Management of Penetrating Cranioencephalic Trauma Caused by Sharp Metal Objects—Therapeutic and Evolutionary Aspects: 12 Cases at the Renaissance University Hospital in N’Djamena

Introduction: Cranioencephalic trauma caused by bladed weapons is rare, and that caused by sharp objects is exceptional. The aim of our study was to describe the clinical, therapeutic and evolutionary aspects. Materials and method: This was a descriptive and analytical study over a 48-month period at CHU la Renaissance from January 1, 2018 to December 31, 2021, concerning patients admitted for penetrating cranioencephalic trauma by pointed object. Results: Twelve cases, all male, of penetrating cranioencephalic sharp-force trauma were identified. The mean age was 34 ± 7 years, with extremes of 11 and 60 years. Farmers and herders accounted for 31% and 25% of cases respectively. The average admission time was 47 hours. Brawls were the circumstances of occurrence in 81.2% of cases. Knives (33%), arrows (25%) and iron bars (16.6%) were the objects used. Altered consciousness was present in 43.8% of cases, and focal deficit in 50%. Scannographic lesions were fracture and/or embarrhment (12 cases), intra-parenchymal haematomas (6 cases) and presence of object in place (4 cases). Surgery was performed in 11 patients. Postoperative outcome was favorable in 9 patients. After 12 months, 2 patients were declared unfit. Conclusion: Penetrating head injuries caused by sharp objects are common in Chad. Urgent surgery can prevent disabling after-effects.

Role of Fresh Cadaver Practice and Jesus Prayers on Daily Base in Innovations of a Difficult Neurosurgical Operation (Craniopagus Separation)

Purpose: Challenging cases in neurosurgery require experience, which is gained by operating on a number of similarly difficult cases. However, even in large population centers, there are extremely rare cases, such as craniopagus twins. In these instances, other case-specific solutions are required which were improved in the course of fresh cadaver practice on daily base. Methods: During a 20-month preparation period by fresh cadavers the surgical strategy was developed step by step, comprising five neurosurgical ideas, facilitated by deep Jesus prayers as a spiritual source. Possible causes of postoperative complications that occured on 33d postoperative day were also analyzed. Results: During surgery, these nuances proved to be useful, which is also reflected by the postoperative clinical results. One of the twins advanced to a GOS score of 5three months after the surgery. The other twin, despite nonsurgical septic complications, continued to progress well, but on postoperative day 33 for seemingly unknown reasons, she suffered a severe cerebral hemorrhage, which significantly delayed her rehabilitation. A thorough revision of the whole process much later revealed a pitfall that could have a role in this complication. Conclusions: The challenging neurosurgical separation of the craniopagus twins was carried out successfully with the help of five novel neurosurgical refinements, which were found during 300 fresh cadaver practices. Mistakes can serve as a lesson. We hope that the procedures developed and the knowledge gained can be applied in the future.

Far Lateral Disc Prolapse: Surgical Options in Limited Resources Centers

Far lateral disc prolapse accounts for 6.5% to 12% of all lumbar disc prolapses. Surgical options include open laminectomy with discectomy, microscopic and endoscopic excision of the prolapsed disc. Some of these options may not be available in limited resources centers. We will highlight the effectiveness of various surgical options. Twenty patients with foraminal and extraforaminal lumbar disc prolapse were operated upon from January, 2015 to June, 2016 in the neurosurgical departments of Cairo and Fayoum Universities in Egypt by different modalities (open laminectomy with discectomy, microscopic and endoscopic discectomy). Seventeen patients had foraminal disc prolapse and only three patients had extraforaminal disc prolapse. Twelve patients were operated by conventional laminectomy approach. Microscope was used in four patients and four patients were operated endoscopically. Excellent radicular pain improvement was achieved in 15 cases (75%) including all of the laminectomy groups. Conventional laminectomy and discectomy in far lateral disc prolapse remains an excellent option especially in limited resources centers. Although building up experience with other surgical modalities is mandatory.

