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Objective: Strong performance in neurosurgical sub-internships is a vital component of a successful residency application and requires adequate familiarity with clinical knowledge and technical skills that may not be covered in standard medical school curricula. Accordingly, a need exists for immersive and comprehensive sub-internship preparation programs that respect time and resource limitations, are optimized based on longitudinal student feedback, provide opportunities for mentorship, and foster enthusiasm for neurosurgery. Therefore, residents at a single institution designed and implemented a comprehensive curriculum for a 1-day sub-internship academy., Methods: Academy curriculum involved hands-on and discussion-based elements split into 3 workshops. Anonymous surveys were conducted immediately following the academy and upon completion of sub-internships to evaluate participant perceptions on the utility of the academy., Results: Twelve medical students participated in the inaugural neurosurgery sub-internship academy. Nine responded to the immediate postsurvey, which revealed the following ratings: the overall program was rated as having maximal impact on sub-internship readiness and enthusiasm for neurosurgery by 8 (88.9%) and 7 (77.8%) respondents, respectively. A largely positive impact on access to mentorship was observed. Six participants responded to a postsub-internship survey, and all 6 indicated they agreed or strongly agreed that the academy prepared them to perform well., Conclusions: Student perceptions of the relevance and utility of the sub-internship academy were positive, and the program fostered enthusiasm for neurosurgery and provided opportunities for mentorship. The participants indicated the academy positively impacted their sub-internship performance, and areas for improvement to guide future iterations of the academy were identified., (Copyright © 2024. Published by Elsevier Inc.)

There have been tremendous strides over the past decade to institute strong policy as means to facilitate alignment on goals and strategies for global neurosurgical systems strengthening. In this chapter, we highlight key historic policy milestones in the global neurosurgery movement. We discuss the role of international organizations in neurosurgery, and the incorporation of neurosurgery into global health agendas. We then delve into specific examples of policies that have been established (such as comprehensive recommendations for neurotrauma, spina bifida, and hydrocephalus), highlight the role of international organizations in shaping neurosurgical policies, emphasize the importance of advocacy, and explore future directions., Competing Interests: Disclosure F.C. Robertson has conflicts of interest with the Zeta Surgical Inc. and the Johnson and Johnson, none of which are pertinent to this manuscript. K.B. Park holds advisory shares of Hoth Intelligence., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Clinical guidelines direct healthcare professionals toward evidence-based practices. Evaluating guideline impact can elucidate information penetration, relevance, effectiveness, and alignment with evolving medical knowledge and technological advancements. As the American Association of Neurological Surgeons/Congress of Neurological Surgeons Section on Tumors marks its 40th anniversary in 2024, this article reflects on the tumor guidelines established by the Section over the past decade and explores their impact on other publications, patents, and information dissemination. Six tumor guideline categories were reviewed: low-grade glioma, newly diagnosed glioblastoma, progressive glioblastoma, metastatic brain tumors, vestibular schwannoma, and pituitary adenomas. Citation data were collected from Google Scholar and PubMed. Further online statistics, such as social media reach, and features in policy, news, and patents were sourced from Altmetric. Online engagement was assessed through website and CNS+ mobile application visits. Data were normalized to time since publication. Metastatic Tumor guidelines (2019) had the highest PubMed citation rate at 26.1 per year and webpage visits (29 100 page views 1/1/2019-9/30/2023). Notably, this guideline had two endorsement publications by partner societies, the Society of Neuro-Oncology and American Society of Clinical Oncology, concerning antiepileptic prophylaxis and steroid use, and the greatest reach on X (19.7 mentions/y). Citation rates on Google Scholar were led by Vestibular Schwannoma (2018). Non-Functioning Pituitary Adenoma led Mendeley reads. News, patent, or policy publications were led by low-grade glioma at 1.5/year. Our study shows that the American Association of Neurological Surgeons/Congress of Neurological Surgeons Section on Tumors guidelines go beyond citations in peer-reviewed publications to include patents, online engagement, and information dissemination to the public., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Introduction: Systematic reviews (SRs) and meta-analyses (MAs) are methods of data analysis used to synthesize information presented in multiple publications on the same topic. A thorough understanding of the steps involved in conducting this type of research and approaches to data analysis is critical for appropriate understanding, interpretation, and application of the findings of these reviews., Methods: We reviewed reference texts in clinical neuroepidemiology, neurostatistics and research methods and other previously related articles on meta-analyses (MAs) in surgery. Based on existing theories and models and our cumulative years of expertise in conducting MAs, we have synthesized and presented a detailed pragmatic approach to interpreting MAs in Neurosurgery., Results: Herein we have briefly defined SRs sand MAs and related terminologies, succinctly outlined the essential steps to conduct and critically appraise SRs and MAs. A practical approach to interpreting MAs for neurosurgeons is described in details. Based on summary outcome measures, we have used hypothetical examples to illustrate the Interpretation of the three commonest types of MAs in neurosurgery: MAs of Binary Outcome Measures (Pairwise MAs), MAs of proportions and MAs of Continuous Variables. Furthermore, we have elucidated on the concepts of heterogeneity, modeling, certainty, and bias essential for the robust and transparent interpretation of MAs. The basics for the Interpretation of Forest plots, the preferred graphical display of data in MAs are summarized. Additionally, a condensation of the assessment of the overall quality of methodology and reporting of MA and the applicability of evidence to patient care is presented., Conclusion: There is a paucity of pragmatic guides to appraise MAs for surgeons who are non-statisticians. This article serves as a detailed guide for the interpretation of systematic reviews and meta-analyses with examples of applications for clinical neurosurgeons., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Previous diffusion MRI studies have reported mixed findings on white matter microstructure alterations in obsessive-compulsive disorder (OCD), likely due to variation in demographic and clinical characteristics, scanning methods, and underpowered samples. The OCD global study was created across five international sites to overcome these challenges by harmonizing data collection to identify consistent brain signatures of OCD that are reproducible and generalizable. Single-shell diffusion measures (e.g., fractional anisotropy), multi-shell Neurite Orientation Dispersion and Density Imaging (NODDI) and fixel-based measures, were extracted from skeletonized white matter tracts in 260 medication-free adults with OCD and 252 healthy controls. We additionally performed structural connectome analysis. We compared cases with controls and cases with early (<18) versus late (18+) OCD onset using mixed-model and Bayesian multilevel analysis. Compared with healthy controls, adult OCD individuals showed higher fiber density in the sagittal stratum (B[SE] = 0.10[0.05], P = 0.04) and credible evidence for higher fiber density in several other tracts. When comparing early (n = 145) and late-onset (n = 114) cases, converging evidence showed lower integrity of the posterior thalamic radiation -particularly radial diffusivity (B[SE] = 0.28[0.12], P = 0.03)-and lower global efficiency of the structural connectome (B[SE] = 15.3[6.6], P = 0.03) in late-onset cases. Post-hoc analyses indicated divergent direction of effects of the two OCD groups compared to healthy controls. Age of OCD onset differentially affects the integrity of thalamo-parietal/occipital tracts and the efficiency of the structural brain network. These results lend further support for the role of the thalamus and its afferent fibers and visual attentional processes in the pathophysiology of OCD., (© 2024. The Author(s).)

