Subcallosal cingulate deep brain stimulation evokes two distinct cortical responses via differential white matter activation.

Subcallosal cingulate (SCC) deep brain stimulation (DBS) is an emerging therapy for refractory depression. Good clinical outcomes are associated with the activation of white matter adjacent to the SCC. This activation produces a signature cortical evoked potential (EP), but it is unclear which of the many pathways in the vicinity of SCC is responsible for driving this response. Individualized biophysical models were built to achieve selective engagement of two target bundles: either the forceps minor (FM) or cingulum bundle (CB). Unilateral 2 Hz stimulation was performed in seven patients with treatment-resistant depression who responded to SCC DBS, and EPs were recorded using 256-sensor scalp electroencephalography. Two distinct EPs were observed: a 120 ms symmetric response spanning both hemispheres and a 60 ms asymmetrical EP. Activation of FM correlated with the symmetrical EPs, while activation of CB was correlated with the asymmetrical EPs. These results support prior model predictions that these two pathways are predominantly activated by clinical SCC DBS and provide first evidence of a link between cortical EPs and selective fiber bundle activation.

Epilepsy among the older population of sub-Saharan Africa: Analysis of the global burden of disease database.

INTRODUCTION: Epilepsy is considered one of the most burdensome neurologic diseases by the World Health Organization due to the high risk of morbidity and mortality. Few studies have investigated the epidemiology of idiopathic epilepsy in Sub-Saharan Africa (SSA). This study aims to characterize the disease burden of epilepsy among the older population in SSA via a large international database. METHODS: Descriptive epidemiological data from the Global Burden of Disease (GBD) database was collected for idiopathic epilepsy in all regions of SSA. The "older" population was defined as 55 years of age and above. The variables of interest included mortality, incidence, prevalence, and disability-adjusted life years (DALYs) rates per one hundred thousand populations. RESULTS: The average mortality rate was highest in Western SSA (6.34 per 100,000), and all regions were significantly higher than the global average (p < 0.001). DALYs and incidence rates of idiopathic epilepsy in all regions of SSA were significantly higher than the global averages (p < 0.01). Globally, the older population had a significantly higher mortality rate than the younger population (2.78 vs 1.62, respectively; p < 0.01). The older population had a higher mortality rate than the younger population in each region of SSA (p < 0.01). Conversely, for DALYs, the younger population had a higher disease burden than the older population globally and in each region of SSA (p < 0.01). CONCLUSION: This study is the first to examine the epidemiologic profile of idiopathic epilepsy in the older population in SSA. Our results indicate that, when compared with the global population, older adults in SSA suffer a greater disease burden and mortality. This study reports the immense need for increased resources and awareness regarding epilepsy in the elderly population of Africa.

Association of moyamoya vasculopathy with autoimmune disease: a systematic review and pooled analysis.

Despite more than six decades of extensive research, the etiology of moyamoya disease (MMD) remains unknown. Inflammatory or autoimmune (AI) processes have been suggested to instigate or exacerbate the condition, but the data remains mixed. The objective of the present systematic review was to summarize the available literature investigating the association of MMD and AI conditions as a means of highlighting potential treatment strategies for this subset of moyamoya patients. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the PubMed, Embase, Scopus, Web of Science, and Cochrane databases were queried to identify studies describing patients with concurrent diagnoses of MMD and AI disease. Data were extracted on patient demographics, clinical outcomes, and treatment. Stable or improved symptoms were considered favorable outcomes, while worsening symptoms and death were considered unfavorable. Quantitative pooled analysis was performed with individual patient-level data. Of 739 unique studies identified, 103 comprising 205 unique patients (80.2% female) were included in the pooled analysis. Most patients (75.8%) identified as Asian/Pacific Islanders, and the most commonly reported AI condition was Graves' disease (57.6%), with 55.9% of these patients presenting in a thyrotoxic state. Of the 148 patients who presented with stroke, 88.5% of cases (n = 131) were ischemic. Outcomes data was available in 152 cases. There were no significant baseline differences between patients treated with supportive therapy alone and those receiving targeted immunosuppressant therapy. Univariable logistic regression showed that surgery plus medical therapy was more likely than medical therapy alone to result in a favorable outcome. On subanalysis of operated patients, 94.1% of patients who underwent combined direct and indirect bypass reported favorable outcomes, relative to 76.2% of patients who underwent indirect bypass and 82% who underwent direct bypass (p < 0.05). On univariable analysis, the presence of multiple AI disorders was associated with worse outcomes relative to having a single AI disorder. Autoimmune diseases have been uncommonly reported in patients with MMD, but the presence of multiple AI comorbidities portends poorer prognosis. The addition of surgical intervention appears to improve outcomes and for patients deemed surgical candidates, combined direct and indirect bypass appears to offer better outcomes that direct or indirect bypass alone.

