Publications by authors named "Edward Komolafe"

25 Publications

  • Page 1 of 1

Developing a Guideline for Neurotrauma in Nigeria.

World Neurosurg 2020 06 13;138:e705-e711. Epub 2020 Mar 13.

Department of Surgery, National Hospital, Abuja, Nigeria.

Background: The Nigerian Academy of Neurological Surgeons in 2019 resolved to standardize the practice of neurosurgery in Nigeria. It set up committees to standardize the various aspects of neurosurgery, such as neurotrauma, pediatrics, functional, vascular, skull base, brain tumor, and spine. The Committee on Neurotrauma convened and resolved to study most of the available protocols and guidelines in use in different parts of the world.

Objective: To formulate a standard protocol for the practice of neurotrauma care within the Nigerian locality.

Methods: The Committee split its membership into 3 subcommittees to cover the various aspects of the Neurotrauma Guidelines, such as neurotrauma curriculum, standard neurotrauma management protocols, and neurotrauma registry. Each subcommittee was to research on available models and formulate a draft for Nigerian neurotrauma.

Results: All the 3 subcommittees had their reports ready on schedule. Each concurred that neurotrauma is a major public health challenge in Nigeria. They produced 3 different drafts on the 3 thematic areas of the project. The subcommittees are: 1. Subcommittee on Fellowship, Training and Research Curriculum; 2. Subcommittee on Standard Protocols and Management Guidelines; and 3. Subcommittee of the Nigerian Neurotrauma Registry.

Conclusion: The committee concluded that a formal protocol for neurotrauma care is long overdue in Nigeria for the standardization of all aspects of neurotrauma. It then recommended the adoption of these guidelines by all institutions offering services in Nigeria using the management protocols, opening a registry, and mounting researches on the various aspects of neurotrauma.
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June 2020

Idiopathic intracranial hypertension: Proposal of a stratification strategy for monitoring risk of disease progression.

Clin Neurol Neurosurg 2019 04 15;179:35-41. Epub 2019 Feb 15.

Neurosurgery Division, Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria; Faculty of Clinical Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria.

Objectives: A general consensus based on a multidisciplinary perspective involving an international panel was recently developed for management of patients with idiopathic intracranial hypertension (IIH). In this paper, the authors sought to develop further on the aspect of this consensus that concerns monitoring progression of the disease.

Patients And Methods: A systematic literature review of previous publications on monitoring disease progression in IIH and a meta-analysis to examine efficacy of method of monitoring employed in each study. The authors present a brief descriptive analysis of challenges with monitoring progression of the disease and propose a risk stratification to aid monitoring.

Results: Of a total of 382 publications identified from the literature search, only 8 studies (144 patients) satisfied inclusion criteria and were included for analysis. Among these, 3 were based on ICP monitoring while the remaining 5 focused on ophthamological evaluation. Interestingly, there were neither any studies on monitoring with progression of clinical features nor any study on monitoring with symptomatology associated with IIH among the selected studies.

Conclusion: There is a paucity of studies in the literature on methods of monitoring disease progression in IIH. Though close attention to adequate evaluation and proper care of patients with IIH remains the key in managing this problem, this proposed risk stratification will be an objective tool and useful guide to better monitor these patients according to their extent of risk from the disease and possibly for planning treatment and intervention.
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April 2019

The pattern, peculiarities, and management challenges of spina bifida in a teaching hospital in Southwest Nigeria.

Childs Nerv Syst 2018 02 12;34(2):311-319. Epub 2017 Oct 12.

Air Force Hospital, Jos, Plateau State, Nigeria.

Purpose: Spina bifida is a common congenital anomaly of the nervous system. It is frequently associated with significant morbidity and sometimes mortality in affected children. In this paper, we review the clinico-epidemiological pattern, peculiarities, and therapeutic challenges of this condition in our practice setting.

Methods: This is a retrospective study of all cases of spina bifida managed from July 2000 to March 2016 at a tertiary health facility located in the southwest region of Nigeria. Relevant information was retrieved from the medical records. The data was collected using a pro forma and analyzed with SPSS version 22.

