Browsing by Author "Candy, Sally"

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    An analysis of the CT and CT angiogram findings of methamphetamine induced stroke in young adults (≤45 years) presenting to GSH Emergency department
    (2023) Ngamolane, Aaron; Candy, Sally
    MMED Title: An analysis of the CT and CT angiogram findings of methamphetamine induced stroke in young adults (≤ 45 years) presenting to GSH emergency department. The recreational use of methamphetamine in the Republic of South Africa is on the rise accounting for 30% of patients admitted to addiction rehabilitation centres countrywide1 . In the Western Cape province alone methamphetamine is the commonly abused drug, detected in 44% of patients admitted for addiction rehabilitation2 . Methamphetamine is a risk factor for stroke especially in young adults, it is therefore important to determine key radiological features of methamphetamine related stroke for prompt and accurate differentiation from other stroke aetiologies. Study of stroke in this group of participants is of paramount importance as stroke is the second most common cause of death worldwide, responsible for 11.8% of all deaths after ischaemic heart disease (14.8%)3 . Stroke is also responsible for 4.5% of disability adjusted life years (DALYs)3 . The aim of the study was to determine whether stroke in young adults (≤ 45 years) exposed to methamphetamine can be differentiated from other stroke aetiologies on brain CT and CT angiogram. A cross-sectional retrospective study was performed in the department of radiology in Groote Schuur Hospital on brain CT and CT angiograms and their final reports from October 2012 to October 2020. All patients aged 45 years old or younger with clinical features of stroke and a history of methamphetamine or polysubstance abuse were included. Data collection tools were designed to suit inclusion criteriums and used as search keywords in the PACS for GSH. A re-read was done by the principal investigator as a second-year radiology registrar with limited neuroradiology experience guided by the study parameters outlined in the data collection tool. The obtained data was correlated with the finalized reports from each study. Our study has shown that in a group of young patients who admitted to using tik and who presented to the emergency room with clinical features of cerebral stroke, ischaemic infarct was found significantly more often than intracerebral haemorrhage. This study demonstrated that MCA territories were most frequently involved with occlusion of the M1 segments bilaterally. Radiologically loss of grey-white matter interface and a wedge-shaped appearance are the predominant patterns of radiographic presentation. This study has demonstrated that CT appearance of methamphetamine induced stroke does not differ from stroke patterns seen with traditional risk factors.
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    Computed tomography findings in patients with minor head trauma presenting with a history of loss of consciousness and/or amnesia, Glasgow Coma Scale 15 and no focal neurological deficit
    (2017) Singata, Chuma; Candy, Sally
    Background: South Africa is a developing country with limited resources. Currently, in our institution, patients who have suffered a minor head injury with a Glasgow Coma Scale (GCS) 15, loss of consciousness (LOC) and amnesia obtain a computed tomography (CT) scan, regardless of the cost that is incurred by the use of this limited resource. Applying recommendations in developing countries requires consideration of resource limitations and patient burden. Objective: Our objectives were twofold: 1. To determine the number of abnormalities found on routine head CTs in patients who have a history of LOC and amnesia/PTA post trauma, but with a normal mental status (GCS 15) on presentation to the trauma unit. 2. To determine the clinical value of routine CT scan of the head in patients who have suffered minor head injury with GCS 15, LOC and amnesia. Methods: The CT scan reports of 460 patients with minor head injury, GCS 15, LOC and amnesia were reviewed retrospectively in the radiology unit of Groote Schuur Hospital between the years 2012 and 2014. These patients were assessed by the trauma doctor and referred to the radiology department for a CT scan of the head. Reports had been prepared and verified by a radiology specialist or senior registrar. Results: The findings on CT were categorized as significant and insignificant. A total of 33 patient reports (7%) met the criteria of significant findings that required neurosurgical intervention. (CI 4, 7-9, 6). 320 patients (70%) had normal findings while 107 patients (23%) had insignificant findings. Conclusion: CT scan of the head in minor head injury patients with normal mental status (GCS 15) is recommended even in the face of the limited resource in view of our study results.