Scoping review on the state of racial disparities literature in the treatment of neurosurgical disease: a call for action.

OBJECTIVE: Racial disparities are ubiquitous across medicine in the US. This study aims to assess the evidence of racial disparities within neurosurgery and across its subspecialties, with a specific goal of quantifying the distribution of articles devoted to either identifying, understanding, or reducing disparities. METHODS: The authors searched the MEDLINE, EMBASE, and Scopus databases by using keywords to represent the concepts of neurosurgery, patients, racial disparities, and specific study types. Two independent reviewers screened the article titles and abstracts for relevance. A third reviewer resolved conflicts. Data were then extracted from the included articles and each article was categorized into one of three phases: identifying, understanding, or reducing disparities. This review was conducted in accordance with the PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines. RESULTS: Three hundred seventy-one studies published between 1985 and 2023 were included. The distribution of racial disparities literature was not equally spread among specialties, with spine representing approximately 48.3% of the literature, followed by tumor (22.1%) and general neurosurgery (12.9%). Most studies were dedicated to identifying racial disparities (83.6%). The proportion of literature devoted to understanding and reducing disparities was much lower (15.1% and 1.3%, respectively). Black patients were the most negatively impacted racial/ethnic group in the review (63.3%). The Hispanic or Latino ethnic group was the second most negatively impacted (25.1%). The following categories-other outcomes (28.0%), the offering of treatment (21.6%), complications (18.6%), and survival (16.7%)-represented the most frequently measured outcomes. CONCLUSIONS: Although strides have been taken to identify racial disparities within neurosurgery, fewer studies have focused on understanding and reducing these disparities. The tremendous rise of literature within this domain but the relative paucity of solutions necessitates the study of targeted interventions to provide equitable care for all patients undergoing neurosurgical treatment.

Stent Design Affects Femoropopliteal Artery Deformation.

BACKGROUND: Poor durability of femoropopliteal artery (FPA) stenting is multifactorial, and severe FPA deformations occurring with limb flexion are likely involved. Different stent designs result in dissimilar stent-artery interactions, but the degree of these effects in the FPA is insufficiently understood. OBJECTIVES: To determine how different stent designs affect limb flexion-induced FPA deformations. METHODS: Retrievable markers were deployed into n = 28 FPAs of lightly embalmed human cadavers. Bodies were perfused and CT images were acquired with limbs in the standing, walking, sitting, and gardening postures. Image analysis allowed measurement of baseline FPA foreshortening, bending, and twisting associated with each posture. Markers were retrieved and 7 different stents were deployed across the adductor hiatus in the same limbs. Markers were then redeployed in the stented FPAs, and limbs were reimaged. Baseline and stented FPA deformations were compared to determine the influence of each stent design. RESULTS: Proximal to the stent, Innova, Supera, and SmartFlex exacerbated foreshortening, SmartFlex exacerbated twisting, and SmartControl restricted bending of the FPA. Within the stent, all devices except Viabahn restricted foreshortening; Supera, SmartControl, and AbsolutePro restricted twisting; SmartFlex and Innova exacerbated twisting; and Supera and Viabahn restricted bending. Distal to the stents, all devices except AbsolutePro and Innova exacerbated foreshortening, and Viabahn, Supera, Zilver, and SmartControl exacerbated twisting. All stents except Supera were pinched in flexed limb postures. CONCLUSIONS: Peripheral self-expanding stents significantly affect limb flexion-induced FPA deformations, but in different ways. Although certain designs seem to accommodate some deformation modes, no device was able to match all FPA deformations.

Limb flexion-induced axial compression and bending in human femoropopliteal artery segments.

