Excelencia en Neurocirugía: María Cristina García-Sancho, the First Latina Neurosurgeon in the World.

BACKGROUND: Neurosurgery is a specialty that has been dominated by males. Although there has been an increase in the number of women in the field, it is not yet close to being equal. Some noteworthy women who have carved the path for other women to follow in their footsteps include Drs. Sofía Ionescu and Diana Beck, the first and second female neurosurgeons worldwide, respectively. However, there are limited publications on Dr. María Cristina García-Sancho, the first Latina neurosurgeon. METHODS: The purpose of this review was to illuminate the neurosurgical community on the life of Dr. García-Sancho. A thorough literature was performed on medical and non-medical publications that were either authored by Dr. García-Sancho or mentioned her directly. RESULTS: Dr. García-Sancho earned her medical degree at the School of Medicine of the National Autonomous University of Mexico under the guidance of Dr. Clemente Robles, who founded Mexico's first neurosurgical department. Her training took her worldwide. CONCLUSIONS: Her expertise allowed her to pioneer a revolutionary advancement known as the one-step bilateral cordotomy. Her perseverance led her to becoming the head of the Department of Neurosurgery at the National Cancer Institute of Mexico and co-found the Mexican Society of Neurological Surgery, where she served on the board of directors. This review aims to advocate for an equitable environment in the field of neurosurgery with Dr. García-Sancho's story.

A Decade of Global Skull Base Researchers: Gender Data from over 2,700 Abstract Authors in the Journal of Neurological Surgery Part B: Skull Base.

Objective The North American Skull Base Society (NASBS) annual conference brings together skull base researchers from surgical and nonsurgical fields. Our objective was to quantify the contributions of the authors by gender, who presented their work at NASBS and were subsequently published in the Journal of Neurological Surgery Part B: Skull Base . Methods Oral and poster abstracts presented at the NASBS annual meeting from January 1, 2011 to December 31, 2020 were extracted from the Journal of Neurological Surgery Part B: Skull Base. The genderize.io Web application programming interface was utilized to determine authorship gender. A minority of first and last authors had departmental affiliations listed; a subgroup analysis was performed of these authors. Results Female gender was assigned to 498 (17.8%) of the 2,798 first authors and 269 (9.7%) of the 2,762 last authors. Female authorship has consistently increased over the last decade. Representation was higher in otolaryngology (23.3% of first authors, 12.1% of last authors; p = 0.018) than neurosurgery (13.5% of first authors, 4.3% of last authors; p = 0.004). Female researchers were not less likely than their male counterparts to receive prestigious oral presentations. Of the 52 total countries represented, 20 (38.5%) had at least one female first author. Representation varied dramatically between countries. Conclusion The NASBS' efforts have undoubtedly contributed to these impressive strides toward gender parity. More work is needed to ensure that the best and the brightest, regardless of background, continue to contribute to skull base surgery research.

A Decade of Global Skull Base Researchers: Authorship Trends from 3,295 Abstracts in the Journal of Neurological Surgery Part B: Skull Base.

Objective The North American Skull Base Society (NASBS) multidisciplinary annual conference hosts skull base researchers from across the globe. We hypothesized that the work presented at the NASBS annual conference would reveal diverse authorship teams in terms of specialty and geography. Methods In this retrospective review, abstracts presented at the NASBS annual meeting and subsequently published in the Journal of Neurological Surgery Part B: Skull Base between 01/01/2011 and 12/31/2020 were collected. Variables extracted included year, type of presentation, and author names and affiliations. Statistical analyses were performed with SPSS V23.0 with p -values less than 0.05 considered significant. Geographic heat maps were created to assess author distribution, and a network analysis was performed to display authorship collaboration between geographic regions. Results Of 3,312 published abstracts, 731 (22.1%) had an author with an affiliation outside of the United States. Fifty-seven distinct countries were represented. Three-hundred twenty-four abstracts (9.8%) had authorship teams representing at least 2 different countries. The top five US states by abstract representation were Pennsylvania, California, New York, Ohio, and Minnesota. A majority of authors reported neurosurgery affiliations (56.7% first authors, 53.2% last authors), closely followed by otolaryngology (39.1% first authors, 41.5% last authors). No solo authors and very few (3.3%) of the first authors reported a departmental affiliation outside of otolaryngology or neurosurgery. Conclusions Authors from many countries disseminate their work through poster and oral presentations at the NASBS annual meeting. Ten percent of abstracts were the product of international collaboration. Most authors were affiliated with a neurosurgery or otolaryngology department.

