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Background: Aneurysm location is a key element in predicting the rupture risk of an intracranial aneurysm. A common impression suggests that pure ophthalmic aneurysms are under-represented in ruptured intracranial aneurysms (RIAs). The purpose of this study was to specifically evaluate the risk of rupture of ophthalmic aneurysms compared with other aneurysm locations., Methods: This multicenter study compared the frequency of ophthalmic aneurysms in a prospective cohort of RIAs admitted to 13 neuroradiology centers between January 2021 and March 2021, with a retrospective cohort of patients with unruptured intracranial aneurysms (UIAs) who underwent cerebral angiography at the same neuroradiology centers during the same time period., Results: 604 intracranial aneurysms were included in this study (355 UIAs and 249 RIAs; mean age 57 years (IQR 49-65); women 309/486, 64%). Mean aneurysm size was 6.0 mm (5.3 mm for UIAs, 7.0 mm for RIAs; P<0.0001). Aneurysm shape was irregular for 37% UIAs and 73% RIAs (P<0.0001). Ophthalmic aneurysms frequency was 14.9% of UIAs (second most common aneurysm location) and 1.2% of RIAs (second least common aneurysm location; OR 0.07 (95% CI 0.02 to 0.23), P<0.0001)., Conclusions: Ophthalmic aneurysms seem to have a low risk of rupture compared with other intracranial aneurysm locations. This calls for a re-evaluation of the benefit-risk balance when considering preventive treatment for ophthalmic aneurysms., Competing Interests: Competing interests: FC is a consultant for Medtronic, Balt Extrusion, Penumbra, Microvention, and Stryker; board member of Artedrone, and has stock options with Intradys and Collavidence. GM is a consultant for Stryker Neurovascular, Balt, Microvention Europe, and Sim and Cure, and has done paid lectures for Medtronic, Phenox, Johnson & Johnson, and Bracco. KJ is a consultant for Balt. AR is a consultant for Balt, Medtronic, Microvention, and Stryker. N-AS is a consultant for Balt, Medtronic Extrusion, and Microvention., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Transcranial Doppler (TCD) ultrasound may enhance the swift diagnosis of large vessel occlusion (LVO) in patients with a clinical suspicion of acute ischemic stroke (AIS). This is a comprehensive review of the literature on the use and performance of TCD ultrasound in diagnosing AIS caused by LVO., Patients and Methods: We conducted a systematic search in PubMed and Google scholar to identify studies reporting data on TCD biomarkers for LVO diagnosis and management of AIS. The main outcomes of interest were the identified TCD-derived biomarkers performances (specificity, sensitivity, predictive values) for LVO diagnosis., Results: A total of 170 studies were screened, of which 7 (4.1 %) studies with a total of 2260 patients (mean age: 65.3 +/- 4.5 years, 1114 (49.3 %) females) were included in this review. Most of the studies were prospective (n=5, 71.4 %), all of the studies had an overall low risk of bias. In 6 studies (85.7 %), TCD was used at the time of hospital admission, on triage field in one study in the context of a confirmed AIS. A total of six TCD based biomarkers were described in the included articles, with high accuracies for LVO diagnosis (ranging from 85.9 % to 99.2 %). Pulsatility Index had the highest reported performances in terms of Accuracy for LVO diagnosis (ranging from 96 % to 99.2 %). Authors reported suboptimal temporal windows for data acquisition in 13-19.7 % of patients., Conclusion: TCD is as a promising non-invasive and cost-effective tool for LVO diagnosis, presenting opportunities to enhance stroke management., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Acute spinal cord infarction (SCI) is a rare ischemic vascular lesion. It is difficult to diagnose during the acute phase because the clinical features can vary widely, and the diffusion-weighted imaging of spinal cord magnetic resonance imaging (MRI) often fails to detect any obvious abnormality. The first aim of this study was to describe the SCI patients' characteristics, evaluate the accuracy of its diagnosis tools and management, and then find the strength of the effect of spinal surgical decompression on the patient's outcome., Methods: A PubMed keyword and Boolean search using ("spinal cord infarction" OR "spinal cord ischemia" AND diagnosis OR management OR outcome) returned 221,571 results by applying filters. We added 17,400 results from Google Scholar. Fourteen studies were included in the quantitative meta-analysis of mean differences., Results: The Time to Nadir was <6 h (56.1%), 6-12 h (30.7%), 12-72 h (5.4%), and more than 72 h (7.8%). The higher proportion of Owl's eye findings in the MRI was reported at the cervical level (39.6%) and thoracic level (22.9%) P = 0.031. The T2DWI has a moderate accuracy (area under the curve = 0.835) in detecting the T2 hypersignal intensity (T2HSI) at the hyperacute time to NADIR (<6 h). The median modified Rankin Scale (mRS) at admission was 3 (2-3), and after a follow-up duration of 12 months (6-15.5), the median mRS was reported to be 1 (1-2). About 68.9% benefited from medical treatment and physiotherapy, whereas spinal surgical decompression was done in 22.8%. Seventy percent of the overall studies favor spinal surgical decompression, with the estimated average standardized mean difference between medical and surgical treatment being = 1.2083 (95% confidence interval: 1.0250-1.3917)., Conclusion: The T2DWI has moderate accuracy in detecting the T2HSI at the hyperacute time (NADIR <6 h). Even though surgical decompression favored good outcomes, medical treatment with physiotherapy was mostly used for the management of SCI., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Surgical Neurology International.)

