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We conducted a systematic review and meta-analysis to: 1) compare time from traumatic spinal injury (TSI) to operating room (OR) in high-income countries (HICs) versus low-middle-income countries (LMICs), and 2) evaluate hospital length of stay (LOS) in HICs versus LMICs.A systematic literature search was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines involving articles of all languages.published between 1991 and 2021, spine trauma population, single country/region, and recorded time from injury to OR. The primary outcome was time from injury to OR, and the secondary outcome was LOS. Means and standard deviations were estimated in a random effects model by DerSimonian and Laird methods.Of 2367 articles, 163 met the inclusion criteria for systematic review. Regarding time from injury to OR, 23 articles were eligible for meta-analysis; 16 studies were conducted in HICs and 7 in LMICs, comprising 3819 patients with TSI. A significantly shorter mean time from injury to OR was found in HICs (1.92 days, 95% confidence interval 1.44-2.41) compared with LMICs (3.27 days, 95% confidence interval 2.27-4.27) (P = 0.020). Regarding length of stay, 14 articles were eligible for meta-analysis, 10 studies were conducted in HICs and 4 in LMICs, comprising 11,003 patients. There was no difference in LOS between HICs and LMICs (25.76 days vs. 20.48 days, P = 0.140).Patients with traumatic spinal injuries in HICs were more likely to undergo earlier surgery compared to patients in LMICs. No difference was found in total LOS between HICs and LMICs. While multiple factors can influence time to surgery, these findings draw attention to the global disparity in spinal trauma care.

Objective: The onset of the COVID-19 pandemic dramatically reduced access to in-person educational activities in neurosurgery, necessitating different educational paradigms. Virtual learning, both live and on-demand, has become an essential educational paradigm in global neurosurgery in response to the pandemic. We discuss the different virtual learning modalities that have been developed or grown within global neurosurgery due to the pandemic. Methods: A narrative and anecdotal review was conducted. Results: We discuss webinars, virtual interactive presence technologies, digital simulation, social media, and web-based connectors and their role in global neurosurgery. Conclusion: As a community of neurosurgeons and future neurosurgeons, if we are to meet the global growing demand for neurosurgical care, we must embrace virtual learning in surgical training. The irreplaceable role of hands-on demonstration and teaching in the operating theatre will always remain paramount. However, development and utilization of progressive connectivity technologies will bring us closer to an achievable and sustainable future for neurosurgical training worldwide.

Objective Persistent hydrocephalus following posterior fossa brain tumor (PFBT) resection is a common cause of morbidity in pediatric brain tumor patients, for which the optimal treatment is debated. The purpose of this study was to compare treatment outcomes between VPS and ETV in patients with persistent hydrocephalus following surgical resection of a PFBT. Methods A post-hoc analysis was performed of the Hydrocephalus Clinical Research Network (HCRN) prospective observational study evaluating VPS and ETV for pediatric patients. Children who experienced hydrocephalus secondary to PFBT from 2008 to 2021 were included. Primary outcomes were VPS/ETV treatment failure and time-to-failure (TTF). Results: Among 241 patients, the VPS (183) and ETV (58) groups were similar in age, extent of tumor resection, and preoperative ETV Success Score. There was no difference in overall treatment failure between VPS and ETV (33.9% vs 31.0%, p=0.751). However, mean TTF was shorter for ETV than VPS (0.45 years vs 1.30 years, p=0.001). While major complication profiles were similar, compared to VPS, ETV patients had relatively higher incidence of minor CSF leak (10.3% vs. 1.1%, p=0.003) and pseudomeningocele (12.1% vs 3.3%, p=0.02). No ETV failures were identified beyond 3 years, while shunt failures occurred beyond 5 years. Shunt infections occurred in 5.5% of the VPS cohort. Conclusions ETV and VPS offer similar overall success rates for PFBT-related postoperative hydrocephalus. ETV failure occurs earlier, while susceptibility to VPS failure persists beyond 5 years. Tumor histology and grade may be considered when selecting the optimal means of CSF diversion.

Objective Burnout is experienced by up to two thirds of neurosurgery residents. Team sport participation as an adolescent protects against adverse mental health outcomes in adulthood. The objective of this study was to determine whether high school or collegiate team sport participation is associated with improved psychological well-being during neurosurgery residency. Methods A cross-sectional survey study of U.S. neurosurgery residents was conducted between June 2020 and February 2021. Outcomes included self-ratings of sadness, anxiety, stress, burnout, optimism, and fulfillment, on 100-point scales, which were averaged into a “Burnout Composite Score” (BCS). Respondents were grouped and compared according to their prior self-reported participation in team sports (participants vs. nonparticipants). A 3-way analysis of variance tested the effects of resident level, exercise days, and team sport participation on BCS. Results Of 229 submitted responses, 228 (99.5%) provided complete data and 185 (81.1%) residents participated in team sports. Days/week of exercise was similar across groups (2.5 ± 1.8 vs. 2.1 ± 1.8, P = 0.20). The team sport group reported lower mean BCS (37.1 vs. 43.6 P = 0.030, Cohen d = 0.369). There was a significant interaction between prior team sport participation and exercise regimen on BCS (F [3, 211] = 3.39, P = 0.019, n2 = 0.046), such that more exercise days per week was associated with decreased BCS for prior team sport athletes (F [3, 211] = 11.10, P Conclusions Prior team sport participation was associated with lower BCS among neurosurgery residents, an effect more pronounced during senior residency. Lessons imparted during early team sport experience may have profound impacts on reducing burnout throughout a 7-year neurosurgery residency.