BACKGROUND: High failure rates of femoropopliteal artery (FPA) interventions are often attributed in part to severe mechanical deformations that occur with limb movement. Axial compression and bending of the FPA likely play significant roles in FPA disease development and reconstruction failure, but these deformations are poorly characterized. The goal of this study was to quantify axial compression and bending of human FPAs that are placed in positions commonly assumed during the normal course of daily activities. METHODS: Retrievable nitinol markers were deployed using a custom-made catheter system into 28 in situ FPAs of 14 human cadavers. Contrast-enhanced, thin-section computed tomography images were acquired with each limb in the standing (180 degrees), walking (110 degrees), sitting (90 degrees), and gardening (60 degrees) postures. Image segmentation and analysis allowed relative comparison of spatial locations of each intra-arterial marker to determine axial compression and bending using the arterial centerlines. RESULTS: Axial compression in the popliteal artery (PA) was greater than in the proximal superficial femoral artery (SFA) or the adductor hiatus (AH) segments in all postures (P = .02). Average compression in the SFA, AH, and PA ranged from 9% to 15%, 11% to 19%, and 13% to 25%, respectively. The FPA experienced significantly more acute bending in the AH and PA segments compared with the proximal SFA (P < .05) in all postures. In the walking, sitting, and gardening postures, average sphere radii in the SFA, AH, and PA ranged from 21 to 27 mm, 10 to 18 mm, and 8 to 19 mm, whereas bending angles ranged from 150 to 157 degrees, 136 to 147 degrees, and 137 to 148 degrees, respectively. CONCLUSIONS: The FPA experiences significant axial compression and bending during limb flexion that occur at even modest limb angles. Moreover, different segments of the FPA appear to undergo significantly different degrees of deformation. Understanding the effects of limb flexion on axial compression and bending might assist with reconstructive device selection for patients requiring peripheral arterial disease intervention and may also help guide the development of devices with improved characteristics that can better adapt to the dynamic environment of the lower extremity vasculature.

Magnetic resonance imaging-guided focused ultrasound thalamotomy for essential tremor in a patient with von Willebrand disease: perioperative optimization for patients with coagulopathies. Illustrative case.

BACKGROUND: Essential tremor (ET) is one of the most common movement disorders worldwide. In medically refractory ET, deep brain stimulation (DBS) of the ventral intermediate nucleus of the thalamus is the current standard of care. However, DBS carries an inherent 2% to 3% risk of hemorrhage, a risk that can be much higher in patients with concomitant coagulopathy. Magnetic resonance imaging-guided focused ultrasound (MRgFUS) thalamotomy is a surgical alternative that is highly effective in treating ET, with no reports of intracranial hemorrhage to date. OBSERVATIONS: This is the first documented case of successful MRgFUS thalamotomy in a patient with von Willebrand disease (VWD). A 60-year-old left-handed male had medically refractory ET, VWD type 2B, and a family history of clinically significant hemorrhage after DBS. He underwent right-sided MRgFUS thalamotomy and received a perioperative course of VONVENDI (recombinant von Willebrand factor) to ensure appropriate hemostasis. Postprocedure imaging confirmed a focal lesion in the right thalamus without evidence of hemorrhage. The patient reported 90% improvement of his left-hand tremor and significant improvement in his quality of life without obvious side effects. LESSONS: MRgFUS thalamotomy with peri- and postoperative hematological management is a promising alternative to DBS for patients with underlying coagulopathies.

Management and outcomes of pediatric traumatic brain injury in Africa: a systematic review.

OBJECTIVE: Traumatic brain injury (TBI) carries a major global burden of disease; however, it is well established that patients in low- and middle-income countries, such as those in Africa, have higher mortality rates. Pediatric TBI, specifically, is a documented cause for concern as injuries to the developing brain have been shown to lead to cognitive, psychosocial, and motor problems in adulthood. The purpose of this study was to investigate the reported demographics, causes, management, and outcomes of pediatric TBI in Africa. METHODS: A literature search was conducted using PubMed, Global Index Medicus, Embase, Scopus, Google Scholar, African Journals Online, and Web of Science. Various combinations of "traumatic brain injury," "head injury," "p(a)ediatric," "Africa," and country names were used. Relevant primary data published in the English language were included and subjected to a risk of bias analysis. Variables included age, sex, TBI severity, TBI cause, imaging findings, treatment, complications, and outcome. RESULTS: After screening, 45 articles comprising 11,635 patients were included. The mean patient age was 6.48 ± 2.13 years, and 66.3% of patients were male. Of patients with reported data, mild, moderate, and severe TBIs were reported in 57.6%, 14.5%, and 27.9% of patients, respectively. Road traffic accidents were the most reported cause of pediatric TBI (50.53%) followed by falls (25.18%). Skull fractures and intracerebral contusions were the most reported imaging findings (28.32% and 16.77%, respectively). The most reported symptoms included loss of consciousness (24.4%) and motor deficits (17.1%). Surgical management was reported in 28.66% of patients, with craniotomy being the most commonly reported procedure (15.04%). Good recovery (Glasgow Outcome Scale score 5, Glasgow Outcome Scale-Extended score 7-8) was reported in 47.17% of patients. Examination of the period post-2015 demonstrated increased spread in the literature regarding pediatric TBI in Africa. CONCLUSIONS: This study provides a comprehensive overview of the literature regarding pediatric TBI in Africa and how it has evolved alongside global neurosurgical efforts. Although there has been increased involvement from various African countries in the neurosurgical literature, there remains a relative paucity of data on this subject. Standardized reporting protocols for patient care may aid in future studies seeking to synthesize data. Finally, further studies should seek to correlate the trends seen in this study, with primary epidemiological data to gain deeper insight into the disease burden of pediatric TBI in Africa.

