Epilepsy in primary intracranial tumors in a neurosurgical hospital in Enugu, South-East Nigeria

BACKGROUND

Seizures may be manifestation of intracranial tumor (IT) and demand thorough neurological evaluation. This paper examines epidemiology, lesion characteristics and outcome of seizures associated with primary IT.

METHODS

Retrospective analysis of medical records, computed tomography and magnetic resonance imaging of patients diagnosed with IT who presented with seizure from 2003 to 2013 at Memfys Hospital for Neurosurgery Enugu. Postoperative seizure outcome was based on Engel classification and correlated with tumor histology, patient age, anatomical location, time of presentation and extent of tumor resection. Data were analyzed using descriptive and inferential statistics.

RESULTS

Sixty-two patients (34.6%) presenting with seizures were analyzed. Peak age at presentation was in 6 th decade. Age of seizure onset had bimodal peak at 4 th and 6 th decades. Apart from IT located in posterior fossa with mortality of 62.5%, postoperative mortality did not depend on anatomical location of tumor. Postoperative seizure outcome and mortality depend on tumor histology (P = 0.025) and preoperative seizure duration (P = 0.036). Seizure duration shorter than 1 month had poor postoperative seizure outcome and high mortality. Although more patients with meningioma experienced seizures compared to glioma (P = 0.025), there was no difference in proportion of patients with meningioma and glioma who presented with seizure (P = 1.00). Extent of resection predicts postoperative seizure outcome based on meningioma sub-group analysis. Overall, 59.7% of patients had good postoperative seizure outcome, 21.0% had poor outcome and 19.3% died.

CONCLUSION

Seizures of short duration, IT located in posterior fossa and gliomas are associated with poor postoperative seizure outcome and high patient mortality. Tumor histology does not seem to affect seizure predisposition. Most seizures associated with IT occur in fifth and sixth decades of life and affect frontal lobe most often.

Neuroimaging findings in pediatric patients with seizure from an institution in Enugu

BACKGROUND

Pediatric seizures in developing countries are often poorly investigated and consequently poorly managed. Sociocultural misconceptions, financial difficulties, and lack of facilities are often blamed. This study studies the structural intracranial abnormalities associated with pediatric seizures and the proportion of these structural lesions that may benefit from surgery.

METHODS

Prospective study of 311 pediatric patients referred with seizure disorders, for computed tomography and magnetic resonance imaging to the Memfys Hospital for Neurosurgery, Enugu, between 2003 and 2014. All patients had contrast studies. Angiography was done for selected cases. Demography, imaging findings, and potential benefits of surgery were analyzed using descriptive and inferential statistics.

RESULT

Analysis of 311 patients representing 21% of all pediatric head scans. Male to female ratio was 1.2:1.0. Definite structural lesion was identified in 53.4%. Lesions that may benefit from surgery were identified in 27.7% of all cases representing 51.8% of abnormal scan findings. Under-5 had the least scan rate of 25.1% compared with 42.4% in the adolescents. Although the older age groups had more abnormal findings, the proportion of abnormal to normal scan findings was the highest (1.7:1.0) in the under-5. Under-5 age group had more lesions that may benefit from surgery (P = 0.001). Intracranial tumor was diagnosed in 10.6%, vascular abnormalities (10.3%), hydrocephalus (5.8%), brain abscess (2.9%), and chronic subdural hematoma (2.6%) (P = 0.001).

CONCLUSION

Structural lesions are common and diverse in pediatric seizures. Significant proportion of these patients may benefit from surgery, and these benefits override financial and sociocultural considerations.

The Pattern of significant lesions found in computerized tomography scan of recurrent seizure patients at a center in Enugu, Nigeria

INTRODUCTION

Seizures are common reasons for neurologic consultations and investigations. In the absence of magnetic resonance imaging, computerized tomography scanning of the brain is a reliable and cheaper alternative. Little is known about the pattern of brain lesions in patients with recurrent seizures in Nigeria.

OBJECTIVES

To determine the pattern of significant intracerebral lesions in patients presenting with recurrent seizures in a tertiary hospital in Enugu.

METHODS

All the medical and computer tomography records of patients with a clinical diagnosis of recurrent seizures were reviewed. The study duration was 11 years (January 2003 to December 2013). Relevant data were obtained and statistical analysis was done using SPSS version 19 and GraphPad Prism 6.

RESULTS

The diagnostic yield of CT was 55.1%. Twenty (9.3%) individuals had two lesions each. The significant findings were tumors (20.4%), encephalomalacia (18.9%) and strokes (7.7% (ischemic stroke, 4.1%, intracerebral hemorrhage, 3.1%, subarachnoid hemorrhage/intraventricular hemorrhage, 0.5%). Hydrocephalus (HCP) was found in 18 (9.2%) cases, and 30% of them occurred together with other lesions. The diagnostic yield increased with age reaching 84.4% from the age of 60 years. Only patients with encephalomalacia were statistically older than those with normal imaging.