Introduction: Intracranial fungal infections' (IcFIs) varying clinical manifestations lead to difficulties in diagnosis and treatment. African populations are disproportionately affected by the high burden of the disease. There is a lack of clarity as to the diagnostic and treatment modalities employed across the continent. In this review, we aim to detail the management, and outcome of IcFIs across Africa., Methods: This scoping review was conducted using the Arksey and O'Malley framework. MEDLINE, EMBASE, Cochrane Library, African Index Medicus, and African Journals Online were searched for relevant articles from database inception to August 10th, 2021. The Preferred Reporting Items for Systematic Review and Meta-Analysis extension for Scoping Reviews guidelines were used to report the findings of the review., Results: Of the 5,779 records identified, 131 articles were included. The mean age was 35.6 years, and the majority (56.4%) were males. The majority (n = 8,433/8,693, 97.0%) of IcFIs presented as a meningitis, the most common communicable predisposing factor of IcFIs was HIV/AIDS (n = 7,815/8,693, 89.9%), and the most common non-communicable risk factor was diabetes mellitus (n = 32/8,693, 0.4%). Cryptococcus species was the most common (n = 8,428/8,693, 97.0%) causative organism. The most commonly used diagnostic modality was cerebrospinal (CSF) cultures (n = 4,390/6,830, 64.3%) for diffuse IcFIs, and MRI imaging (n = 12/30, 40%) for focal IcFIs. The most common treatment modality was medical management with antifungals only (n = 4,481/8,693, 51.6%). The most commonly used antifungal agent in paediatric, and adult patients was amphotericin B and fluconazole dual therapy (51.5% vs 44.9%). The overall mortality rate was high (n = 3,475/7,493, 46.3%), and similar for both adult and paediatric patients (47.8% vs 42.1%)., Conclusion: Most IcFIs occurred in immunosuppressed individuals, and despite the new diagnostic techniques, CSF culture was mostly used in Africa. Antifungals regimens used was similar between children and adults. The outcome of IcFIs in Africa was poor for both paediatric and adult patients., (© 2024. The Author(s).)

Traumatic brain injury (TBI) is a major public health concern globally, with significant implications for morbidity, mortality, and long-term disability. While extensive research has been conducted on TBI management in high-income countries, limited attention has been given to the specific challenges and opportunities faced by healthcare systems in sub-Saharan Africa (SSA). This perspective study aims to provide a comprehensive overview of the current status of TBI management in SSA, focusing on the unique challenges and potential opportunities for improvement. The findings highlight several key challenges faced by SSA healthcare systems in managing TBIs, including limited resources, inadequate infrastructure, and a shortage of trained healthcare professionals. Furthermore, social and cultural factors, such as ignorance of driving laws, financial constraints, and limited access to modern technology services. However, the study also identifies potential opportunities for improving TBI management in SSA. These include strengthening healthcare infrastructure, enhancing pre-hospital care and transportation systems, and increasing public awareness and education about TBI. This perspective study emphasizes the urgent need for tailored interventions and strategies to address the unique challenges faced by SSA in managing TBIs. Addressing the challenges and opportunities in brain injury management in SSA requires a comprehensive approach which can be through investing in health infrastructure, addressing socio-economic inequalities, implementing prevention strategies, and fostering evidence-based research collaboration. Through this, the region can significantly improve TBI care and outcomes, thereby improving the well-being of people affected by TBI in SSA., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background and Purpose: Flow diverter embolization is a recognized method for treating intracranial aneurysms. This study evaluates the safety and efficacy of the Surpass Evolve flow diverter in treating intracranial aneurysm., Material and Methods: From May 2019 to June 2022, our center prospectively enrolled patients presenting with both ruptured and unruptured intracranial aneurysms. We assessed aneurysm occlusion, along with the occurrence of ischemic and hemorrhagic complications, and mortality at 6-months. The 3-month occlusion rate was determined using MR angiography, while the 6-month occlusion rate employed the O'Kelly-Marotta (OKM) grading scale on DSA., Results: A total of 116 patients with 120 aneurysms received treatment with the Surpass Evolve device. The average aneurysm size was 6.6 mm (range: 2-30 mm). All patients were administered two loading doses of ticagrelor (180 mg) one day before the procedure and 2 h pre-embolization. A procedural complication occurred in one case, involving wire-related perforation of an M3 branch distant from the giant aneurysm; however, this evolved favorably. There were no reported deaths linked to the treatment. Permanent neurological deficits were observed in 3 (2.5%) patients, primarily due to early in-stent thrombosis. MR angiography results at 3 months indicated complete occlusion for 87 out of 115 (75.6%) monitored aneurysms. The 6-month DSA showed neck remnant or complete occlusion (OKM grade C or D) in 86 out of the 107 (80.4%) patients who underwent follow-up., Conclusion: The Surpass Evolve stands out as a reliable and effective flow diverter for the management of intracranial aneurysms., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: Epilepsy is a common neurological condition in low- and middle-income countries (LMICs). This study aims to systematically review, analyze, evaluate, and synthesize information on the current state of medical and surgical management and outcomes of epilepsy in LMICs., Materials and Methods: Systematic searches were conducted on MEDLINE, EMBASE, World Health Organization Global Index Medicus, African Journals Online, WOS, and Scopus, covering the period from the inception of the databases to August 18 th , 2021, focusing on studies reporting management and outcomes of epilepsy in LMICs., Results: A total of 2298 unique studies were identified, of which, 48 were included (38035 cases). The mean age was 20.1 ± 19.26 years with a male predominance in 60.92% of cases. The type of seizure commonly reported in most of the studies was absence seizures ( n = 8302, 21.82%); partial focal seizure ( n = 3891, 10.23%); and generalized tonic-clonic seizures ( n = 3545, 9.32%) which were the next most common types of seizures. Mesiotemporal epilepsy was less frequently reported ( n = 87, 0.22%). Electroencephalogram was commonly used ( n = 2516, 6.61%), followed by computed tomography scan ( n = 1028, 2.70%), magnetic resonance imaging ( n = 638, 1.67%), and video telemetry ( n = 484, 1.27%) in the care of patients with seizures. Primary epilepsy was recorded in 582 patients (1.53%) whereas secondary epilepsy was present in 333 patients (0.87%). Carbamazepine was the most used anti-epileptic drug ( n = 2121, 5.57%). Surgical treatment was required for 465 (1.22%) patients., Conclusion: In LMICs, epilepsy is underreported. There is still a lack of adequate tools for the diagnosis of primary or secondary epilepsy as well as adequate access to medical management of those reported., Competing Interests: There are no conflicts of interest., (© 2024 Published by Scientific Scholar on behalf of Journal of Neurosciences in Rural Practice.)

