OpenUCT :: Browsing by Subject "Neurosurgery"

Browsing by Subject "Neurosurgery"

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Open Access
Adult neoplastic spinal cord compression
(2000) Pillay, Robin; Peter, J C
Spinal cord compression ( SCC ) constitutes a neurological emergency, and if left untreated, can result in permanent irreversible neurological dysfunction. Disabilities can range from mild weakness to complete quadriplegia with the inherent associated mental, physical and emotional suffering .The burden of cost to the individual and community is enormous.
Open Access
Advantages of delayed ventriculoperitoneal shunting in post haemorrhagic hydrocephalus seen in low birth weight infants
(1999) Taylor, Allan Grant; Peter, Jonathan C
INTRODUCTION: The incidence of intraventricular hemorrhage (IVH) in very low birth weight infants is between 25 and 50%. Approximately 13-60% of these patients will develop progressive post hemorrhagic hydrocephalus (PHH) and of these 22- 70% will require CSF diversion. The most common therapeutic intervention is insertion of a ventriculoperitoneal shunt but there is considerable controversy surrounding the timing of the operation. Most authors promote early surgery to prevent secondary injury from hydrocephalus but it was our impression that this was associated with a higher incidence of shunt complications. METHOD: The incidence of shunt complications in 36 patients shunted for PHH were retrospectively reviewed. Patients were treated at Red Cross Children's Hospital over an 8 year period. RESULTS: Nine (25%) of the 36 patients required shunt revision for obstruction, seven required revision during the initial admission. Shunt infection occurred in 4 patients (11 %) all during the initial hospital admission. Four patients died, one from a shunt related complication. There was a clear relationship between the timing of surgery and the incidence of complications (chi square test p,0.01 ). Nineteen patients underwent surgery before 5 weeks of age and 9 developed early shunt complications. Of those shunted after 5 weeks none had an early complication. Groups were matched for weight and grade of IVH. DISCUSSION: A possible explanation for these results is that shunt complications are related to the quantity of blood present in the CSF at the time of shunting. A short delay before intervention is recommended in an effort to reduce the morbidity of shunt complications.
Open Access
Brain arteriovenous malformations presenting with haemorrhage
(2012) Mjoli, Ntethelelo; Taylor, Allan; Feuvre, David Le
Includes bibliographical references.
Open Access
The Cape Town Stereotactic pointer clinical development and Applications
(2009) Fieggen, Anthony Graham; Peter, Emeritus Jonathan C
This dissertation describes the development and clinical use of a novel stereotactic neurosurgical system, the Cape Town Stereotactic Pointer (CTSP). This system has four main components; a halo containing three fiducials also serves as the platform for a tripod pointing device which is set with the aid of a 3D phantom or a printed setting diagram, and software which enables transformation of imaging space into patient space. Laboratory tests indicated an application accuracy of 1.9 +/- 0.6mm using the 3D phantom to set the tripod. From the first clinical application, the system underwent a series of iterations which could broadly be divided into four successive phases of refinement. This took place over a six year period, encompassing one hundred patients who underwent 115 stereotactic procedures. Indications for surgery included biopsy (62.6%), aspiration (15.7%) and cannulation (21.7%) and the surgical objective was realized in 101/109 cases (92.7%). Given the fact that six of the eight failures represented errors of surgical judgment that could not be ascribed to the device, and each of two system errors resulted in a significant modification to the system, the CTSP demonstrated a satisfactory level of accuracy in the clinical setting. This was accomplished at an acceptable complication rate, with one death five days after surgery attributable to a stereotactic procedure (mortality 0.9%) and major morbidity in two cases (1.7%); thirteen patients experienced minor complications, all of which proved to be transient (11.3%). A simple protocol for use of the CTSP evolved over the course of this study, making it easier for neurosurgeons from varying backgrounds to introduce stereotaxis into their practice with the help of this system. In addition to satisfactory levels of clinical reliability and safety, the system was versatile and also well tolerated by patients. It is hoped that the CTSP provides a costeffective alternative for neurosurgeons working in under-resourced settings. Sixty units of the production version of the CTSP have been sold and the system is now in use in ten countries.
