Amos Olufemi Adeleye

Diagnosis and management of Rosai-Dorfman disease involving the central nervous system

Abstract Introduction: Rosai–Dorfman disease is a benign non-neoplastic proliferative disorder of histiocytes originally described in the cervical lymph nodes. Extranodal sites were later recognized, and by 1990, they were shown to represent over 40% of cases; however, central nervous system involvement is still considered rare. We review the literature, which shows a steady increase in reports of Rosai–Dorfman disease involving the brain and/or spine. Methods: A literature search was performed for the period 1969–2008, using multiple search engines, with keywords Rosai–Dorfman disease, central nervous system Rosai–Dorfman disease and sinus histiocytosis with massive lymphadenopathy. Results: By December 2008, 111 cases of Rosai–Dorfman disease involving the central nervous system had been reported in the literature, including our cases. In the central nervous system, Rosai–Dorfman disease is ubiquitous. Although it is characterized by unique, indeed pathognomonic, histopathological cytoarchitecture, it may be mistaken for many other neoplastic and inflammatory histioproliferative diseases. Surgical resection with post-operative corticosteroids remains the treatment of choice. Conclusions: Rosai–Dorfman disease involving the central nervous system appears to be more common than previously thought and may well assume a more prominent place in the differential diagnoses of dural-based lesions. Expert awareness of the characteristic histopathology and immunohistochemistry of the disease is required for accurate diagnosis.

Central nervous system congenital anomalies: A prospective neurosurgical observational study from Nigeria

This is a prospective observational study on the profile of central nervous system (CNS) anomalies in a neurosurgical unit in Ikeja, Nigeria. All cases of CNS anomalies seen by the authors in 1 year, January to December 2005, were analyzed. Descriptive variables include some demographics of the patients and their parents; profiles of CNS anomalies, cranial or spinal, neural tube defects (NTD) or others; presence of associated anomalies; and rate of surgical correction of these anomalies. Sixty‐one cases were recorded, approximately 64% of our total pediatric neurosurgical output. Forty‐one cases were males, 20 females, with a male to female ratio of approximately 2 to 1. The age at presentation ranged from 2 days to 60 months (mean 5.6 months) and the majority of the parents were young (the mean ages of the fathers and mothers were 35 years and 28 years, respectively), and low income earners (70%). The cases comprised cranial (61%) and spinal (39%) anomalies, or 54% of NTD versus others. The cranial lesions were mainly congenital primary hydrocephalus in 44% of cases, encephalocele in 28%, and microcephaly in 17%. The spinal lesions were spinal dysraphism in more than 90%; all in the lumbosacral region. Seventy percent of the NTD had associated cranial or other system anomalies, mainly secondary hydrocephalus in 65%. The surgical correction rate of all of these cases was 38%. NTD were significantly more likely to present early, be associated with other anomalies and undergo surgical correction in this series (P < 0.001). CNS congenital anomalies are under‐reported in Nigeria and other developing countries. A call is made for the establishment of nationwide efforts to fully clarify the epidemiology of this silent epidemic.

Post-operative day two versus day seven mobilization after burr-hole drainage of subacute and chronic subdural haematoma in Nigerians