Introduction: Central to neurosurgical care, neurosurgical education is particularly needed in low- and middle-income countries (LMICs), where opportunities for neurosurgical training are limited due to social and economic constraints and an inadequate workforce. The present paper aims (1) to evaluate the validity and usability of a cadaver-free hybrid system in the context of LMICs and (2) to report their learning needs and whether the courses meet those needs via a comprehensive survey., Methods: From April to November 2021, a non-profit initiative consisting of a series of innovative cadaver-free courses based on virtual and practical training was organized. This project emerged from a collaboration between the Young Neurosurgeons Forum of the World Federation of Neurological Societies (WFNS), the NIHR Global Health Research Group on Neurotrauma, and UpSurgeOn, an Italian hi-tech company specialized in simulation technologies, creator of the UpSurgeOn Box, a hyper-realistic simulator of cranial approaches fused with augmented reality. Over that period, 11 cadaver-free courses were held in LMICs using remote hands-on Box simulators., Results: One hundred sixty-eight participants completed an online survey after course completion of the course. The anatomical accuracy of simulators was overall rated high by the participant. The simulator provided a challenging but manageable learning curve, and 86% of participants found the Box to be very intuitive to use. When asked if the sequence of mental training (app), hybrid training (Augmented Reality), and manual training (the Box) was an effective method of training to fill the gap between theoretical knowledge and practice on a real patient/cadaver, 83% of participants agreed. Overall, the hands-on activities on the simulators have been satisfactory, as well as the integration between physical and digital simulation., Conclusions: This project demonstrated that a cadaver-free hybrid (virtual/hands-on) training system could potentially participate in accelerating the learning curve of neurosurgical residents, especially in the setting of limited training possibilities such as LMICs, which were only worsened during the COVID-19 pandemic., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Glycemic index (GI) is a measure of the ability of carbohydrate food to raise blood glucose concentration. The GI of a food and its negative effects has caused an adverse increase in the prevalence of diabetes and other metabolic diseases., Objective: This study aimed to determine the effect of Alchornea cordifolia on glycemic indices of varieties of fufu., Methods: The research was a crossover experimental study involving 10 healthy individuals. A 50-g measure of pure glucose was served on 2 separate occasions and, subsequently, a measured amount of the test foods containing 50 g of available carbohydrates. The GI values were determined by the measure of the blood glucose concentrations of the subjects at fasting and after ingestion of the glucose and the test foods (fufu) within 2 h. Collection of capillary blood for blood glucose measurement started 30 min after consumption and was subsequently taken at 60, 90, and 120 min for both noncomposited and composited fufu GI determination. The phytoconstituents of the A . cordifolia were also determined., Results: For the noncomposited fufu, plantain fufu had the least glycemic response (46%), followed by cassava fufu (50%) and cassava-plantain fufu (53%); however, all were in the low-GI category. For the composited fufu, plantain fufu had the least response (12%), followed by cassava-plantain fufu (14%) and cassava fufu (14%), with all in the low-GI category. A multiple comparison of GI on the various foods by analysis of variance revealed a significant difference between the GI of cassava-plantain fufu and composite cassava-plantain fufu ( P = 0.001); cassava fufu and composite cassava fufu ( P = 0.004); and plantain fufu and composite plantain fufu ( P = 0.006). The phytochemical screening of the A . cordifolia revealed the presence of flavonoids and tannins., Conclusions: Composited A . cordifolia fufu affects the glycemic response., (© 2024 The Author(s).)

For the past three decades, neurosurgeons have utilized cranial neuro-navigation systems, bringing millimetric accuracy to operating rooms worldwide. These systems require an operating room team, anesthesia, and, most critically, cranial fixation. As a result, treatments for acute neurosurgical conditions, performed urgently in emergency rooms or intensive care units on awake and non-immobilized patients, have not benefited from traditional neuro-navigation. These emergent procedures are performed freehand, guided only by anatomical landmarks with no navigation, resulting in inaccurate catheter placement and neurological deficits. A rapidly deployable image-guidance technology that offers highly accurate, real-time registration and is capable of tracking awake, moving patients is needed to improve patient safety. The Zeta Cranial Navigation System is currently the only non-fiducial-based, FDA-approved neuro-navigation device that performs real-time registration and continuous patient tracking. To assess this system's performance, we performed registration and tracking of phantoms and human cadaver heads during controlled motions and various adverse surgical test conditions. As a result, we obtained millimetric or sub-millimetric target and surface registration accuracy. This rapid and accurate frameless neuro-navigation system for mobile subjects can enhance bedside procedure safety and expand the range of interventions performed with high levels of accuracy outside of an operating room.

Background: Analgo-sedation plays an important role during intensive care management of traumatic brain injury (TBI) patients, however, limited evidence is available to guide practice. We sought to quantify practice-pattern variation in neurotrauma sedation management, surveying an international sample of providers. Methods: An electronic survey consisting of 56 questions was distributed internationally to neurocritical care providers utilizing the Research Electronic Data Capture platform. Descriptive statistics were used to quantitatively describe and summarize the responses. Results: Ninety-five providers from 37 countries responded. 56.8% were attending physicians with primary medical training most commonly in intensive care medicine (68.4%) and anesthesiology (26.3%). Institutional sedation guidelines for TBI patients were available in 43.2%. Most common sedative agents for induction and maintenance, respectively, were propofol (87.5% and 88.4%), opioids (60.2% and 70.5%), and benzodiazepines (53.4% and 68.4%). Induction and maintenance sedatives, respectively, are mostly chosen according to provider preference (68.2% and 58.9%) rather than institutional guidelines (26.1% and 35.8%). Sedation duration for patients with intracranial hypertension ranged from 24 h to 14 days. Neurological wake-up testing (NWT) was routinely performed in 70.5%. The most common NWT frequency was every 24 h (47.8%), although 20.8% performed NWT at least every 2 h. Richmond Agitation and Sedation Scale targets varied from deep sedation (34.7%) to alert and calm (17.9%). Conclusions: Among critically ill TBI patients, sedation management follows provider preference rather than institutional sedation guidelines. Wide practice-pattern variation exists for the type, duration, and target of sedative management and NWT performance. Future comparative effectiveness research investigating these differences may help optimize sedation strategies to promote recovery., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Traumatic brain injury (TBI) is a significant cause of mortality and morbidity worldwide and many patients with TBI require intensive care unit (ICU) management. When facing a life-threatening illness, such as TBI, a palliative care approach that focuses on noncurative aspects of care should always be considered in the ICU. Research shows that neurosurgical patients in the ICU receive palliative care less frequently than the medical patients in the ICU, which is a missed opportunity for these patients. However, providing appropriate palliative care to neurotrauma patients in an ICU can be difficult, particularly for young adult patients. The patients' prognoses are often unclear, the likelihood of advance directives is small, and the bereaved families must act as decision-makers. This article highlights the different aspects of the palliative care approach as well as barriers and challenges that accompany the TBI patient population, with a particular focus on young adult patients with TBI and the role of their family members. The article concludes with recommendations for physicians for effective and adequate communication to successfully implement the palliative care approach into standard ICU care and to improve quality of care for patients with TBI and their families., (© 2023. The Author(s).)