Background: Hypnosis-aided craniotomy is a safe alternative to standard asleep-awake-asleep (AAA) surgery in glioma surgery. The impact of these two anesthetic methods on tumor prognosis has never been assessed., Objective: This study aimed to evaluate the possible impact of the type of sedation (i.e., hypnosedation vs. standard sedation) on postoperative outcomes in awake surgery for gliomas., Methods: Adult patients who underwent awake surgery for a diffuse glioma, excluding glioblastomas, between May 2011 and December 2019 at the authors' institution were included in the analysis. Pearson Chi-square, Fisher exact, and Mann-Whitney U tests were used for inferential analyses., Results: Sixty-one (61) patients were included, thirty-one were female (50.8 %), and the mean age was 41.8 years (SD = 11.88). Most patients had IDH mutated tumors (n = 51; 83.6%). Twenty-six patients (42.6%) were hypnosedated while 35 (57.4%) received standard AAA procedure. The overall median follow-up time was 48 months (range: 10 months-120 months). Our results did not identify any significant difference between both techniques in terms of extent of resection (sub-total resection >95% rates were 11.48% vs. 8.20%, OR = 2.2, 95% CI = 0.62-8.44; P = 0.34) and of overall survival (87.5% of patients in the AAA surgery group reach 9 years OS vs. 79% in the hypnosis cohort, cHR = 0.85, 95% CI = 0.12-6.04; P = 0.87)., Conclusion: Hypnosis for awake craniotomy is rarely proposed although it is a suitable alternative to standard sedation in awake craniotomy for LGGs, with similar results in terms of extent of resection or survival., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Background: This study aims to appraise aneurysm scores and ratios' ability to discriminate between ruptured aneurysms and unruptured intracranial aneurysms (UIAs) in subarachnoid hemorrhage (SAH) patients harboring multiple intracranial aneurysms (MICAs). We, then, investigate the most frequent risk factors associated with MICAs., Methods: We retrospectively applied unruptured intracranial aneurysm treatment score (UIATS) and population hypertension age size of aneurysm earlier SAH from another aneurysm site of aneurysm (PHASES) score, aspect, and dome-to-neck ratio to the 59 consecutive spontaneous SAH patients with MICAs admitted between January 2000 and December 2015 to the Department of Neurosurgery of the University Hospital Center "Hôpital des Spécialités" of Rabat (Morocco). Patients with at least two intracranial aneurysms (IAs) confirmed on angiography were included in the study., Results: Fifty-nine patients were harboring 128 IAs. The most frequent patient-level risk factors were arterial hypertension (AHT) 30.5 % ( n = 18) and smoking status 22.0 % ( n = 13). A PHASES score recommended treatment in 52 of 60 ruptured aneurysms and in six of 68 UIAs with a sensitivity of 31.67% and a specificity of 76.47%. UIATS recommended treatment in 26 of 62 ruptured aneurysms and in 35 of 55 UIAs with a sensitivity of 41.9% and a specificity of 63.6%. Aspect ratio recommended treatment in 60 of 60 ruptured aneurysms and in 63 of 68 UIAs with a sensitivity of 100% and a specificity of 88.24%. Dome-to-neck ratio recommended treatment in 45 of 60 ruptured aneurysms and in 48 of 68 UIAs with a sensitivity of 80% and a specificity of 63.24%. The aspect ratio (area under the curve [AUC] = 0.953) AUC > 0.8 has a higher discriminatory power between ruptured aneurysms and UIAs., Conclusion: AHT and smoking status were the most common risk factors for intracranial multiple aneurysms and the aspect ratio and PHASES score were the most powerful discrimination tools between ruptured aneurysms and the UIAs., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Surgical Neurology International.)