Results: Data from 148 patients was reviewed and analyzed. There were 78 males and 70 females. Only 5.8% of these children were delivered at the health institution. A fifth (20%) of the patients were first born of their mothers. The mean maternal age was 29 years. Few (10.1%) mothers use folate medication prior to conception and only 58% of the mothers use folate during antenatal care. Mean duration of pregnancy was 38 weeks. The most common anatomical site was lumbosacral region (74.3%) while the most common pathology was myelomeningocele 80.4%. Mean age at surgery was 88.68 h. Mean duration of surgery was 92.8 min. Mean follow-up duration was 46.8 weeks. As many as 59% of the patients had some neurologic improvement noticed during follow-up clinic visits.

Conclusion: Spina bifida occurs frequently in our environment. Low socio-economic status and poor antenatal clinic visits contributes significantly to its occurrence.
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February 2018

Neurosurgery in rural Nigeria: A prospective study.

J Neurosci Rural Pract 2016 Oct-Dec;7(4):485-488

Department of Surgery, Division of Neurological Surgery, Federal Medical Centre, Ido-Ekiti, Nigeria; Department of Surgery, Division of Neurological Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria.

Background: Africa has very few neurosurgeons. These are almost exclusively in urban centers. Consequently, people in rural areas, most of the African population, have poor or no access to neurosurgical care. We have recently pioneered rural neurosurgery in Nigeria.

Objectives: This report details our initial experiences and the profile of neurosurgical admissions in our center.

Methods: A prospective observational study of all neurosurgical patients managed at a rural tertiary health institution in Nigeria from December 2010 to May 2012 was done. Simple descriptive data analysis was performed.

Results: A total of 249 males (75.2%) and 82 females (24.8%) were managed. The median age was 37 years (range: Day of birth - 94 years). Trauma was the leading cause of presentation with 225 (68.0%) and 35 (10.6%) having sustained head and spinal injuries, respectively. Operative intervention was performed in 54 (16.3%). Twenty-four (7.2%) patients discharged against medical advice, mostly for economic reasons. Most patients (208, 63.4%) had satisfactory outcome while 30 (9.1%) died.

Conclusion: Trauma is the leading cause of rural neurosurgical presentations. There is an urgent need to improve access to adequate neurosurgical care in the rural communities.
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October 2016

Patterns of pre-hospital events and management of motorcycle-related injuries in a tropical setting.

Int J Inj Contr Saf Promot 2017 Sep 9;24(3):382-387. Epub 2016 Aug 9.

c Department of Surgery , Obafemi Awolowo University Teaching Hospitals Complex , Ile-Ife , Nigeria.

This study sought to highlight associated factors and evaluate outcomes of motorcycle-related injuries (MCRI) among adults managed in a university teaching hospital in south-western Nigeria. The study was a cross-sectional descriptive study of 150 adult patients presenting with MCRI at the adult accident and emergency unit of the hospital. Information on the use of helmet, alcohol intake, number of pillion passengers, type of collision and time of arrival at hospital was collected. Patients were followed up and questionnaires were completed after discharge, referral or death. The male to female ratio was 4:1 with patients aged 20-29 years (n = 44, 29.3%) having the highest incidence of MCRI. Only 4 (2.7%) patients used helmet at the time of injury. About one-third of the patients (n = 59, 39.3%) arrived at the hospital within 1-6 hours after injury. The limbs were the most frequently involved site of injury, hence orthopaedic procedures constituted the highest number of interventions. Mortality rate was 10.7% (16 out of 150) with head injury being the leading cause. MCRI requires more emphasis on preventive measures. This will play a crucial role in the reduction of the associated morbidity and mortality.
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September 2017

Paediatric day-case neurosurgery in a resource challenged setting: Pattern and practice.

Afr J Paediatr Surg 2016 Apr-Jun;13(2):76-81

Department of Anaesthesia and Intensive Care, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria.

Background: It has been generally observed that children achieve better convalescence in the home environment especially if discharged same day after surgery. This is probably due to the fact that children generally tend to feel more at ease in the home environment than in the hospital setting. Only few tertiary health institutions provide routine day-case surgery for paediatric neurosurgical patients in our sub-region.

Objective: To review the pattern and practice of paediatric neurosurgical day-cases at our hospital.

Patients And Methods: A prospective study of all paediatric day-case neurosurgeries carried out between June 2011 and June 2014.

