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© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development. Methods: We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)—a composite of life expectancy, education, and income measures—into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation. Findings: Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24–51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34–69) and the youngest in the low HDI tier (median 28 years, IQR 20–38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6–32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55–5·2) and high HDI tier (2·26, 1·23–4·15), but not the low HDI tier (1·66, 0·61–4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17–2·49). Interpretation: Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices. Funding: National Institute for Health Research Global Health Research Group.

Background: Strengthening health systems requires attention to workforce, training needs, and barriers to service delivery. The World Federation of Neurosurgical Societies Young Neurosurgeons Committee survey sought to identify challenges for residents, fellows, and consultants within 10 years of training. Methods: An online survey was distributed to various neurosurgical societies, personal contacts, and social media platforms (April–November 2018). Responses were grouped by World Bank income classification into high-income countries (HICs), upper middle-income countries (UMICs), low-middle-income countries (LMICs), and low-income countries (LICs). Descriptive statistical analysis was performed. Results: In total, 953 individuals completed the survey. For service delivery, the limited number of trained neurosurgeons was seen as a barrier for 12.5%, 29.8%, 69.2%, and 23.9% of respondents from HICs, UMICs, LMICs, and LICs, respectively (P < 0.0001). The most reported personal challenge was the lack of opportunities for research (HICs, 34.6%; UMICs, 57.5%; LMICs, 61.6%; and LICs, 61.5%; P = 0.03). Other differences by income class included limited access to advice from experienced/senior colleagues (P < 0.001), neurosurgical journals (P < 0.0001), and textbooks (P = 0.02). Assessing how the World Federation of Neurosurgical Societies could best help young neurosurgeons, the most frequent requests (n = 953; 1673 requests) were research (n = 384), education (n = 296), and subspecialty/fellowship training (n = 232). Skills courses and access to cadaver dissection laboratories were also heavily requested. Conclusions: Young neurosurgeons perceived that additional neurosurgeons are needed globally, especially in LICs and LMICs, and primarily requested additional resources for research and subspecialty training.

Background Providing a comprehensive and effective neurosurgical service requires adequate numbers of well-trained, resourced, and motivated neurosurgeons. The survey aims to better understand 1) the demographics of young neurosurgeons worldwide; 2) the challenges in training and resources that they face; 3) perceived barriers; and 4) needs for development. Methods This was a cross-sectional study in which a widely disseminated online survey (April 2018–November 2019) was used to procure a nonprobabilistic sample from current neurosurgical trainees and those within 10 years of training. Data were grouped by World Bank income classifications and analyzed using χ2 tests because of its categorical nature. Results There were 1294 respondents, with 953 completed responses included in the analysis. Of respondents, 45.2% were from high-income countries (HICs), 23.2% from upper-middle-income countries, 26.8% lower-middle-income countries, and 4.1% from low-income countries. Most respondents (79.8%) were male, a figure more pronounced in lower-income groups. Neuro-oncology was the most popular in HICs and spinal surgery in all other groups. Although access to computed tomography scanning was near universal (98.64%), magnetic resonance imaging access decreased to 66.67% in low-income countries, compared with 98.61% in HICs. Similar patterns were noted with access to operating microscopes, image guidance systems, and high-speed drills. Of respondents, 71.4% had dedicated time for neurosurgical education. Conclusions These data confirm and quantify disparities in the equipment and training opportunities among young neurosurgeons practicing in different income groups. We hope that this study will act as a guide to further understand these differences and target resources to remedy them.

Introduction Les hemangiomes caverneux rachidiens et extraduraux represente 4 % des lesions epidurales rachidiennes. Cette localisation est souvent secondaire a une extension epidurale d’un hemangiome vertebral. La localisation au niveau de l’espace epidural rachidien sans composante osseuse initiale est rare la forme « en sablier » est exceptionnelle. Cas clinique Nous rapportons l’observation d’un patient âge de 73 ans qui s’est presente pour un tableau d’une compression medullaire lente. L’imagerie par resonance magnetique a objective une lesion thoracique en sablier extradurale sans atteinte osseuse. Une exerese chirurgicale totale de la lesion a ete realisee. Le resultat anatomopathologique etait en faveur d’un angiome caverneux. L’evolution etait bonne avec recuperation progressive du deficit neurologique. Discussion A travers cette observation, nous rappelons que l’aspect en sablier reste evocateur d’un neurinome rachidien. Cependant l’hemangiome caverneux doit etre considere sur la liste des diagnostics differentiels d’un neurinome en sablier.