Outcomes following surgical intervention for acute hemorrhage in severe traumatic brain injury: a review of the National Trauma Data Bank.

OBJECTIVE: Severe traumatic brain injury (TBI) is a public health issue posing significant morbidity and mortality to afflicted patients. While the effect of time to surgery as the primary factor for survival has been extensively studied, long-term dispositional outcomes following intracranial hemorrhage evacuation have not been well described in the literature. Therefore, the aim of this study was to elicit potential prognostic factors in patients presenting with severe TBI that may have a significant impact on discharge disposition. METHODS: The authors searched the National Trauma Data Bank (NTDB) for patients included between 2010 and 2019, solely focusing on those with a Glasgow Coma Scale score ≤ 8, signifying severe TBI, and with associated intracranial hemorrhage treated via surgical intervention. Numerous characteristics were analyzed, including demographics (age, sex, race, ethnicity, payment status), discharge disposition, time to surgery, pupillary response, midline shift (> 5 mm), and postoperative inpatient complications and comorbidities. Disposition included routine discharge to home, discharge to home with home health services (HHSs), discharge to acute inpatient rehabilitation (AIR), discharge to a skilled nursing facility (SNF)/long-term acute care hospital (LTACH), and death. RESULTS: The authors analyzed data on 7308 patients, 69.6% of whom were White and 11.2% of whom were Black. More young Black and Hispanic patients had severe TBI events than their matched elders, whereas more elderly White patients had severe TBI events than their matched younger counterparts. The most common disposition across all ages was SNF/LTACH. Septuagenarians and octogenarians were 12.1 and 21 times more likely, respectively, to die following a severe TBI than their younger counterparts (p < 0.001). Patients aged 18-29 were 1.7 times more likely to be discharged with HHSs (p < 0.001). Minority race/ethnicity groups were less likely to be discharged to AIR. As age increased, a patient's intensive care unit stay increased by 15 days (p < 0.001) and total hospital length of stay increased by 25 days (p < 0.001). CONCLUSIONS: Neurosurgical evacuation of intracranial hemorrhage in severe TBI has variable long-term morbidity. Utilizing the largest collection of trauma data within the United States, the authors present quantitative evidence on discharge disposition. Understanding these tangible points can help neurosurgeons present potential outcomes to patients, promote preventative care, and generate tangible conversations with patients and their family members.

Fluorescein-guided resection for pediatric low-grade gliomas: institutional experience on two cases and a narrative literature review.

PURPOSE: Low-grade gliomas compose 30% of pediatric central nervous system tumors and outcomes of disease-free progression, and survival is directly correlated to the extent of resection. The use of sodium fluorescein (Na-Fl) is an intraoperative method in the localization of tumor cells in adult patients to optimize resection. Our purpose is to describe the use of Na-Fl in pediatric low-grade gliomas and its outcomes. METHODS: Patients under 18 years of age with low-grade gliomas at the author's institution underwent resection with the use of Na-Fl, with review of preoperative imaging findings, intraoperative results, and follow-up. Then, a comprehensive, narrative literature review of the use of Na-Fl in pediatric low-grade glioma was performed. RESULTS: Our single-institution use of Na-Fl in pediatric patients with suspected low-grade glioma demonstrated excellent results of intraoperative enhancement of tumor cells as well as gross total resection. The literature demonstrated 84% Na-Fl staining and 59.2% of gross total resection in pediatric low-grade gliomas with few small case studies, a range of reported findings, and few side effects. CONCLUSION: Na-Fl has a promising use in low-grade glioma resection in the pediatric patient population. Further research is warranted, such as randomized controlled studies, to assess Na-Fl as a potential tool in improving resection and long-term favorable outcomes.

