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ISPN 2008: Yesterday was Great

Yesterday was a remarkable day. I presented our work "Endoscopic Management of Hydrocephalus in Nigerian Children" to the over-600 international audience from over 50 countries at the 36th congress of the International Society for Paediatric Neurosurgery. You would agree with me that it is an honour to present alongside the likes of Ben Warf and Michael Fritsch and to an audience that included the great Hal Rekate and Schuzio Oi.

The paper presentations were followed by an evening of wine tasting during which poster presentations were made. I presented a classic poster on "The profile of hydrocephalus in Nigerian Children with Myelomeningocoele" under the guidance of my mentor and trainer, Professor M. T. Shokunbi.

I shall keep you posted on further developments at the congress. The weather here is getting progressively colder. I now use warmer in my room.

Catch u.

ISPN 2008 Update 12-10-2008

I had a great day today. We had a wonderful neuroendoscopy hands-on workshop at the South African headquarters of Karls Storz in Cape Town. Quite educative. The programme had Profs. Ben Warf and Schizuo Oi on the faculty. These are well respected neurosurgeons all over the world.

After the workshop, we had an exciting welcome cocktail at the Table Bay Hotel before returning to our All Africa House, University of Cape Town, residence.

The 2008 Congress of the International Society for Paediatric Neurosurgery (Cape Town, South Africa)

We had a great day in Cape Town today.

The 1st South Africa ISPN Course was well attended and the discussions were enlightening.

The resource persons were wonderful- including the renowned Ben Warf, formerly of Uganda but now back to the US. We discussed neuro-developmental problems, paediatric brain tumours, neurotrauma in children and neurosurgery in Africa. I enjoyed every bit of the day.

The programme was held at the BoE conference centre, overlooking the magnificent V&A Hotel at Waterfront, Cape Town.

Greetings from Cape Town

I'm writing in from Cape Town, Republic of South Africa, where I'm attending the 2008 Congress of the International Society for Paediatric Neurosurgery. Miss U all. The congress promises to be a memorable one.

My perception of the event and South Africa so far is positive. The weather is cool here and one does not need an air conditioner. The environment is clean and beautiful. Airport formalities were quick, efficient and friendly. Nigeria need to take a cue from this country.

I shall give you regular updates about the conference which brings together paediatric neurosurgeons from all over the word.

More details: ispn2008

Look out for my regular updates on this site.

Cervical Spine Immobilization!!!

 

 

 

See the various means of cervical spine immobilization in a resource-poor facility.

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Clinical assessment of head injury: The history

A quick and concise history is essential in the care of the patient with head injury. Necessary details include:
• Age
• Type of accident that caused the head injury and the events surrounding it
• Time of occurrence
• Details of rescue/transportation to the hospital
• Occurrence and details of

o Vomiting: may indicate raised ICP
o Convulsions (early/late post traumatic seizures)
o Bleeding (craniofacial orifices and others)
o CSF leaks
o Fever
o Loss of consciousness

• Allergies (avoid drugs of allergy)
• Last meal (stomach may need to be emptied before general anaesthesia)
• Details of pre-hospital care
• Co-morbidities

The history is obtained from a conscious patient while relations and bystanders at the site of the accident or from the ambulance officers are important informants for both the conscious and the unconscious .

Initial management of head injury

The initial management of head injury is very important to reduce the morbidity and mortality associated with the condition. The initial care impacts significantly on the eventual outcome and if not properly done, it may make nonsense of any eventual specialist neurosurgical care.

The key aspects in the management of patients following head injury involve:
• accurate clinical assessment of the neurological and other injuries
• determination of the pathological process involved
• accurate assessment of changes in the neurological status of the patient; this indicates an improvement, progression or change in the pathological processes.

At the injury site, immediate care involves careful extraction of the injured individual (e.g from a car wreck, collapsed building, gutters, etc), rapid restoration and maintenance of an adequate airway, protection of the cervical spine, ventilation, essential circulatory resuscitation, first aid treatment of other injuries and the urgent transfer of the patient to hospital.

It is essential to avoid hypoxia and hypotension as these will cause further brain
injury (secondary brain damage). The ‘ABC’ of resuscitation gives a good guide for the initial management of the head-injured patient like other trauma patients.

Clinical Features of Hydrocephalus

Clinical presentation of hydrocephalus depends on the age of the affected individual and the rate of CSF accumulation. In infants, the most striking feature is the abnormal increase in the size of the head whereas in adults, it commonly presents with features of raised intracranial pressure.

