Neurosurgical focus最新文献

Objective: The number of pediatric neurosurgeons worldwide remains inadequate. Opportunities for fellowship training and continuing medical education in pediatric neurosurgery are limited, particularly for neurosurgeons in low- and middle-income countries. This study aimed to describe the setup and conduct of a recurring online meeting to discuss diagnostic and treatment dilemmas in pediatric neurosurgery, organized by a group of pediatric neurosurgeons in Southeast Asia.

Methods: Available meeting reports since inception in 2022 and registration data for the year 2024 were analyzed. Meeting recordings were reviewed to describe the cases presented for opinion. A focus group discussion was conducted among core team members to evaluate the virtual meetings.

Results: From January 2022 to August 2024, the Southeast Asian pediatric neurosurgery group organized 16 online meetings to discuss 50 patients. Based on the report for 12 meetings (75%), the mean number of participants for each session was 45 ± 11, with 91% ± 5% of the attendees being present for at least 15 minutes. Review of 2024 registration data showed that 142 unique participants from 15 countries attended the 5 meetings for this year. Most were neurosurgery residents (65%) and neurosurgery consultants (23%). Of 50 cases presented, the majority were tumors (52%) and craniofacial disorders (16%). Discussions centered on most probable diagnosis (34%), best treatment option (90%), and recommended surgical approach (82%).

Conclusions: International case discussions in pediatric neurosurgery are feasible and sustainable online, with the potential to improve service delivery, strengthen the workforce, and grow professional networks. Leadership and time commitment from a core group are essential to ensure the success of these global neurosurgery collaborations.

Neurosurgery has long faced significant disparities in access to care in low- and middle-income countries (LMICs), where millions lack access to timely, lifesaving neurosurgical interventions. The Duke Division of Global Neurosurgery and Neurology (DGNN) was established to address these inequities by building sustainable neurosurgical capacity through strategic partnerships, training programs, and service initiatives. DGNN's framework evolved from the initial "3-Ts" approach-technology, twinning, and training-to a broader focus on service, research, and training, prioritizing local ownership of neurosurgical systems. Key challenges, such as resource limitations, cross-cultural collaboration, and the retention of trained professionals, were overcome through collaborative efforts and a commitment to capacity building. The introduction of digitized health records and data systems, along with research projects in epilepsy and traumatic brain injury, contributed to a comprehensive model of growth. Through these initiatives, DGNN has expanded neurosurgical services and increased the number of trained neurosurgeons in Uganda, creating a sustainable model that can be adapted to other countries. This paper outlines DGNN's history, challenges, and strategies with the goal of establishing a framework for other institutions to grow similar initiatives and divisions.

Objective: The objective of this study was to develop a pilot traumatic brain injury (TBI) registry through a retrospective review of medical records. This was done to investigate the epidemiology and the prevalence of delays to care, both before and after hospital admission, among patients with TBI in the Teaching Hospital Jaffna, a regional referral hospital in Sri Lanka.

Methods: This was a single-center retrospective cohort study, in which purposive sampling was used to select TBI cases treated between January and December 2021. Patients with TBI were initially identified via International Classification of Diseases, Tenth Revision, Clinical Modification codes and then stratified via mechanism of injury and length of stay; data collection was done through a review of physical medical records.

Results: Among the 99 patients with TBI who were identified, the majority (72%) were referred from peripheral facilities without neurosurgical support. Road traffic accidents were the leading cause of injury (68.7%) and death (75.9%). TBIs were classified as mild (50.5%), moderate (21.2%), and severe (28.3%). Eighty percent of patients with TBIs who were referred to neurosurgery received opinions within 2 hours, with no significant association with mortality rate. Compared to patients with mild/moderate TBI, those with severe TBI had shorter median times before receiving neurosurgical opinions and CT scan reports. Delays in CT scan reports resulted in prolonged times to receive neurosurgical management. Most patients were managed without neurosurgical operative intervention, with subsequent neurosurgical interventions linked to a higher mortality rate (HR 6.08, p < 0.001). The inpatient mortality rate was 29.3%, mainly from severe TBIs (69%). Patients needing intracranial pressure monitoring had higher inpatient mortality (p < 0.001). Deteriorating Glasgow Coma Scale scores prior to intervention, typically due to inadequate vital sign stabilization, predicted significantly lower survival rates (52% vs 82%, p = 0.0019).

