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BACKGROUND: Improved surgical care and protocol-driven intensive care interventions for head injured patients have contributed to the overall reduction in mortality in developed countries. The aim of this study is to highlight the clinical outcomes of patients with severe traumatic brain injury managed in the multispecialty ICU of our institution. STUDY DESIGN: The medical records of all patients with severe TBI managed in our 3-bedded non-dedicated ICU over a 24-month period were reviewed. Data on demographic characteristics, mechanism of injury, neuroimaging and interventions were obtained and the primary outcome measure was the mortality. RESULTS: Fifty one patients, age ranged from 2-75 years and median age of 30 years were studied. The male sex was more involved (M;F of 12;1) and motorcycle crashes caused the majority of the injury (19,{37%}). None of the patients received pre-hospital care and about half (25 {49 %}) presented six hours post trauma. Cranial CT scan showed intracranial haemorrhage in 7 of the 21 patients stabled for neuroimaging. Overall mortality was 70%, with highest mortality recorded in those who did not have post injury brain CT scan (58% vs 82%, p = 0.066). CONCLUSION: Mortality from severe TBI is very high in our environment where routine pre-hospital care and prompt transfer to neurosurgical centres are not practiced. Lack of facilities for monitoring intracranial pressure and arterial blood gases in our ICU also contributed to the high mortality.

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This technical note describes a new simple, cheap and affordable adult cervical traction device that is especially suitable for use in resource-poor third world countries because of its cost-effectiveness. While the widely used imported Gardner-Wells tongs cost over N250,000 (Nigerian) naira (approximately $1630 USD), the new equally effective, durable and locally readily available Odebode-Agaja traction device sells for N35,000 naira (approximately $220 USD). The device does not require scalp incision or skull drilling. It is designed for bedside application in patients with cervical spine injuries, including subluxation and fracture-dislocation of the cervical spine from the atlanto-occipital joint to T1.

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BACKGROUND: Most studies of patients with head injury managed outside of indigenous Africa have shown poorer outcome with increasing age, but data on this subject is scanty in this part of the world. AIM: To determine age related pattern and outcome of head injury in an indigenous African setting. METHODS: A retrospective analysis of clinical characteristics, mechanism of head injury, associated injury, trauma scores and outcome in patients admitted for head injury at the University Teaching Hospital, Ilorin, Nigeria, between 1989 and 1999. RESULTS: The 648 patients comprised of 39 older subjects (= 60 yrs), 357 adults (17-59 yrs) and 252 children (= 16 yrs). They were aged 1 to 105 years (mean = 37years). Road traffic injury was the commonest cause of trauma to the head. Children were most often injured as pedestrians while adults and older patients were more often victims of passenger vehicular accidents. Older patients had the poorest outcome with a mortality rate of 48.7%. They were more prone to severe head injury (41.0%) and multi-system trauma (51.3%), with higher mean injury severity scores and lower probability of survival than younger patients. Outcome was predictable by age and GCS (p = 0.0206 & 0.0000) in all age groups put together and in children while GCS was a predictor in adults (p = 0.0000), and none of the variables could predict outcome in the older patients. CONCLUSION: The study reaffirms that outcome of head injury worsens with advancing age and indicates that severity of head injury and higher frequency of multi-system trauma may contribute to worse outcome in older patients.

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We retrospectively analysed the impact of selected clinicopathological factors on visual and clinical outcome in patients with histologically verified cranial meningioma. The 60 patients analysed for tumour characteristics consisted of 32 females and 28 males (sex ratio 1.1:1) aged 9-77 years (mean 40 years) seen between 1977 and 1999 at the University College Hospital, Ibadan, Nigeria. The patients for whom sufficient clinical data was available (n=35) presented within 2-60 months (mean 18 months) of symptom onset with large tumours (mean size 52 mm), and perifocal oedema (26/35), poor vision, focal neurological deficits, seizures and clinical evidence of intracranial hypertension. The most common tumour site was the convexity. There was loss of vision in 30/35 (85.7%) patients. Loss of vision was significantly related to tumour site and tumour size as well as perifocal oedema, (P<0.05). The case-mortality rate was 11.4% at 1 month and 20% at 6 months post-operation and was significantly correlated with intracranial hypertension. Neither age nor sex affected the outcome (P>0.05).

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Mucocoeles of the paranasal sinuses are relatively uncommon and rarely bilateral, the frontal and ethmoidal sinuses being most commonly affected. Rarely, fronto-ethmoidal mucocoeles expand and extend into the anterior cranial fossa producing mass effect. We report a 66-year-old woman, who presented with a 20-year history of recurrent bilateral progressive proptosis and supra orbital swellings with blindness in the left eye. Ultrasound scan of the left eye showed a large cystic mass in the orbit due to extension of ipsilateral frontal mucocoele. Computed tomographic brain scan showed large bilateral fronto-ethmoidal mucocoeles, erosion of the right orbital roof, right posterior and left anterior sinus walls, and extension of the right frontal sinus into the anterior cranial fossa with mass effect. The patient had a bicoronal craniotomy and bilateral fronto-ethmoidectomy with direct drainage of independent right mucocoele and left mucopyocoele. This case illustrates complications that may result from chronicity and treatment failure in patients with sinus mucocoeles.