Intracranial Fungal Infections: Overview from Two Large Tertiary Hospital in Upper Egypt and Literature Review

Purpose: Fungal infections of the central nervous system (CNS) are potentially lethal conditions with high morbidity and mortality. In this review, we summarise the most common clinical manifestations, diagnostic methods, and treatment strategies for intracranial fungal infection at two tertiary care teaching hospitals. Material and methods: Prospective hospital study is carried out at Department of Neurosurgery;Assiut and Suhaj University Hospitals between January2010 to January 2018 (Minimum 12-months follow-up). Radiographs and hospital data of 74 patients with proven intracranial fungal infections were gathered and analyzed. There were no exclusion criteria: age, gender, clinical presentations, immunity status, radiological findings, laboratory, and microbiological data, types of management and outcome. In surgically treated patients, diagnosis was confirmed by pathologic evaluation. Gathered data were coded and entered into a computer and analyzed using SPSS version 22. Results: The greatest number of the patients had 40 to 60 years old (49;66%) and the mean age was 44 years. There was an overwhelming male patient’s ranged preponderance 66%;49 cases. Sixty-three patients (85%) were immunosuppressed;11 cases (15%) were immunocompetent. The most common causes of immunosuppression were diabetes 27 patients;43%, on chemotherapeutic agents 19 patients;31%, on corticosteroid 16 patients;25% and AIDS in one patient;1%. Five different fungal types were identified but Cryptococcus spp. was the most common cause of CNS fungal infection, occurring in 39 patients (53%). This was followed by Candida spp. in 14 patients (19%), Aspergillus in 11 patients (15%), Blastomyces in 7 patients (9%) and Coccidiosis in 3 patients (4%). Headache was the most common presenting symptom, occurring in 33 patients (45%). Other relatively common symptoms were nausea or vomiting 11 patients (15%), fever 10 patients;(13%), seizures 9 patients (12%), acute mental status changes 8 patients;(11%) and stroke like Symptoms 3patients (4%). Different surgical procedures were done. Stereotactic biopsy is in 19 patients (deep;located in an eloquent region of the brain or multiple small lesion) or excision in 38 patients (cortical, relatively accessible regions of the brain), and CSF shunting in 17 patients. All patients received parenteral and, in some cases, oral antifungal chemotherapy in addition to surgical therapy. Overall mortality was 52.7% (39 deaths). An additional 8 surviving patients exhibited permanent morbidity due to neurological deficits and seizure disorders. Conclusion: This prospective population study demonstrates an insight into the intracranial fungal infection and management. CNS fungal infections have increased in frequency, particularly in immunocompromised patients;most infections are caused by Cryptococcus spp. Diabetes was the most common cause of immunosuppression and headache was the most common symptom at presentation. CNS fungal infection is still associated with a high mortality and morbidity. Prompt diagnosis;early and appropriate medical and surgical management are fundamental to optimize the outcome.

Surgical Management of an Unstable Lumbar Fracture-Dislocation—A Case Report

The lumbar spine is the most common sites for fractures because of the high mobility of the lumbar spine. A spinal cord injury usually begins with a sudden, traumatic blow to the spine that fractures or dislocates vertebrae. A 32-year-old man presented to us after traffic accident. In our patient, unstable fracture-dislocation of the lumbar spine at the L2-L3 level due to traffic accident occurred. The vertebral bodies were fractured and the anterior dislocation happened without spinal cord injury. The patient was a candidate for an open reduction and internal fixation surgery. The posterolateral approach was performed. After insertion of all the pedicle screws, the rods were transversally placed on L2-L3-L4 vertebral bodies and tightened. The reduction of the dislocations was carried out by pushing downwards (foreside) L2 and L4 vertebras and upwards (backside) L3 vertebrae, simultaneously. After securing the reduction of the dislocations, the rods were opened and placed along the spinal column and tightened. This technique is more effective when the pedicle of fractured vertebrae is intact.