Abstract Introduction. The traditional care of patients with subacute/chronic subdural haematoma (S/CSDH) often involves delayed mobilization after burr-hole drainage. It is thought that delayed mobilization aids brain re-expansion thereby reducing the risk of recurrence. However, there is paucity of information regarding its efficacy and safety over early mobilization. We evaluated the efficacy and complications of each type of mobilization following burr-hole drainage of S/CSDH. Method. This was a prospective study from October 2004 and September 2010. A total of 50 patients who had burr-hole drainage of S/CSDH were sequentially allocated to either early (day 2) or late (day 7) mobilization (EM or LM) groups (25 patients in each group). Wound related complications, recurrence of haematoma, complications of prolonged bed rest and Glasgow Outcome Score (GOS) at discharge were studied in the two groups. Patients who could not obey commands to mobilize in the early post-operative period were excluded. Results. There were 43 (86%) males and 7 (14%) females. The mean age was 57 years (range: 27–90 years). Fourteen (28%) of the patients were elderly (age > 65 years). Two complications, wound infection in a 76-year old man in the LM group and tension pneumocephalus requiring re-opening burr-hole drainage in a 55-year old man in the EM group were recorded. There was no recurrence or problem associated with prolonged bed rest in the two groups. Five (10%) patients had moderate disability (GOS 4) at discharge (1 EM, 4 LM) while the others (90%) had good recovery (GOS 5) (24 EM, 21 LM). These differences were not statistically significant (p-value: 0.349). Conclusion. It appears that both EM and LM are equally beneficial in the post-operative care of patients following burr-hole drainage of S/CSDH. There is no significant complication referable to the specific type of mobilization. The authors, therefore, advocate EM of patients to reduce the length of hospital stay.

Updates on the Epidemiology and Pattern of Traumatic Maxillofacial Injuries in a Nigerian University Teaching Hospital: A 12-Month Prospective Cohort In-Hospital Outcome Study

Many studies have been undertaken in Nigeria on maxillofacial trauma. However, only a few have considered both the skeletal and soft tissue injuries (in general) involving all the aspects of the maxillofacial region or considered other etiological sources of trauma apart from road traffic crashes. Fewer still have reviewed the outcome of management of facial injuries in our low-resource environment. This study sets out to examine the recent trends in both the clinical and epidemiological patterns of all facial injuries from all causes seen in a low-resource practice of a developing country. It also assessed the in-hospital treatment outcomes, and the levels of the patients’ satisfaction with treatment received in this setting. Over a 12-month period, the clinical records of consecutive patients who were evaluated and treated for maxillofacial injuries in our unit were prospectively acquired, entered into predesigned forms and subsequently analyzed. There were 259 patients (79.5% males) during the study period. The mean age was 32.21(± 16.588) years. Overall, motor bike crashes, 42.1%, were the commonest source of these traumas; and armed robbery was the commonest form (69.0%) of assault. Mandibular fractures were the commonest maxillofacial fractures (37.8%) whereas head injury had the highest frequency among the associated injuries (71.4%). Closed reduction and immobilization was deployed in 88.0% of those who had treatment and majority was satisfied with the esthetic outcome of the treatment received. Mean length of hospital stay was 12.6 (± 4.423) days. Maxillofacial trauma poses a significant socioeconomic burden on affected individuals in this study population. This is made worse by the presence of associated injuries in the other body systems. More local studies on the outcome of management of maxillofacial trauma will improve the available literature in this region.

A Prospective Study on the Causes of Delayed Diagnosis of Childhood Cancer in Ibadan, Nigeria.

Outcome in cancer may be improved by early diagnosis and prompt treatment. The objectives of this study were to determine the prediagnostic intervals (lag time) in childhood cancer and the factors that influence them at the University College Hospital (UCH), Ibadan. The study was prospective and observational and involved children diagnosed with cancer from July 2012 to June 2014 at UCH, Ibadan, Nigeria. A history of the illness was obtained and physical examination performed on each patient. Information obtained and analyzed included sociodemographic data, cancer diagnosis and stage, time intervals between onset of symptoms and diagnosis, and the reasons for delayed diagnosis. A total of 91 children were studied, comprising 46 males and 45 females. Their ages ranged from 1 month to 15.0 years, with a median of 4.0 years. Median parent lag time was 2.0 weeks, median health system or physician lag time 8.0 weeks, and median overall lag time 15.5 weeks. Overall lag time had a negative correlation with age of child at diagnosis, a positive correlation with the number of health facilities visited before diagnosis, and was shorter in mothers younger than 40 years of age. Lag time was significantly different among the diagnostic tumor categories, with Burkitt lymphoma having short times and retinoblastoma with long times. Delayed diagnosis of childhood cancer is a significant problem in Ibadan. Education of parents and health workers on early presentation and accurate diagnosis are recommended.