Disparities in the treatment of movement disorders using deep brain stimulation.

OBJECTIVE: Deep brain stimulation (DBS) is a well-established treatment for Parkinson's disease (PD) and essential tremor (ET). Although the prevalence of PD and ET can vary by sex and race, little is known about the accessibility of neurosurgical treatments for these conditions. In this nationwide study, the authors aimed to characterize trends in the use of DBS for the treatment of PD and ET and to identify disparities in the neurosurgical treatment of these diseases based on ethnic, racial, sex, insurance, income, hospital, and geographic factors. METHODS: Using the dates January 1, 2012, to December 31, 2019, the authors queried the National Inpatient Sample database for all discharges with an ICD-9 or ICD-10 diagnosis of PD or ET. Among these discharges, the DBS rates were reported for each subgroup of race, ethnicity, and sex. To develop national estimates, all analyses were weighted. RESULTS: Among 2,517,639 discharges with PD, 29,820 (1.2%) received DBS, and among 652,935 discharges with ET, 11,885 (1.8%) received DBS. Amid the PD cases, Black patients (n = 405 [0.2%], OR 0.16, 95% CI 0.12-0.20) were less likely than White patients (n = 23,975 [1.2%]) to receive DBS treatment, as were Hispanic patients (n = 1965 [1.1%], OR 0.76, 95% CI 0.65-0.88), whereas Asian/Pacific Islander patients (n = 855 [1.5%]) did not statistically differ from White patients. Amid the ET cases, Black (n = 230 [0.8%], OR 0.39, 95% CI 0.27-0.56), Hispanic (n = 215 [1.0%], OR 0.39, 95% CI 0.28-0.55), and Asian/Pacific Islander (n = 55 [1.0%], OR 0.51, 95% CI 0.28-0.93) patients were less likely than White patients (n = 10,440 [1.9%]) to receive DBS. Females were less likely than males to receive DBS for PD (OR 0.69, p < 0.0001) or ET (OR 0.70, p < 0.0001). CONCLUSIONS: The authors describe significant racial and sex-based differences in the utilization of DBS for the treatment of PD and ET. Further research is required to ascertain the causes of these disparities, as well as any differences in access to specialty neurosurgical care and referral for neuromodulation approaches.

Epidemiological Burden of Neurotrauma in Nigeria: A Systematic Review and Pooled Analysis of 45,763 Patients.

OBJECTIVE: Neurotrauma is a significant cause of morbidity and mortality in Nigeria. We conducted this systematic review to generate nationally generalizable reference data for the country. METHODS: Four research databases and gray literature sources were electronically searched. Risk of bias was assessed using the Risk of Bias in Non-Randomized Studies of Interventions and Cochrane's risk of bias tools. Descriptive analysis, narrative synthesis, and statistical analysis (via paired t-tests and χ2 independence tests) were performed on relevant article metrics (α = 0.05). RESULTS: We identified a cohort of 45,763 patients from 254 articles. The overall risk of bias was moderate to high. Most articles employed retrospective cohort study designs (37.4%) and were published during the last 2 decades (81.89%). The cohort's average age was 32.5 years (standard deviation, 20.2) with a gender split of ∼3 males per female. Almost 90% of subjects were diagnosed with traumatic brain injury, with road traffic accidents (68.6%) being the greatest cause. Altered consciousness (48.4%) was the most commonly reported clinical feature. Computed tomography (53.5%) was the most commonly used imaging modality, with skull (25.7%) and vertebral fracture (14.1%) being the most common radiological findings for traumatic brain injury and traumatic spinal injury, respectively. Two-thirds of patients were treated nonoperatively. Outcomes were favorable in 63.7% of traumatic brain injury patients, but in only 20.9% of traumatic spinal injury patients. Pressure sores, infection, and motor deficits were the most commonly reported complications in the latter. CONCLUSIONS: This systematic review and pooled analysis demonstrate the significant burden of neurotrauma across Nigeria.