Evaluation of the Neurodevelopmental Outcome of Toddlers with Spinal Dysraphism after Surgical Repair Using ASQ-3™ Scores

Background: Spinal dysraphism represents a wide spectrum of congenital abnormalities of the spine. Myelomeningocele is considered the most common malformation and the most common we saw in our community, with its morbidity problems seen commonly in the postoperative period. ASQ-3TM Scores are the ages and stages questionnaire, third edition, and represent a tool to assess the development progress, especially in toddlers. Objectives: Evaluation of neurodevelopmental outcome among Sudanese toddlers with spinal dysraphism after surgical closure with or without a VP shunt using ASQ-3TM Scores. Methodology: This is a retrospective hospital-based study of 84 patients who underwent myelomeningocele repair at the National Center for Neurological Sciences (NCNS) during the period from 2017 up to 2019. Data were collected through a constructed questionnaire, including ASQ-3TM Scores. Data were processed and analyzed using the Statistical Package for Social Science (SPSS) computer program. Version 25. Results: 84 patients were included in this study;all patients were diagnosed with spinal dysraphism. Out of them, 51 (60.7%) were 2 years old, 33 (39.3%) were 3 years old, 45 (53.6%) were male, 45 (53.6%) of patients mothers attended ANC irregularly, and 54 (64.3%) their mothers didn’t receive folate supplements. 44 (52.3%) of patients underwent MMC repair only, while 40 (47.7%) underwent MMC repair and VP shunt. The commonest postoperative complication was infection, reported in 12 (14.3%) of patients, followed by VP shunt revision in 9 (10.7%) of patients. Neurological assessment showed that the majority of patients need further assessment with a professional, 57 (67.9%) of children don’t walk, run, or climb like other toddlers as their parent’s state;also, half of patients (42, 50%) had medical problems, and 27 (32.1%) of their parent’s state that they do not talk like other toddlers their age. There was a statistically significant association between post-operative complications and communication development, problem-solving development, and personal social development (P value = 0.05), and a statistically significant association was found between age at repair and neurological development (P value = 0.05). Conclusion: The majority of patients had motor deficiency (particularly gross motor) and poor personal and social skills. Age at repair and postoperative complications significantly influenced the neurological development.

Anticonvulsants for Preventing Seizures in Patients with Chronic Subdural Haematoma: Pilot Study

Introduction: There is increasing of the incidence of chronic subdural hematomas (CSDH), due to increase of the elderly population with increase of intake oral anticoagulation and antiplatelet drugs in this category of patients. Seizures occur as a complication in 2.3% to 20.4% of the patients. There is a considerable side effect associated with using of anti-epileptic drugs (AEDs). Aim of the Study: To rule the value of prophylactic antiepileptic drugs in prevention of seizures after surgical evacuation of chronic subdural hematoma. Methods: A prospective controlled non-randomized study was performed on 26 patients with chronic or subacute subdural hematoma that was surgically evacuated through burr-holes from April 2017 to June 2019. We divided the patients into 2 groups: group A patients received prophylactic antiepileptic drugs for 6 month and group B patients didn’t receive prophylactic antiepileptic drugs and the 2 groups were observed to detect occurrence of post-operative seizures for 6-month follow-up after surgery. Medical history, demographic data and imaging characteristics were recorded. Results: Seizure prevalence for all patients during hospitalization and 6-month follow-up was zero among the 13 patients who received prophylactic anti-seizure medications, and was 1 (7.7%) among the 13 patients who didn’t receive prophylactic anti-seizure medications. Conclusions: The incidence of post-operative seizures in patients with chronic subdural hematoma operated upon by burr holes evacuation is low. The administration of prophylactic antiepileptic drugs decreases the incidence of seizures after evacuation of CSDH, but the difference was not significant. So prophylactic antiepileptic drugs should not be routinely given for all patients with CSDH operated upon by burr hole evacuation unless there is risk factor for seizure development.

New Developments in Drug Therapy and Research of Cerebral Vasospasm

In this manuscript a comprehensive coverage of recent developments in the drug therapy of vasospasm while providing the background information that neuroscientists need to understand its rationale. The range of new agents available for treatment of cerebral vasospasm is expanding rapidly along with rapid advances in pharmacology and physiology that are uncovering the mechanisms of this disease. Although there are many publications for treatment of cerebral vaso-spasm, most are focusing on different aspects of vasospasm treatment and many have limited value due to insufficient quality. Moreover, the complexity of this, in many cases deleterious condition, is enormous and the information needed to understand drug effects is accordingly often not readily available in a single source. A number of pharmacological and medical therapies are currently in use or being investigated in an attempt to reverse cerebral vasospasm, but only a few have proven to be useful. Current research efforts promise the eventual production of new medical therapies. At last, recommendations for the use of different treatment stages based on currently available clinical data are provided.

