Nigerian journal of medicine : journal of the National Association of Resident Doctors of Nigeria
To describe the importance of craniofacial approach in extensive tumours of the nose and paranasa... more To describe the importance of craniofacial approach in extensive tumours of the nose and paranasal sinuses with intracranial extension. This is a retrospective study and descriptive analysis of craniofacial approaches to extensive tumors of the nose and paranasal sinuses that were carried at Usmanu Danfodiyo university teaching Hospital Sokoto Nigeria over a nine year period (July 1999 to June 2008). Out of 111 patients seen with tumours of the nose and paranasal sinuses during the period, 29(26.1%) were radiologically reported through computerised tomographic scan to have intracranial extension. Twenty-four (82.8%) were males while 5 (17.2%) were females. Twenty five (86.2%) patients underwent transfacial approach ( modified lateral rhinotomy). Intraoperative findings in these cases only warranted the repair of dural tear in 6 cases through the transfacial approach who had anterior skull base invovlement while 4 had combined transcranial and transfacial approaches (anterior craniof...
A 13-year old boy presented with a 2-week history of right frontotemporal headache, fever and pro... more A 13-year old boy presented with a 2-week history of right frontotemporal headache, fever and progressive painful swelling in that region. There was no preceding trauma. Clinical and radiological evaluation confirmed osteomyelitis of the right frontal bone. Staphylococcus aureus was found to be the causative organism. The affected bone was debrided and appropriate antibiotics administered. A subdural abscess developed requiring drainage. Hospital stay was 8 weeks. Haematogenous (pyogenic) osteomyelitis of the skull is rare in childhood and diagnosis may be missed or delayed. A high index of suspicion is necessary to make an early diagnosis and to avoid morbidity and mortality.
A six-year-old boy presented with a week history of increasing headache, visual loss and convulsi... more A six-year-old boy presented with a week history of increasing headache, visual loss and convulsions. He had repair of myelomeningocele early in life and later had insertion of a ventriculoperitoneal shunt for hydrocephalus after the repair. He was treated for meningitis at the referring hospital without improvement. Computed tomography scan of the brain showed ventricular enlargement. The shunt was found to be broken and blocked and was revised. This was followed by rapid improvement but vision was never regained. Shunt malfunction in patients with spinal dysraphism can lead to visual loss but the features may mimic those of meningitis, and delayed referral and treatment. Early shunt revision should prevent this complication.
Only a few cases of malignant peripheral nerve sheath tumour (MPNST) associated with Von Reckling... more Only a few cases of malignant peripheral nerve sheath tumour (MPNST) associated with Von Recklinghausen's disease or type I neurofibromatosis (NF-1) have so far been reported worldwide, yet the primary disease (NF-I ) does not seem rare even in Africa. We present a case of a 40 year old woman with MPNST of the left thigh associated with NF-1. The diagnosis was based on clinical, radiological and histopathological evidence. She presented with a 25 year history of painless, multiple, generalized skin nodules and hyperpigmented spots. She also noticed a gradually progressive, painless, redundant mass on the left side of the forehead 16 years prior to presentation. Four months before presentation, she noticed another mass at the back of the left thigh, which increased rapidly in size. Examination revealed a middle aged woman with generalized subcutaneous nodules of various sizes (3mm - 2.5cm), multiple café-au-lait spots (2cm-4.5cm), a plexiform neurofibroma on the left side of the forehead measuring 6cm x 5cm x 5cm. There was a firm, non-pulsatile and non-tender mass (11.5cm x 9cm x 5cm) on the posterior aspect of the left upper thigh. The mass was more mobile longitudinally than transversely and was attached to the overlying skin at the summit, the regional Iymph nodes were not enlarged. Most investigations were essentially normal except a plain radiograph, which revealed a soft tissue mass on the left thigh without bony involvement. At surgery, a well localized soft tissue tumour, abutting on the sciatic nerve was widely resected without neural damage to the nerve. Histologic sections of a tru cut as well as the surgical specimens showed a tumour consisting of closely packed serpentine cells arranged in palisades; marked nuclear and cellular pleomorphism and hyperchromatism, many bizarre tumour giant cells, mitotic figures and foci of necroses. The patient received six courses of cytotoxic therapy and is well eleven months after surgery. It is presented to highlight the clinical and pathological features of NF-1 complicated with malignant transformation.