Objective: Alterations in regional neurometabolite levels as well as impaired neurodevelopmental outcomes have previously been observed in children who are HIV-exposed uninfected (CHEU). However, little is known about how neurometabolite profiles may relate to their developmental impairment. This study aimed to compare neurometabolite concentrations in school-aged CHEU and children who are HIV-unexposed (CHU) and to explore associations of neurometabolite profiles with functional neurodevelopment in the context of perinatal HIV exposure., Methods: We used 3 T single voxel proton magnetic resonance spectroscopy ( 1 H-MRS) to quantify absolute and relative neurometabolites in the parietal gray and parietal white matter in school-aged CHEU and aged- and community-matched CHU. Functional neurodevelopmental outcomes were assessed using the early learning outcome measure (ELOM) tool at 6 years of age., Results: Our study included 152 school-aged children (50% males), 110 CHEU and 42 CHU, with an average age of 74 months at the neuroimaging visit. In an adjusted multiple linear regression analysis, significantly lower glutamate (Glu) concentrations were found in CHEU as compared to CHU in the parietal gray matter (absolute Glu, p  = 0.046; Glu/total creatine (Cr+PCr) ratios, p  = 0.035) and lower total choline to creatine ratios (GPC+PCh/Cr+PCr) in the parietal white matter ( p  = 0.039). Using factor analysis and adjusted logistic regression analysis, a parietal gray matter Glu and myo-inositol (Ins) dominated factor was associated with HIV exposure status in both unadjusted (OR 0.55, 95% CI 0.17-0.45, p  = 0.013) and adjusted analyses (OR 0.59, 95% CI 0.35-0.94, p  = 0.031). With Ins as one of the dominating metabolites, this neurometabolic factor was similar to that found at the age of two years. Furthermore, this factor was also found to be correlated with ELOM scores of gross motor development in CHEU (Pearson's r  = -0.48, p  = 0.044). In addition, in CHEU, there was a significant association between Ins/Cr+PCr ratios in the parietal white matter and ELOM scores of fine motor coordination and visual motor integration in CHEU (Pearson's r  = 0.51, p  = 0.032)., Conclusion: Reduced Glu concentrations in the parietal gray matter may suggest regional alterations in excitatory glutamatergic transmission pathways in the context of perinatal HIV and/or antiretroviral therapy (ART) exposure, while reduced Cho ratios in the parietal white matter suggest regional myelin loss. Identified associations between neurometabolite profiles and gross and fine motor developmental outcomes in CHEU are suggestive of a neurometabolic mechanism that may underlie impaired motor neurodevelopmental outcomes observed in CHEU., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Williams, Robertson, Wedderburn, Ringshaw, Bradford, Nyakonda, Hoffman, Joshi, Zar, Stein and Donald.)

Background: Barriers to neurosurgery training and practice in Latin American and Caribbean countries (LACs) have been scarcely documented. The World Federation of Neurosurgical Societies Young Neurosurgeons Forum survey sought to identify young neurosurgeons' needs, roles, and challenges. We present the results focused on Latin America and the Caribbean., Methods: In this cross-sectional study, we analyzed the Young Neurosurgeons Forum survey responses from LACs, following online survey dissemination through personal contacts, social media, and neurosurgical societies' e-mailing lists between April and November 2018. Data analysis was performed using Jamovi version 2.0 and STATA version 16., Results: There were 91 respondents from LACs. Three (3.3%) respondents practiced in high-income countries, 77 (84.6%) in upper middle-income countries, 10 (11%) in lower middle-income countries, and 1 (1.1%) in an unclassified country. The majority (77, or 84.6%) of respondents were male, and 71 (90.2%) were younger than 40. Access to basic imaging modalities was high, with access to computed tomography scan universal among the survey respondents. However, only 25 (27.5%) of respondents reported having access to imaging guidance systems (navigation), and 73 (80.2%) reported having access to high-speed drills. A high GDP per capita was associated with increased availability of high-speed drills and more time dedicated to educational endeavors in neurosurgery, such as didactic teaching and topic presentation (P < 0.05)., Conclusions: This survey found that neurosurgery trainees and practitioners of Latin America and the Caribbean face many barriers to practice. These include inadequate state-of-the-art neurosurgical equipment, a lack of standardized training curricula, few research opportunities, and long working hours., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: This study assessed the international variation in surgical neuro-oncology practice and 30-day outcomes of patients who had surgery for an intracranial tumor during the COVID-19 pandemic., Methods: We prospectively included adults aged ≥18 years who underwent surgery for a malignant or benign intracranial tumor across 55 international hospitals from 26 countries. Each participating hospital recorded cases for 3 consecutive months from the start of the pandemic. We categorized patients' location by World Bank income groups (high [HIC], upper-middle [UMIC], and low- and lower-middle [LLMIC]). Main outcomes were a change from routine management, SARS-CoV-2 infection, and 30-day mortality. We used a Bayesian multilevel logistic regression stratified by hospitals and adjusted for key confounders to estimate the association between income groups and mortality., Results: Among 1016 patients, the number of patients in each income group was 765 (75.3%) in HIC, 142 (14.0%) in UMIC, and 109 (10.7%) in LLMIC. The management of 200 (19.8%) patients changed from usual care, most commonly delayed surgery. Within 30 days after surgery, 14 (1.4%) patients had a COVID-19 diagnosis and 39 (3.8%) patients died. In the multivariable model, LLMIC was associated with increased mortality (odds ratio 2.83, 95% credible interval 1.37-5.74) compared to HIC., Conclusions: The first wave of the pandemic had a significant impact on surgical decision-making. While the incidence of SARS-CoV-2 infection within 30 days after surgery was low, there was a disparity in mortality between countries and this warrants further examination to identify any modifiable factors., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Society for Neuro-Oncology.)

The death of many people in tropical countries can be attributed to microbial infection, probably, because synthetic antibiotics are failing in the treatment of most microbial infections, attributed to the ability of the microorganisms to mutate and adapt to harsh conditions. This study evaluated, in vitro, the antimicrobial activities, antioxidant potentials, and the total phenolic as well as phytochemical contents of aqueous and ethanol extracts of the root of Cryptolepis sanguinolenta (Lindl.) and the crude sap of Pycnanthus angolensis (Welw) using selected standard bacteria strains (Staphylococcus aureus (ATCC 25,923), Staphylococcus saprophyticus (ATCC 15,305), Escherichia coli (ATCC 25,922), Salmonella typhi (ATCC 19,430), Pseudomonas aeruginosa (ATCC 27,853), and Proteus mirabilis (ATCC 49,565). The modified agar well diffusion method was used to evaluate the antimicrobial activities of the plant extracts. Chloramphenicol and tetracycline were used as positive controls. The extracts were screened for specific phytochemicals with total phenolic contents were determined using Folin Ciocalteu reagent test. The phytoconstituents observed were alkaloids, cardiac glycosides, and saponins in both Cryptolepis sanguinolenta and Pycnanthus angolensis. For the antimicrobial activities, all the test bacteria were susceptible to the crude sap of Pycnanthus angolensis except Proteus mirabilis. In the case of the Cryptolepis sanguinolenta, only S. aureus was susceptible to both aqueous and ethanol extracts. The total phenolic content, expressed in g/100 g GAE, recorded values of 55.427 ± 4.248 for the crude sap of Pycnanthus angolensis, and 11.642 ± 4.248 and 26.888 ± 4.248 for the aqueous and ethanol extracts of Cryptolepis sanguinolenta, respectively. It is concluded that Cryptolepis sanguinolenta and Pycnanthus angolensis are excellent candidates for further development of antimicrobial agents in the fight against microbial infections given the pressing need for novel efficacious agents., (© 2023. The Author(s).)

