Neurosurgical Decision-Making and the Ethical Considerations in the Treatment of Traumatic Brain Injury

Purpose: Globally, disparities in the availability of surgical care are prevalent, and for specialty care such as neurosurgery, services are typically scarce to non-existent. In low-and-middle-income countries, most medical centers have limited resources and are not equipped to handle neurosurgical emergencies. Within the field of global neurosurgery, there has been a push to incorporate advanced technologies such as predictive modeling to facilitate triage and neurosurgical care decision-making.
However, to successfully implement such technologies, it is vital to consider the ethical framework within which neurosurgical care decisions are made and how ethical challenges inform decision-making. The objective of this study was to determine whether the potential ethical challenges that neurosurgical care providers encounter are differentially important to decision-making.
Methods: This study utilized a rank-order survey to evaluate surgical risk tolerance, the relative importance of several patient-level and system-level factors to the decision to offer surgery, and perceptions of the fairness of several resource-allocation principles when surgery cannot be offered to all patients in need. Further, we assessed whether geographic, demographic, cultural, and institutional characteristics and utilitarian ethical orientation differentially impact these aspects of decision-making
Results: The key findings of this study show there is a differential impact of ethical challenges on decision-making and there are correlations with decision-making factors and demographic information.
Conclusion: This data will allow the identification of key commonalities and differences in approaches to neurosurgical decision-making across practice settings, which will potentially facilitate ethically responsible, cross-cultural collaborations and implementations of neurosurgical decision support tools.

EMR adoption in Dhaka, Bangladesh: a template to index pediatric central nervous system tumor care and a review of preliminary neuro-oncologic observations

Purpose
To describe the design, implementation, and adoption of a simplified electronic medical record (EMR) and its use in documenting pediatric central nervous system (CNS) tumors at a tertiary care referral hospital in South-East Asia.

Methods
A novel EMR, cataloguing pediatric CNS tumors was used to collect data from August 2017 to March 2020 at National Institute of Neurosciences and Hospital (NINS&H) in Dhaka, Bangladesh.

Results
Two hundred forty-nine pediatric patients with a CNS tumor were admitted to NINS&H. Fifty-eight percent of patients were male, and the median age was 8 years. A total of 188/249 patients (76%) underwent surgery during their index admission. Radiographic locations were known for 212/249 (85%) of cases; the most common radiographic locations were infratentorial (81/212; 38%), suprasellar (45/212; 21%), and supratentorial (29/212; 14%). A histopathological classification was reported on 156/249 (63%) of patients’ cytology. The most common infratentorial pathologies were medulloblastoma (22/47; 47%) and pilocytic astrocytoma (14/47; 30%). The median time between admission and surgery was 36 days, while the median post-operation stay was 19.5 days.

Conclusions
The feasibility of a basic EMR platform for a busy pediatric neurosurgery department in a lower-middle income country is demonstrated, and preliminary clinical data is reviewed. A wide variety of pediatric CNS tumors were observed, spanning the spectrum of anatomic locations and histopathologic subtypes. Surgical intervention was performed for the majority of patients. Barriers to care include limited molecular diagnostics and unavailable data on adjuvant therapy. Future targets include improvement of clinical documentation in the pre-operative and post-operative period.

Establishing collaborations in global neurosurgery: The role of InterSurgeon

The global deficiency in surgical care has been highlighted in the past several years, through the publication of the Lancet Commission on Global Surgery in 2015, the passage of WHA Resolution 68.15, and concerted efforts by advocacy organizations such as the G4 Alliance. Approximately 23,300 additional neurosurgeons are estimated to be needed to address the greater than 5 million essential neurosurgical cases that are not performed annually, most in low- and middle-income countries (LMICs).

However, increasing recognition of the ease and feasibility of virtual technology prompted a shift towards virtual modes of communication. InterSurgeon (https://www.intersurgeon.org/), an independent, internet-based social network platform, has allowed for formal connection between global surgery advocates who may have complementary needs and resources. This manuscript aims to: 1) characterize the current progress of InterSurgeon, 2) describe lessons learned from the creation and use of InterSurgeon, and 3) discuss future directions for InterSurgeon.

Equitable, well-designed collaborations are central to progress in global neurosurgery. InterSurgeon has catalyzed collaborations within global neurosurgery across world regions and country income status. In addition to its role in facilitating traditional in person collaborations, InterSurgeon will become an increasingly important tool for connecting surgeons worldwide as virtual collaboration and augmented reality training paradigms become important components of global surgery capacity building.