ABSTRACTMethacrylate is a valuable tool to the neurosurgeon, even though it is currently being re... more ABSTRACTMethacrylate is a valuable tool to the neurosurgeon, even though it is currently being replaced by custom bone. During cranioplasty in the absence of custom bone, which is preformed based on the patients imaging, one has to make a cast to cover the cranial defect with or without the use of a mould. A good artificial skull outline is necessary for prevention of implant extrusion and acceptable cosmetic outcome. Using the patients head as a mould is a simple, cheap, and useful technique. An incision is made, and either a craniectomy or an attempt at skull elevation or separation of the scalp from dura is done based on the indication for the cranioplasty. The methacrylate monomer is mixed with its solvent. It is placed in between a sliced glove and then thinned out. Several layers of drapes are placed on the patients head, the acrylate which is in between the gloves is then placed on the drapes. As soon as it starts setting and the required shape obtained, it is removed and pla...
s: Background:Penetrating head injury (PHI)remains one of the most complex and fatal forms of tra... more s: Background:Penetrating head injury (PHI)remains one of the most complex and fatal forms of traumatic brain injury. The management of penetrating head injury presents serious challenges to attending neurosurgeons especially in a low resource setting; where facilities for prompt neurocritical care, neuroimaging and neurosurgical reconstruction are grossly inadequate. The study was designed to describe the pattern and outcome of penetrating head injury in our institution. Methods:This is a retrospective analysis of patients with penetrating head injury (breach of dura by foreign object or piece of bone)managedfrom July 2015 to June 2019. Results Out of the total of ninety-one patients managed, males constituted the majority (90%). The mean age of presentation was 34 years ± 19 SD. Road traffic crash was the commonest mechanism of injury (61/91), followed bygunshot injury (15/91). Assaults by armed bandits using machetes and hammers were observed in 11/91 of the cause of penetrating ...
A 60-year-old known hypertensive man developed a massive left parietal cerebral cyst producing a ... more A 60-year-old known hypertensive man developed a massive left parietal cerebral cyst producing a mass effect, following a stroke. Aspiration of the cyst through a burr hole was effective treatment. Though cerebral cysts may occur after hypertensive stroke, large cysts causing mass effect are rare. – 4 A 60-year-old man with systemic hypertension presented with deteriorating level of consciousness, increasing right-sided weakness, aphasia and inability to walk for 2 months. He also had faecal and urinary incontinence. Twelve months prior to presentation he suffered a stroke and was unconscious for 24 h, but recovered with only mild weakness of the right side of the body. There was no history of close contact with animals and no history of easy bleeding or trauma. Physical examination showed no pallor and a temperature of 36.38C. Pulse rate was 70/min and blood pressure 160/100 mmHg. Glasgow coma score was 13 (eye opening 4, verbal response 3, motor response 6), and there was right hemiparesis with power of grade 3/5 in all muscle groups in the right upper and lower limbs. The deep tendon reflexes were brisk on the right side. The pupils were equal and reacted normally to light. There was nominal aphasia. Other examinations were normal. Complete blood count, blood sugar serum electrolytes and urea were normal. CT of the brain showed a left parietal intracerebral cyst, which did not enhance with contrast (Fig. 1). A left parietal burr hole was performed under local anaesthesia and 150 ml of slightly xanthochromic fluid, under pressure was aspirated from the cyst. Microscopy of the fluid showed 3 white cells/mm and culture was sterile. Postoperatively, the hemiparesis and aphasia improved and the patient was fully conscious and fully ambulant by the seventh day. A planned cystoperitoneal shunt was deferred as the patient’s neurological deficits had completely resolved. Repeat CT of the brain showed a small residual cyst, but FIG. 1. The large left parietal intracerebral cyst.