Treatment of Pediatric Brain Tumors in Brazzaville (Congo) about a Case Series

Introduction: Tumors of the central nervous system are the most common group of solid neoplasm in children and account for 20% to 25%. They are common in Sub-Saharan countries, despite the insufficiency of histological diagnosis. No study has been performed concerning the pediatric brain tumors in the Republic of Congo. The aim of this study was to describe the conditions of neurosurgical management of pediatric tumors in Brazzaville. Materials and Methods: We performed a retrospective and descriptive study, from January 2014 to December 2017 (48 months), into the neurological unit of the surgical department of Brazzaville. We included all patients aged from 17 years old and below, hospitalized for a brain tumor. Results: We have identified 11 cases of brain tumors. The average age was 8.1 ± 4.3 years old, a sex ratio of 0.57. Ten out of the eleven patients of our series have intracranial hypertension. We found six cases of infratentorial tumors and five of supratentorial location. Only three cases had histology. Ten patients were operated, limited by ventriculoperitoneal shunt in 6 cases, surgical resection in three cases, biopsy in one case. There were no possibilities of radiotherapy and chemotherapy during this period of study. Conclusion: A multidisciplinary team must be organized to improve the management of pediatric brain tumors in our context. Histological diagnosis and possibilities of radiotherapy are imperatively needed.

Microsurgical Treatment of Craniopharyngiomas: A Retrospective Analysis

Objective: This retrospective study aims to survey the clinical outcomes of 341 consecutive patients surgically treated for and diagnosed with craniopharyngioma (CP) treated in a 10-year period in a single institution. Methods: The clinical reports of three hundred forty-one patients CP patients treated surgically between January 2006 and December 2016 were reviewed and analyzed retrospectively. Results: Our cohort consisted of 341 patients (202 male, 139 female) with a mean age of 34.9 years (range 1 - 74 years);Tumor Features: 129 patients (37.8%) had cystic tumors, 88 (23.8%) had solid tumors whereas 126 (36.4%) had heterogeneous lesions with a solid and cystic portion;calcifications were present in 139 (40.8%);Tumor Topography: Suprasellar 198 (58.1%), Intrasellar 40 (11.7%), Intra-third ventricular 103 (30.2%);Surgical approaches used among the patients included: Pterional 262 (76.8%), Transsphenoidal (TS) 42 (12.3%) Transcallosal 20 (5.9%), Transcortical 16 (4.7%) suboccipital 1 and combined approach 1;Gross total removal (GTR) was achieved in 247 patients (72.4%), Subtotal removal (STR) in 94 patients (27.6%). Good postoperative outcome at discharge was achieved in 324 (95%) patients while 17 (5%) patients had poor outcome including 5 (1.5%) perioperative deaths. Mean hospital length of stay was 21.87 (8 - 129). There were 42 (12.9%) recurrences with a mean time to recurrence of 28.36 (3 - 84) months, among which 37 (88.1%) underwent surgery for recurrence treatment. Follow-up time ranged from 3 months to 10 years. There was a statistical significance between open transcranial surgery and suprasellar tumors (p < 0.0001), TS and intrasellar tumors (p < 0.0001);postoperative diabetes inspidus and gross total resection (p < 0.0001);GTR and cystic tumors (p = 0.034) calcification and GTR (p = 0.0008). Conclusion: Good surgical outcome and long-term tumor control can be achieved through individual-based selective resection, whether total or subtotal resection. Whereas surgical prehistory of CP was found to be a significant risk factor to recurrence (p < 0.0001), the clinical risk factors of CP of recurrence are still arguable, including the presence residual tumor due to subtotal resection. More future studies are necessary.

Intra-Operative Rupture of Remote Aneurysm during Transphenoidal Resection of Pituitary Macroadenoma

Rupture of intracranial aneurysm resulting in subarachnoid hemorrhage is well known to carry significant risk of poor outcome. Intra-operative rupture of an unknown intracranial aneurysm during a neurosurgical procedure is a rare occurrence that can lead to devastating consequences if not recognized and managed appropriately. Here we describe to our knowledge, the first reported case of previously unknown, remote from the surgical site, intra-operative posterior cerebral artery aneurysm rupture during transnasal endoscopic transphenoidal resection of a pituitary macroadenoma, review relevant literature, and discuss strategies to reduce surgical risk and improve patient outcomes.