Evaluation of Computed Tomography Scoring Systems in the Prediction of Short-Term Mortality in Traumatic Brain Injury Patients from a Low- to Middle-Income Country

The present study aims to evaluate the accuracy of the prognostic discrimination and prediction of the short-term mortality of the Marshall computed tomography (CT) classification and Rotterdam and Helsinki CT scores in a cohort of TBI patients from a low- to middle-income country. This is a post hoc analysis of a previously conducted prospective cohort study conducted in a university-associated, tertiary-level hospital that serves a population of >12 million in Brazil. Marshall CT class, Rotterdam and Helsinki scores, and their components were evaluated in the prediction of 14-day and in-hospital mortality using Nagelkerk’s pseudo-R2 and area under the receiver operating characteristic curve. Multi-variate regression was performed using known outcome predictors (age, Glasgow Coma Scale, pupil response, hypoxia, hypotension, and hemoglobin values) to evaluate the increase in variance explained when adding each of the CT classification systems. Four hundred forty-seven patients were included. Mean age of the patient cohort was 40 (standard deviation, 17.83) years, and 85.5% were male. Marshall CT class was the least accurate model, showing pseudo-R2 values equal to 0.122 for 14-day mortality and 0.057 for in-hospital mortality, whereas Rotterdam CT scores were 0.245 and 0.194 and Helsinki CT scores were 0.264 and 0.229. The AUC confirms the best prediction of the Rotterdam and Helsinki CT scores regarding the Marshall CT class, which presented greater discriminative ability. When associated with known outcome predictors, Marshall CT class and Rotterdam and Helsinki CT scores showed an increase in the explained variance of 2%, 13.4%, and 21.6%, respectively. In this study, Rotterdam and Helsinki scores were more accurate models in predicting short-term mortality. The study denotes a contribution to the process of external validation of the scores and may collaborate with the best risk stratification for patients with this important pathology.

Clinicopathological Patterns and Surgical Outcomes of Primary Brain Tumors Managed at a Tertiary Hospital in Arusha, Tanzania:a Cross-sectional Analysis

Purpose: The epidemiology of brain tumors varies globally between different countries and there is observed poor outcomes in lower- and middle-income countries. Our aim is to analyze the clinicopathological pattern of intracranial tumors in our setting and their post-surgical outcomes.

Methods: This is a retrospective study. Data was obtained from clinical records of patients with intracranial tumors treated at our neurosurgery unit between 2019 and 2020. Only patients with primary brain tumors who underwent surgical intervention were included. Analysis was done to identify factors associated with patient outcomes (mortality/survival and performance status).

Results: 39 patients with primary brain tumors underwent surgery (adults 72.8%, males 53.8%, mean age 35.8years). Gliomas (46.2%) comprised the most common tumor diagnosis overall and craniopharyngiomas were the most common tumors in pediatric patients (27.3%). Most patients (83.3%) had a poor performance status before surgery. Gross tumor resection (25.6%) was low and few patients (31.4%) underwent adjuvant therapy. 30-day mortality rate (10.3%) and one year mortality rate (46.2%) were high. Pediatric patients had a much worse outcome (46.2% mortality rate compared to 25% in adults, and 80% with poor performance status) as did males (38.1% mortality rate compared to 27.8% in females). Gliomas accounted for majority (69.2%) of the deaths.

Conclusion: Delayed presentation and poor access to adjuvant therapies are important contributors of the high mortality and abandonment of treatment. Inadequate long-term follow-up is a hinderance to optimal neurooncological care in our setting.

Patterns and Surgical Outcomes of Primary Brain Tumors Managed at a Tertiary Hospital in Arusha, Tanzania: a Cross-sectional Analysis

Purpose: The epidemiology of brain tumors varies globally between different countries and there is observed poor outcomes in lower- and middle-income countries. Our aim is to analyze the clinicopathological pattern of intracranial tumors in our setting and their post-surgical outcomes.

Methods: This is a retrospective study. Data was obtained from clinical records of patients with intracranial tumors treated at our neurosurgery unit between 2019 and 2020. Only patients with primary brain tumors who underwent surgical intervention were included. Analysis was done to identify factors associated with patient outcomes (mortality/survival and performance status).

Results: 39 patients with primary brain tumors underwent surgery (adults 72.8%, males 53.8%, mean age 35.8years). Gliomas (46.2%) comprised the most common tumor diagnosis overall and craniopharyngiomas were the most common tumors in pediatric patients (27.3%). Most patients (83.3%) had a poor performance status before surgery. Gross tumor resection (25.6%) was low and few patients (31.4%) underwent adjuvant therapy. 30-day mortality rate (10.3%) and one year mortality rate (46.2%) were high. Pediatric patients had a much worse outcome (46.2% mortality rate compared to 25% in adults, and 80% with poor performance status) as did males (38.1% mortality rate compared to 27.8% in females). Gliomas accounted for majority (69.2%) of the deaths.

Conclusion: Delayed presentation and poor access to adjuvant therapies are important contributors of the high mortality and abandonment of treatment. Inadequate long-term follow-up is a hinderance to optimal neurooncological care in our setting.