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    CT angiogram findings in patients presenting with mechanical strangulation and near hanging injuries
    (2019) September-Jaffer, Zorina; Candy, Sally
    Background: Blunt cerebrovascular injury (BCVI) is relatively uncommon in near-hanging and strangulation injuries but may have devastating neurological outcome. In developed countries, CT angiography (CTA) of the head and neck is performed as a screening tool in the acute clinical setting. This study was undertaken to assess the prevalence of vascular injury in patients presenting acutely to GSH trauma unit with these injuries and to recommend guidelines to ensure rational use of CTA in our resource restricted environment. Aim: 1. To assess the prevalence and nature of vascular injury in patients referred for CTA imaging following strangulation or hanging injury at our institution. 2. To determine if international criteria (modified Denver Criteria) for CTA referral for suspected BCVI due to strangulation or hanging injuries are followed at our institution. 3. To determine if international criteria for CTA imaging following suspected BCVI are appropriate following strangulation or hanging in a resource-restricted environment, and to identify aspects of existing protocols that may require future discussion. Method: This is a retrospective, quantitative, cross-sectional review of patients who had CTA studies after presenting with either strangulation or hanging to an urban Level 3 Trauma Unit. Radiological reports for the 45-month period ranging from January 2013 until September 2016 were reviewed and the frequency of positive findings was recorded. Results: 45 patients met the inclusion criteria after presenting with a history of strangulation (n=8) or hanging (n=37). The average age was 31 years, 73% were male, 18% presented with strangulation injuries and 82% presented after hanging. 82% received a non-enhanced CT head scan and all patients had CTA scans of the neck and head. Six (13%) vascular injuries were reported on CTA (2 arterial and 4 venous). Both arterial injuries were reported in the strangulation group and none after hanging (p < 0.05). Two venous injuries were reported in each group). No base of skull, cervical spine or Le Fort facial fractures were demonstrated and there was no correlation between nadir of GCS and the presence of vascular injury on CTA. Conclusions: In this study comparing BCVI in strangulation and hanging, arterial injury was reported only in patients presenting after strangulation. Although such injury may be partially attributable to other co-existing mechanisms of trauma we support the continued use of CTA screening in the setting of strangulation injury in a resource restricted environment. The absence of arterial injury in the setting of near-hanging, however, argues against routine screening CTA screening even in patients with depressed level of consciousness.
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    CT angiographic detection of cerebral aneurysms in patients with subarachnoid haemorrhage in a South African institution
    (2020) Chisha, Mike; Candy, Sally; Hartley, Qonita Said
    Study rationale The incidence, location, morphology and size characteristics of cerebral aneurysms in patients presenting to Groote Schuur hospital with either subarachnoid haemorrhage or 3 rd nerve palsy have not been established by a formal audit. Objectives To determine the patient demographics, frequency of CT angiographic detection of cerebral aneurysms and aneurysmal characteristics in patients presenting to Groote Schuur Hospital with sub-arachnoid haemorrhage and /or 3 rd nerve palsy Materials and methods Computed tomographic angiographic reports of cerebral vessels of patients who presented either with subarachnoid haemorrhage or 3 rd nerve palsy to Groote Schuur hospital were reviewed over a 19-month period from January 2018 – July 2019. The data obtained were coded, entered and analysed using IBM SPSS version 25 software. Descriptive statistics was used to report the means, modes and frequencies. Demographic and aneurysmal data were compared with a similar period 5 years previously. Results One hundred and twenty-one aneurysms (121) were analysed in 2018 -2019 and 124 in 2013-2014. The large majority were solitary (92% in both groups), small (94% and 90%) and saccular (96% and 87%) respectively. Significantly more fusiform aneurysms (13% vs 6%) were seen in the earlier group. 8 % of patients had multiple aneurysms. Less than 1% were ‘giant' ( >20mm). The mean age of the patients was the same for both periods (47 years). The mean aneurysm body size was 5.7mm and 7.1mm and the mean body: neck ratio was 6 2.1 vs 1.8b). Themost frequent locations were the posterior communicating artery (31.4% [2018/2019], 35% [2013- 2014]), anterior communicating artery (29% [2018/2019], 18.5% [2013/2014]) and the middle Cerebral Arteries (13.2% [2018/2019], 13.7% [2013/2014]). The least common sites were the Superior Cerebellar artery (SCA) [2018/2019] and the Vertebral artery (0.8%) [2013/2014]. Conclusion This study has compared the demographics of patients presenting to Groote Schuur Hospital with CT angiographically confirmed symptomatic intracranial aneurysms over two periods (January to July) 5 years apart. Both the patient demographics and the aneurysmal architecture were consistent over these time periods. Further our findings conform to that described previously both in Southern Africa and abroad i.e aneurysms which have bled are most commonly related to the posterior communicating, anterior communicating and the middle cerebral arteries and most aneurysms are small and saccular in shape. Over the periods studied, there was no change in the number of patients presenting to Groote Schuur Hospital for CT cerebral angiography and Interventional treatment post aneurysm rupture. These data represent a baseline for future statistical comparison and the information extrapolated from this study will be useful for interventive planning and resource mobilization at our institution and within the Western Cape Department of Health.