CONCLUSION

Computed tomography scan has a high diagnostic yield, especially in elderly patients with recurrent generalized seizures. Brain tumors, encephalomalacia, and HCP are most common causes of recurrent seizures in the adults.

Cranial bony decompressions in the management of head injuries: decompressive craniotomy or craniectomy?

OBJECTIVE

Decompressive surgery is one of the available options in dealing with traumatic brain injury (TBI) when clinical and radiological evidence confirm that medical treatment may be insufficient. This can be achieved either by complete removal of the bone or by allowing it to float, but the indications and utility of these are yet to be resolved. This study examines the indications and outcome for both procedures.

MATERIALS AND METHODS

Review of all cases of bony decompression done at the Memfys Hospital for Neurosurgery, Enugu, Nigeria from August 2002 to May 2010. Prospectively recorded data of CT, MRI, operating room, clinics and wards were utilized.

RESULTS

There were 38 patients out of whom 35 were males and 3 females. The mean age was 36 years (range 15-80). The causes of the predisposing TBI were road traffic accidents (RTA) (79%), gunshot (10.5%), and assault (7.9%). Decompressive surgery was unilateral in 36 and bi-frontal in 2. Decompressive craniectomy with bone stored in anterior abdominal wall pocket was done in 8 patients and decompressive craniotomy with bone left in situ in 30. Of the latter, bone was unsecured and allowed to float in 13 and the craniotomy was lightly anchored with sutures in 17 patients. Surgery was performed within 24 h in 68.4% of cases. Mortality was 21.1% overall but was up to 25% in the more severely injured patients who had craniectomy.

CONCLUSION

Bony decompression is useful in the management of head trauma. Careful selection of cases and appropriate radiological assessment are important and will guide decision for either craniotomy or craniectomy.

Severe traumatic brain injury managed with decompressive craniectomy

Patients with severe traumatic brain injury may develop intractable raised ICP resulting in high mortality and morbidity. This may be anticipated from the patient's clinical status and imaging findings even where intracranial monitoring is unavailable. Outcome may be improved by early and aggressive control of ICP and surgical decompressive craniectomy is increasingly advocated as necessary.

Penetrating orbito-cranial and ocular cow-horn injuries

Cow horn eye injuries are not common but are devastating causes of uniocular blindness amongst young active population. Early and appropriate intervention can save the life of the patient depending on the severity of the injury. This uncommon cause of unilateral visual loss can be prevented if slaughtering of cows are done by trained and appropriately equipped personnel.

Dandy-Walker Syndrome: Incidence in a Defined Population of Tabuk, Saudi Arabia

Dandy-Walker syndrome (DWS) is characterized by cystic dilatation of the 4th ventricle and absence of the cerebellar vermis. There may also be posterior fossa enlargement, hydrocephalus, hypoplastic cerebellar hemispheres and other malformations within and outside the central nervous system (CNS). The condition is uncommon, and the incidence is unknown. We studied the incidence of DWS in a defined Saudi Arabian population of military personnel and their dependants. We identified all patients diagnosed with DWS during an 11-year period (1989-1999) from a cohort of 45,274 live births. The incidence of DWS was 1.0 per 100,000 live births per year. The incidence by sex per 100,000 live births per year was 1.24 for males and 0.78 for females. DWS formed 3.5% of our cases of infantile hydrocephalus.

Geographical neurosurgery

Disparities in manpower and facilities notwithstanding, neuroepidemiology might explain the observed differences in the mix of neurosurgical caseload in different parts of the world. The highest incidence rate of primary intracranial tumor was in Europe and the lowest rate in Africa. Glioma was more common in the West, teratoma in Japan and the Far East and meningioma in Africa. The lowest rates of childhood brain tumors were in South America, Africa and Asia. Stroke rates were very high in Finland and China. Blacks, Japanese and Chinese had more intracranial vascular occlusive disease while whites had more extracranial disease. Finland had a very high SAH incidence rate but the Middle East and Africa had low rates and a reversal of the aneurysm: AVM ratio. Highest incidence rates of neural tube defects occurred in countries where consanguineous marriages are common. Brain abscess, tuberculoma and other granulomas from infestations were preponderant in developing countries. Head injuries accounted for up to 40% of all neurosurgical admissions in some developing countries. Outside the USA and South Africa, civilian gunshot injuries were uncommon.