Results: A total of 53 patients (34 males and 19 females) with age ranging from 2 days to 14 years were seen. Majority of the patients (77.4%) presented with congenital lesions, and the most common procedure carried out was spina bifida repair (32%) followed by ventriculoperitoneal shunt insertion (26.4%) for hydrocephalus. Sixty-eight percentage belonged to the American Society of Anesthesiologists physical status class 2, whereas the rest (32%) belonged to class 1. General anaesthesia was employed in 83% of cases. Parenteral paracetamol was used for intra-operative analgesia for most of the patients. Two patients had post-operative nausea and vomiting and were successfully managed. There was no case of emergency re-operation, unplanned admission, cancellation or mortality.

Conclusion: Paediatric day-case neurosurgery is feasible in our environment. With careful patient selection and adequate pre-operative preparation, good outcome can be achieved.
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September 2017

Optic nerve sonography: A noninvasive means of detecting raised intracranial pressure in a resource-limited setting.

J Neurosci Rural Pract 2015 Oct-Dec;6(4):563-7

Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria.

Objective: The aim was to assess the use of optic nerve sonography (ONS) as a quick, noninvasive diagnostic test tool for detecting raised the intracranial pressure (ICP).

Materials And Methods: A prospective blinded observational study was conducted at Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife, Nigeria. The study population consisted of 160 adult patients referred to the radiology department for cranial computed tomography (CT) scan. There were 80 subjects and 80 controls. Optic nerve sheath diameter (ONSD) was measured by a radiologist using a 7.5 Megahertz ultrasound probe while cranial CT was reviewed by other radiologists blinded to the ONSD.

Results: Sixty-nine subjects (86.3%) had intracranial space occupying lesions (SOL) with cranial CT confirmed features of increased ICP, mean binocular ONSD of 5.7 ± 0.59 mm while 11 (13.7%) had intracranial SOL without any cranial CT evidence of increased ICP, mean binocular ONSD of 4.8 ± 0.39 mm. The difference of mean ONSD of the two groups was statistically significant (P = 0.0001). The controls had a mean binocular ONSD of 4.5 ± 0.22 mm and the difference in mean binocular ONSD for subjects with raised ICP and the controls were also statistically significant (P = 0.0001). A cut-off value of 5.2 mm (sensitivity 81.2% [95% confidence interval (CI): 69.9-89.6], specificity 100% [95% CI: 71.5-100]) was obtained from the receiver operator characteristics curve as the mean binocular ONSD that best predicts raised ICP confirmed by at least a sign on cranial CT.

Conclusions: Optic nerve sonography can differentiate between normal and elevated ICP and may serve as a useful screening tool in resource-limited practice.
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January 2016

Outcome of a posterior spinal fusion technique using spinous process wire and vertical strut.

Ann Afr Med 2014 Jan-Mar;13(1):30-4

Department of Surgery, Division of Neurological Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria.

Background/objective: Spinal fusion is a rapidly developing area of spine surgery. Many of the implants often used are not within the reach of the patients in the developing world. In this study, we describe the outcome of a novel technique of posterior spinal fusion using the rush nail and spinous process wire.

Materials And Methods: We prospectively evaluated patients who underwent the technique since October 2006. We reviewed the patients' biodata, clinical diagnosis, imaging studies, indications for surgery, type of operations, and complications related to the implants and the technique. Clinical test of instability was also determined.

Results: The technique was used in 11 female and 19 male patients. The age range was 11-82 years. The indication for surgery was trauma in 15 patients, degenerative disease in seven patients, tuberculosis of the spine in four patients, and four patients had neoplasms. Occipitocervical fusion was performed in three patients, cervical fusion in six patients, thoracic fusion in 10 patients, thoracolumbar fusion in seven patients, lumbar fusion in three patients, and lumbosacral fusion in one patient. The distal segment of the implant backed out in one patient following fracture of the spinal process. The implant was eventually removed. Clinical evidence of instability necessitating external orthotics was also seen in one patient. Two patients had wound infection. These were managed without removing the implants. We did not observe significant complications in other patients.

Conclusion: The technique appears safe and effective in carefully selected cases. The technique needs further evaluation in a larger patient population and with a longer duration of follow-up.
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October 2014

Epidemiology of neurotrauma in Ife-Ijesha zone of Nigeria.

World Neurosurg 2013 Sep-Oct;80(3-4):251-4. Epub 2012 Nov 24.

Neurosurgery Unit, Department of Surgery, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria. Electronic address:

Background And Objective: Trauma remains one of the important causes of severe disability and high mortality. In this study, we looked at the epidemiology of neurotrauma in our region so as to highlight essential factors for trauma prevention program.

