Caring for patients with brain tumor: The patient and care giver perspectives

Background: Patients with brain tumors form a heterogeneous group in terms of clinical presentation and pathology. However, the impact of the disease on patients’ families is often more homogenous and frequently quite profound. A considerable body of literature is available on the management of brain tumors and recently, the National Institute for Clinical Excellence has developed guidelines on the care of brain tumor patients that should improve the overall outcome for the patient from both the disease and psychological aspects.Objectives: An increasing number of studies have attempted to address the impact of the disease on the care givers and relatives of these patients, but few have considered the problem simultaneously from both the patient’s and care giver’s perspective. In this study, we analyzed the psychosocial and general health of brain tumor patients and related this to the care givers.Materials and Methods: This is a questionnaire-based postal survey of 168 patients and their relatives. We examined how the health and psychological well-being of the caregiver may affect the quality of care.Results: There is significant physical, social, and psychosocial morbidity associated with caring for brain tumor patients. Patients worry about their care givers and this constitutes additional stress for the patient.Conclusions: No constructive and lasting improvement can be made to the quality of life of patients with brain tumor until the health and welfare of their care givers are factored into the care package. With better service to the patient, it is hoped that the burden of care will lighten for the care givers

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.Key words: Craniectomy, craniotomy, trauma flap, traumatic brain injur

Traumatic Extradural Hematoma in Enugu, Nigeria

Aim: Acute traumatic extradural hematoma (EDH) is life threatening and requires prompt intervention. This is a study of incidence and outcome of consecutive patients with EDH managed in Enugu, Nigeria against a background of delayed referral. Materials and Methods: We retrospectively examined all consecutive trauma cases managed between 2003 and 2009 and analyzed patients with acute traumatic extradural hematoma in isolation or in combination with other intra cranial lesions. Age, sex, cause of injury, time of presentation, Glasgow Coma Score (GCS), pupil reactivity, treatment and clinical outcomes were determined.Results: Of 817 head injuries, 69 (8.4%) had EDH, a mean of 9.9 patients per year. Males were 57 (83%) and females 12 (17%). Peak age incidences were the second and third decades of life, with a mean age of 30.2 years. Causes were road traffic accidents (57%), assault (22%) andfalls (9%). Twenty-six (38%) patients presented within 24 h of injury and only one patient presented within 4 h. The average time lag before presentation was 94.2 h. At presentation 39% had GCS of 13-15, 27% had 9-12 and 34% had 3-8. The most common location of hematoma was temporal (27.5%). Forty (59%) patients had surgery while 14 (20%) were managed conservatively. Ten patients (14.5%) died and of these 70% hadGCS <8 and 60% had a seizure.Conclusion: We conclude that early appropriate treatment of EDH results in good high quality survival (Glasgow Outcome Score 4 or 5). Low GCS should not be an absolute contraindication for surgery. Seizure prophylaxisshould be considered in patients with GCS <8.  Keywords: Demography, extradural hematoma, head injury, outcom

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 6th decade. Age of seizure onset had bimodal peak at 4th and 6th 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.Key words: Intracranial tumors, postoperative seizure outcome, seizure

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.Key words: Convulsion, imaging, pediatrics, surger

Decompressive craniectomy in the management of traumatic brain injury: a review of current practice

Wilfred Chukwuemeka Mezue,1 Chika Anele Ndubuisi,2 1Department of Surgery, Neurosurgery Unit, University of Nigeria Teaching Hospital, 2Memfys Hospital for Neurosurgery, Enugu, Nigeria Abstract: Decompressive craniectomy (DC) is now well established in the management of intractable raised intracranial pressure from various indications including trauma, ischemic strokes, and postoperative tumor surgery. In the setting of traumatic brain injury, the procedure has remained controversial – a difficulty that has not been completely resolved by available randomized studies. Available evidence suggests that there is a need for more clarity in the indications for DC in trauma, the intracranial pressure thresholds, and the timing of intervention. There is also a need to carefully distinguish between primary and secondary DC and to distinguish both from decompressive craniotomy if we are to resolve the current controversy. This article reviews the place and utility of DC in traumatic brain injury and the complications of the condition. Keywords: craniectomy, decompression, traumatic brain injur

The utility of storage of bone flaps in anterior abdominal wall pockets following decompressive craniectomies for severe traumatic brain injuries

Background: Decompressive craniectomy is widely practised for intractable raised intracranial pressure. Many methods are available for reconstruction but their use is limited by cost and organisation in developing countries. The simplest and perhaps the most useful is autologous bone. Difficulties arise on how best to store the bone until cranioplasty.Aim: To examine the difficulties and the utility of storing craniectomy bone flaps temporarily in anterior abdominal wall pockets.Methods: In this two-institution study, we retrospectively analysed the use of anterior abdominal wall pockets for the storage of autologous bone flap following decompressive craniectomy. Eleven patients from the Hull Royal Infirmary, UK and four from the Memfy's hospital for Neurosurgery, Nigeria met the criteria. Only patients with severe traumatic brain injury with marked intracranial hypertension as shown on computerized tomography and/or intracranial pressure monitoring, who received maximal medical treatment before and after decompressive craniectomy were included.Result: There was one case of bone flap infection for which titanium cranioplasty was done at 5 months. There was evidence of minimal bone resorption in two patients but this did not pose any difficulties with reconstruction. All patients showed secure and stable healing at follow-up.Conclusion: Cranioplasty using autologous bone flap is a safe and simple method of achieving cover following decompressive craniectomy. Storage of the bone in the anterior abdominal wall carries little and easily avoided risks that are comparable to the risks from the use of more sophisticated methods but is more cost effective. It is concluded that this is a method highly suited for developing countries. Keywords: Intracranial hypertension, Decompressive craniectomy, Autologous bone cranioplasty, Subcutaneous abdominal storag

Case Report - Severe traumatic brain injury managed with decompressive craniectomy

Patients with severe taumatic 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