Background Disseminated pediatric low-grade gliomas and glioneuronal tumors (dpLGG/GNTs) are associated with a poorer prognosis than nondisseminated pLGG/GNTs. To date there is no comprehensive report characterizing the genome profile of dpLGG/GNTs and their relative survival. This systematic review aims to identify the pattern of genetic alterations and long-term outcomes described for dpLGG/GNT. Methods A systematic review of the literature was performed to identify relevant articles. A quality and risk of bias assessment of articles was done using the GRADE framework and ROBINS-I tool, respectively. Results Fifty studies published from 1994 to 2020 were included in this review with 366 cases reported. There was sporadic reporting of genetic alterations. The most common molecular alterations observed among subjects were 1p deletion (75%) and BRAF-KIAA1549 fusion (55%). BRAF p.V600E mutation was found in 7% of subjects. A higher proportion of subjects demonstrated primary dissemination compared to secondary dissemination (65% vs 25%). First-line chemotherapy consisted of an alkylation-based regimen and vinca alkaloids. Surgical intervention ranged from biopsy alone (59%) to surgical resection (41%) and CSF diversion (28%). Overall, 73% of cases were alive at last follow-up. Survival did not vary by tumor type or timing of dissemination. All studies reviewed either ranked low or moderate for both quality and risk of bias assessments. Conclusions Chromosome 1p deletion and BRAF-KIAA1549 fusion were the most common alterations identified in dpLGG/GNT cases reviewed. The relative molecular heterogeneity between DLGG and DLGNT, however, deserves further exploration and ultimately correlation with their biologic behavior to better understand the pathogenesis of dpLGG/GNT.

Expanded access to training opportunities is necessary to address 5 million essential neurosurgical cases not performed annually, nearly all in low- and middle-income countries. To target this critical neurosurgical workforce issue and advance positive collaborations, a summit (Global Neurosurgery 2019: A Practical Symposium) was designed to assemble stakeholders in global neurosurgical clinical education to discuss innovative platforms for clinical neurosurgery fellowships.The Global Neurosurgery Education Summit was held in November 2021, with 30 presentations from directors and trainees in existing global neurosurgical clinical fellowships. Presenters were selected based on chain referral sampling from suggestions made primarily from young neurosurgeons in low- and middle-income countries. Presentations focused on the perspectives of hosts, local champions, and trainees on clinical global neurosurgery fellowships and virtual learning resources. This conference sought to identify factors for success in overcoming barriers to improving access, equity, throughput, and quality of clinical global neurosurgery fellowships. A preconference survey was disseminated to attendees.Presentations included in-country training courses, twinning programs, provision of surgical laboratories and resources, existing virtual educational resources, and virtual teaching technologies, with reference to their applicability to hybrid training fellowships. Virtual learning resources developed during the coronavirus disease 2019 pandemic and high-fidelity surgical simulators were presented, some for the first time to this audience.The summit provided a forum for discussion of challenges and opportunities for developing a collaborative consortium capable of designing a pilot program for efficient, sustainable, accessible, and affordable clinical neurosurgery fellowship models for the future.

OBJECTIVE Early suturectomy with a rigid endoscope followed by orthotic cranial helmet therapy is an accepted treatment option for single-suture craniosynostosis. To the authors’ knowledge, flexible endoscope–assisted suture release (FEASR) has not been previously described. Presented herein is their experience with FEASR for the treatment of isolated sagittal craniosynostosis. METHODS A retrospective analysis of the health records of patients who had undergone FEASR between March 2018 and December 2020 was performed. Patients under the age of 6 months who had been diagnosed with isolated sagittal synostosis were considered eligible for FEASR. Exclusion criteria included syndromic synostosis or multiple-suture synostosis. The cephalic index, the primary measure of the cosmetic endpoint, was calculated at prespecified intervals: immediately preoperatively and 6 weeks and 12 months postoperatively. Parental satisfaction with the cosmetic outcome was determined throughout the clinical follow-up and documented according to a structured questionnaire for the first 12 months. RESULTS A total of 18 consecutive patients met the criteria for study inclusion. The mean patient age at the time of surgery was 3.4 months (range 2–6 months). All patients underwent a wide craniectomy with no need to convert to an open procedure. The mean craniectomy width was 3.61 cm. Estimated blood loss ranged from 5 to 30 ml. The mean operative time was 75 minutes. No intraoperative complications were observed. The average length of stay was 2.6 days. The mean cephalic index was 67.7 preoperatively, 77.1 at 6 weeks postoperatively, and 76.3 at 1 year postoperatively. The mean percentage change in the cephalic index from preoperatively to the 12-month follow-up was 10.44 (p < 0.001). The mean follow-up was 17 months (range 12–28 months). All parents were satisfied with the cosmetic outcome of the procedure. No patients developed symptoms of raised intracranial pressure (ICP) or needed invasive ICP monitoring during the follow-up period. No patients required reoperation. CONCLUSIONS In this modest single-hospital series, the authors demonstrated the feasibility of FEASR in treating sagittal synostosis with favorable cosmetic outcomes. The morbidity profile and resource utilization of the procedure appear similar to those of procedures conducted via traditional rigid endoscopy.

In the twenty-first century, choroid plexus cauterization (CPC) in combination with endoscopic third ventriculostomy (ETV) has emerged as an effective treatment for some infants with hydrocephalus, leading to the favourable condition of 'shunt independence'. Herein we provide a narrative technical review considering the indications, procedural aspects, morbidity and its avoidance, postoperative care and follow-up. The CP has been the target of hydrocephalus treatment for more than a century. Early eminent neurosurgeons including Dandy, Putnam and Scarff performed CPC achieving generally poor results, and so the procedure fell out of favour. In recent years, the addition of CPC to ETV was one of the reasons greater ETV success rates were observed in Africa, compared to developed nations, and its popularity worldwide has since increased. Initial results indicate that when ETV/CPC is performed successfully, shunt independence is more likely than when ETV is undertaken alone. CPC is commonly performed using a flexible endoscope via septostomy and aims to maximally cauterize the CP. Success is more likely in infants aged >1 month, those with hydrocephalus secondary to myelomeningocele and aqueductal obstruction and those with >90% cauterized CP. Failure is more likely in those with post-haemorrhagic hydrocephalus of prematurity (PHHP), particularly those

Primary brain tumors diagnosed during infancy present several challenges for the pediatric neurosurgeon including the management of tumor-related hydrocephalus. Infant tumor-related hydrocephalus (iTRH) is present in over 70% of new diagnoses overall and in over 90% of infants with infratentorial neoplasms. iTRH may be related to direct obstruction of cerebrospinal fluid (CSF) pathways, shedding of protein and/or cells leading to dysfunctional subarachnoid, tumor-related CSF production, or, most frequently, a combination of these mechanisms. Treatment plans must consider the acuity of presentation, the mechanism of iTRH, and the additional neoadjuvant or adjuvant therapies required to treat the neoplasm. This narrative review provides a broad reference on the epidemiology, pathophysiology, and treatment of iTRH.