Methodology: This is a cross-sectional study of all neurotrauma cases admitted to the neurosurgery service of our hospital over an 18-month period. Information was obtained on patients' demographic data, etiology of injury, duration of injury, site, and cause of accident among others.

Results: One hundred forty-three patients were included in the study. The injuries occurred mostly in males and in the third decade. Most of the patients were students and traders. Eighty-one percent of the accidents were due to road traffic crash (RTC), and the most common contributory factors were head-on collision (46.2%) and overtaking (28.6%). Five of six patients who had RTC in the first decade of life were pedestrians. There were more crashes within the cities. None of the patients who had motorcycle accidents used helmet and only four patients used seatbelts at the time of the accident. Transfer to hospital was mostly in vehicles other than ambulance.

Conclusion: Neurotrauma in our study was mostly due to RTC and it is most common in young male students. Contributory factors were head on collision and overtaking.
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December 2013

Predicting intracranial hemorrhage after traumatic brain injury in low and middle-income countries: a prognostic model based on a large, multi-center, international cohort.

BMC Emerg Med 2012 Nov 19;12:17. Epub 2012 Nov 19.

Department of Emergency Medicine, New York Presbyterian, New York, NY, USA.

Background: Traumatic brain injury (TBI) affects approximately 10 million people annually, of which intracranial hemorrhage is a devastating sequelae, occurring in one-third to half of cases. Patients in low and middle-income countries (LMIC) are twice as likely to die following TBI as compared to those in high-income countries. Diagnostic capabilities and treatment options for intracranial hemorrhage are limited in LMIC as there are fewer computed tomography (CT) scanners and neurosurgeons per patient as in high-income countries.

Methods: The Medical Research Council CRASH-1 trial was utilized to build this model. The study cohort included all patients from LMIC who received a CT scan of the brain (n = 5669). Prognostic variables investigated included age, sex, time from injury to randomization, pupil reactivity, cause of injury, seizure and the presence of major extracranial injury.

Results: There were five predictors that were included in the final model; age, Glasgow Coma Scale, pupil reactivity, the presence of a major extracranial injury and time from injury to presentation. The model demonstrated good discrimination and excellent calibration (c-statistic 0.71). A simplified risk score was created for clinical settings to estimate the percentage risk of intracranial hemorrhage among TBI patients.

Conclusion: Simple prognostic models can be used in LMIC to estimate the risk of intracranial hemorrhage among TBI patients. Combined with clinical judgment this may facilitate risk stratification, rapid transfer to higher levels of care and treatment in resource-poor settings.
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November 2012

CRASH-3 - tranexamic acid for the treatment of significant traumatic brain injury: study protocol for an international randomized, double-blind, placebo-controlled trial.

Trials 2012 Jun 21;13:87. Epub 2012 Jun 21.

Clinical Trials Unit, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK.

Background: Worldwide, over 10 million people are killed or hospitalized because of traumatic brain injury each year. About 90% of deaths occur in low- and middle-income countries. The condition mostly affects young adults, and many experience long lasting or permanent disability. The social and economic burden is considerable. Tranexamic acid (TXA) is commonly given to surgical patients to reduce bleeding and the need for blood transfusion. It has been shown to reduce the number of patients receiving a blood transfusion by about a third, reduces the volume of blood transfused by about one unit, and halves the need for further surgery to control bleeding in elective surgical patients.

Methods/design: The CRASH-3 trial is an international, multicenter, pragmatic, randomized, double-blind, placebo-controlled trial to quantify the effects of the early administration of TXA on death and disability in patients with traumatic brain injury. Ten thousand adult patients who fulfil the eligibility criteria will be randomized to receive TXA or placebo. Adults with traumatic brain injury, who are within 8 h of injury and have any intracranial bleeding on computerized tomography (CT scan) or Glasgow Coma Score (GCS) of 12 or less can be included if the responsible doctor is substantially uncertain as to whether or not to use TXA in this patient. Patients with significant extracranial bleeding will be excluded since there is evidence that TXA improves outcome in these patients. Treatment will entail a 1 g loading dose followed by a 1 g maintenance dose over 8 h.The main analyses will be on an 'intention-to-treat' basis, irrespective of whether the allocated treatment was received. Results will be presented as appropriate effect estimates with a measure of precision (95% confidence intervals). Subgroup analyses for the primary outcome will be based on time from injury to randomization, the severity of the injury, location of the bleeding, and baseline risk. Interaction tests will be used to test whether the effect of treatment differs across these subgroups. A study with 10,000 patients will have approximately 90% power to detect a 15% relative reduction from 20% to 17% in all-cause mortality.