Background: Asia has a marked shortage of neurosurgical care, with approximately 2.5 million critical cases left untreated. The Young Neurosurgeons Forum of the World Federation of Neurosurgical Societies surveyed Asian neurosurgeons to identify research, education, and practice., Methods: A cross-sectional study using a pilot-tested e-survey was circulated to the Asian neurosurgical community from April to November 2018. Descriptive statistics were used to summarize variables pertaining to demographics and neurosurgical practices. The chi-square test was used to explore the relationship between World Bank income level and variables on neurosurgical practices., Results: A total of 242 responses were analyzed. Respondents were mostly from the low- and middle-income countries (70%). Most represented institutions were teaching hospitals (53%). More than 50% of the hospitals had between 25and 50 neurosurgical beds. Access to an operating microscope (P = 0.038) or image guidance system (P = 0.001) appeared to increase in correlation to a higher World Bank income level. Limited opportunities for conducting research (56%) and hands-on operating opportunities (45%) were leading challenges in daily academic practice. The leading challenges were limited numbers of intensive care unit beds (51%), inadequate or absent insurance coverage (45%), and lack of organized perihospital care (43%). Inadequate insurance coverage decreased with increasing World Bank income levels (P < 0.001). Organized perihospital care (P = 0.001), regular magnetic resonance imaging access (P = 0.032), and equipment necessary for microsurgery (P = 0.007) increased with higher World Bank income levels., Conclusions: Improving neurosurgical care hinges on regional and international collaboration and national policies to ensure universal access to essential neurosurgical care., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Surgical skills laboratories augment educational training by deepening one's understanding of anatomy and allowing the safe practice of technical skills. Novel, high-fidelity, cadaver-free simulators provide an opportunity to increase access to skills laboratory training. The neurosurgical field has historically evaluated skill by subjective assessment or outcome measures, as opposed to process measures with objective, quantitative indicators of technical skill and progression. The authors conducted a pilot training module with spaced repetition learning concepts to evaluate its feasibility and impact on proficiency., Methods: The 6-week module used a simulator of a pterional approach representing skull, dura mater, cranial nerves, and arteries (UpSurgeOn S.r.l.). Neurosurgery residents at an academic tertiary hospital completed a video-recorded baseline examination, performing supraorbital and pterional craniotomies, dural opening, suturing, and anatomical identification under a microscope. Participation in the full 6-week module was voluntary, which precluded randomizing by class year. The intervention group participated in four additional faculty-guided trainings. In the 6th week, all residents (intervention and control) repeated the initial examination with video recording. Videos were evaluated by three neurosurgical attendings who were not affiliated with the institution and who were blinded to participant grouping and year. Scores were assigned via Global Rating Scales (GRSs) and Task-based Specific Checklists (TSCs) previously built for craniotomy (cGRS, cTSC) and microsurgical exploration (mGRS, mTSC)., Results: Fifteen residents participated (8 intervention, 7 control). The intervention group included a greater number of junior residents (postgraduate years 1-3; 7/8) compared to the control group (1/7). External evaluators had internal consistency within 0.5% (kappa probability > Z of 0.00001). The total average time improved by 5:42 minutes (p < 0.003; intervention, 6:05, p = 0.07; control, 5:15, p = 0.001). The intervention group began with lower scores in all categories and surpassed the comparison group in cGRS (10.93 to 13.6/16) and cTSC (4.0 to 7.4/10). Percent improvements for the intervention group were cGRS 25% (p = 0.02), cTSC 84% (p = 0.002), mGRS 18% (p = 0.003), and mTSC 52% (p = 0.037). For controls, improvements were cGRS 4% (p = 0.19), cTSC 0.0% (p > 0.99), mGRS 6% (p = 0.07), and mTSC 31% (p = 0.029)., Conclusions: Participants who underwent a 6-week simulation course showed significant objective improvement in technical indicators, particularly individuals who were early in their training. Small, nonrandomized grouping limits generalizability regarding degree of impact; however, introducing objective performance metrics during spaced repetition simulation would undoubtedly improve training. A larger multiinstitutional randomized controlled study will help elucidate the value of this educational method.

Objectives: We describe the harmonized MRI acquisition and quality assessment of an ongoing global OCD study, with the aim to translate representative, well-powered neuroimaging findings in neuropsychiatric research to worldwide populations., Methods: We report on T1-weighted structural MRI, resting-state functional MRI, and multi-shell diffusion-weighted imaging of 140 healthy participants (28 per site), two traveling controls, and regular phantom scans., Results: Human image quality measures (IQMs) and outcome measures showed smaller within-site variation than between-site variation. Outcome measures were less variable than IQMs, especially for the traveling controls. Phantom IQMs were stable regarding geometry, SNR, and mean diffusivity, while fMRI fluctuation was more variable between sites., Conclusions: Variation in IQMs persists, even for an a priori harmonized data acquisition protocol, but after pre-processing they have less of an impact on the outcome measures. Continuous monitoring IQMs per site is valuable to detect potential artifacts and outliers. The inclusion of both cases and healthy participants at each site remains mandatory., (© 2022 The Authors. International Journal of Methods in Psychiatric Research published by John Wiley & Sons Ltd.)

Objective: Country-by-country estimates of the macroeconomic disease burden of central nervous system (CNS) cancers are important when determining the allocation of resources related to neuro-oncology. Accordingly, in this study the authors investigated macroeconomic losses related to CNS cancer in 173 countries and identified pertinent epidemiological trends., Methods: Data for CNS cancer incidence, mortality, and disability-adjusted life years (DALYs) were collected from the Global Burden of Disease 2019 database. Gross domestic product data were combined with DALY data to estimate economic losses using a value of lost welfare approach., Results: The mortality-to-incidence ratio of CNS cancer in 2019 was 0.60 in high-income regions compared to 0.82 in Sub-Saharan Africa and 0.87 in Central Europe, Eastern Europe, and Central Asia. Welfare losses varied across both high- and low-income countries. Welfare losses attributable to CNS cancer in Japan represented 0.07% of the gross domestic product compared to 0.23% in Germany. In low- and middle-income countries, Iraq reported welfare losses of 0.20% compared to 0.04% in Angola. Globally, the DALY rate in 2019 was the same for CNS cancer as for prostate cancer at 112 per 100,000 person-years, despite a 75% lower incidence rate, equating to CNS cancer welfare losses of 182 billion US dollars., Conclusions: Macroeconomic losses vary across high- and low-income settings and appear to be region specific. These differences may be explained by differences in regional access to screening and diagnosis, population-level genetic predispositions, and environmental risk factors. Mortality-to-incidence ratios are higher in low- and middle-income countries than in high-income countries, highlighting possible gaps in treatment access. Quantification of macroeconomic losses related to CNS cancer can help to justify the spending of finite resources to improve outcomes for neuro-oncological patients globally.

Children with perinatally acquired HIV (CPHIV) have poor cognitive outcomes despite early combination antiretroviral therapy (cART). While CPHIV-related brain alterations can be investigated separately using proton magnetic resonance spectroscopy ( 1 H-MRS), structural magnetic resonance imaging (sMRI), diffusion tensor imaging (DTI), and functional MRI (fMRI), a set of multimodal MRI measures characteristic of children on cART has not been previously identified. We used the embedded feature selection of a logistic elastic-net (EN) regularization to select neuroimaging measures that distinguish CPHIV from controls and measured their classification performance via the area under the receiver operating characteristic curve (AUC) using repeated cross validation. We also wished to establish whether combining MRI modalities improved the models. In single modality analysis, sMRI volumes performed best followed by DTI, whereas individual EN models on spectroscopic, gyrification, and cortical thickness measures showed no class discrimination capability. Adding DTI and 1 H-MRS in basal measures to sMRI volumes produced the highest classification performance validation accuracy = 85 % AUC = 0.80 . The best multimodal MRI set consisted of 22 DTI and sMRI volume features, which included reduced volumes of the bilateral globus pallidus and amygdala, as well as increased mean diffusivity (MD) and radial diffusivity (RD) in the right corticospinal tract in cART-treated CPHIV. Consistent with previous studies of CPHIV, select subcortical volumes obtained from sMRI provide reasonable discrimination between CPHIV and controls. This may give insight into neuroimaging measures that are relevant in understanding the effects of HIV on the brain, thereby providing a starting point for evaluating their link with cognitive performance in CPHIV., (© 2022 The Authors. Human Brain Mapping published by Wiley Periodicals LLC.)