Giant Cerebriform Nevus Cell Nevus of the Scalp: A Case Report

Giant cerebriform nevus cell nevus of the scalp is an extremely rare form of congenital melanocytic nevus. Giant cerebriform nevus of the scalp has a major psychosocial impact because of its unsightly appearance with fetid maceration. We report the case of a 35-year-old woman who had a painless, malodorous swelling of the cerebriform scalp measuring 20 × 17 cm in diameter with a wide base of insertion at the occipital level adhering to the deep planes. The excision associated with a skin plasty was carried out. Histology concluded that there was a giant cerebriform naevo-cellular nevus of the scalp.

A Chronic Post-Surgical Infectious Lumbar Fistula Providing Protection against Imminent Morbidity: A Case Report and Literature Review

Vertebral osteomyelitis (VOM) and spinal epidural abscesses (SEA) are rare infections on the spinal column, more prominently seen in intravenous drug users, diabetics and the immunosuppressed. We report an extremely rare case of a patient with a chronic history of lumbar post-surgical cutaneo-spinal fistulous infection that was unresponsive to conventional antibiotic therapy and ultimately required surgical debridement and spinal re-instrumentation. The novelty of this case was the chronic nature of the patient’s condition that was made possible only by a fortunate post-surgical cutaneo-spinal fistula that withdrew infected particles away from the neurological structures and thus prevented imminent compressive and neurological deficits, and possible eventual death. This rare case highlights the need for prompt surgical evaluation and intervention in patients with progressive VOM or SEA with associated cutaneo-spinal fistulas, especially in cases where conventional antibiotic treatments have failed. We highly recommend a low threshold for surgical debridement and hardware removal with re-instrumentation as appropriate before a spinal compressive emergency arises and/or sepsis develops.

Clipping of Lateral Posterior Choroidal In-traventricular Aneurysm Related to Ruptured Temporal Arteriovenous Malformation: Case Report

Background: Intraventricular cerebral aneurysms are uncommon brain vascular disease in general population. The previous reported cases point with more frequency to Moyamoya disease as the main factor to originate aneurysms in the choroidal arteries. Those related to an AVM are even rarer and only two cases have been previously reported. Aim: To discuss the unusual location of this aneurysm, its relationship to other conditions and the type of treatment. Case Presentation: We present the case of a patient with a non-ruptured intraventricular aneurysm of lateral posterior choroidal artery related to a ruptured right temporal arteriovenous malformation, who was successfully treated by clipping immediately, after resection of the malformation. Conclusion: Intraventricular choroidal artery aneurysm is a rare pathology. Its deep location makes the treatment challenging but mandatory due to the high probability of bleeding, especially those flow-related to an arteriovenous malformation.

Giant Thoracic Meningocele Causing Acute Respiratory Compromise

Objective: The authors report a rare case of giant thoracic meningocele causing acute respiratory compromise, treated with a ventriculoperitoneal shunt. Case Report: We report the case of a 36-year-old with severe scoliosis status post repair over a decade ago, neurofibromatosis type I, and a known large meningocele in the left thoracic cavity, presenting with new acute respiratory compromise. She was taken to the operating room for a lumboperitoneal shunt, but the operation was aborted due to her severe spinal deformity. Two days later, she successfully underwent a procedure for ventriculoperitoneal shunt placement. Upon discharge a week later, the patient was hemodynamically stable, able to move all extremities with good strength, and demonstrated improved oxygenation. In the following 7 months, the patient demonstrated continued minimal requirement on nasal cannula, and MRI showed a stable left thoracic giant meningocele. Conclusion: Ventriculoperitoneal shunting is a method of treating and stabilizing acutely symptomatic giant meningoceles.