Trial Registration: Current Controlled Trials ISRCTN15088122; NCT01402882.
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June 2012

The social and economic impacts of epilepsy on women in Nigeria.

Epilepsy Behav 2012 May 24;24(1):97-101. Epub 2012 Mar 24.

Department of Medicine, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria.

Background: Persons with epilepsy in sub-Saharan Africa experience stigma and social marginalization. There is paucity of data on the social and economic impacts of epilepsy in these patients and in particular, groups like women. We sought to determine the social and economic impacts of epilepsy on Nigerian women and especially how it affects their treatment and outcomes.

Methods: We carried out a cross-sectional survey of 63 women with epilepsy (WWE) and 69 controls matched for age, social status and site of care. A structured questionnaire was used to document information on demographic characteristics, education, employment status, economic status, health care use, personal safety and perceived stigma. The data were collated and analyzed with SPSS version 15.

Results: Unemployment, fewer years of formal education, lower marriage rates and higher stigma scores were more frequent among WWE than controls. Physical and sexual abuse with transactional sex was also reported among WWE. We also noted poorer environmental and housing conditions and lower mean personal and household incomes among WWE compared to the control group.

Conclusion: WWE in this sample from Nigeria have worse social and economic status when compared with women with other non-stigmatized chronic medical conditions.
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May 2012

The International Tethered Cord Partnership: Beginnings, process, and status.

Surg Neurol Int 2011 Mar 23;2:38. Epub 2011 Mar 23.

David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90024, USA.

Background: Spina bifida presents a significant cause of childhood morbidity in lower- and middle-income nations. Unfortunately, there is a paucity of literature examining outcomes among children with spina bifida in these countries. The goal of the International Tethered Cord Parternship is twofold: (1) to establish an international surveillance database to examine the correlation between time of repair and clinical outcomes in children with spina bifida and tethered cord; and (2) to foster collaboration among international institutions around pediatric neurosurgical concerns.

Methods: Twelve institutions in 7 countries committed to participating in the International Tethered Cord Partnership. A neurosurgeon at each institution will evaluate all children presenting with spina bifida and/or tethered cord using the survey instrument after appropriate consent is obtained. The instrument was developed collaboratively and based on previous measures of motor and sensory function, ambulation, and continence. All institutions who have begun collecting data received appropriate Institutional Review Board approval. All data will be entered into a Health Insurance Portability and Accountability Act (HIPAA) compliant database. In addition, a participant restricted internet forum was created to foster communication and includes non-project-specific communications, such as case and journal article discussion.

Results: From October 2010 to December 2010, 82 patients were entered from the various study sites.

Conclusion: To our knowledge this is the first international pediatric neurosurgical database focused on clinical outcomes and predictors of disease progression. The collaborative nature of the project will not only increase knowledge of spina bifida and tethered cord, but also foster discussion and further collaboration between neurosurgeons internationally.
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March 2011

The technique of using rigid vertical strut and spinal process wire for posterior spinal stabilization.

J Spinal Disord Tech 2011 Aug;24(6):406-8

Department of Surgery, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria.

Background And Objective: High cost of conventional spinal instrumentation and the need for intraoperative imaging have forced us to consider other methods of spinal stabilization especially suitable in low-income societies. In this article, we describe our technique of spinal fusion using spinous process wiring and rigid vertical strut. TECHNIQUE AND METHODOLOGY: Vertical strut which has been bent at one end is passed through loops of wire introduced into the base of the spinous processes to be instrumented. Another vertical strut is passed through the loose ends of the loops. We currently use Rush nail as the vertical strut.

Results: The loose ends of the loops of wire are pulled snugly and twisted. This results in immediate rigid stabilization of the spine.

Conclusions: The technique seems safe and efficient in stabilizing the spine pending definitive bony fusion.
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August 2011

Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial.

Lancet 2010 Jul 14;376(9734):23-32. Epub 2010 Jun 14.

Clinical Trials Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.