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    Reliability and diagnostic performance of CT imaging criteria in the diagnosis of tuberculous meningitis
    (Public Library of Science, 2012) Botha, Hugo; Ackerman, Christelle; Candy, Sally; Carr, Jonathan A; Griffith-Richards, Stephanie; Bateman, Kathleen J
    Introduction Abnormalities on CT imaging may contribute to the diagnosis of tuberculous meningitis (TBM). Recently, an expert consensus case definition (CCD) and set of imaging criteria for diagnosing basal meningeal enhancement (BME) have been proposed. This study aimed to evaluate the sensitivity, specificity and reliability of these in a prospective cohort of adult meningitis patients. METHODS: Initial diagnoses were based on the CCD, classifying patients into: ‘Definite TBM’ (microbiological confirmation), ‘Probable TBM’ (diagnostic score ≥10), ‘Possible TBM’ (diagnostic score 6-9), ‘Not TBM’ (confirmation of an alternative diagnosis) or ‘Uncertain’ (diagnostic score of <6). CT images were evaluated independently on two occasions by four experienced reviewers. Intra-rater and inter-rater agreement were calculated using the kappa statistic. Sensitivities and specificities were calculated using both ‘Definite TBM’ and either ‘Definite TBM’ or ‘Probable TBM’ as gold standards. RESULTS: CT scan criteria for BME had good intra-rater agreement (κ range 0.35-0.78) and fair to moderate inter-rater agreement (κ range 0.20-0.52). Intra- and inter-rater agreement on the CCD components were good to fair (κ  =  ranges 0.47-0.81 and 0.21-0.63). Using ‘Definite TBM’ as a gold standard, the criteria for BME were very specific (61.5%-100%), but insensitive (5.9%-29.4%). Similarly, the imaging components of the CCD were highly specific (69.2-100%) but lacked sensitivity (0-56.7%). Similar values were found when using ‘Definite TBM’ or ‘Probable TBM’ as a gold standard. DISCUSSION: The fair to moderate inter-rater agreement and poor sensitivities of the criteria for BME suggest that little reliance should be placed in these features in isolation. While the presence of the CCD criteria of acute infarction or tuberculoma(s) appears useful as rule-in criteria, their absence is of little help in excluding TBM. The CCD and criteria for BME, as well as any new criteria, need to be standardized and validated in prospective cohort studies.
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    Silent casualties from the measles outbreak in South Africa
    (2011) Albertyn, Christine; Van der Plas, Helen; Hardie, Diana; Candy, Sally; Tomoka, Tamiwe; LeePan, Edward B; Heckmann, Edward B
    South Africa, home to the world’s largest population of people living with HIV (5.7 million), experienced a measles outbreak that started in late 2009.1 There was a stepped increase in cases of measles, with the highest incidence reported in March 2010.2 By September 2010, more than 17 000 new measles cases had been reported to the National Institute of Communicable Diseases since January 2009. A mass vaccination campaign from mid-April to early May 2010 resulted in a significant decline in new measles cases. The measles virus is highly contagious, and outbreaks are fuelled by overcrowding and poor vaccine coverage, making elimination status in South Africa difficult to attain. Measles may infect the central nervous system (CNS) as acute viral encephalitis, or result after 2 - 4 weeks in a post-infectious immune-mediated inflammatory disorder or acute disseminated encephalomyelitis (ADEM). There are 2 further rare and latent CNS complications resulting from a preceding measles infection: subacute sclerosing panencephalitis (SSPE) caused by years of viral persistence in a seemingly immunocompetent host,3 and subacute measles encephalitis (SME), occurring in an immunocompromised host.4 SME manifests 1 - 7 months after the acute measles infection.5 Patients present with seizures, often epilepsy partialis continua, and altered mental status.5 It carries a mortality rate of 85% and survivors often have significant psychomotor retardation.5 SME has hitherto only been described in single case reports as a rare complication of measles in the context of organ transplantation,6,7 immunosuppressive therapy or immunodeficiencies,5,8 and HIV and AIDS.5,9,10 We report 8 cases of SME in HIV-infected patients who presented to a tertiary referral hospital between July and October 2010.