Conclusions: Patients with TBI in our cohort faced delays in three main areas: lengthy referral pathways, late stabilization of vital signs and intracranial pressure, and initial neurosurgical management. Developing strategies to mitigate these delays in care will be a crucial factor in reducing neurological morbidity and mortality for patients with TBI seeking treatment in resource-limited settings.

Objective: Epilepsy surgery is underutilized globally due to patient and/or caregiver reluctance and neurologist knowledge gaps. In Pakistan, the treatment gap is 70%-94% for medically refractory epilepsy (MRE). This study assessed the knowledge and practices of neurologists and patients to identify barriers to adequate epilepsy surgery provision in Pakistan.

Methods: The authors conducted a cross-sectional study consisting of two surveys. One survey was designed for epilepsy patients and their caregivers. The medical records of patients diagnosed with epilepsy at the authors' hospital between July 2018 and December 2020 were retrieved from the neurophysiology database. Patients or their caregivers were then contacted via telephone to complete the survey. The second survey was designed for neurologists working in Pakistan. This form was sent via email.

Results: For the patient survey, 250 patients or caregivers were contacted, of whom 194 responded. The median age of the patients was 10 years (IQR 6-14 years). The authors found that 74.2% (n = 144) of the patients were unaware of surgical options in MRE. Forty-eight (24.7%) patients/caregivers reported more than 1 seizure per month, and 29 (60.4%) of them were unaware of the surgical treatment. Seizures were disabling in 56.7% (n = 110) of the patients. Patients taking more antiepileptic drugs were significantly more likely to be aware of surgical options (p = 0.001). For the neurologist survey, only 6.6% (4/61) always discussed epilepsy surgery with MRE patients. Around half of the neurologists (n = 27, 44.3%) had never referred a patient for epilepsy surgery. However, 95.1% (n = 58) were aware of the underutilization of epilepsy surgery, and 67.2% (n = 41) believed that epilepsy surgery is underrecommended. Almost all neurologists (n = 60, 98.4%) believed that comprehensive epilepsy treatment centers are required in the country.

Conclusions: These surveys demonstrated a major barrier in patient and neurologist awareness, in contrast to high-income countries where physician awareness is adequate but patient perceptions and stigmas are the main barriers. Addressing these barriers requires multifaceted, locally tailored approaches.

Objective: In this review of experiences across the world, the authors aim to demonstrate a roadmap to success in initiating epilepsy surgery programs. The goal of closing the gap of underutilization and inequitable access to epilepsy surgery requires an understanding of potential solutions and evaluation of best practices from a broad range of literature.

Methods: The PubMed and Global Index Medicus databases were systematically queried for eligible articles relevant to the topic. Using a scoping review methodology, the authors described the available narratives of the global experiences of initiating epilepsy surgery centers on a summative basis and through the lens of implementation science and various frameworks. On the basis of relevant public health principles grounded on varied experiences, the authors put forth recommendations for implementing an epilepsy surgery program mainly on a national level.

Results: The results were stratified on the basis of thematic fit to the process stages of social health program implementation and the components of the Global Surgery and Flagship frameworks. Based on documented best practices, initial recommendations that can be applied to nascent programs included the following: organizational leadership at the outset, nuanced patient selection informed by workforce and equipment capacities, and a graduated and stepwise evolution in case selection and therefore capacity. Bellwether procedures for pediatric epilepsy surgery across the settings of different resource levels can include temporal lobectomy and amygdalohippocampectomy, lesional and multilobar resections, corpus callosotomy, and hemispheric disconnection procedures. Advocacy and formal policy work for improved financing and governance arrangements were deemed crucial in supporting the work of improving access to, and addressing the underutilization of, epilepsy surgery.