Background: Tranexamic acid can reduce bleeding in patients undergoing elective surgery. We assessed the effects of early administration of a short course of tranexamic acid on death, vascular occlusive events, and the receipt of blood transfusion in trauma patients.

Methods: This randomised controlled trial was undertaken in 274 hospitals in 40 countries. 20 211 adult trauma patients with, or at risk of, significant bleeding were randomly assigned within 8 h of injury to either tranexamic acid (loading dose 1 g over 10 min then infusion of 1 g over 8 h) or matching placebo. Randomisation was balanced by centre, with an allocation sequence based on a block size of eight, generated with a computer random number generator. Both participants and study staff (site investigators and trial coordinating centre staff) were masked to treatment allocation. The primary outcome was death in hospital within 4 weeks of injury, and was described with the following categories: bleeding, vascular occlusion (myocardial infarction, stroke and pulmonary embolism), multiorgan failure, head injury, and other. All analyses were by intention to treat. This study is registered as ISRCTN86750102, Clinicaltrials.govNCT00375258, and South African Clinical Trial RegisterDOH-27-0607-1919.

Findings: 10 096 patients were allocated to tranexamic acid and 10 115 to placebo, of whom 10 060 and 10 067, respectively, were analysed. All-cause mortality was significantly reduced with tranexamic acid (1463 [14.5%] tranexamic acid group vs 1613 [16.0%] placebo group; relative risk 0.91, 95% CI 0.85-0.97; p=0.0035). The risk of death due to bleeding was significantly reduced (489 [4.9%] vs 574 [5.7%]; relative risk 0.85, 95% CI 0.76-0.96; p=0.0077).

Interpretation: Tranexamic acid safely reduced the risk of death in bleeding trauma patients in this study. On the basis of these results, tranexamic acid should be considered for use in bleeding trauma patients.

Funding: UK NIHR Health Technology Assessment programme, Pfizer, BUPA Foundation, and J P Moulton Charitable Foundation.
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July 2010

The role of human immunodeficiency virus infection in infranuclear facial paralysis.

J Natl Med Assoc 2009 Apr;101(4):361-6

Department of Medicine, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria.

Background: This study describes the pattern of idiopathic infranuclear facial palsy (facial neuropathy) and highlights the role of human immunodeficiency virus (HIV)/AIDS in its occurrence and management.

Patients And Methods: This study conducted in Ile-Ife, Nigeria, assessed individuals with idiopathic facial neuropathy seen at the neurology; maxillofacial surgery; and ear, nose and throat outpatient clinics between 1994 and 2006.

Results: Eighty-eight patients with idiopathic facial neuropathy were seen during the 13-year study period. Forty-six (52.3%) were males, and the age range was 15 to 76 years, with a median of 35.5 years and interquartile range of 24.5 to 54 years. The right side was affected in 59.1%, compared with 40.9% on the left side. Twenty-six patients (29.5%) were HIV positive at presentation: 16 males, 10 females; mean age for HIV-positive patients was 29.15 +/- 8.12 years and 44.39 +/- 18.48 years for HIV-negative patients. There was a significant relationship among the status of the patients and the severity at presentation (p = .035), treatment given (p = .019), and the occurrence of flu-like symptoms (p = .004).

Conclusion: A high index of suspicion of seroconversion is essential in patients presenting with idiopathic facial neuropathy since it has implications for management. Serological testing for HIV, especially in patients at risk and those with history of recent flu-like symptoms, is recommended.
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April 2009

Factors implicated for late presentations of gross congenital anomaly of the nervous system in a developing nation.

Br J Neurosurg 2008 Dec;22(6):764-8

Department of Surgery, Obafemi Awolowo University, Ile-Ife, Nigeria.

Background: Gross congenital lesions of the nervous system are obvious at birth and usually present early for management and corrective surgery. However in tropical and developing nations, late presentations are common.

Aims: To determine the factors responsible for very late presentations of gross congenital lesions.

Methods: We conducted a prospective study of all cases of congenital CNS anomalies that presented very late (>6 months after birth) to our neurosurgical clinic over an eight year period (2000-2008).

Results: A total of 81 patients were seen during the study period. The age ranged from 6 months to 47 years. Hydrocephalus accounted for about half of the cases 37 (48.3%). The others were spina bifida 15 (18.5%), encephalocele 10 (12.4%), subgaleal inclusion dermoid cyst 7 (8.6%), and craniosynostosis 6 (7.4%), neurofibroma 4(4.9%), and anencephaly 2 (2.5%). Reasons given for late presentations were ignorance, poverty and in some the expectation that the baby would die. Other reasons for late presentation were that the patient was either about to start school or get married.