Background: Awake craniotomy (AC) is a common neurosurgical procedure for the resection of lesions in eloquent brain areas, which has the advantage of avoiding general anesthesia to reduce associated complications and costs. A significant resource limitation in low- and middle-income countries constrains the usage of AC., Objective: To review the published literature on AC in African countries, identify challenges, and propose pragmatic solutions by practicing neurosurgeons in Africa., Methods: We conducted a scoping review under Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Scoping Review guidelines across 3 databases (PubMed, Scopus, and Web of Science). English articles investigating AC in Africa were included., Results: Nineteen studies consisting of 396 patients were included. Egypt was the most represented country with 8 studies (42.1%), followed by Nigeria with 6 records (31.6%). Glioma was the most common lesion type, corresponding to 120 of 396 patients (30.3%), followed by epilepsy in 71 patients (17.9%). Awake-awake-awake was the most common protocol used in 7 studies (36.8%). Sixteen studies (84.2%) contained adult patients. The youngest reported AC patient was 11 years old, whereas the oldest one was 92. Nine studies (47.4%) reported infrastructure limitations for performing AC, including the lack of funding, intraoperative monitoring equipment, imaging, medications, and limited human resources., Conclusion: Despite many constraints, AC is being safely performed in low-resource settings. International collaborations among centers are a move forward, but adequate resources and management are essential to make AC an accessible procedure in many more African neurosurgical centers., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Congress of Neurological Surgeons.)

Background: Brain metastases (BMs) are the most common expansive intracranial lesions in adults. Approximately 50% of patients diagnosed with new BMs will have >1 BM at the diagnosis. We report our experience with BMs treated with Leksell Gamma Knife stereotactic radiosurgery (GKSR) and evaluate the outcomes., Methods: Patients treated by GKSR in our institution between 2008 and 2021 for BMs were evaluated retrospectively., Results: A total of 205 patients (56.6% women) were included, with a median age of 59 years (range, 25-83 years). The breast (n = 85; 42.5%) and lung (n = 76; 38%) were the most common original locations for the primary tumors. Of the 205 patients, 103 (50.3%) had a single BM and 102 (49.7%) had ≥2 BMs. The median number of multiple BMs treated was 4 (range, 2-43). The mean overall survival (OS) time was 6.00 months (95% confidence interval [CI], 5.07-6.93 months) for all BMs. The median rate of tumor control after radiosurgery was 65% (range, 20%-99%) during a median follow-up of 6.00 months (95% CI, 3-84 months). In the overall population, the 1-, 2-, and 5-year OS rate was 37.55%, 25.12%, and 18.51%, respectively. The mean OS time was longer for those with multiple BMs than for those with a single BM (mean, 10 months [95% CI, 6.67-13.33 months] vs. mean, 5 months [95% CI, 4.21-5.70 months]; P = 0.03). Retreatment, tumor stability (control), and progression influenced the OS of patients with BMs, whether single or multiple (P < 0.001)., Conclusions: GKSR provides good results in terms of OS and better quality of life for patients with BMs, whether single or multiple. Tumor stability and retreatment influenced the OS of patients with BMs., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: In a resource-limited setting such as sub-Saharan African countries, neurosurgeons need training and fellowship for surgical repair of aneurysmal subarachnoid hemorrhage (aSAH). Surgical repair of ruptured aneurysms costs less and requires less instrumentation compared with endovascular procedures. The purpose of this study is to evaluate the state of training and management of aSAH in sub-Saharan Africa training centers., Methods: An e-survey was sent as a Google Form to neurosurgeons and neurosurgical trainees in neurosurgery training centers in sub-Saharan Africa; responses were accepted from September 9 to October 23, 2022. Statistical analysis was performed using Microsoft Excel and JAMOVI 3.2., Results: All 44 centers from 17 countries responded. Most of the respondents were neurosurgery residents (n = 30; 68.18%). The level of training on clipping was basic after completing the residency program (n = 18; 40.91%). Twenty respondents (45.45%) identified that fellowships on aneurysmal clipping and endovascular treatment are offered abroad. Thirteen participants (29.55%) indicated that endovascular treatment is available at their institutions. The most common challenges with lack of training for neurosurgical aneurysm clipping were scarce scholarship and collaboration with training centers from high-income countries (n = 33; 75%). The availability of intensive care unit beds also contributed to the presence of neurosurgical training of aneurysm clipping (12.1 ± 3.67 vs. 9.29 ± 5.82; P = 0.05)., Conclusions: In sub-Saharan African countries, the lack of collaborations with high-income countries for training through fellowships of young neurosurgeons for aneurysm repair seems to be the most important challenge that should be overcome., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The prediction of raised Intracranial Pressure (ICP) with accuracy in Traumatic Brain Injury (TBI) patients is a clinically important decision and therapeutic tool. This study aimed to evaluate the existing methods used for non-invasive ICP monitoring in TBI patients in LMICs., Methods: Systematic searches of PubMed, Google Scholar, and ScienceDirect were performed from database inception to November 2021. Studies reporting the prediction of raised ICP in TBI patients by non-invasive means in LMICs were included. Pooled estimates of sensitivity, specificity, positive likelihood ratios, and negative likelihood ratios with 95 %CI were calculated for each index test consisting of the fifteen studies, using the MEDDECIDE module 0.0.2 for meta-analysis of diagnostic test accuracy, reliability, and decision studies in JAMOVI 2.2.5., Results: A total of 1032 studies were identified, of which, 15 included 3316 patients with male predominance (n = 2458, 74.13%). Patients' ages range from 15 to 96 years with 40-80 (n = 1205, 36.34%), the most represented population. The ICP measured by Transcranial Doppler (TCD) had a sensitivity of 92.3%, and a specificity of 70%. The positive predictive value was 66.67%, with a negative predictive value of 93.33%. Furthermore, the positive Likelihood Ratio (+LR) was 3.69; 2<+LR < 5 and the negative Likelihood Ratio (-LR) 0.103; 0.1 < -LR < 0.2. We carried out a "Medical Decision", "Plots", "Fagan Normogram" and the ROC curve to find the perfect discrimination point of all the five tests used for the non-invasive measurement of ICP in the TBI patients in LMICs., Conclusion: The TCD had shown high performance in its sensitivity and specificity, placing it on top of the other four different tests used in LMICs for the management of patients with TBI., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier Ltd.)