Background: Supplementary motor area syndrome (SMAS) may occur after frontal tumor surgery, with variable presentation and outcomes. We reviewed the literature on postoperative SMAS after brain tumor resection., Methods: PubMed, Web of Science, Scopus, and Cochrane were searched following the PRISMA guidelines to include studies reporting SMAS after brain tumor resection., Results: We included 31 studies encompassing 236 patients. Most tumors were gliomas (94.5%), frequently of low grade (61.4%). Most lesions were located on the left hemisphere (64.4%), involving the supplementary motor area (61.4%) and the cingulate gyrus (20.8%). Tractography and functional magnetic resonance imaging evaluation were completed in 45 (19.1%) and 26 (11%) patients. Gross total resection was achieved in 46.3% patients and complete SMA resection in 69.4%. A total of 215 procedures (91.1%) used intraoperative neuromonitoring mostly consisting of direct cortical/subcortical stimulation (56.4%), motor (33.9%), and somatosensory (25.4%) evoked potentials. Postoperative SMAS symptoms occurred within 24 hours after surgery, characterized by motor deficits (97%), including paresis (68.6%) and hemiplegia (16.1%), and speech disorders (53%), including hesitancy (24.2%) and mutism (22%). Average SMAS duration was 45 days (range, 1-365 days), with total resolution occurring in 188 patients (79.7%) and partial improvement in 46 (19.5%). Forty-eight patients (20.3%) had persisting symptoms, mostly speech hesitancy (60.4%) and fine motor disorders (45.8%)., Conclusions: Postoperative SMAS may occur within the first 24 hours after mesial frontal tumor surgery. Preoperative mapping and intraoperative neuromonitoring may assist resection and predict outcomes. Neuroplasticity and interhemispheric connectivity play a major role in resolution., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Robotic neurosurgery may improve the accuracy, speed, and availability of stereotactic procedures. We recently developed a computer vision and artificial intelligence-driven frameless stereotaxy for nonimmobilized patients, creating an opportunity to develop accurate and rapidly deployable robots for bedside cranial intervention., Objective: To validate a portable stereotactic surgical robot capable of frameless registration, real-time tracking, and accurate bedside catheter placement., Methods: Four human cadavers were used to evaluate the robot's ability to maintain low surface registration and targeting error for 72 intracranial targets during head motion, ie, without rigid cranial fixation. Twenty-four intracranial catheters were placed robotically at predetermined targets. Placement accuracy was verified by computed tomography imaging., Results: Robotic tracking of the moving cadaver heads occurred with a program runtime of 0.111 ± 0.013 seconds, and the movement command latency was only 0.002 ± 0.003 seconds. For surface error tracking, the robot sustained a 0.588 ± 0.105 mm registration accuracy during dynamic head motions (velocity of 6.647 ± 2.360 cm/s). For the 24 robotic-assisted intracranial catheter placements, the target registration error was 0.848 ± 0.590 mm, providing a user error of 0.339 ± 0.179 mm., Conclusion: Robotic-assisted stereotactic procedures on mobile subjects were feasible with this robot and computer vision image guidance technology. Frameless robotic neurosurgery potentiates surgery on nonimmobilized and awake patients both in the operating room and at the bedside. It can affect the field through improving the safety and ability to perform procedures such as ventriculostomy, stereo electroencephalography, biopsy, and potentially other novel procedures. If we envision catheter misplacement as a "never event," robotics can facilitate that reality., (Copyright © Congress of Neurological Surgeons 2022. All rights reserved.)

Introduction: Exposure to maternal HIV in pregnancy may be a risk factor for impaired child neurodevelopment during the first years of life. Altered neurometabolites have been associated with HIV exposure in older children and may help explain the mechanisms underlying this risk. For the first time, we explored neurometabolic profiles of children who are HIV-exposed and uninfected (CHEU) compared to children who are HIV-unexposed (CHU) at 2-3 years of age., Methods: The South African Drakenstein Child Health Study enrolled women during pregnancy and is following mother-child pairs through childhood. MRI scans were acquired on a sub-group of children at 2-3 years. We used single voxel magnetic resonance spectroscopy to measure brain metabolite ratios to total creatine in the parietal grey matter, and left and right parietal white matter of 83 children (36 CHEU; 47 CHU). Using factor analysis, we explored brain metabolite patterns in predefined parietal voxels in these groups using logistic regression models. Differences in relative concentrations of individual metabolites (n-acetyl-aspartate, myo-inositol, total choline, and glutamate) to total creatine between CHEU and CHU groups were also examined., Results: Factor analysis revealed four different metabolite patterns, each one characterized by covarying ratios of a single metabolite in parietal grey and white matter. The cross-regional pattern dominated by myo-inositol, a marker for glial reactivity and inflammation, was associated with HIV exposure status (OR 1.63; 95% CI 1.11-2.50) which held after adjusting for child age, sex, and maternal alcohol use during pregnancy (OR 1.59; 95% CI 1.07 -2.47). Additionally, higher relative concentrations of myo-inositol to total creatine were found in left and right parietal white matter of CHEU compared to CHU (p=0.025 and p=0.001 respectively)., Discussion: Increased ratios of myo-inositol to total creatine in parietal brain regions at age 2-3 years in CHEU are suggestive of early and ongoing neuroinflammatory processes. Altered relative concentrations of neurometabolites were found predominantly in the white matter, which is sensitive to neuroinflammation, and may contribute to developmental risk in this population. Future work on the trajectory of myo-inositol over time in CHEU, alongside markers of neurocognitive development, and the potential for specific neurodevelopmental interventions will be useful., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Bertran-Cobo, Wedderburn, Robertson, Subramoney, Narr, Joshi, Roos, Rehman, Hoffman, Zar, Stein and Donald.)

A multicystic intraventricular tumour of the right ventricular atrium was incidentally diagnosed on follow-up imaging of a 61-year-old man with a history of prostatic adenocarcinoma. Surgical resection of the lesion was performed after a one-year radio-clinical follow-up due to progressive expansion of the lesion size and a rising prostate specific antigen blood-level. Morphological features with papillary pattern on pathological examination were compatible with malignant adenocarcinoma or choroid plexus carcinoma. The immunoprofile was conclusive for an exceptional choroid plexus metastasis (CPM) of a prostatic adenocarcinoma. To our knowledge, this is the first report of a proven prostatic origin of a CPM., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

The study investigated the influence of Annona muricata extracts on the action of selected antibiotics against biofilm-forming MRSA. The various parts of the plant were processed into powder and extracted with ethanol or hot water and then screened for the presence of phytochemicals. The modulatory effect of the Annona muricata extract was also tested on some antibiotics against Methicillin-resistant Staphylococcus aureus (MRSA). The findings from this study revealed that the various parts of the Annona muricata extract (ethanolic and aqueous) contained different proportions of secondary metabolites. Varied antimicrobial activities were observed when the extract of the A. muricata was exposed to MRSA strain at a concentration of 100 mg/mL. The stem recorded the highest (17.00 and 18.00 mm) inhibitory activity against MRSA for both the aqueous and the ethanolic extract, respectively, and this was not different from the control, tetracycline. Again, the results on the modulatory action indicated that out of the 10 extracts of A. muricata , 4 of them antagonized the activity of ampicillin against the tested MRSA by a factor of 0.5 folds and the rest potentiated the drug within 1-4 folds, respectively. On the other hand, the various test extracts significantly potentiated the efficacy of streptomycin and tetracycline against the MRSA by a range of 1-32 folds with the aqueous root extract recording the highest synergistic effect and ethanol seed extract with the least effect. The findings of this study support the antibacterial activities of the A. muricata plant parts., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 David Neglo et al.)