Open Access
Decompressive craniectomy in children with traumatic brain injury
(2005) Figaji, Anthony Aaron; Peter, Jonathan C; Fieggen, A Graham
Although the conventional role of the operation was that of a salvage procedure when medical therapy failed in the treatment of raised intracranial pressure (ICP), two important concepts have emerged in the recent literature that appear to challenge that approach. In addition to the lack of evidence supporting benefit from current forms of treament, evidence from diverse studies that use data from magnetic resonance images, cerebral owygenation and cerebral blood flow measurements have highlighted potential adverse effects that may occur with these therapies.
Open Access
Development of an in vitro drug recovery model for paediatric tuberculous meningitis using microdialysis with in vivo application
(2022) Lourens, Rentia; Figaji, Anthony
Introduction: Tuberculous Meningitis (TBM) is the most devastating form of tuberculosis, leading to high rates of death and disability. Yet little has changed in drug regimens to treat TBM, in part due to the limitations of studying drugs at the site of the disease: the vast majority of studied samples are from spinal cerebrospinal fluid (CSF), most sampling is sporadic, and drug concentrations are usually reported as total (bound and unbound) concentrations. However, spinal CSF may not be the same as CSF derived directly from the brain (ventricular CSF), continuous or semi-continuous sampling would provide better pharmacokinetic data, and the unbound fraction of the drug would be more informative because it is the pharmacologically active component. Microdialysis (MD) is a method that is used in advanced clinical care to measure molecules in tissue, including the brain. It has some limitations, however, including the difficulty of calculating the relative recovery and potential anatomical compartmental effects in the brain. We aimed to adapt the method to address these limitations and for the first time produce high frequency data of unbound drugs in ventricular CSF using rifampicin in TBM as a model in vitro and in vivo. Aims: We aimed to establish a novel technique, using MD to continually measure Rifampicin in ventricular CSF of TBM patients. This involved 1) developing an appropriate system that could be used clinically, 2) determining the proportion of the drug that is recovered via the MD catheter (termed the recovery), 3) identifying parameters that affects the recovery, and 4) applying the model to the clinical setting. Methods: We developed a system with an embedded MD catheter to continuously drain artificial CSF with known concentration of Rifampicin and protein. The MD catheter had 20 kDa semipermeable membrane that allowed passage of only unbound drugs. To examine recovery, we compared rifampicin concentrations in hourly samples through the MD catheter (termed microdialysate) to total rifampicin in control CSF samples (obtained from the system before passage through the catheter). These were analysed using liquid chromatography – tandem mass spectrometry (LC-MS/MS). We considered several factors that may affect recovery in clinical practice, running several iterations that varied rifampicin concentration, protein concentration, MD perfusion pump rates, CSF draining rates, and system pressure (to mimic intracranial pressure). The method was then applied to paediatric TBM patients, where the MD catheter was placed in-line with an extra-ventricular drain (EVD) and the factors identified in vitro were stabilised. Rifampicin concentrations were measured in hourly microdialysate samples over 24 hours, and compared to control samples of ventricular CSF using LCMS/MS. Results: For the in vitro experiments, the effect of several variables on relative recovery were identified. Increased recovery was seen with a higher CSF draining rate and increased rifampicin concentration, while decreased recovery was seen with increased MD perfusion rate, increased protein concentration, and unexpectedly, increased pressure in the system (to mimic intracranial pressure). When translated to two patients with TBM we aimed to maintain intracranial pressure within a narrow range, and stable CSF drainage and MD pump rates. The in vivo unbound rifampicin concentrations from microdialysate were used to draw a 24-hour pharmacokinetic curve. The peak concentration (Cmax) in microdialysate was 221 ng/mL before enzyme induction (where drug administration had just started) and 100 ng/mL after enzyme induction (where the patient had been on Rifampicin for more than two weeks). The time of the peak (Tmax) in microdialysate was 11 hours after drug administration. The ratio of the unbound drug concentration to the total drug concentration of the control samples varied. Conclusion: This novel method is feasible to study unbound drug concentrations directly and continuously in the brain and provides high quality data for advanced neuropharmacokinetics. Factors in the clinical setting can be accounted for, and microdialysate results can be compared against sporadic control sampling. Clinical translation of this method was successful. These early data suggest very low concentrations of rifampicin in the brain with standard care. The results raise interesting hypotheses about the binding of Rifampicin to protein in the human brain. Our method can be applied to other drugs and data obtained from the method can inform dosing requirements and improve future drug development.