Conclusion: Late presentations of congenital CNS lesions are associated with many complications most of which could have been avoided with early medical treatment. Health education should include issues regarding congenital malformations delivered by trained experts.
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December 2008

New onset neuromyelitis optica in a young Nigerian woman with possible antiphospholipid syndrome: a case report.

J Med Case Rep 2008 Nov 17;2:348. Epub 2008 Nov 17.

Department of Medicine, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria.

Introduction: Devic's neuromyelitis optica is an inflammatory demyelinating disease that targets the optic nerves and spinal cord. It has a worldwide distribution and distinctive features that distinguish it from multiple sclerosis. There has been no previous report of neuromyelitis optica from our practice environment, and we are not aware of any case associated with antiphospholipid syndrome in an African person.

Case Presentation: We report the case of a 28-year-old Nigerian woman who presented with neck pain, paroxysmal tonic spasms, a positive Lhermitte's sign and spastic quadriplegia. She later developed bilateral optic neuritis and had clinical and biochemical features of antiphospholipid syndrome. Her initial magnetic resonance imaging showed a central linear hyperintense focus in the intramedullary portion of C2 to C4. Repeat magnetic resonance imaging after treatment revealed resolution of the signal intensity noticed earlier.

Conclusion: Neuromyelitis optica should be considered in the differential diagnoses of acute myelopathy in Africans. We also highlight the unusual association with antiphospholipid syndrome. Physicians should screen such patients for autoimmune disorders.
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November 2008

Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients.

BMJ 2008 Feb 12;336(7641):425-9. Epub 2008 Feb 12.

London School of Hygiene and Tropical Medicine, London WC1B 3DP.

Objective: To develop and validate practical prognostic models for death at 14 days and for death or severe disability six months after traumatic brain injury.

Design: Multivariable logistic regression to select variables that were independently associated with two patient outcomes. Two models designed: "basic" model (demographic and clinical variables only) and "CT" model (basic model plus results of computed tomography). The models were subsequently developed for high and low-middle income countries separately.

Setting: Medical Research Council (MRC) CRASH Trial.

Subjects: 10,008 patients with traumatic brain injury. Models externally validated in a cohort of 8509.

Results: The basic model included four predictors: age, Glasgow coma scale, pupil reactivity, and the presence of major extracranial injury. The CT model also included the presence of petechial haemorrhages, obliteration of the third ventricle or basal cisterns, subarachnoid bleeding, midline shift, and non-evacuated haematoma. In the derivation sample the models showed excellent discrimination (C statistic above 0.80). The models showed good calibration graphically. The Hosmer-Lemeshow test also indicated good calibration, except for the CT model in low-middle income countries. External validation for unfavourable outcome at six months in high income countries showed that basic and CT models had good discrimination (C statistic 0.77 for both models) but poorer calibration.

Conclusion: Simple prognostic models can be used to obtain valid predictions of relevant outcomes in patients with traumatic brain injury.
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February 2008

Treatment of cerebrospinal fluid shunting complications in a Nigerian neurosurgery programme. Case illustrations and review.

Pediatr Neurosurg 2008 14;44(1):36-42. Epub 2007 Dec 14.

Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria.

Background/aims: For a century since the first cerebrospinal fluid (CSF) shunt surgery, ventriculoperitoneal (VP) shunt insertion for the treatment of hydrocephalus has routinely been performed. A lot of common and rare complications following this procedure have been reported in 24-47% of the cases. The aim of this paper was to present our experience with the treatment of hydrocephalus in our centre and highlight our management of two unusual complications with the available resources.

Methods: Retrospective clinical review.

Results: A total of 86 patients with hydrocephalus were seen in our unit. There were 52 males and 34 females (male:female ratio 3:2). The age of the patients ranged from 1 day to 68 years. The majority of the patients (92%) were below 5 years of age. Sixty-five patients had shunting procedures [VP shunt: 62 (95.4%); endoscopic third ventriculostomy: 3 (4.6%)]. Of the 62 patients with VP shunts, 16 (25.8%) had complications while 2 of the 3 patients with endoscopic third ventriculostomies had complications. The complications following the VP shunts were CSF shunt sepsis (n = 12; 19.4%), abdominal complications (n = 3; 4.8%), subdural haematoma (n = 2; 3.2%) and scalp necrosis in 1 patient.

