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Objective To assess the clinical, racial, and social characteristics of victims of Gunshot wounds (GSWs) to the head and assess for associations between these factors and outcomes. Summary Background Data Previous literature has not focused on the association of race and socioeconomic factors with these specific injuries. Methods We identified patients with GSWs to the head who presented to 2 urban academic medical centers between 1998 and 2020, and extracted patient-level demographic data, information about the clinical and surgical course, and outcomes at discharge and follow-up. Results The cohort included 250 patients, 90% (n = 226) of whom were male, with a mean age of 28 years. Forty-five percent were white (n = 112), 19% Black (n = 48), 18% Latinx (n = 45), with 6% “other” (n = 16), and 12% “unknown” (n = 29). The majority of patients presented with assault-related trauma (n = 153, 61%) as compared to self-inflicted injuries (n = 97, 39%). Across the entire cohort, sex, age, race, and median income by ZIP code were not significant predictors of outcome. Victims of assault by GSW to the head were more likely to be age 18 or younger (OR 5.26, P = 0.01), between the ages of 19 and 33 years (OR 4.7, P = 0.001), Black (OR 6.66, P < .001), and Latinx (OR 2.65, P = 0.03). Most patients (n = 155, 63%) had a poor functional outcome (modified Rankin Score 3–6) at discharge. Conclusion Age, race, and income status were not independent predictors of mortality or functional outcome at discharge in our population. Assault-related GSWs to the head mostly involved young Black or Latinx men of lower socioeconomic status, while self-inflicted injuries were largely seen in older white men.

Background The global burden of neurosurgical disease is substantial, particularly in low- and middle-income countries (LMICs). Medical conferences are important in connecting those from LMICs to those from high-income countries for support and serve as an educational and networking tool. In this study, we sought to quantitatively assess the incorporation of global neurosurgery topics in international conferences related to the neurosurgical specialty. Methods A database of major international neurosurgical conferences, from the conference of a group of 9 major neurosurgical societies, that had global neurosurgery featured from 2015 to 2020 was created. We then did a retrospective analysis to study the characteristics of these conferences ranging from geographic location to number to different components of the conferences. Results There was an increase in the number of conferences with global neurosurgery since 2015. This, in addition to the occurrence of 3 wholly global neurosurgery-related conferences in recent years, is promising and suggests growth in the field. However, 52.6% of conferences took place in North American or European countries, the majority of which were high-income countries. Furthermore, a majority of the presence of global neurosurgery was in the form of individual talks (54.5%) as opposed to plenaries or sessions. Conclusions The preponderance of conferences in North America and Europe can pose barriers for those from LMICs including travel time, expenses, and visa problems. As global neurosurgery becomes an increasing part of the global health movement, we hope that these barriers are addressed. Conferences may become an even stronger tool to promote equity in neurosurgical education and practice.

Background Traumatic brain injury (TBI) has a disproportionately greater impact in low- and middle-income countries (LMICs). One strategy to reduce the burden of disease in LMICs is through the implementation of a trauma registry that standardizes the assessment of each patient's management of care. Objective This study aims to ascertain the interest of Latin America and the Caribbean (LAC) nations in establishing a shared neurotrauma registry in the regional block, based on an existing framework for collaboration. Methods A descriptive review was performed regarding the interests of LAC nations in implementing a shared neurotrauma registry in their region. We convened a meeting with seven Caribbean and five Latin American nations. Results One hundred percent (n = 12) of the LAC representatives including neurosurgeons, neurointensivists, ministers of health, and chief medical officers/emergency medical technicians (EMTs) agreed to adopt the registry for tracking the burden of TBI and associated pathologies within the region. Conclusion The implementation of a neurotrauma registry can benefit the region through a shared database to track disease, improve outcomes, build research, and ultimately influence policy.