Open Access
The endovascular treatment of traumatic cranio-cervical vascular injuries
(2013) Ssenyonga, Peter Kato; Taylor, Allan; Feuvre, David Le
Includes abstract. Includes bibliographical references.
Open Access
Hyperextension injury of the cervical spine with central cord syndrome
(2013) Thompson, Crispin; Welsh, David
Includes abstract. Includes bibliographical references.
Open Access
Intracranial endoscopy
(Health and Medical Publishing Group, 2006) Figaji, A A; Fieggen, A G; Semple, P L; Peter, J C
In modern neurosurgery there has been a strong trend towards the use of minimally invasive techniques, one of which is intracranial endoscopy. Endoscopic third ventriculostomy (ETV) is the commonest procedure performed; it is used to treat hydrocephalus caused by an obstruction to the ventricular system anywhere distal to the mamillary bodies of the third ventricle. The obstruction is bypassed by a stoma created in the floor of the third ventricle, allowing cerebrospinal fluid (CSF) to flow freely into the subarachnoid space. Endoscopy can also be used for the fenestration of various intracranial cysts, intraventricular biopsy, the placement and retrieval of ventricular catheters, the removal of small intraventricular lesions, and improved visualisation in microsurgical operations. At Red Cross Children’s Hospital and Groote Schuur Hospital endoscopy has become an indispensable tool in the management of a wide range of neurosurgical conditions. As experience has accumulated worldwide, a better understanding of the benefits and limitations of endoscopy in diverse circumstances has emerged.
Open Access
Intracranial pressure monitoring as an early predictor of third ventriculostomy outcome
(2012) Roytowski, David; Padayachy, L
Includes abstract (p. [43].) Includes bibliographical references.
Open Access
Multimodality monitoring in paediatric severe traumatic brain injury : the contributions of brain oxygen, transcranial doppler and autoregulation monitoring to conventional methods on monitoring
(2008) Figaji, Anthony A; Peter, Jonathan C; LeRoux, Peter D
Traumatic brain injury (TBI) is a highly complex clinical condition in the most complex organ of the body. The foundation of care of the patient with severe TBI is the prevention of secondary insults to the brain. This relies on conventional monitoring tools to identify patients at risk, but often these may fail to detect important secondary insults. Moreover, the therapies that are used commonly in the critical care environment all have potential adverse effects, many of which may not be evident. TBI treatment in children is further complicated by changing thresholds with age, and the much smaller evidence base compared to their adult counterparts.
Open Access
Neuropsychological sequelae of paediatric posterior fossa brain tumours : the effect on quality of life
(2002) Leng, Jeanette Anne; Hemp, Frances; Peter, Jonathan; Oxtoby, Richard
Bibliography: leaves 248-285.
Open Access
Outcomes of decompressive craniectomy in adults with severe traumatic brain injury: the Groote Schuur Hospital experience
(2014) Enslin, Johannes Marthinus Nicolaas; Semple, P L
Object: The aim of this study was to assess outcome following decompressive craniectomy in adults with severe traumatic brain injury (TBI) in a South African neurosurgical unit. Methods: During a 78 month period (January 2005 – June 2011), 76 patients that underwent decompressive craniectomy for TBI in an attempt to lower raised intracranial pressure (ICP) were reviewed . All were older than 14 years and mass lesions were included. Thirty nine point four percent of the patients sustained blunt, low velocity injuries to the head and 19% were involved in motor vehicle accidents. Unilateral hemi-craniectomies were carried out in 81% of patients and 54 (75%) were done as primary decompressive craniectomies. Survivors were followed up for a period of at least six months and functional outcomes were measured using the Glasgow outcomes score. To simplify outcomes the patients were then dichotomised into outcome groups of good (GOS 4 and 5 ), and poor (GOS 1- 3). Results: At six months follow up 24 patients (33.3%) had a good outcome (GOS 4 or 5) and 48 patients (66.7%) had a poor outcome (GOS 1- 3). 32 patients (44.4%) died (GOS 1). There were 16 survivors in the poor group. Sixty percent o f survivors had a good outcome after decompressive craniectomy. Eighteen patients underwent secondary decompressive craniectomies and 54 (75%) primary decompressive craniectomies. Thirty - five percent of patients that underwent primary decompressive cranie ctomy had a good outcome, versus 38% in the secondary decompression group. Mortality was slightly higher in the primary decompression group (43%) than the secondary group (33%) . Factors that showed significant correlation with outcome were age, admission GCS and good response of ICP to decompressive craniectomy. Complications were encountered in 18% of patients with sepsis being the most common (11%). Conclusion: Decompressive craniectomy was associated with a functional outcome that was better than exp ected in patients with severe TBI and should still form part of salvage therapy in adults with TBI and elevated ICP.