Cranial computed tomographic findings in Nigerian women with metastatic breast cancer

Introduction: Brain metastases (BM) occur in up to one-fifth of patients with metastatic breast cancer (MBC). Imaging plays a key role in diagnosis. The pattern and distribution of these changes are also crucial to their management. These patterns have not been fully studied in Nigerian women. Materials and Methods: Retrospective analysis of the findings on the cranial Computed Tomography (CT) scans performed in 59 breast cancer patients with suspected BM treated at the University Teaching Hospital in Ibadan, between 2005 and 2010. The imaging features were evaluated in relation to their clinical characteristics. Results: In the 59 patients studied (mean age 50.9 years ± 11.75 SD), headache (40.7%) and hemiparesis/hemiplegia (16.9%) were the commonest clinical presentation. Lytic skull lesions were seen in 15 patients (25.4%), most commonly in the parietal bones. Thirty-nine patients (66.1%), had parenchymal brain lesions, and only 8 (20.5%) of these were single lesions. Most of the lesions were isodense (19/39; 51.4%) the parietal lobe was the most common site with 50.8% (30/59) occurrence and the leptomeninges the least with 13.6% (8/59). Orbital or sellar region involvement occurred in only two patients. The size of the lesions, was <2 cm in 17 (28.8%), 2-5 cm in 14 (23.7%) and >5 cm in 5 patients. Sixteen (27.1%) patients were free of any lesion either in the skull or brain. Patient presenting with multiple brain lesions were more likely to have skull lesions though this was not statistically significant (P = 0.584). Conclusion: The brain continues to be a sanctuary site for breast cancer metastases and CT imaging remains an invaluable tool in the clinical evaluation and therapeutic management of Nigerian women with BM from MBC. It also appears that the demographic and imaging findings in these patients are similar to other racial groups.

Low rates of post-craniotomy surgical site infections in a developing country: surgical technique and results

Abstract Introduction: Although neurosurgical surgical site infections (SSI) exert a devastating price on the postoperative course of patients in the developing countries, literature is sparse on the subject from these regions. Methods: This study is an audit of post-craniotomy SSI in a sub-Sahara African academic neurosurgical practice. It is a retrospective descriptive analysis of neurosurgical SSI in a 7-year consecutive cohort of patients who survived more than 5 days following major cranial surgery. Our general neurosurgical operative goal is to keep the incidence of SSI as close to the global range as possible by, amongst other measures, enforcing strict compliance with appropriate operative room practice. Results: There were 211 craniotomies/craniectomies; 194 primary and 17 redo procedures. Male patients constituted 65%. The mean age was 32.2 (Standard Deviation +/− 17.2) years. The procedures were emergencies in 42.7% and urgent or elective in the rest. They were surgery for trauma in 46.9% and for tumour resections in 44.1%. The median duration of surgery was 3 hours (range 1–8.5 hours). Mortality was 4.3%. Functional outcome was assessed using a dichotomized Glasgow Outcome Scale and was good in 90.5%. Surgical site infections, mainly by Gram negative coliforms, occurred in 9 cases, 4.3%, leading to worse in-hospital outcome of 56% (p < .001) in those affected. Patients with a poorer pre-operative Karnofsky performance status had a higher infection rate (7.5%), than those with better clinical performance index, (2.3%). This difference was not significant (p = .09, unadjusted OR 3.46, 95% Confidence Interval 0.84–14.24). Conclusion: Post-craniotomy SSI rates comparable to those in more advanced practice areas is achievable in developing countries

