Department of Surgery

Background Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach. Methods The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low-and middle-income countries. Results The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval. Conclusions In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.

Delay in diagnosis and management of intra-cranial tumors can be costly if not actually fatal. We present a 16-year-old Nigerian girl with bilateral deafness and blindness from a cerebellar intra-axial medulloblastoma. She has regained some hearing function in both ears 5 months after tumor resection. She remains blind.

It has been long thought that hyper-activation of N-methyl-D-aspartate (NMDA) receptors underlies neurological decline after traumatic brain injury. However, all clinical trials with NMDA receptor antagonists failed. Since NMDA receptors are down-regulated from 4h to 2 weeks after brain injury, activation at 24h, rather than inhibition, of these receptors, was previously shown to be beneficial in mice. Here, we tested the therapeutic window, dose regimen and mechanism of action of the NMDA receptor partial agonist D-cycloserine (DCS) in traumatic brain injury. Male mice were subjected to trauma using a weight-drop model, and administered 10 mg/kg (i.p) DCS or vehicle once (8, 16, 24, or 72h) twice (24 and 48h) or three times (24, 48 and 72h). Functional recovery was assessed for up to 60 days, using a Neurological Severity Score that measures neurobehavioral parameters. In all groups in which treatment was begun at 24 or 72h neurobehavioral function was significantly better than in the vehicle-treated groups. Additional doses, on days 2 and 3 did not further improve recovery. Mice treated at 8h or 16h post injury did not differ from the vehicle-treated controls. Coadministration of the NMDA receptor antagonist MK-801 completely blocked the protective effect of DCS given at 24h. Infarct volume measured by 2,3,5-triphenyltetrazolium chloride staining at 48h or by cresyl violet at 28d was not affected by DCS treatment. Since DCS is used clinically for other indications, the present study offers a novel approach for treating human traumatic brain injury with a therapeutic window of at least 24h.

We present an unusual case of ruptured infantile cerebral aneurysm. An eight-month-old infant was delivered to the hospital in poor condition, after convulsions, with no history of trauma. His emergent CT study revealed acute subdural hematoma. The clinical and radiological picture evoked suspicion that the hematoma was of aneurysmal origin. The infant was operated with special preparations and precautions appropriate for aneurysmal surgery, and has shown a good recovery. It is important to consider the possibility of vascular accident in infants with subdural hematoma of nontraumatic origin. A good outcome may be achieved when appropriate preparations are made prior to surgery.

Background: Unlike small and medium size fronto-ethmoidal osteomas which are amenable to surgical excision through limited craniofacial openings, giant lesions require extensive and complex craniofacial dissection, and post lesionectomy reconstruction using an array of modern-day surgical adjuncts. This is a report of our surgical technique for the successful and esthetically fair operative resection of a giant fronto-ethmoidal osteoma in a difficult practice setting. Case Description: A 32-year-old Nigerian lady harbored a giant complex fronto-ethmoidal ivory osteoma. Deploying our understanding of modern-day advanced microsurgical anatomy and technique of skull base surgery, but under severe resource limitations, a radical total surgical resection was performed and an esthetically fair post lesionectomy reconstruction was achieved. The patient remains tumor-free in 20 months, so far, of postoperative follow-up. Conclusions: Even under severe resource limitations, inventive adaptations of modernday skull base surgery techniques can facilitate hitherto unusual functional and esthetically successful resection of giant osteomas of the fronto-ethmoidal sinus complex.

AIM: A prospective observational study of the in-hospital outcome of the management of BSF without antibiotic prophylaxis in a Nigerian neurosurgical unit. MATeRIAL and MeTHodS: All cases of HI with clinical diagnosis of BSF over an 8-month period were reviewed. Their demographic, clinical, and in-hospital outcome parameters were analysed. We also compared some clinical and outcome characteristics between this study group and a contemporary cohort of patients in our unit with Head Injury but without CSF leak ReSULTS: There were 47 cases. The CSF leak was from the nostrils in 18 (38.3%), the ears in 16 (34.04%), and both ears and nostrils in 12 (25.53%). The cause of injury was road accidents in 91%, and the severity of the Head Injury was mild, moderate and severe respectively in 42.55, 25.53 and 31.91%. Meningitis occurred in 2 patients (4.25%); in-hospital outcome was good in 68.1% and poor in 31.9% and this was significantly (p <0.05) affected primarily by the severity of the brain injuries. These in-hospital outcome rates and their determinants were similar to those in our unit's contemporary cohort of Head Injury without BSF. CoNCLUSIoN: Management of traumatic BSF without antibiotic prophylaxis in a developing country setting has not been accompanied with an increased rate of unfavourable outcome.

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% mal...

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. 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. 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 spi...

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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.