Experience with ventriculo peritoneal shunts at the University of Nigeria Teaching Hospital, Enugu

In a study of 212 children at the University of Nigeria Teaching Hospital, Enugu who received ventriculo peritoneal shunt for hydrocephalus over a 13-year period (1977-1989, 14 had infected shunts and one developed shunt nephritis. Staphylococcus aureus was responsible for 36.4% of the positive cultures and was responsible for the only case of shunt nephritis. This is about the fourth case of shunt nephritis associated with Staphylococcus aureus shunt infection, in the literature. The pertinent features of this case were intraventricular haemorrhage as the cause of the hydrocephalus, frequent revision of shunts before the onset of nephritis and full recovery following intravenous antibiotic therapy and reimplantation of a new shunt.

Ventriculo peritoneal shunts in children. A ten year experience at the University of Nigeria Teaching Hospital, Enugu-Nigeria

In a ten year period (1977--1986) one hundred and fifty children with hydrocephalus who received ventriculo-peritoneal shunt as their modality of treatment were followed up. Seventy-one per cent of these children were neonates and infants, the majority of them presenting within the first 3 months of onset of symptoms and signs. The major causes of hydrocephalus in these children were congenital malformations, meningitis, tumours and trauma. Pudenz shunt systems were favoured in the 1977--81 period, while 1982--86 period witnessed an upsurge of self devised catheters because of dwindling national economy. The latter were cheaper and more readily available. Apart from blockage of shunts which occurred more in self devised catheters, the performance of these catheters in terms of shunt infections and other complications were same in both self devised and conventional catheters. The main complications encountered were blockage and infection of the shunts, while rare complications included migration and extrusion of shunts to and from the peritoneal cavity, CSF ascites and recurrent abdominal cysts.

Ethnic distribution of intracranial aneurysms

The reported higher incidences of intracranial arterial aneurysms (IAA) in Africa and Asia raised the question of possible racial differences in aneurysm incidence. This prompted a retrospective study of the 244 cases of IAA seen at the Henry Ford Hospital (HFH) from 1979 to 1985. There were 171 whites and 73 blacks in the study group. The results showed a higher white to black case ratio (2.3:1) than the white to black hospital population ratio (1.14:1). If only bleeding aneurysms were considered, there were 81 whites and 52 blacks, with a white to black case ratio of 1.6:1, thus giving only a borderline racial difference. The peak age of aneurysm incidence was the fifth decade for blacks and the sixth decade for whites. The most common aneurysms sites were: [table: see text]

Surgically treated traumatic subacute and chronic subdural haematomas: a review of 132 cases

One hundred and thirty-two cases of surgically treated traumatic subacute and chronic subdural haematomas are reviewed. A high male to female ratio of 5:1 is noted. The age distribution and the clinical picture are comparable with the pattern in other reported studies. All patients were treated with simple burr holes and evacuation of blood without membranectomy, postoperative drainage or posturing. The results were excellent as 62 per cent made a good recovery, 33 per cent had mild disability, 4 per cent had severe disability and only 1 patient died. There were no recurrences. The simplicity of making burr holes recommends the method to more doctors, thereby extending the frontiers of treatment beyond the confines of neurosurgical centres.

Intracranial tumors in Enugu, Nigeria

Over a five-year period, there were 48 cases of intracranial tumors at the University of Nigeria Teaching Hospital, Enugu, Nigeria. All the patients were Nigerian Negroes. Glial tumors accounted for 20.8%, pituitary tumors 18.8%, and meningiomas 16.7%. There were five cases of tuberculomas and five cases of metastatic tumors. Miscellaneous tumors contributed 22.9% of the total. There were more males than females, especially in the meningioma and tuberculoma groups. Nearly one-half of the tumors were in people in their first and second decades of life; two-thirds of the tumors were in those under 30 years of age. One-third of the patients have died within the five years under review. The results of this survey are strikingly different from Caucasian series. The relatively low incidence of gliomas and the high incidence of meningiomas and pituitary tumors in this study are interestingly similar to the results of other workers who studied Negro populations and may underscore the importance of genetic factors in the development of some brain tumors.

Unusual craniocerebral injuries from nailing

Three cases of unusual craniocerebral injuries caused by deliberate driving of nails into the head are reported. All injuries were on or near the midline in the parietal area and the nails measured about 10 cm. Two of the patients experienced little pain during the procedure and did not lose consciousness. The extraction of each nail was extremely easy. The only patient who died was admitted in a coma and had meningitis.