Open Access
Paediatric brain tumours: The University of Cape Town experience from 1996 - 2017
(2019) Arnold-Day, Christel; Figaji, Anthony
Brain tumours are the second most common malignancy in children(1) (2), and despite some advancements being made over the last 2 decades, patient outcomes in general remain poor when compared with other childhood cancers. Optimal treatment of children with brain tumours is challenging and expertise and resources are not widely available in South Africa. This is important because the outcomes of children with brain tumours depend critically on the expertise and resources of a multidisciplinary team tasked with their treatment. Despite the importance of paediatric brain tumours though, little is known about childhood brain tumours in South Africa as limited data have been published and there have been no funded studies to support research in this area. In addition, we know very little about the resources available across the country to treat these children. In international centres of excellence the best outcomes are achieved by combining good epidemiological data, strong multidisciplinary teams, centralization or regionalization of services, available resources, and a research foundation. To start, we need to know more about the patients presenting to us with brain tumours. PURPOSE The overall aim of this project was to collect epidemiological data for childhood brain tumours at a tertiary paediatric hospital in South Africa with a dedicated multidisciplinary team. METHODS Study design: A retrospective review of records of patients diagnosed with a primary brain tumour and who presented to Red Cross Children’s Hospital (RCCH) system from 1 January 1996 to 31 December 2017. 2 Patient selection & data collection: Patients were identified by combining databases and admission logs from paediatric neurosurgery, oncology, radiotherapy, histopathology and radiology. Data collected included: age at diagnosis, sex, province of referral, tumour site and diagnosis. RESULTS A total of 554 paediatric patients with primary brain tumours were identified over the study period. Tumours were more common among males (55.4%) and were located in the supratentorial compartment in 52%. The median age at diagnosis was 5.92 years. The commonest tumours were astrocytomas (n=114 patients; 20.3%), followed by medulloblastomas (incl. PNETs) (n=107 patients; 19.1%), and craniopharyngiomas (n=55; 9.8%). As expected, most patients referred and seen at RCCH/GSH were from the expected drainage area in the Western Cape (73%), but a significant number of referrals (27%) were from outside the province referrals, especially in the last 10 years. CONCLUSION Our findings were largely consistent with the published literature in terms of histological diagnosis, sex profile and age ranges for children diagnosed with brain tumours with some small differences possibly related to referral bias. More patients than expected were referred from outside of the province, which emphasizes the need for establishing an ongoing tumour database registry and co-ordinating patient care across institutions. A follow-up study to assess patient management and outcomes is of critical importance to assess resource availability and patient outcomes.
Open Access
Pituitary apoplexy : can histopathology, radiological imaging and predisposing factors be used in predicting outcome?
(2008) Semple, Patrick Lyle; Peter, J C
Pituitary apoplexy is an uncommon, yet potentially fatal illness, usually the result of infarction, hemorrhage or a combination of both in a pituitary tumor. The management of pituitary apoplexy consists of replacement therapy and in the majority of patients, surgical decompression, although some cases may be treated conservatively. Up to now no study has attempted to separate the two histopathological types of pituitary apoplexy or to analyze their clinical and radiological significance on presentation and outcome.