Conclusion: VP shunt procedures have come to stay and will remain with us despite recent advances such as endoscopic third ventriculostomy. Care should be taken to prevent all complications whether common or rare by paying particular attention to patient selection, shunt selection and surgical details. The adaptation of local technology and justified use of limited facilities and resources can go a long way in the management of both common and rare complications in developing nations.
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February 2008

Compound elevated skull fracture: a forgotten type of skull fracture.

Surg Neurol 2006 May;65(5):503-5

Department of Surgery, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria 20001.

Background And Objective: We report 4 patients who presented with a rare type of vault fracture. This form of fracture has only been described in few instances in the literature.

Case Description: All the patients presented with elevation of free skull fracture fragments. The etiologies were assault (1 patient), domestic accident (1 patient), and road traffic accident (2 patients). All the fractures were compound as in previously reported cases. Delay in surgery resulted in cerebral abscess in 1 patient. Surgery was performed in all the patients: wound debrident, duroplasty, and reduction of fracture in 3 patients and craniotomy with excision of abscess in 1 patient. Two of the patients did well after surgery. The patients with abscess died 9 days after surgery. Another patient developed CSF fistula after surgery, and died of aspiration while waiting for the closure of the fistula.

Conclusion: Elevated skull fractures in our series were all compound fractures. Both long, sharp objects as well as blunt objects can cause this injury. Delay in surgery could result in intracranial sepsis. We suggest that this fracture should be included in the classification of skull fractures.
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May 2006

Final results of MRC CRASH, a randomised placebo-controlled trial of intravenous corticosteroid in adults with head injury-outcomes at 6 months.

Lancet 2005 Jun 4-10;365(9475):1957-9

MRC CRASH is a randomised controlled trial (ISRCTN74459797) of the effect of corticosteroids on death and disability after head injury. We randomly allocated 10,008 adults with head injury and a Glasgow Coma Scale score of 14 or less, within 8 h of injury, to a 48-h infusion of corticosteroid (methylprednisolone) or placebo. Data at 6 months were obtained for 9673 (96.7%) patients. The risk of death was higher in the corticosteroid group than in the placebo group (1248 [25.7%] vs 1075 [22.3%] deaths; relative risk 1.15, 95% CI 1.07-1.24; p=0.0001), as was the risk of death or severe disability (1828 [38.1%] vs 1728 [36.3%] dead or severely disabled; 1.05, 0.99-1.10; p=0.079). There was no evidence that the effect of corticosteroids differed by injury severity or time since injury. These results lend support to our earlier conclusion that corticosteroids should not be used routinely in the treatment of head injury.
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September 2005

Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial.

Lancet 2004 Oct 9-15;364(9442):1321-8

Background: Corticosteroids have been used to treat head injuries for more than 30 years. In 1997, findings of a systematic review suggested that these drugs reduce risk of death by 1-2%. The CRASH trial--a multicentre international collaboration--aimed to confirm or refute such an effect by recruiting 20000 patients. In May, 2004, the data monitoring committee disclosed the unmasked results to the steering committee, which stopped recruitment.

Methods: 10008 adults with head injury and a Glasgow coma score (GCS) of 14 or less within 8 h of injury were randomly allocated 48 h infusion of corticosteroids (methylprednisolone) or placebo. Primary outcomes were death within 2 weeks of injury and death or disability at 6 months. Prespecified subgroup analyses were based on injury severity (GCS) at randomisation and on time from injury to randomisation. Analysis was by intention to treat. Effects on outcomes within 2 weeks of randomisation are presented in this report. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN74459797.

Findings: Compared with placebo, the risk of death from all causes within 2 weeks was higher in the group allocated corticosteroids (1052 [21.1%] vs 893 [17.9%] deaths; relative risk 1.18 [95% CI 1.09-1.27]; p=0.0001). The relative increase in deaths due to corticosteroids did not differ by injury severity (p=0.22) or time since injury (p=0.05).

Interpretation: Our results show there is no reduction in mortality with methylprednisolone in the 2 weeks after head injury. The cause of the rise in risk of death within 2 weeks is unclear.
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November 2004