Pineal epidermoid and dermoid cysts are rare lesions of the pineal region. Only few cases were reported. Clinical presentation is similar to all lesions of the pineal region lesions. Imaging data is a good help for diagnosis. Surgical management is the principal therapeutic option of these cysts. Surgery is challenging because of the characteristics of the anatomical location and the histological nature of epidermoid and dermoid cysts. Particular complications related to these cysts are important to take into account during the management of these cysts.

Introduction MRI multivoxel spectroscopy mapping is helpful in surgical decision-making. Unfortunately, in daily practice, MRI multivoxel spectroscopy mapping is not always compatible with the current version of Leksell GammaPlan (LGP) (Elekta, Stockholm, Sweden). The aim of this study is to develop a tool to allow the use of this modality in radiosurgical treatments using LGP. Material and methods Multivoxel spectroscopy digital imaging and communications in medicine (DICOM) images were analyzed to identify tags to be modified to make the images compatible with LGP. We identify four important tags to be modified for compatibility with LGP. Using Python language, a new software was designed to modify the identified tags and allow the automatic conversion of images to meet LGP requirements. Results By modifying the tags of DICOM images, we could use spectroscopic cartography images in radiosurgical planning using LGP. We created a software to reproduce these modifications using a simple and rapid interface. This software executes all the protocols established in the methodology. Conclusion The new software, "GP Adapting Solution", can convert any DICOM image and make it compatible with LGP. The integration of multivoxel spectroscopic images was feasible and could be used for radiosurgical planning. This work is the first step in allowing the potential use of new MRI modalities in radiosurgical planning using LGP. The next steps are to evaluate the impact of these modalities in radiosurgical treatments and to develop methods for integrating other imaging modalities.

Brain malignancies are still associated with poor prognosis despite multimodal radiosurgical therapeutic approach using Gamma Knife (GK), CyberKnife (CK), and linear accelerator-based technologies [1]. These advances have significantly improved the treatment outcome. However, the surgical and radiosurgical concept is still “image-guided”, and the success is closely related to precise tumor volume definition. The gross tumor volume (GTV) is defined as the visible contrast- enhancing lesion on magnetic resonance (MR) images with high three-dimensional spatial accuracy. Target delineation requires always both T2-weighted and volumetric T1-weighted sequences. T2-weighted fluid attenuated inversion recovery (FLAIR) sequences analyze the lesions surrounding brain tissues [2,3]. Objective assessment of apparently healthy tissue surrounding brain tumors seems to be a considerable factor interfering not only with the radiosurgical procedure, but also with the recurrence rate and overall survival. Several studies identified infiltrative spectroscopic pattern of the perilesional edema in more than 96% of high-grade gliomas cases and in 11,5% of patients with brain metastasis [4]. Moreover, some autopsy series of brain metastases confirmed infiltrative growth in radiologically healthy surrounding tissues in more than 60% of cases. This unseen malignant component is responsible of 80 % of “early recurrence” which should be considered as natural evolution of the main tumor [5]. In the management of high grade gliomas, the radiosurgeons are faced either to carcinologic incomplete procedures or to overestimated target irradiation with unbalanced benefit/risk action mostly related to radiation-induced brain necrosis [6]. The delineation of clinical target volume (CTV) which is defined as the volume of tissue that contains the GTV and any microscopic tumor or paths of spread, became a standard for any radio-surgical planning. Since a decade, the magnetic resonance spectroscopy (MRS) was standardized in the target volume assessment. The aim is to establish a metabolic lesional cartography. It had been reported that choline/ N- acetylaspartate (NAA) multivoxel MR spectroscopy index higher that 2,5 is in favor of malignancy in glioma with sensitivity of 90 % and specificity of 85 % [7]. However, NAA/Creatine (Cr) and Choline/Cr ratios are more relevant in the analysis of perilesional edema in brain metastasis cases. The introduction of MRS metabolic cartography concept, the use of relevant metabolite and adapted metabolites ratio estimation contributed to precision in radiosurgery. However, MRS is not used for target delineation for Gamma Knife radiosurgical treatment because of its incompatibility with the Leksell Gamma Knife planning software. Recently, we described the development of the first software allowing the integration of metabolic cartography based on multivoxel spectroscopic MRI in the radiosurgical planning for Leksell Gamma Knife Radiosurgery. The few existing meta-analysis could not lead to gold standard volume delineation techniques despite objective advance in imaging assessment [8,9]. Prospective studies using multimodal imaging data will help to overcome this insufficiency for target delineation in radiosurgery