Gender Representation at Conferences, Executive Boards, and Program Committees in Otolaryngology.

OBJECTIVE: Women represent approximately 28.0% of academic otolaryngologists. Previous studies have shown that women in academic medicine, including surgical subspecialties, have disparate career advancement opportunities and grant funding compared to male counterparts. Representation at major academic meetings is an important career advancement opportunity. In this study, we assess the representation of women at otolaryngology conferences. STUDY DESIGN: Cross-sectional analysis of otolaryngology conference programs. METHODS: All publicly available scientific programs from The American Academy of Otolaryngology-Head and Neck Surgery Foundation Annual Meeting (AAO-HNSF), the Triological Society Annual Combined Sections Meeting (TS), and the Triological Society Annual Meeting at Combined Otolaryngology Spring Meetings (TS-COSM) were obtained and analyzed. Name and gender were collected, along with the type of role: speaker, panelist, oral session moderator, and other leadership positions. Yearly trends were analyzed and compared between the conferences and in aggregate. RESULTS: AAO-HNSF had available scientific programs from 2012-2017, while TS and TS-COSM had programs available from 2003-2018. Across all conferences and years, 16.9% of recorded opportunities were occupied by women, with an upward trend from 2005 to 2018. Program committees had the highest proportion of women (21.4%) and presidential citation and guest of honor recipients had the lowest (9.1%). Of all panels, 87.5% did not have any women panelists in 2003, but by 2018 only 24.0% panels were male-only. There was marked repetition among women occupying roles, with only 423 unique women occupying a total of 1,733 filled spots. CONCLUSION: Measured representation of women in academic otolaryngology conferences has improved from 2003-2018. Despite this improvement, gender disparity still exists. LEVEL OF EVIDENCE: 5 Laryngoscope, 131:E373-E379, 2021.

Gender differences in NIH grant funding in neurological surgery.

Research productivity is a vital component to an academic neurosurgeon's career. We sought to evaluate gender differences in NIH funding among faculty in neurological surgery departments. NIH funding awarded to PIs of neurological surgery departments from 2014 to 2019 were obtained and analyzed for gender differences in funding trends, with attention to terminal degree and academic rank, as well as publication range in length of years and h-index. 79.4% of all NIH grants were awarded to male PIs, with the remaining 20.5% given to their female counterparts. Mean of the total NIH grants awarded to men was significantly higher at $1,796,684 (± Standard Error of Mean (SEM) $155,849, IQR: $1,759,250) compared to women at $1,151,968 (± SEM $137,914, IQR: $1,388,538) (P = 0.022). Mean NIH funding per grant for men was $365,760 (± SEM: $39,592, IQR: $189,692) and for women was $292,912 (± SEM: 28,239, IQR: $283,177). Differences in mean NIH funding per grant approached but did not reach statistical significance between men and women (P = 0.122). When stratified for academic rank, there was a significant difference in mean NIH funding per grant between men and women on the associate professor level (p < 0.005), with women exceeding men in funding at this academic level, with other academic ranks remaining non-significant. Overall, male neurosurgeons receive significantly more total NIH grant funding than their female counterparts, except at the level of associate professor where women were found to surpass men.

Obstruction of Ventriculoperitoneal Shunt After Myelography-Report of a Unique Case and Its Treatment.