In young children, hydrocephalus could present with any combination of the following symptoms and signs:

• Abnormally large head; usually with the rate of growth of the cranium greater than that of the face (craniofacial disproportion)
• Irritability
• Poor neck/head control
• Poor developmental milestone attainment/loss of previously attained milestones such as social amile, neck control, sitting, walking and talking
• Nausea and vomiting
• Bulging fontanelle(s)
• Widening of the cranial sutures (sutural diastasis)
• Prominent, enlarged and engorged scalp veins
• ‘Setting sun sign’ or sunset appearance of the eye due to paralysis of upward gaze (Parinaud syndrome) from pressure of the accumulated CSf in the suprapineal recess on the tectum of the midbrain
• Sixth nerve (abduscens) palsy (due to its long intracranial course)
• Macewen’s sign: cracked pot sign on percussion of the skull
• Miscellaneous findings
o Hyperactive reflexes
o Irregular respirations with apneic spells

In older children/adults, it presents with features of increased ICP:
• Headache
• Nausea and vomiting
• Gait abnormalities
• Papilloedema
• Upward gaze palsy
• Sixth nerve palsy

If the ventricles enlarge slowly, the condition may initially be asymptomatic.
The classic triad of normal pressure hydrocephalus is:
• Dementia
• Urinary incontinence
• Gait ataxia

Causes of Hydrocephalus

The conditions causing hydrocephalus include the following:

• Excessive CSF production by the choroid plexuses
o Choroid plexus papilloma

• Blockage in the CSF circulation, either within the ventricle, or on the outside of them
o Aqueductal stenosis
o Tumours
o Chiari malformation especially types I and II
o Dandy-Walker malformation
o Intraventricular haemorrhage
o Meningitis
o Spinal tumour
o Myelomeningocoele

• Impairment of CSF absorption by the arachnoid villi.
o Meningitis
o Subarachnoid haemorrhage

The causes enumerated above could also be classified into congenital or acquired.

Hydrocephalus: Introduction

Hydrocephalus is a neurosurgical condition in which there is excessive accumulation of brain water (called cerebrospinal fluid) in the head. Hydro = water; cephalus = head. It is rare but certainly present in our community.

Many of the children, and alas! Adults that you see around with big heads suffer from this condition. Do not stigmatize the sufferer, it is definitely not his/her making.

The causes of the condition are many; some are congenital (occur before birth) while some others are acquired (contracted after birth). To properly understand the causes of hydrocephalus, you need to appreciate the formation and flow of the brain water. A simple overview of this is as follows:

• The brain has large spaces within it called the ventricle (four of them, called right lateral, left lateral, third & fourth)

• The ventricles communicate with a space surrounding the brain, called the subarachnoid space through openings (foramina in the 4th ventricle)

• The subarachnoid space in turn coomunicates with a similar space surrounding the spinal cord

• Cerebrospinal fluid (CSF) is produced by flower like structures in the ventricles called the choroid plexus

• The fuid circulate in the ventricle and into the subarachnoid space (around the brain and the spinal cord)

• The fluid get absorbed into the blood stream via finger-like structures called arachnoid villi located in the coverings of the brain

• CSF production is in dynamic balance with absorption to prevent its accumulation.

From the foregoing, you would probably have deduced that hydrocephalus can result from:
1. Excessive CSF production by the choroid plexuses
2. Blockage in the CSF circulation, either within the ventricle, or on the outside of them
3. Impairment of CSF absorption by the arachnoid villi.

Simple isn’t it? You don’t have to be a genius to understand this. Watchout for my updates on this topic. I will appreciate your feedback on how useful you think this introduction is. I will also make myself available on this site to answer any question that bothers you about this very important condition. In addition, I shall appreciate your comments on the topic.

Join this discussion.

The Glasgow Coma Scale

The Glasgow Coma Scale was introduced by Graham Teasdale and Lord Jennet in 1974. Till date, it is the most widely used and accepted measure of level of consciousness. The scale has 3 parameters as defined below. Obtainable scores are from 3 to 15 with scores below 15 indicating diminished levels of consciousness. A patient with a score of 8 or below is said to be in coma.

The scale is renowned for its simplicity, reproducibility and objectivity. It provides a fast means of patient assessment which can be used by various cadres of health workers including paramedics, nurses and physicians.

Parameter Numerical Value

Eye Opening
Spontaneous 4
To speech 3
To pain 2
None 1

Best Verbal Response
Orientated 5
Confused 4
Inappreopriate 3
Incomprehensible sounds 2
None 1

Best Motor Response
Obeys commands 6
Localizes pain 5
Flexion withdrawal 4
Abnormal flexion 3
Extension to pain 2
None 1

TOTAL 3-15

Head Injury-Overview

Head injuries are a major cause of morbidity and mortality in all communities. Trauma is the third most common cause of death in the United States, exceeded only by cerebrovascular disease and cancer. Trauma is the leading cause of death in youth and early middle age and the death is often associated with major head trauma. Head injury contributes significantly to the outcome in over half of trauma-related deaths.