OBJECTIVEThere are limited data on the pediatric neurosurgical workforce in Asia and Australasia. The training and clinical practice of pediatric neurosurgeons need to be characterized in order to identify gaps in knowledge and skills, thereby establishing a framework from which to elevate pediatric neurosurgical care in the region.METHODSAn online survey for pediatric neurosurgeons was created in REDCap (Research Electronic Database Capture), collecting demographic information and data on pediatric neurosurgical training and clinical practice. The link to answer the survey was sent to the mailing lists of the Asian Australasian Society for Pediatric Neurosurgery and the Japanese Society for Pediatric Neurosurgery, disseminated during the 2019 Asian Australasian Pediatric Neurosurgery Congress, and spread through social media. The survey was open to neurosurgeons who operated on patients ≤ 18 years old in Asian Australasian countries, whether or not they had completed fellowship training in pediatric neurosurgery. Descriptive statistics were computed and tabulated. Data were stratified and compared based on surgeon training and World Bank income group.RESULTSA total of 155 valid survey responses were analyzed, representing neurosurgeons from 21 countries. A total of 107 (69%) considered themselves pediatric neurosurgeons, of whom 66 (43%) had completed pediatric neurosurgery training. Neurosurgeons in East Asia commonly undergo a fellowship in their home countries, whereas the rest train mostly in North America, Europe, and Australia. A majority (89%) had operating privileges, and subspecialty pediatric training usually lasted from 6 months to 2 years. On average, trained pediatric neurosurgeons perform a higher number of pediatric neurosurgical operations per year compared with nonpediatric-trained respondents (131 ± 129 vs 56 ± 64 [mean ± SD], p = 0.0001). The mean number of total neurosurgical operations per year is similar for both groups (184 ± 129 vs 178 ± 142 [mean ± SD], p = 0.80). Respondents expressed the desire to train further in pediatric epilepsy, spasticity, vascular malformations, craniofacial disorders, and brain tumors.CONCLUSIONSBoth pediatric and general neurosurgeons provide neurosurgical care to children in Asia and Australasia. There is a need to increase pediatric neurosurgery fellowship programs in the region. Skill sets and training needs in pediatric neurosurgery vary depending on the country’s economic status and between pediatric-trained and nonpediatric-trained surgeons.

Craniosynostosis leads to craniofacial deformity and may result in raised intracranial pressure, neurocognitive deficits, and psychosocial issues if left untreated. The global epidemiology of craniosynostosis is unknown. We conducted a meta-analysis to estimate global birth prevalence.PubMed, Embase, and Scopus were searched. Articles were screened by title and abstract and then full text. Meta-analysis of birth prevalence was conducted. Birth prevalence figures were combined with metrics detailing the number of births in 2019 to estimate the number of children worldwide born with craniosynostosis annually.Of 1378 resultant articles, 24 studies were included, including 20 providing data for craniosynostosis overall and 9 for nonsyndromic craniosynostosis. World Health Organization regions of included studies were 9 (37.5%) European Region, 8 (33.3%) Region of the Americas, 4 (16.7%) Western Pacific region, 2 (8.3%) African Region, and 1 (4.2%) Eastern Mediterranean Region. Lower middle-income countries represented only 4% of study manuscripts. The overall birth prevalence of craniosynostosis was 5.9 per 10,000 live births (20 studies; 95% confidence interval [CI]: 3.9, 8.4; ICraniosynostosis is a common condition that affects the neurocognitive and craniofacial skeletal development of children worldwide. Initiatives to scale up capacity for craniosynostosis epidemiologic research and clinical care are warranted, particularly in low- and middle-income countries.

Choroid plexus cysts rarely grow to be symptomatic. Few large choroid plexus cysts have been reported in the pediatric population. The authors report a 15-month-old boy with increased head circumference and a bony deformity in the left parietal region due to mass effect from a giant choroid plexus cyst. The child had a craniotomy for open resection of the cyst, and made an excellent recovery. The differential diagnosis for intraventricular cysts and the literature surrounding choroid plexus cysts are discussed.

Blunt cerebrovascular injury (BCVI) is uncommon in the pediatric population. Among the management options is medical management consisting of antithrombotic therapy with either antiplatelets or anticoagulation. There is no consensus on whether administration of antiplatelets or anticoagulation is more appropriate for BCVI in children < 10 years of age. Our goal was to compare radiographic and clinical outcomes based on medical treatment modality for BCVI in children < 10 years. Clinical and radiographic data were collected retrospectively for children screened for BCVI with computed tomography angiography at 5 academic pediatric trauma centers. Among 651 patients evaluated with computed tomography angiography to screen for BCVI, 17 patients aged less than 10 years were diagnosed with BCVI (7 grade I, 5 grade II, 1 grade III, 4 grade IV) and received anticoagulation or antiplatelet therapy for 18 total injuries: 11 intracranial carotid artery, 4 extracranial carotid artery, and 3 extracranial vertebral artery injuries. Eleven patients were treated with antiplatelets (10 aspirin, 1 clopidogrel) and 6 with anticoagulation (4 unfractionated heparin, 2 low-molecular-weight heparin, 1 transitioned from the former to the latter). There were no complications secondary to treatment. One patient who received anticoagulation died as a result of the traumatic injuries. In aggregate, children treated with antiplatelet therapy demonstrated healing on 52% of follow-up imaging studies versus 25% in the anticoagulation cohort. There were no observed differences in the rate of hemorrhagic complications between anticoagulation and antiplatelet therapy for BCVI in children < 10 years, with a nonsignificantly better rate of healing on follow-up imaging in children who underwent antiplatelet therapy; however, the study cohort was small despite including patients from 5 hospitals.