The Epidemiology of Spinal Neurosurgery in Nigeria: A Systematic Review and Patient-Level Analysis.

OBJECTIVE: Spinal pathologies are prevalent in Nigeria, though epidemiological data remains sparse. This systematic review used pooled patient-level data from across the country to generate a standardized epidemiological reference. METHODS: Four research databases and gray literature sources were searched. Risk of bias assessment was conducted using Risk of Bias in Non-Randomised Studies - of Interventions and Cochrane's risk of bias tool. We descriptively analyzed all article metrics and statistically analyzed relevant data variables via paired t-test and χ2 independence tests (α = 0.05). RESULTS: One hundred twenty-seven articles, comprising a patient cohort of 8425 patients, were analyzed. Most were retrospective cohort studies (46.5%) and case reports/series (31.5%), with an overall moderate-high risk of bias. Most studies were published in the last 20 years. Most patients were male (∼2.5 males per female), with an average age of 43.2 years (±16.4). Clinical diagnoses spanned the breadth of spinal neurosurgery. Approximately 45.0% of patients had complete spinal impairment. Pain (41.7%) was the most reported presenting feature. X-ray (45.1%) was the most common investigation used. Intervertebral disc herniation (18.9%) was the most prevalent imaging finding on MRI. Most patients were managed nonoperatively (57.8%), with a favorable outcome in 27.4% of patients. Posttreatment complications included pressure sores, infection, and motor deficits. CONCLUSIONS: This systematic review and pooled analysis provide an epidemiological overview of spinal neurosurgery in Nigeria over the last 60 years and serves as a useful reference to direct future global research in this arena.

The Epidemiological Burden of Neurovascular Pathology in Nigeria: A Systematic Review and Pooled Patient-Level Analysis.

OBJECTIVE: Vascular neurosurgery has developed significantly in Nigeria, but its burden and challenges remain unclear. This study systematically reviewed vascular neurosurgical literature from Nigeria. METHODS: Four research databases and gray literature sources were searched from 1962-2021. ROBINS-I tool was used to assess risk of bias. Descriptive, narrative, and statistical analyses were conducted on all variables. Where appropriate, paired t-tests and Chi-squared independence tests were used (α = 0.05). RESULTS: 56 articles were included and 3203 patients pooled for analysis. Risk of bias was moderate-high. Most articles were published over the last 20 years with retrospective cohort studies and case reports being the most common study designs. The cohort had a relatively even gender split and an average age of 49 years (±22). Cerebrovascular accidents accounted for over 85% of diagnoses, with most etiologies being traumatic. Headache and motor deficit were the most prevalent clinical features. X-ray and carotid angiography were the most commonly reported imaging modalities, closely followed by computed tomography (CT) and CT angiography. The top two radiological diagnoses were ischemic cerebrovascular disease and intracerebral hematoma. Aneurysmal clipping and hematoma evacuation were the most commonly reported treatment modalities. Outcome at last follow-up was favorable in 48%. The mortality rate was 6%. Post-treatment complications included chest infection and rebleeding. CONCLUSIONS: This study illustrates the epidemiological burden of neurovascular pathology (based on the available data in published literature) in Nigeria, and raises awareness amongst service providers and researchers of the attendant challenges and epochal trends seen within vascular neurosurgery in Nigeria.

Epidemiology and Management Trends of Neuro-Oncology in Nigeria: A Systematic Review and Pooled Analysis.