Traumatic pneumocephalus is an uncommon complication of head injury1 and presentation with blindn... more Traumatic pneumocephalus is an uncommon complication of head injury1 and presentation with blindness is rare. A 27-year-old man presented with sudden loss of vision in the left eye 2 months after involvement in a road traffic accident. He lost consciousness for 10 days, but recovered without neurological deficits. He bled from the left nostril and sustained a left supraorbital frontal laceration. There was no convulsion and no other associated injuries. The left nose bleeding changed to cerebrospinal fluid (CSF) rhinorrhoea, which stopped 3 days later. The pulse rate was 70/min and blood pressure 130/ 90 mmHg. Glasgow coma score was 15. The left pupil was dilated and reacted sluggishly to light and visual acuity was reduced to light perception in that eye. The right eye was normal. There was palsy of the left sixth cranial nerve. Power, tone and reflexes were normal in all limbs and there were no sensory deficits. CT of the brain showed fracture of the frontal sinus and a large frontal pneumocephalus (Fig. 1). The patient had a bifrontal craniotomy, release of tension subdural pneumocephalus, and intradural repair of the floor of the anterior cranial fossa and the frontal sinus. Postoperatively he regained full vision in the left eye and the sixth nerve palsy gradually recovered. He was well at 1 year follow-up. Tension pneumocephalus may follow sinus fracture, neurosurgical operations,2–5 radionecrosis of the skull4 and infections. Delayed onset of tension pneumocephalus may follow head injury,5 with most patients presenting with altered levels of consciousness. Presentation with blindness is rare. Tension pneumocephalus should be excluded in patients presenting with acute visual loss several weeks after head trauma. Prompt treatment should achieve recovery of vision.
Grossly displaced cervical spine fracture-dislocation without permanent neurological deficit is r... more Grossly displaced cervical spine fracture-dislocation without permanent neurological deficit is rarely reported. A 32-year-old man presented with neck and anterior chest wall pain, and the inability to use both upper limbs for 4 weeks following a road traffic accident. The neck was short. There was tenderness over the lower cervical spine and all neck movements were limited to 208. Power in the shoulder muscles was 5/5, 4/5 in elbow flexors and extensors, and 3/5 in wrist flexors and extensors. Handgrip was poor. Power in lower limbs was normal. Tendon reflexes were exaggerated in all limbs and planter response up going. There was no sensory loss. Other examinations were normal. Cervical magnetic resonance imaging (MRI) at presentation is shown in Fig. 1. Skull traction under radiological control failed. Operative reduction was not attempted. A hard cervical collar was applied and physiotherapy commenced. Neck pains subsided and he was discharged home after 6 weeks. A cervical collar was maintained for 6 months. Neck movements after 2 years improved to 30 – 408, but hypothenar wasting persisted (Fig. 1). This was a hyperextension injury, causing fracture of the posterior elements and disruption of the longitudinal ligaments, allowing the spinal cord to be displaced backward, minimizing cord damage. Ligamentous rupture also minimizes vascular damage. Delay in presentation may have resulted in bony fusion, making reduction by skull traction difficult. Operative reduction or manipulation under fluoroscopy was not attempted as it may worsen the neurological state. References
Although pneumocephalus is not uncommon, most reports from Africa are of single or few cases. A r... more Although pneumocephalus is not uncommon, most reports from Africa are of single or few cases. A retrospective review of 20 patients with pneumocephalus managed in 4 years was done. There were 19 males and one female aged 22-45 years (median 35 years). The cause of pneumocephalus was head trauma in 18 patients and spontaneous in 2. The commonest symptoms were headache 19 and CSF rhinorrhoea 11. Skull radiographs and brain CT scan were used to confirm the diagnosis in all the patients. Eight patients had surgery while 12 were managed non-operatively. Of the eight that had surgery; six recovered fully, one had residual neurologic deficit and one died from meningitis. Nine patients that were managed non-operatively recovered fully; one died also from meningitis and one refused treatment and left the hospital against advice. Air in the cranial cavity behaves like any space-occupying lesion; a high index of suspicion is needed to make a diagnosis, prompt treatment and control of infection will prevent unwanted morbidity and mortality.