Conclusions: Working to address the global magnitude of the need for epilepsy surgery needs to be matched by what could be a thoughtful process of implementation that examines contextual challenges and resources. This review informs a roadmap to address the very substantial challenges posed when attempting to initiate epilepsy surgery programs, particularly in under-resourced settings and in low- and middle-income countries.

Objective: The ongoing war in Ukraine has introduced many challenges to an already overburdened and resource-limited medical system. Longitudinal collaborations, material support, educational outreach, and surgical mentorship are essential for improving outcomes and standards of neurosurgical care in extreme settings such as in times of war.

Methods: Operating in Ukraine since 2016 through the coordination of Razom, the Co-Pilot Project has organized multiple United States-based mission trips to Ukraine to support local physicians during wartime, including a trip between April and May of 2023.

Results: A team of two anesthesiologists, two neurosurgeons, a neurointerventional radiologist, and an industry representative providing technical expertise aided in the instruction and performance of complex neurosurgical and neurovascular procedures by Ukrainian physicians at St. Panteleimon Hospital and St. Nicholas Children's Hospital in Lviv. Such efforts are crucial for helping to address the sharp rise in elective neurosurgical volume caused by the increase in internally displaced persons in Western Ukraine since February 2022. In an illustrative case, the authors provide an in-depth description of a foramen magnum meningioma resection via a far lateral craniotomy in a 48-year-old female.

Conclusions: Despite the supply shortages and logistical challenges brought on by war, the Co-Pilot Project continues to utilize a long-term approach to continually improve the operative capabilities of Ukrainian neurosurgeons through both in-person and virtual collaborations. It is hoped that the lessons learned from a recent trip to Ukraine will help to inform and inspire other global neurosurgery initiatives in the future.

As many as 80 million people in the world have epilepsy. Those living in the developing world are disproportionately affected. Approximately 770,000 people in Uganda are affected by epilepsy. Drug-resistant epilepsy affects approximately 30%-40% of patients with epilepsy, and one-third of these patients may be eligible for surgical management. This article describes the formation of an epilepsy monitoring unit in Uganda as the first step toward establishing a surgical epilepsy program for pediatric patients. A hybrid remote and in-person collaborative model was developed between teams in Mbale and Kampala in Uganda and Chicago in the US. The authors describe a process that spanned 2 years (2021-2023) for developing readiness for referrals for pediatric epilepsy surgery candidates in Uganda.

Objective: The aim of this study was to examine female authorship in research from collaborations between high-income countries (HICs) and lower-middle-income and low-income countries (LMICs/LICs) across two time periods: 2018-2020 and 2021-2023.

Methods: A bibliometric analysis of neurosurgical research articles from the Scopus database, published between 2018 and 2023, was performed to investigate collaboration trends between HICs and LMICs/LICs. Only neurosurgical publications were included, and female authors were identified based on names traditionally associated with female gender identity, verified through online searches and tools such as Genderize.io. Articles with more than 25 authors, commentaries, letters, and news items were excluded to ensure a focus on original research. The selected articles spanned various neurosurgical specialties and were restricted to English-language journals with an impact factor greater than 1. The country affiliations of first, corresponding, and last authors were categorized using the 2018 World Bank classification to understand collaboration patterns across income levels.

Results: The analysis revealed a steady increase in neurosurgical publications from 2018 to 2023, with a notable rise in the second triennium (2021-2023). Authors from HICs consistently held the majority of first, corresponding, and last authorship positions. Concerning first authorship, authors with affiliations from HICs increased from 66% in the first triennium to 75% in the second. Similarly, corresponding authors from HICs increased from 75% to 82% over the same period. Male authors dominated all key authorship roles, with 127 male-led first authorships compared with 46 female-led first authorships in the second triennium. This male predominance persisted in corresponding and last author roles as well.

Conclusions: Global neurosurgical research is growing but significant gender disparities persist, especially in LMICs/LICs, with female researchers underrepresented in key authorship roles, requiring targeted efforts to address systemic barriers and promote gender equity in academic leadership.