OBJECTIVE: Access to neuro-oncologic care in Nigeria has grown exponentially since the first reported cases in the mid-1960s. In this systematic review and pooled analysis, we characterize the growth of neurosurgical oncology in Nigeria and build a reference paper to direct efforts to expand this field. METHODS: We performed an initial literature search of several article databases and gray literature sources. We included and subsequently screened articles published between 1962 and 2021. Several variables were extracted from each study, including the affiliated hospital, the number of patients treated, patient sex, tumor pathology, the types of imaging modalities used for diagnosis, and the interventions used for each individual. Change in these variables was assessed using Chi-squared independence tests and univariate linear regression when appropriate. RESULTS: A total of 147 studies were identified, corresponding to 5,760 patients. Over 4000 cases were reported in the past 2 decades from 21 different Nigerian institutions. The types of tumors reported have increased over time, with increasingly more patients being evaluated via computed tomography (CT) and magnetic resonance imaging (MRI). There is also a prevalent use of radiotherapy, though chemotherapy remains an underreported treatment modality. CONCLUSIONS: This study highlights key trends regarding the prevalence and management of neuro-oncologic pathologies within Nigeria. Further studies are needed to continue to learn and guide the future growth of this field in Nigeria.

Fulfilling the specialist neurosurgical workforce needs in Africa: a systematic review and projection toward 2030.

OBJECTIVE: Africa contributes significantly to the global neurosurgical disease burden but has only 1% of the neurosurgery workforce. This study appraises the neurosurgical workforce and training capacity in Africa and projects the workforce capacity by 2030. METHODS: The authors conducted a systematic review of the online literature on neurosurgical workforce and training in Africa obtained from three journal databases (PubMed, Embase, and African Index Medicus), as well as from a gray literature search, between September and December 2020. Included literature passed a two-level screening conducted using a systematic review software by a team of two independent reviewers. Data were extracted from selected articles and documented and analyzed on spreadsheets. RESULTS: One hundred and fifty-nine eligible articles were analyzed: 1974 neurosurgeons serve 1.3 billion people in Africa (density 0.15 per 100,000 persons, ratio 1:678,740), with uneven distribution between the regions. North Africa has 64.39% of the neurosurgical workforce (n = 1271), followed by Southern Africa (12.66%, n = 250), West Africa (11.60%, n = 229), East Africa (8.26%, n = 163), and Central Africa (3.09%, n = 61). At an exponential growth rate of 7.03% (95% CI 5.83%-8.23%) per annum, Africa will have 3418 (95% CI 1811-6080) neurosurgeons by 2030, with a deficit of 5191 neurosurgeons, based on population workforce targets. In terms of training, there are 106 neurosurgery training institutions in 26 African countries. North Africa has 52 training centers (49.05%), West Africa 23 (21.70%), East Africa 15 (14.15%), Southern Africa 14 (13.21%), and Central Africa 2 (1.89%). The major regional training programs are those of the West African College of Surgeons (24 sites in 7 countries) and the College of Surgeons of East, Central, and Southern Africa (17 sites in 8 countries). CONCLUSIONS: The study is limited as it is based on the online literature, some of which includes modeled estimates with questionable reliability. However, the results indicate that while countries in North Africa are expected to surpass their population workforce requirements, sub-Saharan African countries are likely to have significant workforce deficits accentuated by the paucity of neurosurgery training programs. To meet the 2030 population workforce requirements, the continent's exponential growth rate should be scaled up to 15.87% per annum. Scaling up neurosurgical training would help to meet this target and requires collaborative efforts from continental, regional, and national agencies and international organizations.

Promoting diversity in neurosurgery through a virtual symposium.

OBJECTIVE: The rates of women and underrepresented racial and ethnic minority (UREM) students successfully matching into neurosurgical residency are extremely low and do not reflect the makeup of the general population. As of 2019, only 17.5% of neurosurgical residents in the United States were women, 4.95% were Black or African American, and 7.2% were Hispanic or Latinx. Earlier recruitment of UREM students will help to diversify the neurosurgical workforce. Therefore, the authors developed a virtual educational event for undergraduate students entitled "Future Leaders in Neurosurgery Symposium for Underrepresented Students'' (FLNSUS). The primary objectives of the FLNSUS were to expose attendees to 1) neurosurgeons from diverse gender, racial, and ethnic backgrounds; 2) neurosurgical research; 3) opportunities for neurosurgical mentorship; and 4) information about life as a neurosurgeon. The authors hypothesized that the FLNSUS would increase student self-confidence, provide exposure to the specialty, and reduce perceived barriers to a neurosurgical career. METHODS: To measure the change in participant perceptions of neurosurgery, pre- and postsymposium surveys were administered to attendees. Of the 269 participants who completed the presymposium survey, 250 participated in the virtual event and 124 completed the postsymposium survey. Paired pre- and postsurvey responses were used for analysis, yielding a response rate of 46%. To assess the impact of participant perceptions of neurosurgery as a field, pre- and postsurvey responses to questions were compared. The change in response was analyzed, and a nonparametric sign test was performed to check for significant differences. RESULTS: According to the sign test, applicants showed increased familiarity with the field (p < 0.001), increased confidence in their abilities to become neurosurgeons (p = 0.014), and increased exposure to neurosurgeons from diverse gender, racial, and ethnic backgrounds (p < 0.001 for all categories). CONCLUSIONS: These results reflect a significant improvement in student perceptions of neurosurgery and suggest that symposiums like the FLNSUS may promote further diversification of the field. The authors anticipate that events promoting diversity in neurosurgery will lead to a more equitable workforce that will ultimately translate to enhanced research productivity, cultural humility, and patient-centered care in neurosurgery.