OBJECTIVEThe authors aimed to evaluate clinical, radiological, and surgical factors associated with posterior fossa tumor resection (PFTR)–related outcomes, including postoperative complications related to dural augmentation (CSF leak and wound infection), persistent hydrocephalus ultimately requiring permanent CSF diversion after PFTR, and 90-day readmission rate.METHODSPediatric patients (0–17 years old) undergoing PFTR between 2000 and 2016 at Monroe Carell Jr. Children’s Hospital of Vanderbilt University were retrospectively reviewed. Descriptive statistics included the Wilcoxon signed-rank test to compare means that were nonnormally distributed and the chi-square test for categorical variables. Variables that were nominally associated (p < 0.05) with each outcome by univariate analysis were included as covariates in multivariate linear regression models. Statistical significance was set a priori at p < 0.05.RESULTSThe cohort consisted of 186 patients with a median age at surgery of 6.62 years (range 3.37–11.78 years), 55% male, 83% Caucasian, and average length of follow-up of 3.87 ± 0.25 years. By multivariate logistic regression, the variables primary dural closure (PDC; odds ratio [OR] 8.33, 95% confidence interval [CI] 1.07–100, p = 0.04), pseudomeningocele (OR 7.43, 95% CI 2.23–23.76, p = 0.0007), and hydrocephalus ultimately requiring permanent CSF diversion within 90 days of PFTR (OR 9.25, 95% CI 2.74–31.2, p = 0.0003) were independently associated with CSF leak. PDC versus graft dural closure (GDC; 35% vs 7%, OR 5.88, 95% CI 2.94–50.0, p = 0.03) and hydrocephalus ultimately requiring permanent CSF diversion (OR 3.30, 95% CI 1.07–10.19, p = 0.0007) were associated with wound infection requiring surgical debridement. By multivariate logistic regression, GDC versus PDC (23% vs 37%, OR 0.13, 95% CI 0.02–0.87, p = 0.04) was associated with persistent hydrocephalus ultimately requiring permanent CSF diversion, whereas pre- or post-PFTR ventricular size, placement of peri- or intraoperative extraventricular drain (EVD), and radiation therapy were not. Furthermore, the addition of perioperative EVD placement and dural closure method to a previously validated predictive model of post-PFTR hydrocephalus improved its performance from area under the receiver operating characteristic curve of 0.69 to 0.74. Lastly, the authors found that autologous (vs synthetic) grafts may be protective against persistent hydrocephalus (p = 0.02), but not CSF leak, pseudomeningocele, or wound infection.CONCLUSIONSThese results suggest that GDC, independent of potential confounding factors, may be protective against CSF leak, wound infection, and hydrocephalus in patients undergoing PFTR. Additional studies are warranted to further evaluate clinical and surgical factors impacting PFTR-associated complications.

Repeat surgery (RS) after decompressive craniectomy/craniotomy (DC) for traumatic intracranial hemorrhage (TICH) is a devastating complication. In patients undergoing DC for TICH, we sought to 1) describe the population requiring RS, 2) compare outcomes of those requiring RS with those who did not, and 3) discern RS predictors.A single-institution retrospective case-control study was conducted from 2000 to 2015. Inclusion criteria were DC for acute supratentorial TICH (subdural hemorrhage, epidural hemorrhage, and intraparenchymal hemorrhage) and ≥7 day survival. Patients underwent RS within 7 days of DC; controls did not require RS. Outcomes and predictors of RS were evaluated with univariate and multivariate logistic regression (MLR).Of 201 patients requiring DC, 28 (14%) underwent RS. Common mechanisms were ground-level fall (45%) and motor vehicle collision (29%). Anticoagulation/antiplatelet medication was used by 44 patients (21%). Subdural hemorrhage was the most common hemorrhage (64%). Using MLR, those requiring RS were more likely to experience major complications (odds ratio [OR], 22.6; 95% confidence interval [CI], 5.06-101.35; P0.001) and in-hospital mortality (OR, 2.76; 95% CI, 1.02-7.43; P = 0.045) and be dead/dependent at 6 months (OR, 2.50; 95% CI, 1.08-5.82; P = 0.033) and 2 years (OR, 2.44; 95% CI, 0.99-6.00; P = 0.051). Predictors of undergoing RS identified by MLR were smaller hemorrhage (OR, 0.32; 95% CI, 0.13-0.78; P = 0.012), larger midline shift (OR, 4.40; 95% CI, 1.43-13.51; P = 0.010), and better preoperative Glasgow Coma Scale score (OR, 1.28; 95% CI, 1.13-1.46; P0.001).Patients requiring RS after DC represent a heterogenous population with worse outcomes. Although the identified risk factors for RS are not modifiable, surgeons should be aware of these factors during the initial surgery.

OBJECTIVEThe optimal revascularization for pediatric moyamoya for reducing the incidence of future stroke events remains to be determined.METHODSThe authors conducted a search of PubMed, MEDLINE, Embase, and Web of Science electronic databases from inception until January 2019. The primary endpoint was the presence of a future ischemic stroke event. Secondary endpoints were angiographic outcomes as measured by postoperative Matsushima grade and clinical symptom persistence. Patients who underwent either direct or combined direct/indirect revascularization were classified into the direct cohort. Data from each study on presence of postoperative stroke events were used to generate standardized mean differences and 95% confidence intervals, which were combined using inverse variance-weighted averages of standardized mean differences in a random effects model.RESULTSTwenty-nine studies met the inclusion criteria for analysis, comprising 2258 patients (1011 males, mean age 8.3 ± 1.8 years) who were followed up clinically for an average of 71.4 ± 51.3 months. One hundred fifty-four patients underwent direct bypass alone, 680 patients underwent either direct or combined direct/indirect revascularization procedures, while 1424 patients underwent indirect bypass alone. The frequencies of future stroke events in patients undergoing direct bypass alone, combined bypass, or indirect bypass alone were 1 per 190.3 patient-years, 1 per 108.9 patient-years, and 1 per 61.1 patient-years, respectively, in each cohort. The estimated stroke rates were 9.0% with indirect revascularization, 4.5% with direct revascularization alone, and 6.0% with combined revascularization. A forest plot did not reveal any significant differences in the incidence of future stroke events or angiographic outcomes following direct-only, combined, or indirect-only revascularization.CONCLUSIONSDirect, indirect, and combined indirect/direct bypass techniques are all effective revascularization options for pediatric moyamoya disease. A relative paucity of granular studies—and inherent surgical selection bias—limits direct comparison between interventions. Suitably designed prospective cohort studies may be useful in identifying patients likely to receive benefit from specific procedures.