Proliferaton index in pituitary adenomas from a black African population

Abstract Background The WHO has recognized a variant of pituitary adenomas with potential aggressive behaviour which have been termed atypical pituitary adenomas. This group of tumours are recognized by their mitotic rate of more than >3%, p53 expression and invasion of surrounding structures. There has however been no study of the occurrence of these tumours in a black African population. This study is a preliminary attempt to examine this group of tumours in blacks. Methods This study retrospectively reviewed fifty-seven histologically diagnosed and immunohistochemically characterized pituitary adenomas received in our department over a twenty-one year period. Specimens were stained with ki67, a nuclear marker of cell proliferation which has been identified as the single best predictor of atypical pituitary adenoma. Results Twelve of the tumours showed atypical features with eight (67%) of these tumours being prolactinomas. Two of the tumours were gonadotrophs and two were null cell adenomas. There was no correlation with age or gender. Two of the tumours required neurosurgical re-exploration with one of these showing a higher mitotic index in the second biopsy. Conclusion The study suggests similarity in the rate of occurrence of pituitary adenomas with atypical features in a black African population with what is seen in Caucasians. Prolactinomas constitute a significant percentage of the tumours with this feature.

Central nervous system tumours in children in Ibadan, Nigeria: a histopathologic study.

Introduction Contrary to some earlier teachings that central nervous system (CNS) tumours are uncommon in black children, these neoplasms are the fourth most common paediatric tumours in Ibadan. Our centre is the major referral centre for CNS tumours in Nigeria. The last major study of paediatric CNS neoplasms from Ibadan was in 1985. An update of the data on paediatric CNS neoplasms at our centre is presented. Methods A retrospective review of all histologically diagnosed CNS tumours in children (0-14 years) from January 2001 to December 2010 from the database of the Department of Pathology, University College Hospital, Ibadan, Nigeria was done. The cases were classified using the 2007 WHO Classification of Tumours of the Central Nervous System and were also based on their supratentorial and infratentorial locations. Results Seventy-seven tumours, 44 in males, were included in the study. Astrocytic tumour comprised 20 cases, embryonal tumours 15, ependymal tumours 15, germ cell tumours 6, sellar tumours (all craniopharyngiomas) 9 and other histological types- 12 cases. Thirty-seven were WHO Grade 1, eleven Grade 2, ten Grade 3 and nineteen Grade 4 neoplasms. Thirty-six cases were supratentorial and thirty-eight were infratentorial in location. The most common tumours in this series were pilocytic astrocytomas, medulloblastomas, craniopharyngiomas and ependymomas in that order. Conclusion Childhood CNS tumours are being increasingly diagnosed in our centre. This is largely explained by the recent expansion of the available neurosurgical services.

Single-Stage Surgical Reconstruction of Posttraumatic Compound Complex Fronto-Basal Cranial Vault Fracture in a Resource-Limited Practice.

Background:The extant literature on the surgical treatment of posttraumatic compound, complex frontal basal calvarial skull fracture suggests that this be a staged procedure. There are many socioeconomic constraints in low-resource regions of the world to the feasibility of this standard practice. Methods:A single-stage operative procedure for the surgical treatment of these fractures in a neurosurgery practice in Nigeria is here annotated. In addition, an observational outcome analysis of this surgical technique in a prospective consecutive cohort of patients over a 6-year period is presented. Results:Fourteen patients, all males, mean age 33.9 years (SD, 6.6) underwent this surgical procedure. Majority were late neurosurgical referrals, hence median time to surgery was 96 hours (range, 48–2160). Twelve patients (85.7%) had history of loss of consciousness, median duration of 34 hours; 7 (50%) had associated brain contusions; 6 (43%) significant pneumocephalus; and acute extradural and subdural haematoma in 4 and 2 patients respectively. The surgery was successful in all; 13 (93%) had normal outcome on the Glasgow outcome scale at hospital discharge; 12 have been followed up for 1 to 72 months, median 33. Seven of these were for 30 months or more. There was no patient of surgical site infection in the perioperative or the follow-up period to date. The aesthetic outcome was also acceptable. Conclusion:The pragmatic surgical technique herein annotated appears clinically and aesthetically effectual in the operative treatment of compound, complex frontal basal cranial vault fracture.