Pediatric postoperative neurosurgical care is an essential component of a child's treatment pathway. It is important to better understand how neurosurgeons in lower middle-income countries (LMICs) have been able to address socioeconomic and systemic factors to improve their patients' access to quality pediatric postoperative neurosurgical care. We aim to characterize the pediatric neurosurgical postoperative system in place in Zambia and to discuss how these efforts have been implemented to improve outcomes and address socioeconomic barriers to accessing health care.We acquired a patient list of 90 tenants of House of Hope (HOH)-an out-of-hospital center caring for children awaiting surgery, as well as those recovering from surgery. Of the patient list, 44 patients qualified for our study. Survey responses and occurrence of demographic and clinical characteristics were calculated. Non-normally distributed variables (age) were reported by median and interquartile range (IQR). Dichotomous variables were presented as percentages. Fisher's Exact test was applied to compare categorical data and hospital re-admission. A P-value of0.05 was considered significant.Our study demonstrates two key findings: (1) low 30-day hospital re-admission rate of 9% and (2) favorable postoperative experience by patient families. Of the 44 patients, a majority were 1-year-old children (n = 31, 70%) and female (n = 24, 55%) (IQR 1-2 years). Presenting conditions included: hydrocephalus only (n = 35, 80%), hydrocephalus and myelomeningocele (n = 5, 11%), myelomeningocele only (n = 2, 5%), cerebral palsy (n = 1, 2%), and encephalocele (n = 1, 2%). Half (n = 22, 50%) of the patients lived in east Zambia, 8 (18%) lived in central, 8 (18%) in north, 5 (11%) in south, and 1 (2%) in west Zambia.We report the first qualitative and quantitative analysis of postoperative care for LMIC pediatric neurosurgical patients in the academic literature. Quality, patient-centered postoperative pediatric neurosurgical care that is rooted in addressing socioeconomic determinants of health produces good outcomes in LMICs.

Introduction: Pediatric gunshot wounds (GSWs) to the head are not well studied in the literature, especially in civilians. With a dearth of case-based and clinically relevant information, pediatric neurosurgeons may be challenged when considering the risks and benefits of removing retained bullet fragments in different intracranial locations. We explore the literature and highlight the key factors in the surgical decision-making case of a 16-year-old girl with GSW to the visual cortex. Case Report: A 16-year-old girl was shot in the head in a parieto-occipital trajectory with the bullet crossing midline, lodging in the occipital lobe into the straight sinus. Her initial Glasgow Coma Scale was 7, and she was urgently stabilized with intracranial pressure monitoring and external ventricular drainage. She underwent craniectomy, debridement, and irrigation and then a reoperation for further debridement and culture 2 weeks later for persistent fevers; cultures remained negative. The retained bullet was not removed. At 18 months post-injury, she had normal speech and motor function, moderate memory dysfunction, and 3-quadrant field loss with retained macular vision. Discussion/Conclusion: Pediatric penetrating GSWs to the head may be challenging to manage since literature is sparse. In this case, the primary focus of management was to maintain normal intracranial pressure, reduce risk of infection, and preserve potentially viable visual cortex. In the civilian context of available antibiotics and serial imaging, it may be possible to manage retained bullets conservatively without delayed complications.

Background Global neurosurgery encompasses the social and surgical practices that effect the neurologic health of vulnerable and underserved populations in domestic and international resource-limited settings. Formal academic engagement in global neurosurgery is limited in residency programs. Here we explore the current status of global neurosurgery education in residency programs across the United States. Methods We contacted 115 Accreditation Council for Graduate Medical Education–accredited residency programs in the United States to complete an 8-question electronic survey on global neurosurgery education. Questions were framed with binary “yes” or “no” answers to indicate presence of a global health activity. Respondents provided additional information if desired. Global education activity was categorized based on the number of resources attributed to global health activities: low (0–2), moderate (3–5), or high (6–8). Results Thirty-four residency programs completed the survey (29.6%). The majority of respondents reported offering funding for research and educational opportunities in global neurosurgery (n = 22). Programs tended to support global neurosurgery conferences (n = 20), periodic dedicated lectures (n = 15), and rotations in resource-constrained or marginalized communities domestically or abroad (n = 15). Some programs offer continuity clinics in marginalized settings (n = 10), supplementary reading material (n = 8), core curricula (n = 6), or a designated residency track in global neurosurgery (n = 3). The majority of residency programs had low-level engagement in global neurosurgery (n = 18), with only 3 programs having high levels of engagement. Conclusions Formal global neurosurgery training is limited within US residency programs. With rising trends in the neurosurgical disease burden globally, it may benefit residency programs to develop training paths to equip the next generation of neurosurgeons to address such needs.

