude that in well selected cases, non-operative treatment is a viable option in the treatment of chronic subdural hematoma.

Clinical Epidemiology of Head Injury from Road-Traffic Trauma in a Developing Country in the Current Era

Objectives Africa and other Asian low middle-income countries account for the greatest burden of the global road-traffic injury (RTI)-related head injury (HI). This study set out to describe the incidence, causation, and severity of RTI-related HI and associated injuries in a Nigerian academic neurosurgical practice. Methods This is a retrospective cross-sectional analysis of RTI-related HI from a prospective HI registry in an academic neurosurgery practice in Nigeria. Results All-terrain RTI accounted for 80.6% (833/1,034) of HI over a 7-year study period. All age groups were involved, mean 33.06u2009years (SD 18.30), mode 21–30, 231/833 (27.7%). The male:female ratio was 631:202, ≈3:1. The road trauma occurred exclusively from motorcycle-and motor-vehicle crash (MCC/MVC), MCC caused 56.8% (473/833) of these; the victims were vulnerable road users (VRU) in 74%, and >90% belong in the low socioeconomic class. Using the Glasgow Coma Scale grading, the HI was moderate/severe in 52%; loss of consciousness occurred in 93%, the Abbreviated Injury Severity-headu2009>u20093 in 74%, and computed tomography (CT) Rotterdam scoreu2009>u20093 in 52%. Significant extracranial injuries occurred in many organ systems, 421/833 (50.5%) having Injury Severity Score (ISS)u2009>u200925. Surgical lesions included extensive brain contusions in 157 (18.8%); acute extradural hematoma in 34 (4.1%); acute subdural hematoma in 32 (3.8%); and traumatic intracerebral hemorrhage in 27 (3.2%), but only 97 (11.6%) received operative care for various logistic reasons. The in-hospital outcome was good in 71.3% and poor in 28.7%; the statistically significant (pu2009<u20090.001) determinants of this outcome profile were the severity of the HI, the CT Rotterdam score, and the ISS. Conclusion In this study from Nigeria, RTI-related HI emanates from significant trauma to vulnerable road users and are caused exclusively by motorcycles and motor vehicles.

Incidental cranial CT findings in head injury patients in a Nigerian tertiary hospital.

Background: Incidental findings on computed tomography (CT) scans are occasionally noted in patients presenting with head injury. Since it can be assumed that head injured patients are of normal health status before the accident, these findings may be a representation of their frequency in the general population. Our aim was to determine the prevalence of such incidental findings among head injured patients in Nigerias foremost center of clinical neurosciences. Materials and Methods: We conducted a retrospective review of CT scan images of 591 consecutive eligible patients over a 5-year period (2006-2010) to identify incidental findings. The images were evaluated by consensus agreement of two radiologists. Associations with gender and age were explored using appropriate statistical tests with an alpha level of 0.05. Results: The mean patient age was 34.6 ± 21.2 years, and male to female ratio was 3.2: 1. Incidental findings were noted in 503/591 (85.1 %) of the scans. Intracranial calcification was the commonest finding occurring in 61.8% of patients. Over 90% of the findings were benign. Compared with older ones, patients under the age of 60 were less likely, (P < 0.001), to have incidental findings. Conclusion: Although the majority of incidental findings in this African cohort of head injury patients are benign some clinically significant lesions were detectable. It is therefore recommended that such findings be adequately described in the radiological reports for proper counseling and follow-up.