Background: This study looks at how COVID-19 affected the admission and training of neurosurgical residents worldwide., Methods: From 2019 to 2021, we reviewed multiple databases (i.e., Google Scholar, Science Direct, PubMed, and Hinari) to evaluate the impact of the COVID-19 pandemic on neurosurgery resident training and admission in low middle-income countries (LMICs) and high-income countries (HICs). We then utilized a Wilcoxon signed-rank test to evaluate the difference between the two LMIC/HICs and employed Levene's test to assess the homogeneity of variances., Results: There were 58 studies that met our inclusion criteria; 48 (72.4%) were conducted in HIC and 16 (27.6%) in LMIC. The admission of new residents was mostly canceled in HIC (31.7%; n = 13) and in LMIC (25%; n = 4) from 2019 to 2021 due to COVID-19. Learning modalities changed to include predominantly video conferencing (i.e., 94.7% [ n = 54] of cases). Further, neurosurgery was largely restricted to emergency cases alone (79.6% [ n = 39]), with only 12.2% ( n = 6) elective cases. The result was a marked reduction in resident surgical training (i.e., 66.7% [ n = 10] in LMIC and 62.9% [ n = 22] in HIC), despite increased workloads in (i.e., LMIC [37.4%; n = 6] and HIC [35.7%; n = 15]). This was attributed to the marked reduction in the number of surgical patients allotted to each resident (i.e., LMIC [87.5%; n = 14] than HIC [83.3%; n = 35])., Conclusion: The COVID-19 pandemic markedly disrupted neurosurgical education globally. Although differences have been found between LMICs and HICs training, the reduction of neurosurgical case-loads and surgical procedures has significantly impacted neurosurgical training. The question remains, how can this "loss of experience" be redressed in the future?, Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Surgical Neurology International.)

Introduction: The protocol presents the methodology of a scoping review that aims to synthesise contemporary evidence on the management and outcomes of intracranial fungal infections in Africa., Methods and Analysis: The scoping review will be conducted in accordance with the Arksey and O'Malley's framework. The research question, inclusion and exclusion criteria and search strategy were developed based on the Population, Intervention, Comparator, Outcome framework. A search will be conducted in electronic bibliographic databases (Medline (OVID), Embase, African Journals Online, Cochrane Library and African Index Medicus). No restrictions on language or date of publication will be made. Quantitative and qualitative data extracted from included articles will be presented through descriptive statistics and a narrative description., Ethics and Dissemination: This study protocol does not require ethical approval. Findings will be reported in a peer-reviewed medical journal and presented at local, regional, national and international conferences., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Conflicts of Interest The authors do not have any conflicting interests in this case report and any financial resources.

Background: Brain metastases (BM) occur in the natural course of malignant tumors in 18-40% of cases. Their management has changed considerably over the past decade thanks to the advent of Gamma knife Stereotactic Radiosurgery (GKSR)., Objective: We report our experience on Single Brain metastasis treated with (GKSR)., Methods: Patients treated by Gamma Knife stereotaxic radiosurgery (GKSR) in our institution between 2009 and 2021 for Single BM were recorded retrospectively., Results: A total of 103 patients (n = 52; 50.5% females) were included, with a mean age of 56.33 ± 11.33. Breast (n = 39, 37.9%) and lung (n = 36, 35%) were the common original location for the primary tumors. GKSR alone without prior surgery, radiotherapy, or chemotherapy was achieved in 81.5% (n = 84). Thirteen patients (15.1%) progressed in BM volume while finding the appearance of de novo BM in 5 (5.8%) patients. The median percentage of tumor control after radiosurgery treatment was 70% (IQR: 65-78) and only 26.2% (n = 27) of patients had > 80% tumor control and stability over the median follow-up time of 5 (95% CI, 4-6) months. We found only two cases of radionecrosis (1.9%). The median survival time was 5.21 (IQR, 3-8) months. Retreatment, recursive partitioning analysis (RPA) class, and tumor stability influenced the overall survival of BM respectively (Hazard Ratio adjust (HRa)= 5.610,p = 0.045; HRa= 6.133,p = 0.031; HRa= 22.463, p = 0.036)., Conclusion: Stereotaxic Radiosurgery provides good results in terms of Overall survival with fewer neurocognitive disorders.RPA class and tumor control (stability) influenced the overall survival of single BM., (© 2023 The Authors.)