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BACKGROUND: Neurofibromatosis type 1 (NF1) is the commonest single gene autosomal dominant disorder, and its diagnosis is usually composed of a set of clinical criteria. Histological examination of skin lesions is often neglected. This study was designed to evaluate the clinical and pathologic pattern of NF1 among Nigerians and to emphasize the place of histological examination. METHODS: A retrospective case study of 98 clinically diagnosed NF1 patients whose dermal mass lesions (neurofibromas) were excised and processed for histological diagnosis over a period of 22 years (1980-2001) at the University of Ilorin Teaching Hospital (UITH), Ilorin, Nigeria. RESULTS: There were 98 patients: 60 males and 38 females (ratio 3 : 2) aged 1-99 (mean +/- S.D. = 3.4 +/- 1.7) years. All patients had neurofibromas, which were benign in 95 patients (96.9%) and malignant in three (3.1%) patients, while 94 (96%) patients had cafe-au-lait spots. Benign neurofibromas were clinically cutaneous [50 (51%)], subcutaneous [37 (37.8%)] and plexiform [8 (8.2%)]. Site distribution of the neurofibromas included the extremities (50%), trunk (20.4%), head and neck (19.4%), and multiple sites (10.2%). Three patients presenting with neurofibosarcomas were aged 4, 23 and 27 years, respectively. Their deaths were responsible for the mortality rate of 3.1% recorded in this study. CONCLUSIONS: In our setting, NF1 is more common among males, with the highest density of neurofibromas covering the extremities.

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PURPOSE: To evaluate the pattern of ocular and visual complications of head injury. METHOD: A prospective study of 225 head-injured patients managed at the University of Ilorin Teaching Hospital, Ilorin, Nigeria. For the purpose of extracting visual complications, a Neurosurgeon and an Ophthalmologist examined each patient and appropriate investigations were carried out. Patients with ocular morbidity were analysed for age, sex, cause of injury, admission Glasgow coma score, and associated injuries in addition to findings at ophthalmic and neurosurgical evaluations. RESULTS: Two major types of ocular and visual complications were observed in 57 (25.3%) of 225 head-injured patients studied. Soft-tissue injury to the globe and adnexae included periorbital ecchymosis, subconjuctival haemorrhage, lid laceration, or rarely globe rupture in 29 patients. Neuro-ophthalmic ocular cranial nerve palsies occurred in 28 patients, while orbital fracture was encountered in two patients. Ocular injuries were multiple in 60% of cases. The patients, comprising 37 male and 20 female subjects, were aged 9 months to 57 years (mean=28 years). Traffic accident was the leading cause of head injuries (84.2%), while fall from height (7%), assault (7%), and gunshot (1.8%) were miscellaneous causes. CONCLUSION: Injury to the globe and adnexae and ocular cranial nerve palsies constitute the most common oculovisual complications following head injury in our centre.

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The essence of this study is to investigate the incidence, clinical profile and outcome of conservative treatment of cerebrospinal fluid rhinorrhoea and/or otorrhoea in head injured patients. Records of head injured patients between 1991 and 2000 at the University of Ilorin Teaching Hospital, Ilorin, Nigeria were retrieved and reviewed for demographic data, cause of head injury, incidence of CSF rhinorrhoea and/or otorrhoea and outcome of conservative management. Of the 794 patients, 39 (4.9%): 28 (71.8%) males and 11 (28.2%) females presented with CSF rhinorrhoea and/or otorrhoea. Nineteen (48.7%) of them had rhinorrhoea, 13 (33.3%) otorrhea and 7 (18%) had both. They were aged 1 to 60 years with a mean age of 28. More than 40% of them were aged 10 years or less and about a quarter were in the fourth decade of life. The commonest cause of injury in these patients was road traffic accident, 27 (69.2%). About a quarter sustained their injuries as a result of fall from height. The mortality rate among patients with CSF rhinorrhoea and/or otorrhoea (33.3%) was higher than among the total population of the head injured (23%). All survivors had spontaneous cessation of CSF leakage within two weeks of head injury. In our centre, the incidence of CSF rhinorrhoea and/or otorrhoea following head injury is 4.9%. Though this complication of head injury was associated with increased mortality rate, it does not appear to be a prognostic factor in head injury (P>0.05).