Nigerian journal of medicine : journal of the National Association of Resident Doctors of Nigeria
To describe the importance of craniofacial approach in extensive tumours of the nose and paranasa... more To describe the importance of craniofacial approach in extensive tumours of the nose and paranasal sinuses with intracranial extension. This is a retrospective study and descriptive analysis of craniofacial approaches to extensive tumors of the nose and paranasal sinuses that were carried at Usmanu Danfodiyo university teaching Hospital Sokoto Nigeria over a nine year period (July 1999 to June 2008). Out of 111 patients seen with tumours of the nose and paranasal sinuses during the period, 29(26.1%) were radiologically reported through computerised tomographic scan to have intracranial extension. Twenty-four (82.8%) were males while 5 (17.2%) were females. Twenty five (86.2%) patients underwent transfacial approach ( modified lateral rhinotomy). Intraoperative findings in these cases only warranted the repair of dural tear in 6 cases through the transfacial approach who had anterior skull base invovlement while 4 had combined transcranial and transfacial approaches (anterior craniof...
A 13-year old boy presented with a 2-week history of right frontotemporal headache, fever and pro... more A 13-year old boy presented with a 2-week history of right frontotemporal headache, fever and progressive painful swelling in that region. There was no preceding trauma. Clinical and radiological evaluation confirmed osteomyelitis of the right frontal bone. Staphylococcus aureus was found to be the causative organism. The affected bone was debrided and appropriate antibiotics administered. A subdural abscess developed requiring drainage. Hospital stay was 8 weeks. Haematogenous (pyogenic) osteomyelitis of the skull is rare in childhood and diagnosis may be missed or delayed. A high index of suspicion is necessary to make an early diagnosis and to avoid morbidity and mortality.
A six-year-old boy presented with a week history of increasing headache, visual loss and convulsi... more A six-year-old boy presented with a week history of increasing headache, visual loss and convulsions. He had repair of myelomeningocele early in life and later had insertion of a ventriculoperitoneal shunt for hydrocephalus after the repair. He was treated for meningitis at the referring hospital without improvement. Computed tomography scan of the brain showed ventricular enlargement. The shunt was found to be broken and blocked and was revised. This was followed by rapid improvement but vision was never regained. Shunt malfunction in patients with spinal dysraphism can lead to visual loss but the features may mimic those of meningitis, and delayed referral and treatment. Early shunt revision should prevent this complication.
Only a few cases of malignant peripheral nerve sheath tumour (MPNST) associated with Von Reckling... more Only a few cases of malignant peripheral nerve sheath tumour (MPNST) associated with Von Recklinghausen's disease or type I neurofibromatosis (NF-1) have so far been reported worldwide, yet the primary disease (NF-I ) does not seem rare even in Africa. We present a case of a 40 year old woman with MPNST of the left thigh associated with NF-1. The diagnosis was based on clinical, radiological and histopathological evidence. She presented with a 25 year history of painless, multiple, generalized skin nodules and hyperpigmented spots. She also noticed a gradually progressive, painless, redundant mass on the left side of the forehead 16 years prior to presentation. Four months before presentation, she noticed another mass at the back of the left thigh, which increased rapidly in size. Examination revealed a middle aged woman with generalized subcutaneous nodules of various sizes (3mm - 2.5cm), multiple café-au-lait spots (2cm-4.5cm), a plexiform neurofibroma on the left side of the forehead measuring 6cm x 5cm x 5cm. There was a firm, non-pulsatile and non-tender mass (11.5cm x 9cm x 5cm) on the posterior aspect of the left upper thigh. The mass was more mobile longitudinally than transversely and was attached to the overlying skin at the summit, the regional Iymph nodes were not enlarged. Most investigations were essentially normal except a plain radiograph, which revealed a soft tissue mass on the left thigh without bony involvement. At surgery, a well localized soft tissue tumour, abutting on the sciatic nerve was widely resected without neural damage to the nerve. Histologic sections of a tru cut as well as the surgical specimens showed a tumour consisting of closely packed serpentine cells arranged in palisades; marked nuclear and cellular pleomorphism and hyperchromatism, many bizarre tumour giant cells, mitotic figures and foci of necroses. The patient received six courses of cytotoxic therapy and is well eleven months after surgery. It is presented to highlight the clinical and pathological features of NF-1 complicated with malignant transformation.