Background: Neurosurgery inequity between High-Income Countries and Low- and Middle-Income Countries is striking. Currently, several models of education and training are available each has advantages and limitations. Our goal is to suggest an integrative model of Education and Training with international collaboration which will assure the most cost-effective Training Model., Materials and Methods: The authors reviewed the literature narratively and examined in broad stroke the different existing models of international education and training programs to analyze their strengths, limitations, and cost-effectiveness in addressing the needs of Neurosurgery in Low and middle-Income Countries., Results: Several international institutions have been involved in Education and Training in Global Neurosurgery. The most common models for international education include short-term surgical mission and boot camps, a full residency training program in HICs, and a full residency training Program in Local or regional World Federation of Neurosurgical Societies (WFNS) reference centers in Low and Middle-Income Countries, and online education. In Africa, both Local residency training centers and WFNS reference centers are available and provide full training programs in Neurosurgery. Among them, WFNS Rabat Training Center is the first established center in Africa in 2002. This program is supported by the WFNS Foundation and by the Africa 100 Project. Some of these education models face currently challenges such as sustainability, financial support, and ethical issues., Conclusion: Training neurosurgeons from Low and Middle-Income countries in local and regional WFNS Training centers might be the most cost-effective model of training that helps close the gap in neurosurgery. This training Model is duplicable and may be integrated into a global cohesive and collaborative model of education with international institutions., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Traumatic spinal cord injury (TSCI) is a subset of neurotrauma, which is a significant contributor to global trauma mortality and morbidity in children. The management and outcomes of pediatric TSCI in low- and middle-income countries (LMICs) is unknown. We conducted a scoping review to characterize the methods of management and outcomes of TSCI in LMICs., Methods: MEDLINE, Embase, and Global Index Medicus were searched from database inception to February 15, 2021. Studies reporting management or outcomes of pediatric TSCI in LMICs were included. Pooled statistics were calculated using measures of central tendency and spread., Results: A total of 1171 studies were identified, of which 5 were included. A total of 212 patients were included in our review with age of participants ranging from 2.5 to 18 years (mean, 15.4 years). Most patients were male (n = 162; 76.4%). The commonest cited cause of injury were falls (n = 104/212; 49.1%). The most common level of injury was cervical (n = 83; 39.2%). Most patients underwent surgery (n = 134/212; 63.2%). The extent of injury was quantified and classified using the American Spinal Injury Association chart in only 1 study. Long-term management data were not present in any of the included studies., Conclusions: There is a scarcity of studies reporting the management and outcome of pediatric TSCI in LMICs. The paucity of studies in this domain provides insufficient data to be compared, reducing the ability to draw a strong conclusion. This situation hinders the development of guidelines to inform best practice., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Over the last decade, many advancements have been made in the management of low-grade gliomas (LGGs). Overall survival outcomes are correlated with factors such as postoperative residual volumes and specific tumor biomolecular profiles such as IDH mutation status. It is unclear whether these advancements have benefited LGG patients in Africa. This scoping review protocol outlines how the authors will evaluate the epidemiology, presentations, management and outcomes of LGGs in Africa., Methods: MEDLINE, Embase and African Journals Online will be searched from database inception to date in order to identify the relevant studies. Patients of all ages with histologically and/or radiologically confirmed LGGs that were managed in an African country will be included. Surgical and chemoradiation management of LGG tumours will be considered. Original research, reviews, commentaries, editorials and case reports will be included., Results: Primary outcomes of the review will include LGG management, morbidity and mortality. Secondary outcomes include epidemiology and recurrence of LGGs., Discussion: This scoping review will be the first to evaluate the current landscape of LGG management and outcomes in Africa, highlighting pertinent themes that may be used to guide further research as well as health system strengthening efforts by policymakers and stakeholders., Scoping Review Registration: The protocol has been registered on the Open Science Framework (OSF; registration link: https://doi.org/10.17605/OSF.IO/E732G )., Highlights: LGGs account for 17% to 22% of total brain tumours and have a median survival time between 5.6 and 13.3 years.Despite many recent advancements in the management of LGGs, there is a paucity in the data within the African landscape.This scoping review will be the first to evaluate the current landscape of LGG management and outcomes in Africa, highlighting pertinent themes that may be used to guide further research and policymaking efforts., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2022 The Author(s).)

Introduction: Three million African patients need a neurosurgical consultation every year, but there are not enough neurosurgeons to meet this need. Efforts have been made to increase the neurosurgical capacity through the creation of training programs in Africa. Although these programs have been successful, there is still a long way to go. Aspiring African neurosurgeons (AANs) will become neurosurgeons in the future if they are given the resources and opportunities. The authors set out to understand the perceptions, needs, and difficulties faced by AANs., Methods: An e-survey containing 45 questions was created using Google Forms and distributed via social media. The survey was anonymous, and it was distributed from June 2, 2020, to June 16, 2020. Summary descriptive statistics and the Chi-Square test were calculated. The p -value was considered to be significant below .05., Results: A total of 221 AANs aged 23.5 ± 3.3 years and from 22 African countries responded to the survey. Most were male (66.1%) and medical students (84.6%). Few had assisted a neurosurgical intervention in-person (24.9%), had a mentor (29.0%) or attended a journal club (10.3%). A small proportion was unwilling to train in their home country (19.5%) or a neighboring country (16.3%). The top three reasons for choosing neurosurgery were prestige, advice from a family member, and projected income. Also, respondents felt neurosurgery was expensive., Conclusion: AANs are passionate about neurosurgery but lack the information, guidance, or opportunities to fulfil their wish.