The scope, trends, and challenges of neurosurgical research in Nigeria: A bibliometric review.

OBJECTIVE: This study investigates the scope, trends, and challenges of neurosurgical research in Nigeria since inception of the specialty in 1962. METHODS: A bibliometric review of the neurosurgical literature from Nigeria was done. Variables extracted included year and journal of publication, article topic, article type, research type, study design, article focus area, and limitations. Descriptive and quantitative analyses were performed for all variables. Trends of research publications were described in three periods - pioneering (1962-1981), recession (1982-2001), and resurgent (2002-2021). RESULTS: Of the 1023 included articles, 10.0% were published in the pioneering period, 9.2% in the recession period, and 80.8% in the resurgent period. Papers were predominantly published in World Neurosurgery (4.5%) and Nigerian Journal of Clinical Practice ( 4.0%). 79.9% of the 4618 authors were from Nigerian institutions. 86.3% of the articles covered clinical research and were mainly focused on service delivery and epidemiology (89.9%). The most prominent topics were traumatic brain injury (25.8%) and CNS malignancy (21.4%). Only 4.4% of the publications received funding, mostly from agencies in the US (31.7%). Barriers to neurosurgical research included lack of clinical databases (18.0%), increasing burden of disease (12.5%), and diagnostic challenges (12.4%). CONCLUSION: Neurosurgical research in Nigeria continues to grow due to increased training, workforce, and infrastructural improvements. Addressing the major challenges through establishment of research databases, development of evidence-based management guidelines, and increasing research training, funding and opportunities can increase research capacity in Nigeria.

Profile of pediatric neurosurgery in Nigeria from 1962 to 2021: A systematic review.

OBJECTIVE: This study aims to provide a comprehensive overview of pediatric neurosurgery in Nigeria, since 1962, by assessing epidemiological data, management strategies, and case outcomes. METHODS: A systematic bibliometric review of Nigerian neurosurgical literature was reported with the PRISMA guidelines. The Risk of Bias Assessment Tool was applied to all non-randomized studies, and a descriptive analysis was performed for all variables. RESULTS: We identified 12,295 pediatric patients from 196 published studies. Most publications (72.4%) occurred in the recent two decades, of which 40.3% were observational case reports/series. The patients were predominantly male (57.2%) and aged 0-18 years, with the majority (66.1%) belonging to the 0-5 age range. Most patients (63.4%) presented between 1-12 months. The most common presenting feature was altered consciousness (7.7%), with computed tomography (38.8%) being the most frequently utilized diagnostic imaging modality. The diagnoses with the greatest prevalence (60.2%) were congenital abnormalities such as hydrocephalus and neural tube defects. 57.5% of cases received surgical therapy, with ventriculoperitoneal shunt placement being the most noticeable procedure performed (36.4%). Complications were identified in 9.5% of cases, with a 4.5% death rate. The Glasgow Outcome Score (95.7%) was the primary outcome measure utilized, with positive outcomes reported in 59.3% of cases. CONCLUSION: This review provides significant epidemiological data which emphasizes the country's enormous burden of pediatric neurosurgical cases. The findings can help guide clinical decisions as well as future research and policy development.

The role of international collaborations in sustainable neurosurgical development in Nigeria.