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Head injury is the most common cause of death following trauma among children in most developed and underdeveloped countries. Management of the head-injured child remained conservative in the hands of the general and orthopedic surgeons until October 2000 in our center. To determine outcome and outcome-predictors in children managed nonoperatively for head injury in Ilorin, Nigeria, a 10-year retrospective study of children managed for head injury was done. Outcome was measured by Glasgow outcome scoring. Clinical variables including age, gender, and postresuscitation Glasgow coma score were tested against Glasgow outcome score by linear regression analysis. During the study period (1989-1999), 267 children (173 males and 94 females) aged 16 years and below with head injuries were admitted. Their injuries were due mostly to road traffic accidents (64.1%) and falls (30.7%). Other injuries were domestic, sport-related, or due to assaults or the fall of collapsed walls, water-pots, and coconut shells on victims' heads. Head injuries were isolated in 60% of patients but associated with skeletal, facial, and spinal injuries in 58, 18, and seven cases, respectively. They were mild in 100 (37.5%), moderate in 73 (27.3%), but severe in 94 (35.2%) cases. Outcome was good in 207 (77.5%) but fatal in 38 (14.2%) children. Only age (p=0.0206) and coma score (p=0.0000), but not gender (p= 0.3043), could predict outcome. Outcome was good in more than 75% of cases of head-injured children managed nonoperatively. It varied with the patient's age and postresuscitation Glasgow coma score.

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Dementia is a growing medico-social problem worldwide because of the rising population of the elderly. About 10-30% of the cases have been found to be treatable or reversible with the improvement in neuro-diagnostic and neuro-imaging techniques. These reversible cases should be diagnosed without over-investigating the many patients with irreversible disease. We present a case of a reversible dementia due to Normal Pressure Hydrocephalus with dramatic surgical therapeutic response.

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Fronto-ethmoidal mucocoele is rare and will cause visual impairment and blindness when management is belated. In order to improve the awareness of its ophthalmic manifestations and problems associated with its management we retrospectively analyzed clinical, radiological and histological features in five illustrative cases. They all presented with unilateral supra-orbital swellings and proptosis, antedated by head injury in two cases. Other ophthalmic manifestations included eye lid swelling, progressive visual loss, unilateral ptosis, exotropia and diplopia. Only two patients had nasal symptoms. In all cases, x-rays of the paranasal sinuses revealed radiolucent frontal sinuses with eroded anterior walls, floors and midline septa. Brain scan in one case demonstrated opacification and enlargement of the corresponding sinus. Fronto-ethmoidectomy in four cases confirmed erosion of sinus' walls and floors and in one case of the contiguous supra-orbital ridge in addition to colored fluid aspirates. In all cases, the curetted sinus lining comprised of chronic inflammatory tissue. Surgical intervention was followed by prompt postoperative resolution of ophthalmic manifestations. A high level of suspicion is essential for early diagnosis and treatment of fronto-ethmoidal mucocoeles and will assist in preventing irreversible visual loss.

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PURPOSE: The cerebrum is frequently malformed in children with myelomeningocoele. This anomaly renders them potentially susceptible to cerebral visual impairment. In these patients, hydrocephalus is an important and frequent complicating lesion which compromises intellectual function and may also cause cerebral visual impairment. In this study, we determined whether hydrocephalic patients with lumbar myelomeningocoele (HLM) are at a greater risk of visual impairment than hydrocephalic patients without this lesion (H). METHODS: In this prospective study, we assessed five parameters of visual function in 20 hydrocephalic children with lumbar myelomeningocoele and compared the total visual function scores (TVFS) obtained with those from hydrocephalic children without overt spinal dysraphism, but similar in age, sex and ventricular size. The parameters, which were assessed with the aid of a quantitative grading scale, were pupillary size and reaction, optic atrophy, visual fixation and tracking. RESULTS: The age and sex distributions of the patients in the two groups were similar. The anterior and posterior dimensions of the lateral ventricles were also similar. The mean (SD) of the TVFS were 24.25 (3.63) and 24.20 (3.47) respectively for the two groups (P = 0.90). CONCLUSIONS: The results suggest that, in hydrocephalic infants with lumbar myelomeningocoele, visual function is not further diminished by the associated dysraphism and that ventricular dilatation is the major determinant of visual impairment.

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An omphalopagus set of female conjoined twins, undiagnosed prenatally, who presented as obstructed labour needing operative delivery is reported. Their anatomic characteristics and clinical features, including overwhelming sepsis in twin II which forced early separation, and those which led to their demise are described. Twelve other cases reported in Nigeria over the past 60 years are reviewed with reference to the aetiology and epidemiology of conjoined twinning and the determinants of successful surgical separation.

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We examined the relationship between ventricular size and visual function in 50 children (36 males and 14 females) with hydrocephalus. The third and lateral ventricular sizes and the visual function scores did not significantly differ between the sexes. Ventricular enlargement was most pronounced at the trigones and least at the level of the foraminae of Monro. The visual function score correlated inversely with the size of the lateral ventricle measured at the levels of the anterior horn and the trigone and expressed as coronal diameter and "Modified" Evans' ratio (r = 0.49; P = 0.001 and r = -0.38, P = 0.01 for the anterior horn; r = 0.48, P = 0.001 and r = -0.35, P = 0.001 for the trigone). The size of the third ventricle did not correlate with visual function score. A "modified" anterior Evans ratio of 0.60 and a trigonal Evans ratio of 0.73 were associated with very low visual function score. Furthermore, there was significant inverse correlation between occipitofrontal circumference (OFC) and visual function (r = -0.6379, P = 0.001), but OFC was not valuable for predicting visual function before the onset of head enlargement.

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