Introduction: Neurosurgical equipment donation from high-income countries (HICs) to low-and-middle income countries (LMICs) exists. However, there is currently no published literature on whether there is a need for neurosurgical equipment donations or how to design equipment donation programmes that meet the needs of LMIC neurosurgeons. The primary aims of this study were to explore: (1) the need for the donation of neurosurgical equipment from the UK and Ireland to LMICs within the African continent, and (2) the ways through which neurosurgical equipment donations could meet the needs of LMIC neurosurgeons., Methods: This was a qualitative study using semi-structured, one-on-one, audio-recorded interviews. Purposive sampling was used to recruit and interview consultants or attending neurosurgeons from Ireland, the UK and LMICs in Africa in a continuous process until data saturation. Interviews were conducted by members of the Association of Future African Neurosurgeons during March 2021. Qualitative analysis used a thematic approach using open and axial coding., Results: Five HIC and 3 LMIC neurosurgeons were interviewed. Five overarching themes were identified: (1) inequality of access to neurosurgical equipment, (2) identifying specific neurosurgical equipment needs, (3) importance of organisations, (4) partnerships between LMIC and HIC centres, and (5) donations are insufficient in isolation., Conclusion: There is a need for greater access to neurosurgical equipment in LMICs. It is unclear if neurosurgical equipment donations are the optimal solution to this issue. Other solutions that are not linked to dependency need to be explored and executed. Collaborative relationships between LMICs and HICs better ensures that neurosurgical equipment donations meet the needs of the recipients. These relationships may be best created within an organisation framework that has the logistical capabilities of coordinating international equipment donation and providing a quality control measure., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Sichimba, Bandyopadhyay, Ciuculete, Erhabor, Kotecha, Egiz, Bankole, Higginbotham, Dalle and Kanmounye.)

Introduction: Despite recent advancements in the management of low-grade gliomas (LGGs), there is a paucity in the data within the African landscape. We aim to evaluate the epidemiology, management, and outcomes of LGGs in Africa., Methods: Systematic searches of MEDLINE, Embase and African Journals Online were performed from database inception to January 27, 2021, for studies reporting on LGGs in Africa. Pooled statistics were calculated using measures of central tendency and spread., Results: 554 unique studies were identified, of which 25 were included. The mean age of patients was 15.7 years (95% confidence interval (CI): 11.8-19.6) and 56.4% were male (95% CI: 55.6-62.6%). Most patients had solitary lesions (86.0%, 95% CI: 82.8-89.1%) located in the infratentorial region (71.6%, 95% CI: 66.1-77.1%). Most LGGs received histopathological diagnosis (71.7%, 95% CI: 69.2-74.2%) and astrocytoma was the most common type (81.1%, 95% CI: 78.5-83.7%). 37 patients had awake surgery (3.1%, 95% CI: 2.0-4.0%) and there were no reports of molecular pathology testing, intraoperative neuroimaging, or 5-aminolevulinic acid. Gross total resection was achieved in 74.8% (95% CI: 69.6-80.0%) and there was a recurrence rate of 1.7% (95% CI: 0.9-2.4%), with a mean follow-up of 19.4 months (95% CI: 6.9-31.9)., Conclusion: LGGs are underreported in Africa. We found a lag in the uptake of techniques established in high-income countries for improving patient outcomes. Future efforts will require further training and funding in molecular pathology testing and advanced surgical adjuncts., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2022 The Authors.)

Implementing health-system strengthening policies remains a challenge in Africa. Past successes, predictable but unanticipated flaws, underutilization of health services, traditional medicine, global inequity and poor practice by local stakeholders are some of the reasons many African countries have made little progress towards attaining global health goals. As a result, Africa has the highest disease burden despite multiple efforts from the global health community. These raise the question: what has to change so that health systems strengthening efforts in Africa are successful?, Competing Interests: The authors declare no competing interests., (Copyright: Berjo Dongmo Takoutsing et al.)

Introduction: Intracranial suppurations account for a significant proportion of intracranial masses in low- and middle-income countries (LMICs), particularly among children. The development of better imaging equipment, antibiotics, and surgical techniques has enabled significant progress in detecting and treating intracranial abscesses. However, it is unclear whether these advances are accessible and utilised by LMICs. In this review, we aimed to describe the landscape of paediatric intracranial suppurations in LMICs. Methods: This scoping review was conducted using the Arksey and O'Malley framework. MEDLINE, EMBASE, WHO Global Index Medicus, AJOL and Google scholar were searched for relevant articles from database inception to January 18th, 2021. Publications in English and French were included. Results: Of the 1,011 records identified, 75 were included. The studies, on average, included 18.8 (95% CI = 8.4-29.1) children (mean age: 8.2 years). Most children were male (62.2%, 95% CI = 28.7-95.7%). Intracranial suppurations were most commonly (46.5%) located in the supratentorial brain parenchyma. The most prevalent causative mechanism was otitis (37.4%) with streptococcus species being the most common causative organism (19.4%). CT scan (71.2%) was most commonly used as a diagnostic tool and antibiotics were given to all patients. Symptoms resolved in 23.7% and improved in 15.3% of patients. The morbidity rate was 6.9%, 18.8% of patients were readmitted, and the mortality rate was 11.0%. Conclusion: Most intracranial suppurations were complications of preventable infections and despite MRI being the gold standard for detecting intracranial suppurations, CT scans were mostly used in LMICs. These differences are likely a consequence of inequities in healthcare and have resulted in a high mortality rate in LMICs., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Ooi, Sichimba, Dalle, Higginbotham, Takoutsing, Bankole, Egiz, Kotecha, de Koning, Nguembu, Zolo, Dokponou, Chilawa, Bandyopadhyay and Kanmounye.)

