Muhimbili Medical Centre
An epidemic of subacute bilateral visual failure has affected large numbers of teenagers and young adult Africans in coastal Tanzania since 1988. Previous work had indicated that many patients had sensory symptoms, but the nature of the neurological involvement was uncertain. The primary objective of a study was to characterize the accompanying neurological disorder. Furthermore, the nature of the visual loss was uncertain from previous reports as both retinopathy and optic neuropathy had been suggested. Full ophthalmic and neurological examinations were carried out at the Muhimbili University Hospital in Dar es Salaam. Nerve conduction studies, pattern electro-retinograms and cortical visually evoked responses and colour contrast sensitivity tests were carried out. Thirty eight young Africans and 12 controls were included in the study. The characteristic fundus picture was symmetrical temporal optic atrophy, and thinning of the caeco-central nerve fibre layer. Fluorescein angiography was normal. The electrophysiological and colour contrast sensitivity tests confirmed optic neuropathy in the majority of cases but primary retinal involvement was indicated in some. Neurological examination and nerve conduction measurements showed evidence of a peripheral neuropathy in 47% of the patients. The peripheral neuropathy is likely to have involved large fibres (from the nerve conduction studies) but the symptoms suggest small fibre loss also. 42% had developed hearing loss. Urinary thiocyanate levels were uniformly low. Serum was negative for antibodies to HTLV-1. DNA analysis from three cases was negative for three known mutations associated with Leber's hereditary optic atrophy (11778, 3460 and 14484). This entity, occurring predominantly in a young age group, does not correspond closely to other tropical neurological syndromes previously described from East Africa although it is clinically very similar to Strachan's syndrome (originally described in the Caribbean and more recently in prisoners of war) and also to an epidemic of optic and peripheral neuropathy that has recently occurred in Cuba. The aetiology has not yet been determined. A micronutrient deficiency is likely but has not been established 1).
Of 11 patients with pituitary tumor or suprasellar tumor seen at Muhimbili Medical Centre, Dar es Salaam, from January, 1980, until July, 1982, 6 (54.5%) were totally blind, 3 (27.3%) were blind in one eye and had severe visual impairment in the other, and 2 (18.2%) had marked visual field abnormalities but normal visual acuity in one eye. Blindness in most of these patients highlights the absence of neurosurgical services in many developing countries. In addition there is little prospect of countries like Tanzania establishing neurosurgical services in the foreseeable future. The only help for patients with neurosurgical problems is from referral overseas. This, however, is possible for only a limited number because of costs, unless neurosurgical units in developed countries offer their services at nominal cost. Such an offer would not only benefit patients who would otherwise die but would also help to further the interests of neurosurgery in the helper country 2).
A rare case of a 2-year-old boy with extremely large intracranial parasagittal meningioma is presented. To our knowledge, this case is the largest parasagittal meningioma to be reported to date in the pediatric age group.
The tumor size at its largest diameter was 14.2 cm. Two-stage craniotomy was performed within 3 weeks to resect the tumor totally by Simpson grade II while preserving the superior sagittal sinus. Three months after the second resection, the patient had a complication of subdural hematoma, which was managed by external drainage and urokinase.
The patient's postoperative recovery was unremarkable, and the previously compressed brain rebounded. There was no evidence of recurrence after two years of follow-up. Every effort should be exerted to achieve radical resection of the tumor, which can result in a satisfactory prognosis and a low recurrence rate 3).
A case of dural arteriovenous fistula (dAVF) developed after radical neck dissection for lymph node metastasis 2 years after oral surgery for tongue cancer.
The patient was asymptomatic during follow-up visits with no evidence of metastasis on follow-up CT scan of the neck. However, diagnostic angiography showed left internal carotid artery (ICA) stenosis and dAVF involving the posterior meningeal artery and transverse sinus at the left posterior fossa with cortical venous reflux (Cognard type III). They were treated with carotid stenting and surgery, respectively.
The postoperative course was uneventful. Follow-up angiography revealed obliteration of the dAVF.
This was a rare case of iatrogenic dAVF after surgical ligation of venous outflow during radical neck dissection. The surgical plan is presented along with a literature review regarding the development of iatrogenic dAVFs induced by direct surgical trauma 4).
In a retrospective review of 5 cases of OPI treated in the Neurotrauma Department at Xiangya Hospital of Central South University in the last 5 years. Also, we performed comprehensive literature searches using Web of Science and the terms “orbitocranial injury,” “penetrating ocular trauma,” “penetrating orbital trauma,” and “transorbital chopstick penetrating injury” to search for presentation, mechanism of injury, and management of transorbital penetrating injury.
In 2 patients, there was right internal carotid artery occlusion while in other 2 patients, the penetrating objects reached the brainstem through the cavernous sinus, resulting in orbital apex syndrome. All patients underwent a thorough physical examination followed by diagnostic imaging. The cases were successfully managed surgically by removing the foreign bodies through their trajectories.
Computed tomography, magnetic resonance imaging, and computed tomography angiography are key imaging modalities that are frequently used to determine the course of the foreign object and the extent of brain tissue injury as well as to rule out vascular injury in these types of cases. Early surgical exploration by a multidisciplinary team approach is essential to attain good recovery and a favorable outcome 5).
Bureta et al., reported a rare case of lumbar spine epidural abscess and facet joint septic arthritis caused by Streptococcus agalactiae, which had spread to the iliopsoas muscles, leading to urine retention.
A 68-year-old woman with low back pain experienced a sudden onset of bilateral lower limb weakness, it was followed 14 days later by urine retention. At consultation, magnetic resonance imaging and identification of serum β-hemolytic streptococci provided a diagnosis of Streptococcus agalactiae infection. She was started on antibiotics. Despite diminishing signs of inflammation, preoperative MRI showed an epidural mass at T12-L4 compressing the cord and involving the paravertebral muscles as well. Group B beta-hemolytic streptococci were detected in both urine and blood. Because of bilateral lower limb weakness and urine retention, T12-L4 hemilaminectomy was performed. The L3/L4 intertransverse ligament resected and abscess drained. Histopathology revealed that inflammatory cells had invaded the facet joint. Group B beta-hemolytic streptococci were identified, confirming the diagnosis. The patient continued with the antibiotics postoperatively, and her health rapidly improved.
Lumbar spine epidural abscess and facet joint septic arthritis caused by Streptococcus agalactiae is a clinical emergency, with significant morbidity and mortality especially with delayed diagnosis. A delay in both diagnosis and aggressive treatment can lead to not only severe neurological deficit but also to septicaemia, multiorgan failure, and even death 6).