Abstract: A 53-year-old man presented with a 9-month history of symptoms of right-sided weakness, tingling and hypersentivity to clothes on both sides of the body. MRI revealed a large intraspinal intradural tumour at the level of C3-C4 in the cervical cord. The final histology was a solitary fibrous tumour (SFT) of the cervical spinal cord. The radiological diagnosis, surgical management and histology are reviewed.
Abstract: BACKGROUND AND PURPOSE: Stroke is a significant economic, social, and medical problem worldwide. This retrospective follow-up study aimed to review the pattern, types, and case fatality of stroke in Nigeria. METHODS: Records of all stroke patients admitted into Ogun State University Teaching Hospital (OSUTH), Sagamu, from December 1993 to November 2003 were reviewed. Patients were classified into hemorrhage or infarct using the World Health Organization criteria. Information was obtained as to the time of death in those who died and case fatality at 24 hours, 7 days, 30 days, and 6 months recorded. Autopsy records were also reviewed. RESULTS: A total of 708 stroke patients were reviewed and this constituted 2.4% of all emergency admissions. On clinical grounds, 49% of the patients had cerebral infarction (CI) and 45% had intracerebral hemorrhage (ICH), whereas 6% had subarachnoid hemorrhage. Stroke constituted 1.8% of all deaths at the emergency unit and the case fatality was 9% at 24 hours, 28% at 7 days, 40% at 30 days, and 46% at 6 months. CONCLUSIONS: Stroke constitutes a significant cause of mortality and the need for prompt institution of intensive treatment is emphasized. A changing pattern with an increasing frequency of hemorrhagic stroke in our population is suspected. However, because this was a retrospective study based on clinical examination in a highly selected stroke population, neuroimaging confirmation would be needed for any future prospective hospital or population-based studies.
Abstract: Glioblastoma Multiforme frequently metastasises from their original location by for example infiltration along white matter tracts [1]. GBM metastasis outside the central nervous system is distinctly rare though there are previous reports of spread to various organs [2-5]. We add an unusual case of a patient with aggressive cerebral GBM metastasis to the parotid gland and the lungs.
Abstract: We report the case of a 43-year-old patient with delayed ischemic neurological deficit and an ischemic penumbra, reversed with triple H therapy (hypertension, hypervolemia, and hemodilution). The patient presented with subarachnoid hemorrhage caused by an aneurysm of the anterior communicating artery. He underwent surgical clipping and developed cerebral ischemia due to vasospasm. Permanent damage to the area of ischemic brain was prevented by institution of the triple H therapy. He recovered and was discharged with no subsequent neurological deficits.
Abstract: Our goal was to review published literature on the epidemiology, diagnosis and treatment of subarachnoid haemorrhage (SAH) in Nigeria. With an estimated population of 126 million, roughly 6 million persons in Nigeria have or will develop an intracranial aneurysm in their lifetime. This study should highlight the areas requiring research and development, and facilitate future health care planning. A Medline and Embase literature review of reports on the management of SAH in Nigeria was conducted. The search terms were as follows: stroke, subarachnoid haemorrhage, intracerebral haemorrhage, brain, Nigeria, Nsukka, Ibadan, Lagos, Kaduna, Jos, Benin, Port Harcourt, Africa. All identified abstracts were reviewed for inclusion in the study. Only papers dealing with the study objectives were obtained for review of the bibliography and further analysis. Thirty articles have now been published about stroke in Nigerians. Fifteen of these either discussed SAH specifically or, in general, with other stroke subtypes (ischaemic stroke and intracerebral haematoma) or reviewed vascular intracranial anomalies such as aneurysms. The most detailed paper on this issue was published in 1970 and according to that report SAH is more common in males and prevalent in young people below the age of 40 years (68% of the patients reviewed). Worldwide improvements in medical and surgical management have not been reflected in the literature on SAH. Neurologists, stroke physicians and not neurosurgeons, treat patients with SAH in Nigeria. The results presented in this study reflect the current status of the medical and surgical management of SAH in Nigeria. Conclusive data relating to epidemiology, incidence, diagnosis, current treatment modalities and outcome of SAH in Nigeria have not been published. There is, therefore, a pressing need for further study in these areas and improvements in the management of patients with SAH.