There are approximately 2.5 deaths from head injury per 10 000 population in Australia and neurotrauma causes approximately 3.5% of all deaths. Road traffic injuries (RTI) are responsible for about 65% of all fatal head injuries in Australia. In developing economies, trauma is the leading cause of death with many of them resulting from road traffic injuries (motor vehicles or motor cycles {AKA Okada in Nigeria}).Other causes include fall from heights (particularly in children), sports injuries and assault.

There is a wide spectrum of head injury from mild concussion to severe brain injury resulting in death. The management of the patient following a head injury requires the identification of the pathological processes that have occurred. Adequate attention must be paid to associated injuries whose management may sometimes take precedence over the head injury management.

CLASSIFICATION
The various ways of classifying head injury are:
1. According to aetiology e.g RTI, fall, sports

2. According to mode of injury:
a. Blunt
b. Penetrating

3. According to the state of the scalp and skull
a. Closed: in which scalp and skull are intact
b. Open: in which both are breached

4. According to the Glasgow Coma Score (GCS)
a. Mild: GCS 13-15
b. Moderate: GCS 9-12
c. Severe: GCS 3-8

NB: a. Coma is GCS < 8
b. Some workers classify GCS 3 - 4 as critical head injury

ABC of Resuscitation

Resuscitation of the injured patient is often an Herculean task for the untrained health workers. Similarly, some students find it difficult answering questions on the initial care of the acutely injured patient. In this entry I have tried to summarise, in simple language, the essential components of resuscitation, specifically for use in head injury, but with wide-ranging applications in other trauma cases. This information is also useful to the members of the public who may at one time or the other find themselves at accident scenes and have to provide initial care for the injured.

The components are:

• Airway and cervical spine control: check for, and maintain airway patency. Remove debris or food particles which may occupy the mouth and the upper airway thereby preventing adequate air entry. Jaw thrust and/or traction on the tongue might be needed to keep the airway patent. Insertion of oropharyngeal airways, and when indicated/available, oro- or nasotracheal intubation are essential in keeping the airways open. The patient may die rapidly from asphyxia if this initial step is not quickly and meticulously carried out. In doing all these, it is essential to protect the cervical spine which must be assumed to have been injured in all unconscious patients and in those who have sustained significant impact to the cranium, face, neck and upper chest as well as those involved in high-velocity impacts and falls from height.

C-spine protection can be achieved with:

o Rigid neck collars
o Head strappings
o Supportive sand bags placed on each side of the neck

• Breathing: If there is no spontaneous breathing, assisted breathing is essential once airway patency is confirmed. Mouth-to-mouth breathing (Kiss of life; through an handkerchief), ambu-bagging and mechanical ventilation are done as necessary

• Circulation: a quick assessment of the patient’s circulation is done; radial pulse is palpated and BP measurement carried out. Maintenance of the circulation is done using intravenous fluids (crystalloids and colloids) as necessary. This is particularly important in the poly-traumatized patients with haemorrhage. If the initial circulation is not optimal, a search must be made for extracranial bleeding sites as intracranial bleed is not sufficient to cause circulatory collapse except in infants and very young children.

• Drugs may need to be administered. Commonly used drugs in head injury includes mannitol, analgesics, H2-receptor blockers/proton pump inhibitors, inotropic agents, anaesthetic agents, tetanus prophylaxis, etc. Watch-out for a review of these drugs. It is important to also adequately assess the dysfunction of the nervous system

• Environment: it is important to ensure that the environment in which care of the patient is done is safe to prevent further injuries to the patient as well as the care givers

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Symptoms of Brain Tumour

A brain tumour takes up space within the skull and
interferes with normal brain activity. A tumour
can cause damage by increasing pressure in the brain,
shifting the brain or pushing against the skull, and invading
and damaging nerves and healthy brain tissue. The location
of a brain tumor influences the type of symptoms that occur.
This is because different functions are controlled by different
parts of the brain.

A brain tumor can block the flow of cerebrospinal fluid (CSF) between
the ventricles, causing a buildup of CSF and swelling,
called brain oedema. Oedema can lead to symptoms including
headaches, seizures, or focal deficits. Focal deficits include
damage to sensory or movement abilities, problems in the ability
to process information, personality changes, and speech disorders.
A tumour of the spinal cord can block the communication
between the brain and nerves throughout the body. This can
lead to problems with movement or physical sensation.

The most common symptoms include:
• Headaches, which can be most severe at nights
• Seizures or convulsions
• Difficulty thinking, speaking, or finding words
• Personality changes
• Weakness or paralysis in one part or one side of the body
• Loss of balance
• Vision changes
• Nausea or vomiting, particularly early-morning
• Confusion and disorientation

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