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Objectives. To determine if endovascular treatment of cerebral aneurysms is cost effective when compared with conventional surgical treatment.Design. A retrospective study.Subjects. Seventeen patients treated between August 2002 and August 2003 had posterior communicating artery aneurysms. This group was selected for detailed analysis.Outcome measures. Total treatment costs, in South African rands (R), were calculated for each patient. Average treatment costs for each group were then compared.Results. Surgically clipped and endovascularly coiled groups were comparable for age, sex and clinical condition. The average cost for endovascular treatment per patient was R37 041. Surgical treatment was more expensive at R44 104, a difference of 16%.Conclusions. Despite the high cost of endovascular devices, appropriate use of this technology ultimately offers less expensive treatment than microsurgical clipping of aneurysms.

Background. In resource-limited settings, mothers infected with human immunodeficiency virus type 1 (HIV-1) face a difficult choice: breastfeed their infants but risk transmitting HIV-1 or not breastfeed their infants and risk the infants dying of other infectious diseases or malnutrition. Recent results from observational studies and randomized clinical trials indicate daily administration of nevirapine to the infant can prevent breast-milk HIV-1 transmission.

Cholesterol granulomas of the petrous apex are rare lesions that pose challenging surgical decisions and approaches when attempting surgical drainage. In this article we present 2 cases of successful surgical management using an endoscopic trans-sphenoidal approach and review the requirements and considerations for this procedure.

We previously developed a multiassay algorithm (MAA) to identify recent HIV infection that includes the BED-capture enzyme immunoassay, an avidity assay based on the Genetic Systems HIV-1/HIV-2 + O enzyme immunoassay, CD4 cell count, and HIV viral load. We used this MAA to evaluate the association between recent maternal HIV infection and in-utero transmission of HIV.Plasma samples were collected at delivery from 2561 HIV-infected women in the postexposure prophylaxis of infants-Malawi trial. The MAA described above was used to identify women with recent HIV infection. Logistic regression models assessed association between recent HIV infection and in-utero HIV transmission (defined as a positive infant HIV DNA test at birth).Seventy-three women were identified as recently infected using the MAA. Those women were younger and had lower parity than women who were identified as not recently infected using the MAA (P0.0001 for age and parity). The frequency of in-utero HIV transmission was 17.8% among women identified as recently infected, compared with 6.7% among women identified as not recently infected (13/73 vs. 166/2488, P = 0.001). In a multivariate model, three factors were independently associated with in-utero HIV transmission: recent infection [adjusted odds ratio (AOR): 2.49, 95% confidence interval (CI): 1.30-4.78, P = 0.006], log(10) HIV viral load at delivery (AOR: 2.01, 95% CI: 1.60-2.51, P0.0001), and younger age (per 10 year increase, AOR: 0.66, 95% CI: 0.43-0.93, P = 0.02).Results obtained using a MAA suggest that recent maternal HIV acquisition is strongly associated with in-utero HIV transmission, independent of HIV viral load at delivery.

INTRODUCTION: The International Subarachnoid Aneurysm Trial confirmed endovascular treatment as the treatment of choice for intracranial 'berry' aneurysms. The durability of coiling and the relevance of stable neck remnants needed to be addressed next. METHODS: We retrospectively assessed the follow-up angiograms of patients who presented with subarachnoid haemorrhages or third-nerve palsies and had berry aneurysms treated endovascularly between 2002 and 2003. Patients were phoned to assess their wellbeing and to see whether they were back at work or not. Angiograms were assessed to ascertain the percentage of the aneurysm coiled at the initial procedure, and then stability was assessed by percentage change in the residual aneuysm neck on later angiograms. RESULTS: Over a 1-year period 75 patients were treated endovascularly; 100% occlusion was achieved in 52% at the initial procedure, and although only 40 and 34 respectively attended for 3-month and 1-year follow-up angiograms there was a trend toward progressive thrombosis in 65% and 82% respectively. In only 1 of the neck remnants was growth noted at the 3-month angiogram. One patient bled after missing his 3-month follow-up angiogram. Although only 40% of the patients were contactable at 4 years there were no rebleeds among them. CONCLUSION: Coiling is durable, as shown by our results over a 4-year period, and while neck remnants that look unchanged are generally stable any growth should be viewed as grounds for concern and treated either endovascularly or surgically if required. The 5-year angiogram may be unnecessary, which is of importance in our setting where socio-economic factors influence patient follow-up.

Endovascular treatment was confirmed by the International Subarachnoid aneurysm Trial1 as the treatment of choice for intracranial “berry” aneurysms. The durability of coiling and the relevance of stable neck remnants next needed to be addressed. Methods We retrospectively assessed the follow-up angiograms of patients, who presented with subarachnoid haemorrhages or IIIrd nerve palsies and had berry aneurysms treated endovascularly between 2002 and 2003, Patients were phoned to assess their wellbeing and to see whether they were back at work or not. Angiograms were assessed to ascertain percentage of aneurysm coiled at initial procedure and then stability was assessed by percentage change in the residual on later angiograms. Results Over a 1-year period 75 patients were treated endovascularly. 100% occlusion was attainable in 52% at the initial procedure and although the number of patients who attended their 3-month and 1year follow-up angiograms were 40 and 34 respectively there was a trend toward progressive thrombosis to 65% and then 82% respectively. In only 1 of the neck remnants was there growth at the 3-month angiogram. One patient bled having missed his 3-month follow-up angiogram. Although only 40% of the patients were contactable at 4 years there was no re-bleeds amongst them. Conclusion Coiling is durable as shown by our results over a 4 year period and while neck remnants may be observed any growth should be viewed as unstable and treated either endovascularly or surgically if required.

Objective: To review management and outcome of patients with brain abscess treated at Groote Schuur Hospital (GSH) between 1993 and 2003. Patients and methods: Case notes, radiological results and laboratory records were reviewed retrospectively for 121 patients at GSH who underwent a neurosurgical procedure for treatment of a brain abscess between 1993 and 2003. Patients not treated surgically were excluded. Follow-up with serial computed tomography (CT) scans, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels and the temperature chart were used to determine the duration of parenteral antibiotic treatment and the need for repeat surgical evacuation of pus by either aspiration or excision of the capsule. Results: The mean patient age was 33 years, with a male-to-female ratio of 5:1. Headache, depressed level of consciousness and pyrexia were the commonest presenting symptoms. Other symptoms included seizures and hemiparesis. The frontal lobe was the commonest site (44%); the majority of abscesses occurred as a result of infection following trauma. Mastoiditis (21%) and sinusitis (8%) were the second and third most common causes. Organisms were identified in 81% of cases; polymicrobial infections occurred in half of these. Thirty-three different organisms were identified, the majority of which were Gram-positive bacteria. Anaerobes were present in 23%, while methicillin-resistant Staphylococcus aureus was identified in 1 patient. Nocardia was seen in 3 patients, 2 of whom were diabetic. The average duration of parenteral antibiotic therapy was 15 and 19 days for excision and aspiration respectively. Accurate ESR records were available in 75% of cases, with a positive predictive value in 81%, while CRP (in use since 1999) was helpful in 92% of cases.Outcome: Sixteen patients (13%) died, 12 of whom had been admitted with a Glasgow Coma Score (GCS) of less than 4T/15. Thirteen patients developed epilepsy. On discharge, patients continued to take oral antibiotics for another 4 weeks, at the end of which they were reviewed at the neurosurgery outpatient department.Conclusion: Compared with previous studies from this hospital, mortality and morbidity have been diminishing progressively. GCS at the time of admission remains the most important prognostic factor.South African Journal of Surgery Vol. 43(3) 2005: 79-82