ABSTRACTMethacrylate is a valuable tool to the neurosurgeon, even though it is currently being re... more ABSTRACTMethacrylate is a valuable tool to the neurosurgeon, even though it is currently being replaced by custom bone. During cranioplasty in the absence of custom bone, which is preformed based on the patients imaging, one has to make a cast to cover the cranial defect with or without the use of a mould. A good artificial skull outline is necessary for prevention of implant extrusion and acceptable cosmetic outcome. Using the patients head as a mould is a simple, cheap, and useful technique. An incision is made, and either a craniectomy or an attempt at skull elevation or separation of the scalp from dura is done based on the indication for the cranioplasty. The methacrylate monomer is mixed with its solvent. It is placed in between a sliced glove and then thinned out. Several layers of drapes are placed on the patients head, the acrylate which is in between the gloves is then placed on the drapes. As soon as it starts setting and the required shape obtained, it is removed and pla...
s: Background:Penetrating head injury (PHI)remains one of the most complex and fatal forms of tra... more s: Background:Penetrating head injury (PHI)remains one of the most complex and fatal forms of traumatic brain injury. The management of penetrating head injury presents serious challenges to attending neurosurgeons especially in a low resource setting; where facilities for prompt neurocritical care, neuroimaging and neurosurgical reconstruction are grossly inadequate. The study was designed to describe the pattern and outcome of penetrating head injury in our institution. Methods:This is a retrospective analysis of patients with penetrating head injury (breach of dura by foreign object or piece of bone)managedfrom July 2015 to June 2019. Results Out of the total of ninety-one patients managed, males constituted the majority (90%). The mean age of presentation was 34 years ± 19 SD. Road traffic crash was the commonest mechanism of injury (61/91), followed bygunshot injury (15/91). Assaults by armed bandits using machetes and hammers were observed in 11/91 of the cause of penetrating ...
A 60-year-old known hypertensive man developed a massive left parietal cerebral cyst producing a ... more A 60-year-old known hypertensive man developed a massive left parietal cerebral cyst producing a mass effect, following a stroke. Aspiration of the cyst through a burr hole was effective treatment. Though cerebral cysts may occur after hypertensive stroke, large cysts causing mass effect are rare. – 4 A 60-year-old man with systemic hypertension presented with deteriorating level of consciousness, increasing right-sided weakness, aphasia and inability to walk for 2 months. He also had faecal and urinary incontinence. Twelve months prior to presentation he suffered a stroke and was unconscious for 24 h, but recovered with only mild weakness of the right side of the body. There was no history of close contact with animals and no history of easy bleeding or trauma. Physical examination showed no pallor and a temperature of 36.38C. Pulse rate was 70/min and blood pressure 160/100 mmHg. Glasgow coma score was 13 (eye opening 4, verbal response 3, motor response 6), and there was right hemiparesis with power of grade 3/5 in all muscle groups in the right upper and lower limbs. The deep tendon reflexes were brisk on the right side. The pupils were equal and reacted normally to light. There was nominal aphasia. Other examinations were normal. Complete blood count, blood sugar serum electrolytes and urea were normal. CT of the brain showed a left parietal intracerebral cyst, which did not enhance with contrast (Fig. 1). A left parietal burr hole was performed under local anaesthesia and 150 ml of slightly xanthochromic fluid, under pressure was aspirated from the cyst. Microscopy of the fluid showed 3 white cells/mm and culture was sterile. Postoperatively, the hemiparesis and aphasia improved and the patient was fully conscious and fully ambulant by the seventh day. A planned cystoperitoneal shunt was deferred as the patient’s neurological deficits had completely resolved. Repeat CT of the brain showed a small residual cyst, but FIG. 1. The large left parietal intracerebral cyst.