Purpose This review describes the evidence base that has helped define the role of decompressive craniectomy (DC) in the management of patients with traumatic brain injury (TBI). Recent Findings The publication of two randomized trials (DECRA and RESCUEicp) has strengthened the evidence base. The DECRA trial showed that neuroprotective bifrontal DC for moderate intracranial hypertension is not helpful, whereas the RESCUEicp trial found that last-tier DC for severe and refractory intracranial hypertension can significantly reduce the mortality rate but is associated with a higher rate of disability. These findings have reopened the debate about (1) the indications for DC in various TBI subtypes, (2) alternative techniques (e.g., hinge craniotomy), (3) optimal time and material for cranial reconstruction, and (4) the role of shared decision-making in TBI care. Additionally, the role of primary DC when evacuating an acute subdural hematoma is currently undergoing evaluation in the context of the RESCUE-ASDH randomized trial. Summary This review provides an overview of the current evidence base, discusses its limitations, and presents a global perspective on the role of DC, as there is growing recognition that attention should also focus on low-and middle-income countries due to their much greater TBI burden.

BACKGROUND: Brain metastasis (BM) from breast cancer is increasingly encountered clinically because of the continuing success in the oncological control of the primary disease. Data-driven reports on the surgical treatment of BM from breast cancer are sparse in sub-Saharan Africa.-METHODS: This is a prospective cohort study of the outcome of surgical excision of BM from breast cancer in an academic surgical practice in Ibadan, Nigeria.-RESULTS: A total of 12 consecutive cerebral metastasectomies, all in females with primary breast cancer, were recorded over the study period. The median age (range) at breast cancer diagnosis was 41 (27e72) years, and the time interval from primary disease to BM was 19 (12e29) months. The BM was the first site of systemic disease progression in all, and was heralded by headache, seizures, and hemiparesis in more than two-thirds of the patients. The brain lesions were multiple in a quarter: >4 cm large in 42% and were located supratentorial in >80%. They all achieved good recovery and in-hospital outcome after surgical lesionectomy-infra-and supratentorial craniotomies-but only two-thirds could access postsurgical adjuvant whole brain radiation therapy. Median survival after cerebral metastasectomy was 18 (11e55) months, and more than a quarter were alive for ‡3years. These survival statistics were significantly better than those of a contemporary cohort of our patients with breast cancer who also had BMs that were not surgically treated for various clinical and logistic limitations.-CONCLUSIONS: Surgical resection is feasible for BM from breast cancer even in low-resource clinical practice. It has a salutary effect on the patients' quality of life.

Breaking of medical bad news is anecdotally deemed culturally unacceptable, even intolerable, to native Africans. We explored this hypothesis among a cohort of relatives of patients who had difficult neurosurgical diagnoses in an indigenous practice. Materials and Methods: A semi-structured, interviewer-administered questionnaire was used in a cross-sectional survey among a consecutive cohort of surrogates/relatives of concerned patients. Their opinion and preferences regarding the full disclosure of the grave neurosurgical diagnoses, and prognoses, of their wards were analyzed. Results: A total of 114 patients' relatives, 83 (72.8%) females, were sampled. They were mainly young adults, mean age 40.2 (SD 14.2) years; 57% had only basic literacy education; but the majority, 97%, declared themselves to have serious religious commitments. Ninety nine percent of the study participants deemed it desirable that either they or the patients concerned be told the bad news; 80.7% felt that this is best done with both patients and relations in attendance; 3.5% felt only the patients need be told. These preferences are similar to those expressed by the patients themselves in an earlier study. But a nearly significant greater proportion of patients' relatives (15 vs 5%, p = 0.06) would rather be the only ones to be told the patients' bad news. Conclusion: This data-driven study showed that contrary to anecdotal belief about them, a cohort of native Nigerian-African surrogates of neurosurgical patients was well disposed to receiving, and appeared able to handle well, the full disclosure of difficult medical diagnostic/prognostic information.

The Glasgow Coma Scale, GCS, is a universal clinical means of quantifying the level of impaired consciousness. Although physicians usually receive undergraduate and postgraduate training in the use of this scale in our university hospital we are aware of studies suggesting that the working knowledge of the GCS among practising physicians might not be adequate. Methods: We carried out a questionnaire-based survey across all specialties and levels of training of physicians in active patient care in a Nigerian university hospital. Results: Of the 100 physicians sampled, 98 correctly spelled out what the three-letter abbreviation, GCS, stands for. Ninety-three percent also conceded it to be an important clinical rating scale. However, only 55-89% of the participants correctly identified the three respective clinical variables, (eye opening, verbal response, and motor response), of the GCS. More particularly, the participants' ability to itemize and correctly score all the respective components of each of the three clinical variables ranged from 0 to 35% across specialties and levels of training. Performance was best for the four-item eye opening variable and, worst for the six-item motor response variable. Conclusion: In our university hospital, practising physicians' working knowledge of the GCS is inadequate and is dependent on the degree of the complexity of each of the three clinical variables of the scale.