INTRODUCTIONGliomas account for approximately 46% of all pediatric CNS tumors. There is growing awareness of pediatric low-grade gliomas (PLGG) that disseminate to distant parenchymal or leptomeningeal locations either at the time of initial diagnosis or upon disease surveillance. Disseminated PLGGs (dPLGGs) are associated with a poorer prognosis than non-disseminated PLGGs. To date there is no comprehensive report characterizing the genome profile of dPLGGs and their associated management. This systematic review aims to identify the pattern of genetic alterations and treatment outcomes described for dPLGG.METHODSA systematic review of the literature was performed to identify relevant articles. A quality and risk of bias assessment of articles was done using the GRADE framework and ROBINS-I tool, respectively.RESULTSFifty-two studies published from 1994 to 2020 were included in this review with 368 cases reported. There was sporadic reporting of genetic alterations. The most common genetic alteration observed among study subjects was 1p deletion (76%) and BRAF-KIAA1549 fusion (55%). BRAF p.V600E mutation was found in 7% of subjects. A higher proportion of cases demonstrated primary dissemination compared to secondary dissemination (65% vs 25%). First-line chemotherapy consisted primarily of an alkylation-based regimen and vinca alkaloids. Surgical intervention ranged from biopsy alone to surgical resection and CSF diversion, and depended largely upon tumor location and timing of dissemination. Overall, 73% of cases were alive at last follow-up (median, 40.2 months). All studies reviewed either ranked low or moderate for both quality and risk of bias assessments. CONCLUSIONWhile 1p deletion and BRAF-KIAA1549 fusion are the most commonly described molecular alterations in dPLGG, these tumors appear to express heterogeneous molecular and biological characteristics distinct from non-disseminated PLGGs. Additional studies on the molecular and biological features of these tumors are needed to better understand the pathogenesis of dPLGG and to inform the development of additional targeted regimens.

BACKGROUND Neurofibromatosis type 1 (NF-1) is a neurocutaneous autosomal dominant disorder that predisposes patients to develop intracranial low-grade gliomas (LGGs). Most LGGs in patients with NF-1 involve the optic pathway but can arise anywhere throughout the central nervous system. NF-1–related disseminated pediatric LGG (dPLGG) in the absence of a dominant optic pathway glioma has not been described. OBSERVATIONS The authors discussed a case of a 10-year-old boy who presented with consideration for biopsy with nonoptic pathway PLGG with craniospinal dPLGG in the setting of NF-1. The patient’s primary lesion, located in the right medulla, was initially treated with surveillance before induction chemotherapy with carboplatin and vincristine was initiated. However, surveillance imaging demonstrated significant increase in size and enhancement, and subsequent craniospinal imaging demonstrated extensive nodular dissemination in the cervicothoracic spine. A biopsy and molecular testing were subsequently performed to further evaluate the tumor, and the patient was diagnosed with dPLGG with CDKN2A deletion. LESSONS Thorough craniospinal magnetic resonance imaging evaluation and biopsy in nonoptic pathway–dominant brain lesions in NF-1 are warranted in patients with atypical clinical and radiological findings in whom standard chemotherapeutic therapy fails.

Background: Several studies have highlighted the use of human amniotic membrane (HAM) in neurosurgical procedures as an effective dural substitute. HAM has inherent antifibrotic and anti-inflammatory properties and exhibits immunomodulatory effect that makes it an ideal dural substitute. Other advantages including easy availability, low cost of procurement, and storage also render it a promising dural substitute especially in low- and middle-income countries. Methods: A systematic literature search was performed using PubMed, Scopus, and Google Scholar databases, using the search terms “human amniotic membrane,” “dural repair,” and “neurosurgery.” To be eligible for inclusion in our review, papers had to report primary data, be published in English language and report dural repair on humans with human amniotic membrane. Eligibility assessment was conducted by two independent reviewers with qualitative analysis on the basis of surgical utility, postoperative complications, and histological analysis. Results: Eight articles met the predefined inclusion criteria, including three randomized control trials and five cohort studies. We evaluated the use of HAM grafts in dural repair for elective cranial surgery (four studies), trauma surgery (three studies), and elective spine surgery (one study). Cases with postoperative cerebrospinal fluid (CSF) leak were reported by two studies. Other postoperative complications including meningitis, hydrocephalus, pseudomeningocele, CSF collection in subdural space, and subacute subdural hematoma were reported by one study each. Postsurgical histological analysis was reported by three studies highlighting the antiadhesive and integrative properties of HAM. Conclusion: The current review of evidence suggests that in terms of postsurgical outcomes, HAM is comparable with commercially available dural substitutes.

To describe the design, implementation, and adoption of a simplified electronic medical record (EMR) and its use in documenting pediatric central nervous system (CNS) tumors at a tertiary care referral hospital in South-East Asia.A novel EMR, cataloguing pediatric CNS tumors was used to collect data from August 2017 to March 2020 at National Institute of Neurosciences and Hospital (NINSH) in Dhaka, Bangladesh.Two hundred forty-nine pediatric patients with a CNS tumor were admitted to NINSH. Fifty-eight percent of patients were male, and the median age was 8 years. A total of 188/249 patients (76%) underwent surgery during their index admission. Radiographic locations were known for 212/249 (85%) of cases; the most common radiographic locations were infratentorial (81/212; 38%), suprasellar (45/212; 21%), and supratentorial (29/212; 14%). A histopathological classification was reported on 156/249 (63%) of patients' cytology. The most common infratentorial pathologies were medulloblastoma (22/47; 47%) and pilocytic astrocytoma (14/47; 30%). The median time between admission and surgery was 36 days, while the median post-operation stay was 19.5 days.The feasibility of a basic EMR platform for a busy pediatric neurosurgery department in a lower-middle income country is demonstrated, and preliminary clinical data is reviewed. A wide variety of pediatric CNS tumors were observed, spanning the spectrum of anatomic locations and histopathologic subtypes. Surgical intervention was performed for the majority of patients. Barriers to care include limited molecular diagnostics and unavailable data on adjuvant therapy. Future targets include improvement of clinical documentation in the pre-operative and post-operative period.

Radiation-associated aneurysms are rare, difficult to treat, and associated with high morbidity and mortality when ruptured, compared with aneurysms unrelated to radiation treatment. We present a 16-year-old patient with a radiation-induced intracranial aneurysm arising from the left posterior inferior cerebellar artery (PICA), 10 years following radiotherapy for medulloblastoma. The patient successfully underwent endovascular coil embolization of the parent artery across the neck of the aneurysm. CT angiography and MRI in the days following the procedure demonstrated maintained flow in the anterior and lateral medullary PICA segments with no brainstem infarct.