Background: Giant cavernous malformations of the central nervous system are quite rare. They are more common in children and may be misdiagnosed as other intracranial neoplasms. Here, we presented a very rare giant cavernous angioma mimicking a neoplastic temporal lobe lesion in an 18-month-old male. Case Description: An 18-month-old male presented with two initial seizures. Although the clinical examination was normal, the computed tomography (CT) scan showed a large left temporal mass (66 mm diameter) exerting significant mass effect and midline shift. The brain magnetic resonance (MR) imaging demonstrated a large left temporal heterogeneously enhancing lesion with significant perilesional edema and mass effect. The patient underwent gross total removal of the lesion that proved to be an intracranial cavernous angioma. Postoperatively, he did well, exhibiting no residual neurological deficit, and has remained lesion and seizure-free. Conclusion: This and 12 other cases in the literature focus on intracranial cavernous angiomas that could have been readily misdiagnosed as tumors. It confirms why obtaining appropriate preoperative MR and CT studies, followed by surgical intervention, is essential to confirm the correct underlying pathology and appropriately and optimally treat the patient.

Les traumatismes de l'etage anterieur de la base du crâne representent 15 a 20% des traumatismes crâniens en general. Ils menacent les structures neuro-encephaliques sus jacentes et sont tres souvent responsables de breches osteo-meningees exposant au risque infectieux. Notre travail a concerne 136 dossiers exploitables de traumatisme de l'etage anterieur de la base du crâne colliges sur une periode de 10 ans entre janvier 2003 et decembre 2012. Le diagnostic a ete suspecte devant les signes cliniques evocateurs (ecchymose peri-orbitaire, rhinorrhee…) et a ete confirme dans la plupart des cas par la TDM. Le traitement ideal est la fermeture chirurgicale de la breche en association aux moyens medicaux (vaccination, anti-epileptiques, mesures de reanimation…) Le moment ideal de la reparation est au-dela de la 72eme heure apres la diminution de l'oedeme cerebral en cas d'absence d'une lesion intracrânienne necessitant une intervention en urgence. Notre equipe ne pratiquant pas la voie endoscopique, l'abord frontal est souvent indique. Le pronostic depend des lesions cerebrales associees et surtout de la presence d'une breche dont le diagnostic et la reparation doivent etre les plus rapides et les plus precis possibles. Ainsi toute rhinorrhee post-traumatique necessite une exploration systematique, le timing ideal: c'est la disparition de l'oedeme cerebral pour faciliter l'exploration, ceci est en general possible a partir de la 72eme heure sauf dans les cas associes a une autre lesion intra crânienne necessitant une exploration en urgence.

Le siège intraventriculaire est une localisation rare des cavernomes de l'encéphale. Le quatrième ventricule est le moins concerné de toutes les localisations. Nous rapportons le cas d'une patiente âgée de 52 ans qui présente depuis 12 mois un syndrome d'hypertension intracrânienne et trouble de l’équilibre. Elle s'est présentée aux urgences avec un GCS à 14, nuque subraide, un syndrome cérébelleux statokinétique avec une acuité visuelle basse et un oedeme papillaire bilatéral. Une TDM cérébrale réalisée aux urgences a objectivé un hématome du 4ème ventricule avec hydrocéphalie active triventriculaire. Une dérivation ventriculaire interne a été réalisée en urgence avec une bonne évolution clinique post opératoire. Le bilan a été complété par une IRM cérébrale objectivant un processus du quatrième ventricule évoquant un cavernome. Un abord direct a été réalisé permettant une exérèse totale du cavernome siégeant au sein du quatrième ventricule. L'anatomo-pathologie a confirmée le diagnostic. A notre connaissance, il s'agit du 13ème cas rapporté dans la littérature. Les cavernomes intraventriculaires représentent 2,5-10% de tous les cavernomes dont 9% est au niveau 4ème ventricule. Les patients sont souvent admis aux urgences suite au saignement de cette malformation angiomateuse. Le diagnostic est rendu accessible par les différentes séquences de l'IRM. Le traitement est souvent chirurgical vu le risque de resaignement. Le pronostic dépend de l’état initial du patient et de l'infiltration du plancher du quatrième ventricule.