OBJECTIVE: Despite six decades of existence, neurosurgery is still in the developing stages in Nigeria. In this era of collaborative health system capacity-building in low- and middle-income countries, this article reviews past efforts and future prospects for collaborative neurosurgical development in Nigeria. METHODS: A bibliometric review of the Nigerian neurosurgical literature and data from a structured survey of Nigerian neurosurgeons and residents provided details of current local and international collaborations for neurosurgical research, service delivery, training, and capacity building. These were analyzed to provide an overview of the role of collaborations in sustainable neurosurgical development in Nigeria and to recommend approaches to enhance neurosurgical capacity. RESULTS: In 1023 peer-reviewed neurosurgery publications from Nigeria, there were 4618 authors with 3688 from 98 Nigerian institutions and 930 from 296 foreign institutions in 70 countries. While there were significant research collaborations amongst Nigerian institutions, the most common were with institutions in the US, UK, and Cameroon. From the survey, 62 of 149 respondents (41.6%) from 32 health facilities noted their institution's involvement in capacity-building neurosurgical collaborations. These collaborations involved 22 Nigerian institutions and 13 foreign institutions in 9 countries and were mostly for training and workforce development (78.1%), and research and data management (59.4%). The majority of foreign institutions were from the US and UK. CONCLUSION: Current and previous neurosurgical collaborations have led to sustainable progress in Nigeria. Further local, regional, and international collaborations would enhance the capacity to address the needs and challenges affecting neurosurgery in Nigeria.

Evolution of Intracranial-Intracranial Bypass Surgery: A Bibliometric Analysis.

OBJECTIVE: Modern cerebrovascular bypass surgery uses either extracranial-intracranial (EC-IC) or intracranial-intracranial (IC-IC) approaches. Compared with EC-IC bypasses, IC-IC bypasses allow neurosurgeons to safely address tumors, aneurysms, and other lesions using shorter grafts that are well matched to the size of recipient vessels. Fewer than 100 articles have been published on IC-IC bypasses compared with more than 1000 on EC-IC bypasses. This study examined the increase of interest and innovation in IC-IC bypass. METHODS: PubMed and Web of Science were searched using keywords specific to IC-IC bypass, yielding 717 articles supplemented with 36 reports from other databases and gray literature. The articles were reviewed, and 98 articles were selected for further evaluation. Final articles were categorized as innovations or retrospective studies. Publication metrics were passed through an analytic program to assess statistical measures of growth. RESULTS: The number of publications describing innovations (n = 52) and retrospective studies (n = 46) in IC-IC surgical techniques increased exponentially (R2 = 0.983 and R2 = 0.993, respectively), with both interest and research in the field increasing. The rate of publications in each group also increased. In recent years, increasing numbers of global institutions have researched and published on IC-IC bypasses. CONCLUSIONS: As more work is undertaken on IC-IC bypasses, it is critical for knowledge to be shared through research, collaboration, publication, and early teaching within residency training programs. This field has increased exponentially in the past 2 decades and has yet to reach an inflection point, indicating possible additional interest and growth over time.

Deep Learning to Predict Traumatic Brain Injury Outcomes in the Low-Resource Setting.

OBJECTIVE: Traumatic brain injury (TBI) disproportionately affects low- and middle-income countries (LMICs). In these settings, accurate patient prognostication is both difficult and essential for high-quality patient care. With the ultimate goal of enhancing TBI triage in LMICs, we aim to develop the first deep learning model to predict outcomes after TBI and compare its performance with that of less complex algorithms. METHODS: TBI patients' data were prospectively collected in Kampala, Uganda, from 2016 to 2020. To predict good versus poor outcome at hospital discharge, we created deep neural network, shallow neural network, and elastic-net regularized logistic regression models. Predictors included 13 easily acquirable clinical variables. We assessed model performance with 5-fold cross-validation to calculate areas under both the receiver operating characteristic curve and precision-recall curve (AUPRC), in addition to standardized partial AUPRC to focus on comparisons at clinically relevant operating points. RESULTS: We included 2164 patients for model training, of which 12% had poor outcomes. The deep neural network performed best as measured by the area under the receiver operating characteristic curve (0.941) and standardized partial AUPRC in region maximizing recall (0.291), whereas the shallow neural network was best by the area under the precision-recall curve (0.770). In several other comparisons, the elastic-net regularized logistic regression was noninferior to the neural networks. CONCLUSIONS: We present the first use of deep learning for TBI prognostication, with an emphasis on LMICs, where there is great need for decision support to allocate limited resources. Optimal algorithm selection depends on the specific clinical setting; deep learning is not a panacea, though it may have a role in these efforts.