Abstract: OBJECT: The authors reviewed the management protocols for young adults who presented with subarachnoid hemorrhage (SAH) at the Regional Neurosurgery Unit in Newcastle during a study period of 9 years. Aneurysmal SAH is uncommon in the age group selected (18-39 years) and, therefore, the performance of these patients has not been extensively reported in the literature. The authors also evaluated the good-grade rebleed rate (an index of management efficiency) in this cohort of patients. METHODS: The Newcastle neurosurgical unit serves a population of close to 3 million people, and an average of 180 patients with SAH are seen each year. The majority of patients are transferred from other hospitals in the region. This study includes patients admitted between January 1990 and December 1998. A total of 1,609 patients were admitted during this period, of whom 295 (18.4%) between the ages of 18 and 39 years constituted the study population of young adults. Two hundred ninety-five young adults presented with SAH; 181 (61.4%) were women and 114 (38.6%) were men, a ratio of 3:2. Of 246 patients in whom this value was recorded, 15 (6.1%) presented with a history of hypertension, and there was an association between hypertension and the occurrence of multiple aneurysms (Fisher two-tailed exact test, p = 0.008). Thirty-five patients (11.9%) presented with a hematoma on computerized tomography scans; of these, 20 (57%) were women and 15 were men. In six patients the lesion had rebled before treatment. The good-grade rebleed rate was three (1.7%) of 178. The overall favorable outcome rate was 83.8% (Glasgow Outcome Scale [GOS] 4 and 5) and unfavorable outcome occurred in 16.2% (GOS 1-3), with a total of 40 deaths in this group (13%). Age had no influence on outcome in young adults. Comparing the outcome at discharge with the follow-up evaluation at 6 months revealed that patients in the moderate and severe disability groups continued to improve and many achieved good recovery. CONCLUSIONS: In this report the authors detail the outcome of a large number of young adults with SAH. The incidence of SAH was higher in the female population, although the ratio was not as high as previously reported. The authors have also demonstrated a progressive increase in the incidence of aneurysmal SAH with age, even in young adults. Hypertension but not age influenced the occurrence of multiple aneurysms. The good-grade rebleed rate is low, although it is not zero. Generally, a satisfactory outcome was obtained and significant continuing improvements were noted between discharge and follow-up evaluation. This reflects the power of recovery in young adults. These are people whose economic productivity and fertility are at peak levels and therefore the financial and social burden occasioned by less-than-perfect outcomes is large.
Abstract: The authors present a 37-year-old lady with symptoms and signs suggestive of benign intracranial hypertension (BIH). Routine CT and MRI scans were normal. Further investigations were performed with magnetic resonance venography (MRV) and cerebral venography. These revealed obstruction of the right transverse sinus with high pressure (40 mmHg) proximal to the obstruction and low pressure (15 mmHg) distally. She was treated by transvenous stent deployment with resolution of her symptoms and the bilateral papilloedema. Evaluation of the cerebral venous system with MRV and or with formal cerebral venography should be included in routine investigations of patients with suspected BIH.
Abstract: The results of endovascular management of anterior communicating artery aneurysms (ACoAA) using Guglielmi Detachable Coils (GDC) are presented. We detail the clinical and radiological features, and postoperative clinical and radiological outcome in a consecutive series of patients. We have prospectively collected comprehensive data on our patients with SAH since 1989. This study reports on patients admitted between January 1990 and December 1998, and focuses on 30 patients who had their ACoAA endovascularly treated. An independent observer (TE) carried out long-term follow-up in January 2002. Statistical analysis was performed to study the relationship between clinical factors, the radiological morphology of aneurysms and the long-term outcome. The age ranged from 25 to 74 years (median: 54) and endovascularly treated ACoAA were more common in women, 19 (63%) compared with men, 11 (37%). Seventy-seven per cent were in good grade (WFNS 1 & 2) before treatment. Three patients rebled before treatment. The aneurysms were less than 10 mm in maximal diameter in 27/30 patients. The follow-up period was from 1 to 53 months (mean 32.5, median 36.6 months). Excellent outcome was recorded for 11 patients (36.7%), good in seven patients (23.3%), fair in three patients (10%) and poor in four cases (13.3%). Five patients had died (mortality 16.7%). Favourable outcome was achieved in younger patients, women, and in those who presented in grades 1 and 2. The long-term radiological follow-up revealed residual necks in 13 patients. Only one has required retreatment and no rebleed has occurred in 3-6 years. This study reports a contemporary experience with the endovascular management of ACoAA. Long-term stability of the coil and good outcome is demonstrated. Endovascular treatment using GDC is an efficient technique for treating acutely ruptured ACoAA with little additional morbidity. The clinical and radiological results are comparable with those in the literature.
Abstract: A 69-year-old man presented with a cholesteatoma in the right mastoid process and a vestibular schwannoma at the left internal acoustic meatus. Cholesteatoma co-existing with a vestibular schwannoma has not been documented previously in the contemporary literature. The clinical dilemma in the management of his progressive bilateral hearing loss is discussed. He presented with dizziness and bilateral hearing loss worse on the right side. Pressure over the mastoid process elicited vertigo and nystagmus. He had no history of previous operation or infection in the ear canal. Audiograms confirmed high-tone hearing loss. Radiological investigations revealed a symptomatic cholesteatoma on the right side and an incidental vestibular schwannoma on the left. We have elected to manage both lesions conservatively. Bilateral cholesteatoma and bilateral vestibular schwannomas have been previously reported. Co-existing lesions, as in our patient have, however, not been reported previously. The management options of his hearing loss are discussed.