Cerebrospinal fluid ascites complicating a ventriculoperitoneal shunt

An unusual case of intermittent cerebrospinal fluid ascites complicating a ventriculoperitoneal shunt is presented. The patient developed hydrocephaly secondary to blockage of the third ventricle by a recurrent craniopharyngioma. The ascites responded to paracenteses and on several occasions resolved spontaneously. There was no satisfactory explanation for the "rejection" of the cerebrospinal fluid by the peritoneal cavity. The ascites was resolved without conversion of the ventriculoperitoneal shunt to a ventriculoatrial shunt being required.

Experience with brain abscesses treated by simple aspiration

No deaths have occurred in 15 consecutive cases of intraparenchymatous brain abscesses in Nigerian patients who were treated by aspiration, systemic antibiotics, dexamethasone and anticonvulsants. Four patients had persistent convulsions which responded well to drug therapy and two patients had hemiparesis but were able to return to their jobs. The simplicity of this method of treatment and the results, achieved without the benefit of computerised tomographic scan, raise the question as to whether the recent trend towards excision of brain abscess is justifiable.

Tuberculoma of the central nervous system in Eastern Nigeria

Although tuberculosis is prevalent in Eastern Nigeria, only 5 cases of tuberculoma of the central nervous system (CNS) were recorded over a 5 year period in a hospital in which about 4000 tuberculosis patients were treated. All the patients were Igbo males. In 4 cases the tuberculoma was supratentorial and in 1 case there was an extradural extraosseous spinal tuberculoma.

Ectopic epidural calvarial meningioma

A rare case of ectopic epidural calvarial fibroblastic meningioma is reported in a 31-year-old male. Arising from the inner table of the skull, it produced an intracranial mass which resulted in hemiparesis and Jacksonian epilepsy.

Racial bias in intracranial arterial aneurysms?

Low incidence of intracranial arterial aneurysms has been reported from India, Iran, and many parts of Africa. From Enugu, Nigeria, five proven cases and two suspected cases of intracranial arterial aneurysms are reported over a three year period. Only one of these was situated in the anterior communicating artery, the others were in the region of the posterior communicating artery. The epidemiology and pathogenesis of aneurysms are reviewed. According to the experience reported intracranial aneurysm in Nigerians is not different from that in Caucasians. Research efforts should be focused on congenital factors rather than on the acquired ones which are common in Nigeria.

Analysis of 1089 cases of head injury

1089 patients treated for head injuries at the Unversity of Nigeria Teaching Hospital, Enugu, are analysed. Seventy-two percent of them were males. The age group 20-30 years was most vulnerable, accounting for 32% of the total. Road traffic accidents were responsible for a staggering 80% of the total. Most of the children in this group were pedestrians hit by vehicles on the roads. About 42% of the head injuries were complicated, but the incidence of intracranial haematoma was only 1.3%. The mortality rate was 9% and most of the deaths (83%) occurred few hours after the accident. Road traffic accident was responsible for 97% of the deaths. Bronchopneumonea and brain oedema was the cause of death in 70.6% of the inpatient deaths from head injury.

Giant cell tumour of the sphenoid bone with dural extension

A case of giant cell tumour of the sphenoid bone is reported. Besides the familiar presentation with headaches, ocular manifestations, and upper cranial nerve lesions, this case showed previously undescribed features such as grand mal seizures, hemiparesis with facial palsy, and dural extension. The reported high incidence in females is questioned. The tumour histologically showed some cartilage.

Spinal extraosseous extradural tuberculoma

A case of spinal extraosseous, extradural tuberculoma is described. The 42-year-old patient had no other tuberculous lesion detectable elsewhere in his body. Following surgical removal of the tuberculoma the patient achieved complete neurological recovery from a preoperative state of total paralysis in his lower limbs.

"Congenital" plexiform neurofibroma of the occipital scalp. Case report

An occipital scalp tumor first noted in a Nigerian girl during the first month of her life gradually increased in size and 13 years later measured 10 X 16 X 17 cm. A skull film revealed a 2 X 4-cm skull defect underneath the tumor over the lambdoid suture. Complete excision of the tumor was achieve although it was adherent to the dura of the transverse sinus. It was histologically confirmed to be plexiform neurofibroma. There were no other signs of van Recklinghausen's neurofibromatosis.

Peripheral nerve injuries from intramuscular injection of drugs

17 patients who were treated at the University of Nigeria Teaching Hospital for peripheral nerve paralysis resulting from intramuscular injection of drugs are analyzed. Ten of them were below the age of 5 years. Sciatic nerve was affected in 16 patients and only one patient had median nerve paralysis. Penicillin, ampicillin, tetracycline, paraldehyde and optalgin were some of the offending drugs. The prognosis was poor as only three patients achieved a partial recovery of function in the paralyzed nerves. With determination and public education, this iatrogenic tragedy could be eradicated.