Traumatic pneumocephalus is an uncommon complication of head injury1 and presentation with blindn... more Traumatic pneumocephalus is an uncommon complication of head injury1 and presentation with blindness is rare. A 27-year-old man presented with sudden loss of vision in the left eye 2 months after involvement in a road traffic accident. He lost consciousness for 10 days, but recovered without neurological deficits. He bled from the left nostril and sustained a left supraorbital frontal laceration. There was no convulsion and no other associated injuries. The left nose bleeding changed to cerebrospinal fluid (CSF) rhinorrhoea, which stopped 3 days later. The pulse rate was 70/min and blood pressure 130/ 90 mmHg. Glasgow coma score was 15. The left pupil was dilated and reacted sluggishly to light and visual acuity was reduced to light perception in that eye. The right eye was normal. There was palsy of the left sixth cranial nerve. Power, tone and reflexes were normal in all limbs and there were no sensory deficits. CT of the brain showed fracture of the frontal sinus and a large frontal pneumocephalus (Fig. 1). The patient had a bifrontal craniotomy, release of tension subdural pneumocephalus, and intradural repair of the floor of the anterior cranial fossa and the frontal sinus. Postoperatively he regained full vision in the left eye and the sixth nerve palsy gradually recovered. He was well at 1 year follow-up. Tension pneumocephalus may follow sinus fracture, neurosurgical operations,2–5 radionecrosis of the skull4 and infections. Delayed onset of tension pneumocephalus may follow head injury,5 with most patients presenting with altered levels of consciousness. Presentation with blindness is rare. Tension pneumocephalus should be excluded in patients presenting with acute visual loss several weeks after head trauma. Prompt treatment should achieve recovery of vision.
Grossly displaced cervical spine fracture-dislocation without permanent neurological deficit is r... more Grossly displaced cervical spine fracture-dislocation without permanent neurological deficit is rarely reported. A 32-year-old man presented with neck and anterior chest wall pain, and the inability to use both upper limbs for 4 weeks following a road traffic accident. The neck was short. There was tenderness over the lower cervical spine and all neck movements were limited to 208. Power in the shoulder muscles was 5/5, 4/5 in elbow flexors and extensors, and 3/5 in wrist flexors and extensors. Handgrip was poor. Power in lower limbs was normal. Tendon reflexes were exaggerated in all limbs and planter response up going. There was no sensory loss. Other examinations were normal. Cervical magnetic resonance imaging (MRI) at presentation is shown in Fig. 1. Skull traction under radiological control failed. Operative reduction was not attempted. A hard cervical collar was applied and physiotherapy commenced. Neck pains subsided and he was discharged home after 6 weeks. A cervical collar was maintained for 6 months. Neck movements after 2 years improved to 30 – 408, but hypothenar wasting persisted (Fig. 1). This was a hyperextension injury, causing fracture of the posterior elements and disruption of the longitudinal ligaments, allowing the spinal cord to be displaced backward, minimizing cord damage. Ligamentous rupture also minimizes vascular damage. Delay in presentation may have resulted in bony fusion, making reduction by skull traction difficult. Operative reduction or manipulation under fluoroscopy was not attempted as it may worsen the neurological state. References
Although pneumocephalus is not uncommon, most reports from Africa are of single or few cases. A r... more Although pneumocephalus is not uncommon, most reports from Africa are of single or few cases. A retrospective review of 20 patients with pneumocephalus managed in 4 years was done. There were 19 males and one female aged 22-45 years (median 35 years). The cause of pneumocephalus was head trauma in 18 patients and spontaneous in 2. The commonest symptoms were headache 19 and CSF rhinorrhoea 11. Skull radiographs and brain CT scan were used to confirm the diagnosis in all the patients. Eight patients had surgery while 12 were managed non-operatively. Of the eight that had surgery; six recovered fully, one had residual neurologic deficit and one died from meningitis. Nine patients that were managed non-operatively recovered fully; one died also from meningitis and one refused treatment and left the hospital against advice. Air in the cranial cavity behaves like any space-occupying lesion; a high index of suspicion is needed to make a diagnosis, prompt treatment and control of infection will prevent unwanted morbidity and mortality.
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Papers by Bello B Shehu