Purpose: Thalamic gliomas are rare neoplasms that pose significant surgical challenges. The literature is limited to single-institution retrospective case series. We systematically review the literature and describe the clinical characteristics, treatment strategies, and survival outcomes of adult thalamic gliomas., Methods: Relevant articles were identified on PubMed, Scopus, and Cochrane databases. Papers containing cases of adult thalamic gliomas with clinical outcome data were included. A comprehensive review of clinical characteristics and survival analysis was conducted., Results: We included 25 studies comprising 617 patients. The median age was 45 years (male = 58.6%). Glioblastoma was the most frequent histological type (47.2%), and 82 tumors were H3 K27M-mutant. Motor deficit was the most common presenting symptom (51.8%). Surgical resection was performed in 69.1% of cases while adjuvant chemotherapy and radiotherapy were administered in 56.3% and 72.6%, respectively. Other treatments included laser interstitial thermal therapy, which was performed in 15 patients (2.4%). The lesion laterality (P = 0.754) and the surgical approach (P = 0.111) did not correlate with overall survival. The median progression-free survival was 9 months, and the overall two-year survival rate was 19.7%. The two-year survival rates of low-grade and high-grade thalamic gliomas were 31.0% and 16.5%, respectively. H3 K27M-mutant gliomas showed worse overall survival (P = 0.017)., Conclusion: Adult thalamic gliomas are associated with poor survival. Complete surgical resection is associated with improved survival rates but is not always feasible. H3 K27M mutation is associated with worse survival and a more aggressive approach should be considered for mutant neoplasms., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: The Woven EndoBridge (WEB) can be used to treat wide-necked aneurysms without antiplatelet medications, suggesting it may have advantages in the setting of aneurysmal subarachnoid hemorrhage (aSAH). The goal was assessment of safety and efficacy of WEB in aSAH given the delayed nature of aneurysmal thrombosis., Methods: An international retrospective analysis of patients with aSAH treated with WEB was conducted at 7 tertiary centers from 2016 to 2020. Outcomes included rates of rebleeding, retreatment, complications, and complete occlusion. Furthermore, a systematic review and meta-analysis was conducted from 2011 to 2020 assessing the same outcomes. All pooled event rates were calculated using a random effect model., Results: Consecutive patients with aSAH harbored 25 aneurysms that were treated with 29 WEB devices. The mean age was 53 years, and 65% were female. Zero experienced rebleeding, 2 were retreated, 2 experienced complications, 16 were completely occluded at 3 months, and 21 were completed occluded at 9-12 months. Meta-analysis of 309 WEB treatments for aSAH from 7 case series revealed 2.5% (95% CI 1-5%) had rebleeding, 9% (95% CI 4-17%) were retreated, 17% (95% CI 10-30%) had complications, and 61% (95% CI 51-71%) were completely occluded at 3-6 months., Conclusion: WEB embolization in the setting of aSAH provides similar protection against rebleeding with comparable retreatment rates to traditional approaches. However, there is a higher rate of incomplete radiographic occlusion and operative complications compared to WEB embolization of unruptured aneurysms. Long-term prospective studies are needed to fully delineate the role of WEB embolization in aSAH., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: A major obstacle to improving bedside neurosurgical procedure safety and accuracy with image guidance technologies is the lack of a rapidly deployable, real-time registration and tracking system for a moving patient. This deficiency explains the persistence of freehand placement of external ventricular drains, which has an inherent risk of inaccurate positioning, multiple passes, tract hemorrhage, and injury to adjacent brain parenchyma. Here, the authors introduce and validate a novel image registration and real-time tracking system for frameless stereotactic neuronavigation and catheter placement in the nonimmobilized patient., Methods: Computer vision technology was used to develop an algorithm that performed near-continuous, automatic, and marker-less image registration. The program fuses a subject's preprocedure CT scans to live 3D camera images (Snap-Surface), and patient movement is incorporated by artificial intelligence-driven recalibration (Real-Track). The surface registration error (SRE) and target registration error (TRE) were calculated for 5 cadaveric heads that underwent serial movements (fast and slow velocity roll, pitch, and yaw motions) and several test conditions, such as surgical draping with limited anatomical exposure and differential subject lighting. Six catheters were placed in each cadaveric head (30 total placements) with a simulated sterile technique. Postprocedure CT scans allowed comparison of planned and actual catheter positions for user error calculation., Results: Registration was successful for all 5 cadaveric specimens, with an overall mean (± standard deviation) SRE of 0.429 ± 0.108 mm for the catheter placements. Accuracy of TRE was maintained under 1.2 mm throughout specimen movements of low and high velocities of roll, pitch, and yaw, with the slowest recalibration time of 0.23 seconds. There were no statistically significant differences in SRE when the specimens were draped or fully undraped (p = 0.336). Performing registration in a bright versus a dimly lit environment had no statistically significant effect on SRE (p = 0.742 and 0.859, respectively). For the catheter placements, mean TRE was 0.862 ± 0.322 mm and mean user error (difference between target and actual catheter tip) was 1.674 ± 1.195 mm., Conclusions: This computer vision-based registration system provided real-time tracking of cadaveric heads with a recalibration time of less than one-quarter of a second with submillimetric accuracy and enabled catheter placements with millimetric accuracy. Using this approach to guide bedside ventriculostomy could reduce complications, improve safety, and be extrapolated to other frameless stereotactic applications in awake, nonimmobilized patients.

Background: Transradial access for neurointerventional procedures was adopted and modified from cardiovascular intervention and is increasingly established as a safe and effective alternative to transfemoral catheterization. As social media influences public opinion on medical treatment, this study analyzes Twitter conversations to elucidate social media's depiction of transradial access as a neurointerventional tool., Materials and Methods: Twitter hashtags #RadialFirst and #RadialForNeuro were evaluated using a mixed-method analysis of quantitative social media metrics and qualitative thematic analysis., Results: Between January 2015 and April 2020, 104,146 tweets from 141 countries employed the hashtag #RadialFirst (2015 (1); 2016 (0); 2017 (22,804); 2018 (33,074); 2019 (38,352); 2020 (9,915 January-April)). These generated 226,909,374 impressions and were retweeted 80,120 times by 13,707 users. Media was present in 62.5% of tweets (e.g. wrist image, angiographic runs) but only 14.5% had a reference article. Physicians authored 70.8% of tweets; interventional cardiologists accounted for 83% of top 100 influencers. #RadialForNeuro is more nascent (6 posts in 2019; 323 posts January-April 2020), with 392,662 impressions, and 254 retweets by 177 users; physicians authored 35.6%. Compared to #RadialFirst, #RadialforNeuro tweets were more likely to include media (76%), less likely to include citations (9.7%), and more likely to discuss complications and troubleshooting techniques., Conclusion: Twitter activity regarding transradial access permits information dissemination and discussion on approach benefits and challenges. However, many posts arise from non-physician sources and lack links to peer-reviewed publication. The public should be mindful that tweets may reflect opinions, rather than experience or scientific evidence.