This study sought to determine the previously undescribed cytologic and metabolic alterations that accompany endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC). Cerebrospinal fluid (CSF) samples were collected from infant patients with hydrocephalus at the time of index ETV/CPC and again at each reintervention for persistent hydrocephalus. Basic CSF parameters, including glucose, protein, and cell counts, were documented. A multivariable regression model, incorporating known predictors of ETV/CPC outcome, was constructed for each parameter to inform time-dependent normative values. A total of 187 infants were treated via ETV/CPC for hydrocephalus; initial laboratory values were available for 164 patients. Etiology of hydrocephalus included myelomeningocele (53, 32%), intraventricular hemorrhage of prematurity (43, 26%), aqueductal stenosis (24, 15%), and others (44, 27%). CSF parameters did not differ significantly with age or etiology. Glucose levels initially drop below population average (36 to 32 mg/dL) post-operatively before slowly rising to normal levels (42 mg/dL) by 3 months. Dramatically elevated protein levels post-ETV/CPC (baseline of 59 mg/dL up to roughly 200 mg/dL at 1 month) also normalized over 3 months. No significant changes were appreciated in WBC. RBC counts were very elevated following ETV/CPC and quickly declined over the subsequent month. CSF glucose and protein deviate significantly from normal ranges following ETV/CPC before normalizing over 3 months. High RBC values immediately post-ETV/CPC decline rapidly. Age at time of procedure and etiology have little influence on common clinical CSF laboratory parameters. Of note, the retrospective study design necessitates ETV/CPC failure, which could introduce bias in the results.

The two-hit hypothesis of neural injury in the wake of open neural tube defects suggests an opportunity for preservation of function and potential reversibility of early morphological changes in the fetus diagnosed with myelomeningocele. The Management of Myelomeningocele Study (MOMS) demonstrated reduced need for shunting and improved neurological function in patients treated in utero relative to postnatally, thereby offering level 1 evidence supporting fetal repair. Subsequent studies have offered additional information about urological, orthopedic, radiological, and maternal factors surrounding fetal repair. The quest for robust long-term neurocognitive and motor function data is underway and poised to shape the future of fetal repair. In addition, technical innovations such as fetoscopic surgery aim to minimize maternal morbidity while conferring the beneficial effects observed with open intrauterine intervention.

While obtaining accurate estimates of tumor incidence volume is a difficult technical problem because it requires collating and analyzing data from dozens of world-wide sources curated under different conditions, our study aims to determine the global incidence of brain and spinal tumors. We analyzed 207 tumor registries on five continents, and calculated age-standardized rates to compare tumor incidence between geographic regions and income levels. Based on data available in current cancer registries, the apparent global incidence of malignant brain tumors was 4.25 cases per 100,000 person-years (95% CI [4.21-4.29]), and varied by region from 6.76 [6.71-6.80] in Europe to 2.81 [2.64-2.99] in Africa. Incidence also varied by World Bank income group, ranging from 6.29 [6.26-6.32] cases per 100,000 in high income countries (HICs), to 4.81 [4.77-4.86] in low and middle-income countries (LMICs). Malignant spinal tumors were much less frequent globally (0.098 [0.093-0.104]) and varied similarly by region and income group. The incidence of brain and spinal tumors varies by region and income group, although case ascertainment bias driven by limited resources in low income regions likely plays a role in variance. The burden of neurosurgical disease in LMICs is large, and similar in scale to HICs.

OBJECTIVEThe Management of Myelomeningocele Study (MOMS) established several important benefits of myelomeningocele fetal closure, including decreased need for shunting at 30 months. However, the effects of fetal closure on long-term quality of life (QOL) have not been studied. In this study, the authors aimed to analyze the differences in long-term QOL between children treated with intrauterine repair and those treated with postnatal repair.METHODSCaregivers of children treated with either intrauterine or postnatal closure at a tertiary acute care hospital between 1997 and 2003 were contacted to participate. The Pediatric Quality of Life Inventory (PedsQL 4.0) and a surgical history questionnaire were administered over the phone. Responses to the QOL survey were reverse scored and linearly transformed to a 0–100 scale, with a higher score indicating better QOL. The Mann-Whitney U-test was used to analyze differences in means.RESULTSSeventy-four children had MMC repair between 1997 and 2003. Twenty-three (31%) of the patients’ families responded to the PedsQL 4.0 questionnaire. Of these 23 children, 11 had intrauterine closure and 12 had postnatal closure. The intrauterine group did not differ in age (median [IQR] 17 years [14–17 years] vs 15 years [14–19 years], p = 0.926), sex (27.3% vs 41.7% male, p = 0.469), or lesion level (p = 0.199) from the postnatal group. Fewer patients in the intrauterine group underwent neurosurgical procedures than those in the postnatal group (55.6% vs 100%, p = 0.018). However, of the children receiving neurosurgical procedures, there was no difference in the number of procedures between the intrauterine and postnatal groups (median [IQR] 4 [2–10.5] vs 2.5 [1.75–6.25], p = 0.458). There was no difference in the percentage of children receiving nonneurosurgical procedures between the two groups (100% vs 100%, p > 0.99). Children who underwent intrauterine closure had significantly higher psychosocial health (median [IQR] 70.0 [56.7–83.3] vs 55.0 [42.1–60.0], p = 0.015) as well as total QOL (median [IQR] 56.5 [55.4–81.5] vs 49.5 [32.9–59.0], p = 0.019) than children with postnatal closure. Physical health was not significantly different between the two groups (median [IQR] 62.5 [37.5–78.1] vs 39.1 [18.8–59.4], p = 0.108).CONCLUSIONSRelative to postnatal closure, children who underwent intrauterine closure of MMC demonstrated better long-term QOL as measured by psychosocial and overall QOL metrics. Given that not all medical and socioeconomic confounders were adjusted for due to the low sample size, validation of these results in a larger population and across multiple centers is needed.