Open Access
The prevalence of cerebral hypoxia/ischemia in pediatric severe traumatic brain injury
(2010) Padayachy, L C
Open Access
Profiling medulloblastoma and juvenile pilocytic astrocytoma brain tumours in a South African paediatric cohort
(2017) Nair, Omesan; Figaji, Anthony; Blackburn, Jonathan M
Brain tumours in children are one of the most challenging diseases to treat, and so outcomes are variable and often lacking. There are currently no reliable data of presentation of disease, the spectrum of tumours treated, how these are treated, and what the outcomes are for children in South Africa, and certainly no molecular biology data. In this respect, this thesis investigated the two commonest types of childhood brain tumour, the highly malignant Medulloblastoma (MB) and the generally less aggressive Juvenile Pilocytic Astrocytoma (JPA) with relation to their molecular biology and their clinical correlates to begin to address this gap and build capacity for further molecular-based studies in an African context. The study design in this thesis takes a systematic approach and is structured into MB and JPA biochemical characterisation followed by 4 studies of their respective proteomic profiles. The study design involved creating appropriate patient cohorts and determining sample characteristics for interpretation of results. The statistical power achieved in this thesis showed a minimum of 2-fold difference for a power greater than 0.8 in each case. Proteomic clustering was used to validate or delineate any discrepancies in subtype assignments for MB. Molecular profiles together with proteomic data of MB and JPA cases in this thesis provide evidence for some novel molecular pathways, proteins and peptides associated with pathogenesis. This work therefore provides extensive data that is hypothesis generating for further studies that could build upon molecular understanding in a South African and larger African context.
Open Access
Radiotherapy for head and neck paragangliomas: A 10 year retrospective review 2005-2014 at Groote Schuur Hospital and UCT Private academic hospital
(2019) Wegoye, Emmanuel; Parkes, Jeannette; Taylor, Allan
Objective. Over the last two decades there has been increasing evidence that radiosurgery and radiotherapy management of skull-base paragangliomas is as effective as microsurgical resection and carries less morbidity. This 10 year retrospective review of 24 patients in a single institution, treated over 10 years assesses tumour control rates and morbidity associated with radiosurgery and radiotherapy treatment. Method. Patients with a radiological diagnosis of skull-base paragangliomas were treated with different techniques of stereotactic and image-guided radiotherapy delivering hypo fractionated irradiation. Techniques used included conventional radiotherapy or intensity modulated radiotherapy (IMRT), dynamic arc (DA) and volumetric modulated arc therapy (VMAT). Analysis of local tumour control was performed using RECIST criteria and the KaplanMeier method. 69% of patients received 14-16gy in 1-3 fractions while 31% received 48- 50gy in 25 fractions. Radiation-associated toxicity was graded according to the commonly used Radiation therapy Oncology group (RTOG) toxicity criteria. Results. 24 patients with skull-base paragangliomas were treated with a median follow up of 43 months. One patient lost to follow up and was excluded. Tumour control was achieved in 96% of patients. 76% of patients treated reported no radiation associated toxicity. 24% of patients had some radiation associated toxicity: the conventional group 12%, stereotactic radiosurgery 8% and stereotactic radiotherapy 4%. 43% of patients in the conventional group had progression of hearing loss in the affected ear. One patient in the radiosurgery group developed osteonecrosis of the temporal bone at 5 year follow up. Conclusion. Radiosurgery and radiotherapy are efficacious in achieving tumour control with minimal morbidity. Tumour control rates in the study are similar to control rates in literature. Radiation associated toxicities are mainly minor. Study is limited by the retrospective nature and limited duration of follow up.
Open Access
Severe head injuries in children
(1997) Semple, Patrick Lyle; Bass, David
The aim of this dissertation is to review the current literature on severe head injuries in children, with particular respect to epidemiology, clinical features and investigation, pathophysiology, management and outcome. In addition a retrospective study was carried out on severe head injuries at Red Cross War Memorial Children's Hospital. Finally, the findings of this study are discussed in the light of the experience of other neurosurgical and trauma centres. In this way similarities as well as features peculiar to our setting can be identified with the aim of improving the understanding and management of severe head injuries in children in the Western Cape.
Open Access
Spinal compression in childhood : the University of Cape Town experience
(1996) Buwembo, Joseph E; Peter, Jonathan
Aim: A retrospective study of cases of childhood spinal compression over a 30-year period (1963-1992) was undertaken in order to determine the trend in incidence, aetiology, diagnosis, treatment and prognosis. Patients and Methods: The study includes children less than 15 years of age who were treated for spinal compression at the Red Cross War Memorial Children's Hospital, Maitland Cottage Hospital and Groote Schuur Hospital. Children who had tuberculosis of the spine without a neurological deficit, were excluded. The study also excludes dysraphism and non-compressive causes of paraplegia, such as Guillain-Barre Syndrome and poliomyelitis.