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

Malaria is an important global health disease which puts individuals, particularly children, at a greater risk of mortality. Plasmodium falciparum is distinguished from the rest of the Plasmodia by its high level of parasitaemia. They infect liver cells (hepatocytes), and multiply into merozoites and rupture liver cells in the process, prior to infection of red blood cells. This study sought to estimate the extent to which P. falciparum parasitaemia correlates with hepatocellular dysfunction among Ghanaian children suffering from acute malaria in three malaria endemic districts in Ashanti Region and to predict liver dysfunction from the estimation of haemoglobin (HB) levels. A prospective uncontrolled before- and after study was conducted among under five years children with acute malaria (n = 300) and a control group (n = 20) within the same age brackets. The serum activities of liver enzymes such as aspartate transaminase (AST), alanine transaminase (ALT), alkaline phosphatase (ALP) and gamma glutamyl transferase (GGT) were measured in patients and control subjects. The study observed an inverse relationship between mean HB and parasitaemia (mean HB level of 10.34 ± 0.14 versus parasitaemia <10,000 parasites/μL as against 8.06 ± 0.16 versus parasitaemia ≥10,000 parasites/μL). The mean levels of AST, ALT, ALP and GGT were higher ( p < 0.0001) in the serum of the infected children before treatment compared with post treatment. Moreover, the receiver operating characteristics (ROC) curve was applied to establish that HB level at 10.9 g/dL predicted liver dysfunction with the area under the curve (AUC) being 0.75 ± 0.03 (P < 0.0001). The parasitaemia estimation and prediction of hepatocellular dysfunction in Ghanaian children with acute malaria could be done via HB levels., Competing Interests: The authors declare no conflict of interest., (© 2021 The Author(s).)

Objective: This study aimed to elucidate current medical student perceptions on barriers to a career in surgery, with a particular focus on gender-specific differences., Summary Background Data: Although gender parity in medical school composition has been reached, women continue to be underrepresented in the field of surgery., Methods: An anonymous, single-institution, internet-based survey conducted at Harvard Medical School., Results: Approximately 720 medical students were surveyed and 261 completed the questionnaire (36.3%; 58.6% women, 41% men, 0.4% transgender). Overall, there was no significant gender difference in intention to pursue surgery (27% of men, 22% of women; P = 0.38). Sixty-nine percent of all students and 75% of those pursuing surgery reported verbal discouragement from pursuing a surgical career. Women were significantly more likely to perceive that the verbal discouragement was based on gender (P < 0.0001), age (P < 0.0001), and family aspirations (P = 0.043) compared to men. Surgical work hours and time for outside interests were the greatest deterrents for both genders. Significantly more women reported concerns about time to date or marry (P = 0.042), time to spend with family (P = 0.015), finding time during residency to have a child (P < 0.0001), taking maternity/paternity leave during residency (P < 0.0001), and being too old after residency to have a child (P < 0.0001)., Conclusions: Both men and women reported high rates of verbal discouragement, but more women perceived that the discouragement was gender-based. Concerns about marriage and childbearing/rearing significantly deterred more women than men. Family aspirations were also a significant factor for men to choose an alternative career path. Additional support within the surgical field is needed to mitigate these concerns and support trainees in both their career and familial aspirations., Competing Interests: The authors report no conflicts of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: We aim to systematically review and summarize the demographics, clinical features, management strategies, and clinical outcomes of primary and radiation-induced skull-base osteosarcoma (SBO)., Methods: PubMed, Scopus, and Cochrane databases were used to identify relevant articles. Papers including SBO cases and sufficient clinical outcome data were included. A comprehensive clinical characteristic review and survival analysis were also conducted., Results: Forty-one studies describing 67 patients were included. The median age was 31 years (male = 59.7%). The middle skull-base was most commonly involved (52.7%), followed by anterior (34.5%) and posterior (12.7%) skull-base. Headache (27%), exophthalmos (18%), and diplopia (10%) were common presenting symptoms. Sixty-eight percent of patients had primary SBO, while 25% had radiation-induced SBO. Surgery was the main treatment modality in 89% of cases. Chemotherapy was administered in 65.7% and radiotherapy in 50%. Median progression-free survival (PFS) was 12 months, and the overall 5-year survival was 22%. The five-year survival rates of radiation-induced SBO and primary SBO were 39% and 16%, respectively (P < 0.05)., Conclusion: SBO is a malignant disease with poor survival outcomes. Surgical resection is the primary management modality, in conjunction with chemotherapy and radiotherapy. Radiation-induced SBO has a superior survival outcome as compared to its primary counterpart. Complete surgical resection showed a statistically insignificant survival benefit as compared to partial resection.

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

Background: WORLD NEUROSURGERY (WN) is among the most influential peer-reviewed neurosurgery journals and has had an explicitly global focus historically. The goal of the current study was to perform quantitative bibliographic and social network analyses to identify key contributors and trends influencing article citation patterns., Methods: WN articles were searched using Web of Science and the sampling frame January 1, 1990, to June 18, 2020. Articles were sorted in decreasing order of total citations; the 200 most cited articles were included. BibExcel was used to calculate the H-index of the authors of the top 200 most cited articles; VOSViewer was used to visualize networks by document, author, and keyword., Results: Twenty-one individual authors published at least 2 first-author articles within the 200 most cited manuscripts, including Hakuba (4 articles), Jaaskelainen (4 articles), Cho (3 articles), and Rhoton (3 articles). Authors with the highest H-index were Hernesniemi (5), Rhoton (4), Jaaskelainen (4), Hakuba (4), and Ausman (4). Articles by Huang (2006), Wieser (1982), and Foo (1981) had the largest number of links to other articles (connections between nodes). Ausman articles demonstrated the highest number of collaborations with coauthors who had also published top 200 articles. The most prevalent topics among included articles were neuro-oncology in the 1990s, cerebrovascular in the early 2000s, and skull base in the 2010s., Conclusions: Bibliographic analysis suggests that WN has published a wide range of novel and impactful research studies in neurosurgery, which collectively demonstrate strong collaborative trends in association with advancement of new tools and techniques in all aspects of neurosurgery., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Traumatic brain injury (TBI) and stroke have devastating consequences and are major global public health issues. For patients that require a cerebral decompression after suffering a TBI or stroke, a decompressive craniectomy (DC) is the most commonly performed operation. However, retrospective non-randomized studies suggest that a decompressive craniotomy (DCO; also known as hinge or floating craniotomy), where a bone flap is replaced but not rigidly fixed, has comparable outcomes to DC. The primary aim of this project was to understand the current extent of usage of DC and DCO for TBI and stroke worldwide., Method: A questionnaire was designed and disseminated globally via emailing lists and social media to practicing neurosurgeons between June and November 2019., Results: We received 208 responses from 60 countries [40 low- and middle-income countries (LMICs)]. DC is used more frequently than DCO, however, about one-quarter of respondents are using a DCO in more than 25% of their patients. The three top indications for a DCO were an acute subdural hematoma (ASDH) and a GCS of 9-12, ASDH with contusions and a GCS of 3-8, and ASDH with contusions and a GCS of 9-12. There were 8 DCO techniques used with the majority (60/125) loosely tying sutures to the bone flap. The majority (82%) stated that they were interested in collaborating on a randomized trial of DCO vs. DC., Conclusion: Our results show that DCO is a procedure carried out for TBI and stroke, especially in LMICs, and most commonly for an ASDH. The majority of the respondents were interested in collaborating on a is a future randomized trial.

As progress is gradually being made toward increased representation and retention of women in neurosurgery, the neurosurgical community should elevate effective efforts that may be driving positive change. Here, the authors describe explicit efforts by the neurosurgery community to empower and expand representation of women in neurosurgery, among which they identified four themes: 1) formal mentorship channels; 2) scholarships and awards; 3) training and exposure opportunities; and 4) infrastructural approaches. Ultimately, a data-driven approach is needed to improve representation and empowerment of women in neurosurgery and to best direct the neurosurgical community's efforts across the globe.