BACKGROUND: There are currently no published data directly comparing postoperative seizure incidence following endoscopic third ventriculostomy (ETV), with/without choroid plexus cauterization (CPC), to that for ventriculoperitoneal shunt (VPS) placement. OBJECTIVE: To compare postoperative epilepsy incidence for ETV/CPC and VPS in Ugandan infants treated for postinfectious hydrocephalus (PIH). METHODS: We performed an exploratory post hoc analysis of a randomized trial comparing VPS and ETV/CPC in 100 infants (

OBJECTIVEThe objective of this study was to estimate the economic consequences of neurosurgical disease in low- and middle-income countries (LMICs).METHODSThe authors estimated gross domestic product (GDP) losses and the broader welfare losses attributable to 5 neurosurgical disease categories in LMICs using two distinct economic models. The value of lost output (VLO) model projects annual GDP losses due to neurosurgical disease during 2015–2030, and is based on the WHO’s “Projecting the Economic Cost of Ill-health” tool. The value of lost economic welfare (VLW) model estimates total welfare losses, which is based on the value of a statistical life and includes nonmarket losses such as the inherent value placed on good health, resulting from neurosurgical disease in 2015 alone.RESULTSThe VLO model estimates the selected neurosurgical diseases will result in $4.4 trillion (2013 US dollars, purchasing power parity) in GDP losses during 2015–2030 in the 90 included LMICs. Economic losses are projected to disproportionately affect low- and lower-middle-income countries, risking up to a 0.6% and 0.54% loss of GDP, respectively, in 2030. The VLW model evaluated 127 LMICs, and estimates that these countries experienced $3 trillion (2013 US dollars, purchasing power parity) in economic welfare losses in 2015. Regardless of the model used, the majority of the losses can be attributed to stroke and traumatic brain injury.CONCLUSIONSThe economic impact of neurosurgical diseases in LMICs is significant. The magnitude of economic losses due to neurosurgical diseases in LMICs provides further motivation beyond already compelling humanitarian reasons for action.

OBJECTIVEEpilepsy is one of the most common neurological disorders, yet its global surgical burden has yet to be characterized. The authors sought to compile the most current epidemiological data to quantify global prevalence and incidence, and estimate global surgically treatable epilepsy. Understanding regional and global epilepsy trends and potential surgical volume is crucial for future policy efforts and resource allocation.METHODSThe authors performed a systematic literature review and meta-analysis to determine the global incidence, lifetime prevalence, and active prevalence of epilepsy; to estimate surgically treatable epilepsy volume; and to evaluate regional trends by WHO regions and World Bank income levels. Data were extracted from all population-based studies with prespecified methodological quality across all countries and demographics, performed between 1990 and 2016 and indexed on PubMed, EMBASE, and Cochrane. The current and annual new case volumes for surgically treatable epilepsy were derived from global epilepsy prevalence and incidence.RESULTSThis systematic review yielded 167 articles, across all WHO regions and income levels. Meta-analysis showed a raw global prevalence of lifetime epilepsy of 1099 per 100,000 people, whereas active epilepsy prevalence is slightly lower at 690 per 100,000 people. Global incidence was found to be 62 cases per 100,000 person-years. The meta-analysis predicted 4.6 million new cases of epilepsy annually worldwide, a prevalence of 51.7 million active epilepsy cases, and 82.3 million people with any lifetime epilepsy diagnosis. Differences across WHO regions and country incomes were significant. The authors estimate that currently 10.1 million patients with epilepsy may be surgical treatment candidates, and 1.4 million new surgically treatable epilepsy cases arise annually. The highest prevalences are found in Africa and Latin America, although the highest incidences are reported in the Middle East and Latin America. These regions are primarily low- and middle-income countries; as expected, the highest disease burden falls disproportionately on regions with the fewest healthcare resources.CONCLUSIONSUnderstanding of the global epilepsy burden has evolved as more regions have been studied. This up-to-date worldwide analysis provides the first estimate of surgical epilepsy volume and an updated comprehensive overview of current epidemiological trends. The disproportionate burden of epilepsy on low- and middle-income countries will require targeted diagnostic and treatment efforts to reduce the global disparities in care and cost. Quantifying global epilepsy provides the first step toward restructuring the allocation of healthcare resources as part of global healthcare system strengthening.

OBJECTIVEWorldwide disparities in the provision of surgical care result in otherwise preventable disability and death. There is a growing need to quantify the global burden of neurosurgical disease specifically, and the workforce necessary to meet this demand.METHODSResults from a multinational collaborative effort to describe the global neurosurgical burden were aggregated and summarized. First, country registries, third-party modeled data, and meta-analyzed published data were combined to generate incidence and volume figures for 10 common neurosurgical conditions. Next, a global mapping survey was performed to identify the number and location of neurosurgeons in each country. Finally, a practitioner survey was conducted to quantify the proportion of disease requiring surgery, as well as the median number of neurosurgical cases per annum. The neurosurgical case deficit was calculated as the difference between the volume of essential neurosurgical cases and the existing neurosurgical workforce capacity.RESULTSEvery year, an estimated 22.6 million patients suffer from neurological disorders or injuries that warrant the expertise of a neurosurgeon, of whom 13.8 million require surgery. Traumatic brain injury, stroke-related conditions, tumors, hydrocephalus, and epilepsy constitute the majority of essential neurosurgical care worldwide. Approximately 23,300 additional neurosurgeons are needed to address more than 5 million essential neurosurgical cases—all in low- and middle-income countries—that go unmet each year. There exists a gross disparity in the allocation of the surgical workforce, leaving large geographic treatment gaps, particularly in Africa and Southeast Asia.CONCLUSIONSEach year, more than 5 million individuals suffering from treatable neurosurgical conditions will never undergo therapeutic surgical intervention. Populations in Africa and Southeast Asia, where the proportion of neurosurgeons to neurosurgical disease is critically low, are especially at risk. Increasing access to essential neurosurgical care in low- and middle-income countries via neurosurgical workforce expansion as part of surgical system strengthening is necessary to prevent severe disability and death for millions with neurological disease.