Intracranial abscess in the pediatric population is an overall rare occurrence—4 in a million. The most common predisposing factor is underlying cyanotic congenital heart disease (CCHD), which is associated with ~ 30% of all cases. We present an unusual case of cerebral abscess in a 17-month-old female with partially treated Tetralogy of Fallot and fever of unknown origin without associated neurologic symptoms. We propose a low threshold for intracranial imaging as part of the fever of unknown origin work-up in children with underlying cyanotic congenital heart disease.

Five million neurosurgical cases go untreated each year. This is in part due to the lack of neurosurgical care providers. The World Federation of Neurosurgical Societies has spearheaded efforts to monitor the number of neurosurgical providers around the globe since 2016. In this perspective, we discuss why, when, and how the neurosurgical workforce should be measured.

BackgroundThe use of quantitative and qualitative scientometrics provides deductive and inductive insights into the landscape of research in a specific area. In this manuscript, the authors identified the major contributors of African neurosurgery and emerging terms.MethodsArticles on African neurosurgery were searched on Web of Science and 8 other repositories without language or date restrictions. The H-index, co-author, author country, time trend, and keyword analyses were done using Bibexcel and VOSviewer.Results115 articles on African neurosurgery were published in 36 journals by 90 first authors. The journals with the most articles were World Neurosurgery (46, 40.0%), Journal of Neurosurgery Pediatrics (8, 7.0%), and Neurosurgery (7, 6.1%). There was a rapid increase in the number of articles from 2010 and the median number of citations was 8 (IQR: 4-16). Qureshi MM had the highest H-index score (6) while Warf BC (5, 4.3%), Adeleye AO (4, 3.5%), and El Khamlichi (4, 3.5%) contributed the most to the 115 articles. The articles by Lanzino G (1999), Warf BC (2011), and Warf BC (2005) were the most influential. The U.S.A. had the largest node and South Africa, Kenya and Uganda were the most impactful African countries. Pediatric neurosurgery dominated the keywords and global neurosurgery was an emerging term. ConclusionThe most cited articles on African neurosurgery are published in prestigious specialty journals and neurosurgeons from Southern and East Africa are the most impactful local researchers. Future research should analyze the differences between African regions.

BackgroundAfrican neurosurgical practice is faced with numerous challenges. Although there have been improvements in recent years, some problems persist. Research can help identify these problems and propose solutions for the growth of African neurosurgery. In this study, we decided to evaluate the landscape of African research.MethodsPubMed, Embase, and Web of Science were searched from inception to April 24, 2020. Duplicate articles were excluded, and at least two authors reviewed non-duplicate articles on Rayyan. After data had been extracted, they were analyzed to generate descriptive statistics (number of articles and articles per local neurosurgeon). The Kruskal Wallis test and Spearman's correlation were used for bivariate data analyses.ResultsThe authors reviewed 667 articles on neurosurgery in 34 (63%, n=54) African countries. Malawi (4.50), South Africa (3.33), and Benin (2.33) had the highest number of articles per local neurosurgeon (after excluding articles by foreign researchers). Foreign researchers published 1.0 (IQR=2.5) articles per country. Articles were published in World Neurosurgery (120, 18.0%), South African Medical Journal (44, 6.6%), and Journal of Neurosurgery Pediatrics (34, 5.1%). The articles were on pediatric neurosurgery (167, 25.0%) and neurotrauma (129, 19.3%). Also, the majority (411, 61.6%) of studies were cross-sectional.ConclusionAfrican neurosurgeons produce a median of 0.4 articles and publish in well-established journals. Collaboration with foreign researchers significantly increases local research output. In the future, we should assess the impact of this research.