Background: Africa has a large burden of spine pathology but has limited and insufficient infrastructure to manage these spine disorders. Therefore, we conducted this e-survey to assess the prevalence and identify the determinants of the availability of spine surgery navigation techniques in Africa., Materials and Methods: A two-part questionnaire was disseminated amongst African neurological and orthopedic surgery consultants and trainees from January 24 to February 23, 2021. The Chi-Square, Fisher Exact, and Kruskal-Wallis tests were used to evaluate bivariable relationships, and a p-value <0.05 was considered statistically significant., Results: We had 113 respondents from all regions of Africa. Most (86.7 %) participants who practiced or trained in public centers and centers had an annual median spine case surgery volume of 200 (IQR = 190) interventions. Fluoroscopy was the most prevalent spine surgery navigation technique (96.5 %), followed by freehand (55.8 %), stereotactic without intraoperative CT scan (31.9 %), robotic with intraoperative CT scan (29.2 %), stereotactic with intraoperative CT scan (8.8 %), and robotic without intraoperative CT scan (6.2 %). Cost of equipment (94.7 %), lack of trained staff to service (63.7 %), or run the equipment (60.2 %) were the most common barriers to the availability of spine instrumentation navigation. In addition, there were significant regional differences in access to trained staff to run and service the equipment (P = 0.001)., Conclusion: There is a need to increase access to more advanced navigation techniques, and we identified the determinants of availability., (© 2021 The Authors.)

Rationale: Interventional neurovascular procedures are effective in lowering the burden of mortality and complications resulting from aneurysmal subarachnoid hemorrhage (aSAH). Despite the wide uptake of interventional neurovascular procedures in high-income countries, access to care in low- and middle-income countries remains limited, and little is known about accessibility in Africa. In this survey, we decided to assess access to diagnostic tools and treatment of aSAH in Africa. Methodology: A Google form e-survey was distributed to African neurosurgery centers accepting responses from January 4th to March 21st 2021. Data on accessibility to diagnostic tools, treatment methodologies, and interventional neuroradiology personnel in African centers were collected. Ninety five percent confidence intervals were computed for each variable. Results: Data was received from 36 neurosurgical centers in 16 African countries (16/54, 30%). Most centers were public institutions. Ninety four percent of the centers had the necessary resources for a lumbar puncture (LP) and a laboratory for the diagnosis of aSAH. Most centers had at least one computed tomography (CT) scanner, 81% of the centers had access to CT angiography and some had access to conventional angiography. Forty seven percent of the centers could obtain a head CT within 2 h of presentation in an emergency. Sixty one percent of centers provided clipping of intracranial aneurysms whilst only 22% of centers could perform the endovascular treatment. Sixty four percent of centers did not have an endovascular specialist. Conclusion: This survey highlights health inequity in access to endovascular treatment for aSAH. Lack of diagnostic tools to identify an aneurysm and a shortfall of qualified endovascular specialists are prime reasons for this. Our findings can inform health system strengthening policies including the acquisition of equipment and capacity building in Africa., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Dokponou, Kotecha, Bandyopadhyay, Erhabor, Ooi, Egiz, Boutarbouch, Dalle, Higginbotham, Thioub, Sichimba, Bankole and Kanmounye.)

Introduction: Africa has many untreated neurosurgical cases due to limited access to safe, affordable, and timely care. In this study, we surveyed young African neurosurgeons and trainees to identify challenges to training and practice. Methods: African trainees and residents were surveyed online by the Young Neurosurgeons Forum from April 25th to November 30th, 2018. The survey link was distributed via social media platforms and through professional society mailing lists. Univariate and bivariate data analyses were run and a P -value < 0.05 was considered to be statistically significant. Results: 112 respondents from 20 countries participated in this study. 98 (87.5%) were male, 63 (56.3%) were from sub-Saharan Africa, and 52 (46.4%) were residents. 39 (34.8%) had regular journal club sessions at their hospital, 100 (89.3%) did not have access to cadaver dissection labs, and 62 (55.4%) had never attended a WFNS-endorsed conference. 67.0% of respondents reported limited research opportunities and 58.9% reported limited education opportunities. Lack of mentorship ( P = 0.023, Phi = 0.26), lack of access to journals ( P = 0.002, Phi = 0.332), and limited access to conferences ( P = 0.019, Phi = 0.369) were associated with the country income category. Conclusion: This survey identified barriers to education, research, and practice among African trainees and young neurosurgeons. The findings of this study should inform future initiatives aimed at reducing the barriers faced by this group., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Kanmounye, Robertson, Thango, Doe, Bankole, Ginette, Ondoma, Balogun, Opoku, Jokonya, Mbaye, Shabhay, Ashour, Silva, Cheserem, Karekezi, Hassani, Mentri, Laeke, Aklilu, Sanoussi, Musara, Ntalaja, Ssenyonga, Bakhti, El Abbadi, Mahmud, El-Ghandour, Al-Habib, Kolias, Servadei, Fieggen, Qureshi, Esene, CAANS Young Neurosurgeons Committee and WFNS Young Neurosurgeons Committee.)