Management of Cerebral Metastases—About 25 Cases

Approximately, 20% of all cancer patients will end up having brain metastases. This is especially the case of patients in which the primary tumor is lung cancer, breast and colorectal cancers, melanoma, or renal cell carcinoma. Development of brain metastases contributes substantially to overall cancer mortality in patients with advanced-stage cancer given the associated poor prognosis despite multimodal treatments and advances in systemic therapies. The objective of this retrospective single center study is to describe the experience of the Department of Neurosurgery of the Ibn Sina University Hospital in Rabat in the management of patients with brain metastases, highlighting the therapeutic choices as well as the various challenges encountered during treatment.

Four Levels Anterior Cervical Discectomy and Fusion by Stand Alone PEEK Cages

Background: cervical spondylotic myelopathy is a common health problem that neurosurgeons face in Egypt. The aim of this study is to evaluate the efficacy of PEEK cage only in 4 levels anterior cervical discectomy as one of surgical option other than anterior cervical corpectomy, fixation by plat or posterior approach for cervical laminectomy, and assessment of post spinal surgery pain. Methods: this prospective study on 28 patients with cervical spondylotic myelopathy (CSM) over a period of 3 years (between April 2012 and April 2015) with mean period of follow up 30 months. We have done anterior cervical discectomy with fixation by cage only for all cases with perioperative assessment and scoring clinically and radiologically (Japanese Orthopaedic Association [JOA] scores, Visual Analogue Scale [VAS] scores for assessment of neck and arm pain, perioperative parameters (hospital stay, blood loss, operative time), the European Myelopathy Scoring (EMS) and Odom’s criteria, and the incidence of complication,post spinal surgery pain assessment). Results: clinical outcome was excellent (28.55), good (50%) and fair (21.5) according to Odom criteria. The European Myelopathy Scoring (EMS), improved from 10 to 16. The mean JOA score improved from 10.1 ± 2.1 to 14.2 ± 2.3. Fusion failure had been seen in 4 patients in one level for each secondary to anterior displacement of the cage with no other major complications. Conclusion: 4 levels anterior cervical discectomy with PEEK cage only is an effective, save and less costly with less post operative complication and hospital stay and less post spinal surgery pain.

Surgical Treatment for Neonatal Hydrocephalus: Catheter-Based Cerebrospinal Fluid Diversion or Endoscopic Intervention?

Neonatal hydrocephalus can arise from a multitude of disturbances, among them congenital aqueductal stenosis, myelomeningocele or posthemorrhagic complications in preterm infants. Diagnostic work-up comprises transfontanellar ultrasonography, T2 weighted MRI and clinical assessment for rare inherited syndromes. Classification of hydrocephalus and treatment guidelines is based on detailed consensus statements. The recent evidence favors catheter-based cerebrospinal fluid diversion in children below 6 months, but emerging techniques such as neuroendoscopic lavage carry the potential to lower shunt insertion rates. More long-term study results will be needed to allow for individualized, multidisciplinary decision making. This article gives an overview regarding contemporary pathophysiological concepts, the latest consensus statements and most recent technical developments.

Intracranial Epidural Plasmacytoma Presenting as a Neurosurgical Emergency: Case Report

Intracranial plasmacytomas are infrequently encountered in neurosurgical practice, and the literature consists predominantly of isolated case reports. We present the first English medical literature case of intracranial epidural plasmacytoma with no calvarial lytic changes masquerading as an extradural hematoma in a 60 year-old-man. In addition, we discuss the pathogenesis of this unusual tumor location with brief review of the relevant literature concerning its treatment and outcome.

Unusual Scalp Process Revealing a Thyroid Cancer: “Illustrative Case”

Background: Thyroid cancers commonly display slow evolution with local and or regional extension. The classic presentation is a painless nodule of the thyroid region in a euthyroid patient. Sometimes, the nodule is discovered only on ultrasonography. Cervical lymph node is often seen in papillary thyroid cancer due to their propensity to invade lymph node. This means that follicular thyroid cancers are more insidious. Observation: We report a painless slow-growing lesion of the scalp revealing a skull metastasis of thyroid cancer. Despite catastrophic intraoperative bleeding, a total removal was achieved. Lessons: Thus, in addition to local and regional control in the management of thyroid cancers, distant metastasis should be surgically removed to provide the best chance to prolong the patient’s survival. Moreover, neurosurgeon must be prepared to deal with massive bleeding in skull metastasis of thyroid cancer.