OBJECTIVEThere remains uncertainty regarding the appropriate level of care and need for repeating neuroimaging among children with mild traumatic brain injury (mTBI) complicated by intracranial injury (ICI). This study’s objective was to investigate physician practice patterns and decision-making processes for these patients in order to identify knowledge gaps and highlight avenues for future investigation.METHODSThe authors surveyed residents, fellows, and attending physicians from the following pediatric specialties: emergency medicine; general surgery; neurosurgery; and critical care. Participants came from 10 institutions in the United States and an email list maintained by the Canadian Neurosurgical Society. The survey asked respondents to indicate management preferences for and experiences with children with mTBI complicated by ICI, focusing on an exemplar clinical vignette of a 7-year-old girl with a Glasgow Coma Scale score of 15 and a 5-mm subdural hematoma without midline shift after a fall down stairs.RESULTSThe response rate was 52% (n = 536). Overall, 326 (61%) respondents indicated they would recommend ICU admission for the child in the vignette. However, only 62 (12%) agreed/strongly agreed that this child was at high risk of neurological decline. Half of respondents (45%; n = 243) indicated they would order a planned follow-up CT (29%; n = 155) or MRI scan (19%; n = 102), though only 64 (12%) agreed/strongly agreed that repeat neuroimaging would influence their management. Common factors that increased the likelihood of ICU admission included presence of a focal neurological deficit (95%; n = 508 endorsed), midline shift (90%; n = 480) or an epidural hematoma (88%; n = 471). However, 42% (n = 225) indicated they would admit all children with mTBI and ICI to the ICU. Notably, 27% (n = 143) of respondents indicated they had seen one or more children with mTBI and intracranial hemorrhage demonstrate a rapid neurological decline when admitted to a general ward in the last year, and 13% (n = 71) had witnessed this outcome at least twice in the past year.CONCLUSIONSMany physicians endorse ICU admission and repeat neuroimaging for pediatric mTBI with ICI, despite uncertainty regarding the clinical utility of those decisions. These results, combined with evidence that existing practice may provide insufficient monitoring to some high-risk children, emphasize the need for validated decision tools to aid the management of these patients.

Background: Occipitocervical distraction injuries (OCDI) in children occur on a wide spectrum of severity, and decisions about treatment suffer from a lack of rigorous guidelines and significant inter-institutional variability. While clear cases of frank atlanto-occipital dislocation (AOD) are treated with surgical stabilization, the approach for less severe cases of OCDI is not standardized. These patients require a careful assessment of both radiographic and clinical criteria, as part of a complex risk-benefit analysis, to establish whether occipitocervical fusion (OCF) is indicated. Here, we performed a systematic review of the literature that describes traumatic OCDI in children < 18 years of age. Summary: We performed a systematic review, according to PRISMA guidelines, of children < 18 years of age presenting with traumatic etiologies of OCDI. We searched PubMed to identify papers congruent with these criteria. Exclusion criteria included (1) reports on atraumatic causes of OCDI and (2) studies with insufficient clinical and radiographic details on individual patients. We identified 16 reports describing a total of 144 patients treated for pediatric traumatic OCDI. Based on the synthesis of these findings and the collective experience of the authors, we present the demographic, clinical, and radiographic factors that underlie OC instability, which we hope will serve as components of a grading system in the future. We considered various clinical and radiographic findings including: (1) the mechanism of injury, (2) the patient’s age, (3) CT/CT angiography of head and neck findings and parameters, (4) MRI findings, and (5) neurological exam, for the purpose of determining the severity of the OCDI and offering treatment guidelines based on the summative risk of underlying OC instability. Key Messages: OCDI is a potentially devastating injury, especially in children. Although missing the diagnosis can have potentially catastrophic consequences, reverting to surgical fixation in less severe cases can subject children to unnecessary operative risk and permanently reduce their range of motion. After reviewing all the available reports of pediatric traumatic OCDI in the neurosurgical literature, we propose an outline of clinical and radiographic factors influencing underlying OC instability that could be incorporated into a grading scale to guide treatment. We hope this study stimulates discussion on the standardization of treatment for pediatric OCDI.

Primary central nervous system (CNS) tumors represent an important and growing cause of worldwide morbidity and mortality. There are global variations in the reported case burden of CNS tumors, with high-income countries reporting a higher incidence of cases than low- and middle-income countries. Variations are attributed to differences in access to care, diagnostic capacity, risk exposure, and under-reporting in LMICs. This study aims to review existing literature on the distribution of primary CNS tumors and neuro-oncologic care, and the contribution of scientists and institutions to neuro-oncologic research across 18 East African countries over the last 5 decades. A search was conducted using OVID Medline and PubMed databases to identify relevant East African neuro-oncologic studies published over the last 50 years. The authors reviewed 36 neuro-oncology articles published across 8 of 18 East African countries. Kenya represented the highest number of published articles; ten countries queried yielded zero publications. A total of 2006 cases from all age groups were represented in published literature consisting of a wide spectrum of CNS tumors. One-third of reported cases were pediatric. Meningioma formed the largest proportion (43.3%) followed by glioma (33.7%). Sixty-seven percent of publications gave an overview of clinical care received by patients with most patients not receiving comprehensive neuro-oncologic care. The modest collection of neuro-oncology publications from East Africa shows that the case diversity of primary CNS tumors in East Africa is comparable to the rest of the world. There is, however, poorer access to neurosurgical care and adjuvant therapy. Multidisciplinary efforts from clinicians, researchers, and healthcare agencies are needed to quantify and address the requisite neuro-oncology needs in this region.

In the twenty-first century, choroid plexus cauterization (CPC) in combination with endoscopic third ventriculostomy (ETV) has emerged as an effective treatment for some infants with hydrocephalus, leading to the favourable condition of 'shunt independence'. Herein we provide a narrative technical review considering the indications, procedural aspects, morbidity and its avoidance, postoperative care and follow-up. The CP has been the target of hydrocephalus treatment for more than a century. Early eminent neurosurgeons including Dandy, Putnam and Scarff performed CPC achieving generally poor results, and so the procedure fell out of favour. In recent years, the addition of CPC to ETV was one of the reasons greater ETV success rates were observed in Africa, compared to developed nations, and its popularity worldwide has since increased. Initial results indicate that when ETV/CPC is performed successfully, shunt independence is more likely than when ETV is undertaken alone. CPC is commonly performed using a flexible endoscope via septostomy and aims to maximally cauterize the CP. Success is more likely in infants aged1 month, those with hydrocephalus secondary to myelomeningocele and aqueductal obstruction and those with90% cauterized CP. Failure is more likely in those with post-haemorrhagic hydrocephalus of prematurity (PHHP), particularly those1 month of corrected age and those with prepontine scarring. High-quality evidence comparing the efficacy of ETV/CPC with shunting is emerging, with data from ongoing and future trials offering additional promise to enhance our understanding of the true utility of ETV/CPC.