Abstract: The objective of this study was to review published reports on the epidemiology of primary brain tumours in adults and present the body of knowledge related to these tumours in Great Britain and Ireland. A literature search of all published epidemiological data on brain tumours was conducted in Pre-Medline, Medline, Embase and the Cochrane databases from 1966 to the present. A hand search of all the references alluded to was conducted and older studies identified. The articles were reviewed and tabulated. The papers were subjected to descriptive analysis. Information available to the public and held with the Cancer Registries was reviewed, and cross-referenced with published evidence. To our knowledge, only seven papers have discussed the epidemiology of primary brain tumours in adults. The different methodology of the population-based studies of brain tumours and the different time periods they investigated makes them incomparable. Two papers with comprehensive and detailed strategies for case ascertainment have both recorded tumour incidences of 21 per 100,000 person years. The results of the better studies are at variance with reports from the Cancer Registries. On the basis of the current studies, Cancer Registries appear to under-estimate the incidence of such tumours in adults. It is apparent that a significant number of tumours especially benign varieties are not recorded by some Cancer Registries. The previous estimates, patterns of incidence, prevalence, and survival of brain tumours in Great Britain and Ireland, may thus be incorrect. Patterns of primary brain tumours in adults have not been widely reported in GB and Ireland and the aetiology remains largely unknown. The need for current estimation of geographical and secular variations was identified. This demands closer co-operation between medical and allied staff, and the Cancer Registries. Prospective regional studies of incidence patterns and up to date epidemiological appraisal is deemed necessary. Meanwhile, Cancer Registries should seriously consider the inclusion of all primary brain tumours in their database.
Abstract: The case of a fracture of the clivus in a 10-year-old boy following a road traffic accident is reported. He also suffered a contusion of the cerebellar vermis and the management dilemma in this case is highlighted. Fracture of the clivus in a child is extremely rare; this is the second reported case and the first reported with survival.
Abstract: This article reviews trends in the management of subarachnoid haemorrhage (SAH) at the Regional Neurosurgery Unit in Newcastle over 9 years. This is a comprehensive analysis of prospectively collected data on patients with SAH. We review the changes in clinical therapy and outcome with regards to conservative (non-surgical), surgical and endovascular therapy. Since 1990, the demographic and management/outcome details of patients with SAH have been recorded systematically. This study involves patients admitted over the 9 years, from January 1990 to December 1998. The data were computerized using Microsoft Access (Microsoft Inc. USA), and analysed using SPSS statistical package. A total of 1609 had aneurysmal SAH confirmed with CT, lumbar puncture and/or angiography. Sixty-seven per cent (1,073 patients) were female with a female to male ratio of 2:1. This ratio was maintained from 1990 to date. The mean age has slowly increased from 49 years in 1990 to 55 years of age in 1998, (range 18-91). Overall, 53.9% (from 66.3% in 1990 to 35.3% in 1998) were surgically treated, 8.1% had embolization (range 0.6-18.4%) and 38% (range 28.2-46.4%) were managed without surgical intervention for the aneurysm. The proportion of patients undergoing surgery has decreased since 1994 with improvements in endovascular therapy, participation in the ISAT trial and increased admission of poor grade patients (WFNS grades 4 and 5, from 17% in 1990 to 31% in 1998). The mortality rate has doubled over the years under review (18-32%). The percentage of severely disabled patients has remained constant at about 7% with none in a vegetative state. Only 54% had a favourable outcome in 1998 compared with 78% in 1990. Total morbidity and mortality has increased particularly during the last 3 years. This has been associated with double the number of admissions in grade 5. Favourable outcome occurred in 90% of good grade patients (WFNS 1 and 2) with 6.2% mortality in surgical candidates and 5.5% in patients treated endovascularly. The mortality for poor grade (WFNS 4 and 5) patients was 64%.
Abstract: Microvascular decompression (MVD) is now recognized as an effective operation for the cure of trigeminal neuralgia (TN), and is far superior to the other surgical procedures utilized in the treatment of TN. TN is common in the elderly, but there is debate concerning MVD in 'elderly' patients. Some clinicians have a policy of not offering patients over a certain age the choice of MVD, yet the recurrence rate is inversely related to the age of the patient. Previous failed procedures and a long period of pain before MVD, also affect the outcome negatively. This study is a retrospective review of the outcome in elderly patients following MVD. Forty-two patients over the age of 65 years are reviewed after undergoing MVD for TN. The results indicate that there was no serious morbidity or mortality that could be ascribed to old age and the length of stay in the hospital was not influenced by the age of the patient. The results are compared with the outcome in a younger age group and the literature on MVD for TN reviewed.
Abstract: Intramedullary cervical spinal cord schwannomas are rare tumours and complete excision is often an elusive goal. The use of the KTP laser to accomplish complete excision has not been reported previously. Postoperatively, our patient had no additional deficit and after 1 year has made a good recovery. This case further highlights the difficulty in interpretation of intraoperative biopsy specimens.