Intracranial epidermoid cysts are one of the rare tumors of all intracranial tumors. They represent 0,2 to 1% of intracranial tumors and 7 % of tumors in the cerebellopontine angle. The pineal region is exceptionally subject to such kind of tumor. Cushing was the first to report the pineal localization of the epidermoid cyst in 1928. Up to now, 85 cases of pineal epidermoid cyst were cited in the literature. We report a clinical case concerning a 45 years old man who presented an intracranial hypertension during 18 months. The clinical examination found a hemiparesis with a facial hypoesthesis. The MRI showed a process of the pineal region. The patient underwent a surgery with a large resection. The histological examination confirms the epidermoid cyst. Many approaches were described in the literature. The outcome is related to this localization.Key words: Pineal epidermoid cyst, intracranial tumor, cerebellopontine angle

Les auteurs proposent des options therapeutiques dans la prise en charge des abces encephaliques, en fonction des parametres cliniques et radiologiques des patients, en degageant des facteurs pronostiques a long terme. Il s'agit d'une etude retrospective incluant tous les abces encephaliques pris en charge, sur une periode 13 ans, au service de Neurochirurgie de l'Hopital Ibn Sina de Rabat. L'analyse a porte sur : le Glasgow coma scale (GCS), la presence de deficit neurologique, l'imagerie cerebrale avec contraste, et la recherche d'une porte d'entree; le traitement a compris chirurgie et antibiotherapie, et le pronostic a ete evalue a long terme. 82 cas d'abces ont ete analyses, un score de GCS inferieur a 12 a ete trouve dans 24%. La porte d'entree a ete d'origine ORL dans 45%. La trepanoponction seule a ete decidee dans 34% des cas en situation d'urgence avec troubles de conscience. Elle a ete suivie d'une exerese de la coque dans 16% des cas lors de persistance ou recidive de la collection. La ponction stereotaxiques a ete realisee dans 10% des cas lors de localisations eloquentes et l'exerese d'emblee dans 38% des cas avec abces collecte non menacant. La mortalite operatoire a ete de 1,22%, la morbidite de 19,30%. Les facteurs de bon pronostic a long terme ont ete l'âge jeune, un GCS superieur a 12 a l'admission, et la trepanoponction suivie de l'exerese da la coque. L'amelioration du pronostic passe par le diagnostic precoce, un geste neurochirurgical precis et antibiotherapie adaptee, et le traitement des portes d'entree. Key words : abces,cerveau,chirurgie, antibiotherapie, prise en charge

Le siege intraventriculaire est une localisation rare des cavernomes de l'encephale. Le quatrieme ventricule est le moins concerne de toutes les localisations. Nous rapportons le cas d'une patiente âgee de 52 ans qui presente depuis 12 mois un syndrome d'hypertension intracrânienne et trouble de l'equilibre. Elle s'est presentee aux urgences avec un GCS a 14, nuque subraide, un syndrome cerebelleux statokinetique avec une acuite visuelle basse et un oedeme papillaire bilateral. Une TDM cerebrale realisee aux urgences a objective un hematome du 4eme ventricule avec hydrocephalie active triventriculaire. Une derivation ventriculaire interne a ete realisee en urgence avec une bonne evolution clinique post operatoire. Le bilan a ete complete par une IRM cerebrale objectivant un processus du quatrieme ventricule evoquant un cavernome. Un abord direct a ete realise permettant une exerese totale du cavernome siegeant au sein du quatrieme ventricule. L'anatomo-pathologie a confirmee le diagnostic. A notre connaissance, il s'agit du 13eme cas rapporte dans la litterature. Les cavernomes intraventriculaires representent 2,5-10% de tous les cavernomes dont 9% est au niveau 4eme ventricule. Les patients sont souvent admis aux urgences suite au saignement de cette malformation angiomateuse. Le diagnostic est rendu accessible par les differentes sequences de l'IRM. Le traitement est souvent chirurgical vu le risque de resaignement. Le pronostic depend de l'etat initial du patient et de l'infiltration du plancher du quatrieme ventricule. Key words : Cavernome, ventricule cerebraux, encephale