Background: The Idea, Development, Exploration, Assessment and Long-term study (IDEAL) framework was created to provide a structured way for assessing and evaluating novel surgical techniques and devices., Objectives: The aim of this paper was to investigate the utilization of the IDEAL framework within neurosurgery, and to identify factors influencing implementation., Methods: A bibliometric analysis of the 7 key IDEAL papers on Scopus, PubMed, Embase, Web of Science, and Google Scholar databases (2009-2019) was performed. A second journal-specific search then identified additional papers citing the IDEAL framework. Publications identified were screened by two independent reviewers to select neurosurgery-specific articles., Results: The citation search identified 1336 articles. The journal search identified another 16 articles. Following deduplication and review, 51 relevant articles remained; 14 primary papers (27%) and 37 secondary papers (73%). Of the primary papers, 5 (36%) papers applied the IDEAL framework to their research correctly; two were aligned to the pre-IDEAL stage, one to the Idea and Development stages, and two to the Exploration stage. Of the secondary papers, 21 (57%) explicitly discussed the IDEAL framework. Eighteen (86%) of these were supportive of implementing the framework, while one was not, and two were neutral., Conclusion: The adoption of the IDEAL framework in neurosurgery has been slow, particularly for early-stage neurosurgical techniques and inventions. However, the largely positive reviews in secondary literature suggest potential for increased use that may be achieved with education and publicity.

Magnetic resonance imaging (MRI) is an indispensable tool for investigating brain development in young children and the neurobiological mechanisms underlying developmental risk and resilience. Sub-Saharan Africa has the highest proportion of children at risk of developmental delay worldwide, yet in this region there is very limited neuroimaging research focusing on the neurobiology of such impairment. Furthermore, paediatric MRI imaging is challenging in any setting due to motion sensitivity. Although sedation and anesthesia are routinely used in clinical practice to minimise movement in young children, this may not be ethical in the context of research. Our study aimed to investigate the feasibility of paediatric multimodal MRI at age 2-3 years without sedation, and to explore the relationship between cortical structure and neurocognitive development at this understudied age in a sub-Saharan African setting. A total of 239 children from the Drakenstein Child Health Study, a large observational South African birth cohort, were recruited for neuroimaging at 2-3 years of age. Scans were conducted during natural sleep utilising locally developed techniques. T1-MEMPRAGE and T2-weighted structural imaging, resting state functional MRI, diffusion tensor imaging and magnetic resonance spectroscopy sequences were included. Child neurodevelopment was assessed using the Bayley-III Scales of Infant and Toddler Development. Following 23 pilot scans, 216 children underwent scanning and T1-weighted images were obtained from 167/216 (77%) of children (median age 34.8 months). Furthermore, we found cortical surface area and thickness within frontal regions were associated with cognitive development, and in temporal and frontal regions with language development (beta coefficient ≥0.20). Overall, we demonstrate the feasibility of carrying out a neuroimaging study of young children during natural sleep in sub-Saharan Africa. Our findings indicate that dynamic morphological changes in heteromodal association regions are associated with cognitive and language development at this young age. These proof-of-concept analyses suggest similar links between the brain and cognition as prior literature from high income countries, enhancing understanding of the interplay between cortical structure and function during brain maturation., Competing Interests: Declaration of competing interest The authors report no conflicts of interest., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Traumatic brain injury (TBI) is the most common neurosurgical condition globally. In Cameroon, there are 572 cases of TBI per 100,000 people, but <40% of Cameroonians live within 4 hours of a neurosurgical facility. We sought to understand the clinical outcomes at a neurosurgical center in Central Cameroon., Methods: This cross-sectional study was conducted at the largest neurosurgical center of Cameroon, the Yaounde Central Hospital. Data included 100 consecutive patients undergoing an intervention 72 hours after their injury from February 1, 2015 to February 1, 2019. Patients with missing data or undergoing surgery >72 hours after injury were excluded. Analyses of covariance were performed, and a P value >0.05 was considered significant. A Kaplan-Meier survival curve was computed., Results: The patients had a mean age of 31.3 ± 17.4 years, with a male predominance of 91.0%, and the principal mechanism of injury was road traffic accidents (68.0%). Only 11% arrived via ambulance, and 36.0% were admitted <3 hours after the traumatic event. The postoperative mortality was 15.0%, mean survival was 25.0 postoperative days (95% confidence interval, 23.42-26.52), and the mean Glasgow Outcome Scale score at 28 days was 3.9 ± 1.4., Conclusions: Most patients with TBI undergoing neurosurgery 72 hours after injury in Cameroon arrive at the hospital late and have a high mortality risk during the first postoperative week. Investments in prehospital care should be made to improve surgical outcomes., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Importance: Burnout among health care professionals has been increasingly associated with suicide risk. An examination of possible risk factors may help in the prevention of suicide among health care professionals., Objective: To assess suicide risk factors for 3 categories of health care professionals (surgeons, nonsurgeon physicians, and dentists) compared with non-health care professionals., Design, Setting, and Participants: Data from the National Violent Death Reporting System were reviewed to identify all individuals who died by suicide in the United States between January 1, 2003, and December 31, 2016. Individuals were divided into health care professionals and non-health care professionals (general population), with the health care professionals further categorized into surgeons, nonsurgeon physicians, and dentists. The covariates of suicide decedents included demographic characteristics (age, sex, race, and marital status), medical history (mental illness, substance use, and physical health), and documented factors associated with the suicide death (job, intimate partner, financial, legal, and other problems). Data were analyzed from October 2 to December 17, 2019., Main Outcomes and Measures: In this analysis, the outcome variable was occupation, with health care professionals overall and by category compared with the general population. Multiple logistic regression analyses with backward stepwise selection were performed., Results: A total of 170 030 individuals who died by suicide between 2003 and 2016 were identified. Of those, 767 individuals (0.5%) were health care professionals (mean [SD] age, 59.6 [15.6] years; 675 men [88.0%]; 688 white [89.7%]), with the remainder of the sample (95.5%) comprising the general population (mean [SD] age, 46.8 [31.5] years; 77.7% men; 87.8% white). A total of 485 health care professionals (63.2%) were nonsurgeon physicians, 179 professionals (23.3%) were dentists, and 103 professionals (13.4%) were surgeons. Compared with the general population, risk factors for suicide among health care professionals included having Asian or Pacific Islander ancestry (odds ratio [OR], 2.80; 95% CI, 1.96-3.99; P < .001), job problems (OR, 1.79; 95% CI, 1.49-2.17; P < .001), civil legal problems (OR, 1.61; 95% CI, 1.15-2.26; P = .006), and physical health problems (OR, 1.40; 95% CI, 1.19-1.64; P < .001) and currently receiving treatment for mental illness (OR, 1.45; 95% CI, 1.24-1.69; P < .001). Compared with the general population, health care professionals had a lower risk of suicide if they had black ancestry (OR, 0.55; 95% CI, 0.36-0.84; P < .001) or were female (OR, 0.44; 95% CI, 0.35-0.55; P < .001) or unmarried (OR, 0.36; 95% CI, 0.31-0.42; P < .001). Health care professionals who died by suicide were also less likely to have problems with intimate partners (OR, 0.71; 95% CI, 0.60-0.86; P < .001) or alcohol use (OR, 0.58; 95% CI, 0.45-0.73; P < .001) compared with the general population. Surgeons had a higher risk of suicide compared with the general population if they were older, male, married, had Asian or Pacific Islander ancestry, were currently receiving treatment for mental illness, or had problems with their job or alcohol use. Compared with their nonsurgeon physician colleagues, surgeons had a higher risk of suicide if they were male, older, married, or currently receiving treatment for mental illness., Conclusions and Relevance: This study highlights risk factors for suicide among health care professionals, with additional analyses of surgeon-specific risk factors. The results may be useful in improving the detection of burnout and the development of suicide prevention interventions among health care professionals.