Background Neurotrauma is a leading cause of morbidity and mortality around the world. Assessment of injury prevention and prehospital care for neurotrauma patients is necessary to improve care systems. Methods A 29-question electronic survey was developed based on the Enhancing the Quality and Transparency Of health Research (EQUATOR) checklist to assess neurotrauma policies and laws related to safety precautions. The survey was distributed to members of World Health Organization regions that were considered to be experienced medical authorities in neurosurgery and traumatic brain injury. Results There were 82 (39%) responses representing 46 countries. Almost all respondents (95.2%) were within the neurosurgical field. Of respondents, 40.2% were from high-income countries (HICs), and 59.8% were from low- and middle-income countries (LMICs). Motor vehicle accidents were reported as the leading cause of neurotrauma, followed by workplace injury and assault. Of respondents, 84.1% reported having a helmet law in their country. HICs (4.38 ± 0.78) were ranked more likely than LMICs (2.88 ± 1.34; P = 0.0001) to enforce helmet laws on a scale of 1–10. Effectiveness of helmet laws was rated as 3.94 ± 0.95 out of 10. Measures regarding prehospital care varied between HICs and LMICs. Patients in HICs were more likely to use public emergency ambulance transportation (81.8% vs. 42.9%; P = 0.0004). All prehospital personnel having emergency training was also reported to be more likely in HICs than LMICs (60.6% vs. 8.7%; P = 0.0001). Conclusions When injuries occur, timely access to neurosurgical care is critical. A focus on prehospital components of the trauma system is paramount, and policymakers can use the information presented here to implement and refine health care systems to ensure safe, timely, affordable, and equitable access to neurotrauma care.

BACKGROUND The Caribbean is a unique region of islands and cays home to nearly 43 million people. A significant challenge facing this population is the burden of traumatic brain injury, which disproportionately affects younger individuals and carries a significant economic burden. A preventive measure to reduce this burden is consistent wearing of helmets. This study aims to assess TBI prevention through helmet safety in Caribbean nations in order to demonstrate the regional impact of public health solutions. METHODS We assess the member states of the Caribbean Community (CARICOM) and sought to evaluate CARICOM nations' TBI prevention through helmet safety with relation to public health, policy, laws, infrastructure, and regulations. We produced the Rolle Scoring System (RSS) to ascertain the influence of governance around helmet safety for TBI prevention. The RSS aims to provide a quantifiable method of how well a CARICOM nation is performing in efforts to reduce TBI. The RSS is broken down into 2 categories, with scores ranging from 1 (worst) to 5 (best). The range of possible scores a CARICOM nation could receive was 8 to 40. RESULTS Fourteen CARICOM nations were ultimately incorporated into our analysis. From the initial cohort, 3 were removed. These nations were Anguilla, Saint Kitts & Nevis, and Montserrat. We analyzed values derived from the RSS, finding a mean Rolle score of 22. We further subdivided the nations into low Rolle score (8-24) and high Rolle score (>24). Trinidad and Tobago had the highest Rolle score at 29. Haiti was found to have the lowest Rolle score at 8. CONCLUSION Several Caribbean nations have demonstrated leadership pertaining to TBI prevention through helmet safety. The regional momentum of helmet safety in the Caribbean can serve as a model for other geographical regional blocs that share interests and culture to consider comprehensive approaches to public health challenges.

Background Access to timely neurosurgical care in particular remains limited worldwide, and is associated with increased morbidity and mortality, a decrease in overall life expectancy, and catastrophic economic costs. To date, access to neurosurgical care has not been completely studied and reported in the Caribbean neurosurgical literature. In this study, we aim to understand the geographic distribution of hospital facilities with neurosurgical capacity among the CARICOM member states to determine timely access to neurosurgical care. Methods We assessed geographical access to facilities capable of providing neurosurgical care in the Caribbean. The GPS coordinates of the hospitals that provide neurosurgical care were identified using street addresses and satellite imaging from Google Maps. Facilities with neurosurgical care were mapped in ArcGIS Pro (Version 2.6.0). using Manhattan distance. We identified the area around each facility and stratified by 30- minute, 1-hour, 2-hour, and 4-hour geographic driving intervals. Results A total of 16 hospitals were identified as providing neurosurgical care in the Caribbean. Our results suggest that 14 million people (76% of the population) had 4-hour geographic access to a facility capable of providing neurosurgical care. In addition, 7 million people (40% of the population) had 2-hour geographical access to neurosurgical care. Conclusions Timely access to care is an important tenet of global neurosurgery. We found that 3.5 million Caribbean residents are outside of the access zone to neurosurgical capacity. Public health advocates, governments, providers, and patients should be aware of the inequity in access to neurosurgical care and should collectively work to close the gap.

Obtaining a solid bony fusion after an extensive skull base and upper cervical spine resection in a patient who has previously received radiation therapy is extremely diffi cult and usually results in a pseudoarthrosis. We report a technique that uses a free fi bular graft with an arteriovenous loop for a posterior occipital cervical fusion.