Evaluating the impact of neurosurgical rotation experience in Africa on the interest and perception of medical students towards a career in neurosurgery: a protocol for a continental, cross-sectional study

Introduction
Africa has the second highest neurosurgical workforce deficit globally. Despite the many recent advancements in increasing neurosurgical access in Africa, published reports have shown that the vast majority of undergraduate students have little or no exposure to neurosurgery. The lack of exposure may pose a challenge in reducing the neurosurgical workforce deficit, which is one of the long-term strategies of tackling the unmet burden of disease. Students may also miss the opportunity to appreciate the specialty and its demands as well as nurture their interest in the field. This study aims to assess the impact of a neurosurgical rotation during medical school in shaping the perception and interest of students towards a career in neurosurgery.

Methods
The cross-sectional study will be conducted through the dissemination of a self-administered e-survey hosted on Google Forms from 21st February 2021 to 20th March 2021. The survey will contain five-point Likert scale, multiple-choice and free-text questions. The structured questionnaire will have four sections with 27 items: (i) socio-demographic background, (ii) neurosurgical experience, (iii) perception towards a neurosurgical career and (iv) interest in a neurosurgical career. All consenting medical students in African medical schools who are in their clinical years (defined as fourth to sixth years or higher years of study) will be eligible. Odds ratios and their 95% confidence intervals, Wilcoxon rank-sum test, Welch t-test and adjusted logistic regression models will be used to test for associations between independent and dependent variables. Statistical significance will be accepted at P < 0.05.

Public awareness, knowledge of availability, and willingness to use neurosurgical care services in Sub-Saharan Africa: A cross-sectional study

Introduction
Low- and middle-income countries bear the majority of neurosurgical disease burden and patients face significant barriers to seeking, reaching, and receiving care. We aimed to understand barriers to seeking care among adult Africans by evaluating the public perception, knowledge of availability, and readiness to use neurosurgical care services.

Methods
An e-survey was distributed among African adults who are not in the health sector or pursuing a health-related degree. Chi-square test and ANOVA were used for bivariate analysis and the alpha value was set at 0.05. Odds ratios and their 95% confidence intervals were calculated.

Results
Six hundred and sixty-two adults from 16 African countries aged 25.4 (95% CI: 25.0, 25.9) responded. The majority lived in urban settings (90.6%) and were English-speaking (76.4%) men (54.8%). Most respondents (76.3%) could define neurosurgery adequately. The most popular neurosurgical diseases were traumatic brain injury (76.3%), congenital brain and spine diseases (67.7%), and stroke (60.4%). Unwillingness to use or recommend in-country neurosurgical services was associated with rural dwelling (β = -0.69, SE = 0.31, P = 0.03), lack of awareness about the availability of neurosurgeons in-country (β = 1.02, SE = 0.20, P<0.001), and believing neurosurgery is expensive (β = -1.49, SE = 0.36, P<0.001).

Conclusion
Knowledge levels about neurosurgery are satisfactory; however, healthcare-seeking is negatively impacted by multiple factors.

Casemix, management, and mortality of patients receiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

Background
Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.

Methods
We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital’s 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)—a composite of life expectancy, education, and income measures—into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.

Findings
Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24–51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34–69) and the youngest in the low HDI tier (median 28 years, IQR 20–38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6–32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55–5·2) and high HDI tier (2·26, 1·23–4·15), but not the low HDI tier (1·66, 0·61–4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17–2·49).

Interpretation
Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

Funding
National Institute for Health Research Global Health Research Group.

Pediatric Hydrocephalus in Northwest Tanzania: a descriptive cross-sectional study of clinical characteristics and early surgical outcomes from the Bugando Medical Centre.

Objectives
In this study, we present data from a neurosurgical training program in Tanzania for the treatment of pediatric hydrocephalus. The objectives of the study were to identify the demographics and clinical characteristics of pediatric patients with hydrocephalus that were admitted to Bugando Medical Centre in Mwanza, Tanzania as well as to describe their surgical treatment and early clinical outcomes.

Methods
This cross-sectional study included 38 pediatric patients. Physical examinations were conducted pre- and post-operatively, and their mothers completed a questionnaire providing demographic and clinical characteristics.

Results
There was a slight preponderance of male sex (21/38; 55.3%) with median age at the time of admission of 98.5 days. The majority of patients were surgically treated (33/38; 86.8%). Among those surgically treated, most received a ventriculoperitoneal shunt (23/33; 69.7%), while seven were treated with an endoscopic third ventriculostomy (7/33; 21.2%). At the time of admission, the majority of patients (86%) had head circumferences that met criteria for macrocephaly. The median time between admission and surgery was 23 days (2-47 days). Overall, five patients (13.2%) died, including two that did not receive surgical intervention.

Conclusions
We found that in our population, pediatric patients with hydrocephalus often present late for treatment with additional significant delays prior to receiving any surgical intervention. Five patients died, of which two had not undergone surgery. Our study reinforces that targeted investments in clinical services are needed to enable access to care, improve surgical capacity, and alleviate the burden of neurosurgical disease from pediatric hydrocephalus in sub-Saharan Africa.