BACKGROUND: Myelography, frequently supplanted by noninvasive, efficient magnetic resonance imaging, remains a useful technique when evaluating the spinal canal in nerve root avulsion, radiation therapy treatment planning, cerebrospinal fluid (CSF) loculation, and CSF leak. Myelography is achieved through a lumbar puncture and instillation of nonionic, water-soluble intrathecal iohexol (Omnipaque, GE Healthcare, Marlborough, Massachusetts, USA) contrast. The aim of the study was to highlight a possible complication of obstruction of a shunt valve due to an increased viscosity of the CSF after intrathecal Omnipaque contrast administration during myelography. CASE DESCRIPTION: The authors report a case of myelography that resulted in obstruction of a ventriculoperitoneal (VP) shunt. A 23-year-old female with significant medical history of neurofibromatosis type I, obstructive hydrocephalus, anterior cervical diskectomy and fusion, and VP shunt placement underwent diagnostic computed tomography after myelography with Omnipaque contrast to assess possible CSF loculation and cord impingement from her cervical instrumentation. The patient experienced somnolence after myelography from obstruction of the VP shunt, with marked ventriculomegaly demonstrated by computed tomography of the head. A shunt tap and shunt pumping regimen resulted in resolution of the obstruction and hydrocephalus, with return to neurologic baseline. CONCLUSIONS: This is a recent case of VP shunt obstruction after myelography, of which previous cases reported are decades old. A shunt pumping regimen may be a nonoperative, effective mean for similar mechanical obstructions of VP shunts for restoration of flow and patency of the shunt system in these patients. We encourage physicians to consider the possibility of shunt obstruction after diagnostic myelography. Caution and close observation should be considered in patients undergoing myelography with a programmable VP shunt.

Neurosurgery in the Brazilian Amazon: Is It Possible?

BACKGROUND: The need for neurosurgical care across the globe remains a public health issue. The creation of sustainable neurological surgery departments and training programs will be indispensable in alleviating the burden of neurological disease in low to middle income countries (LMICs). METHODS: We reviewed the history of the neurological surgery department and residency program of Santarém in the state of Pará, Brazil, from 1999 to the present. We have described the epidemiology unique to the region and provided evidence of a sustainable practice in a LMIC. The challenges, limitations, and resources were explored. RESULTS: We have provided a historical vignette of the evolution of neurological surgery in the Brazilian Amazon, including the creation of a sustainable neurological surgery practice and accredited residency program. In addition, we assessed the neurological surgery burden and epidemiology unique to the region, with an emphasis on the community and indigenous health in this remote area. We also explored the future directions of this example, which could affect the international neurological surgery community. CONCLUSION: A sustainable neurosurgery practice and training program is possible in a LMIC. Training neurosurgeons in developing regions of LMICs is a sustainable method to decrease the morbidity and mortality of neurological diseases and prevent the misdistribution of physicians in a country. We encourage adaptation of sustainable neurological surgery practices in similar regions across the world to increase access to necessary neurosurgical care.

Female Medical Student Retention in Neurosurgery: A Multifaceted Approach.

BACKGROUND: Since 2011, more women than men have graduated from medical school, yet there remains a paucity of female physicians in surgical specialties. After the 2018 Neurosurgery Match, only 17.5% of neurosurgery residents are women. Previous literature documented gender inequality, poor medical school exposure, and lack of female mentorship as reasons for this disparity. We sought to further explore factors that deter female medical students from pursuing neurosurgery. METHODS: A comprehensive survey was created and distributed to the 2017-2018 Rutgers New Jersey Medical School student body, requesting anonymous input from female medical students. RESULTS: Of 104 female respondents, 26.9% had considered neurosurgery as a career and felt dissuaded because of their gender. Of respondents, 88% did not have a senior female medical student pursuing neurosurgery or a female neurosurgical resident as a mentor. More than half of respondents disagreed that they would be dissuaded from a field if they did not have a female mentor. The 88.46% of women who felt that there was a glass ceiling in medicine were also more likely to feel that they would face inequality and adversity that would inhibit training in a male-dominated field. Women who described themselves as seeking challenging and competitive careers strongly felt that they would benefit from exposure to surgical subspecialties during their preclinical years. CONCLUSIONS: Female medical students remain resilient, ambitious, interested in competitive specialties, and eager to explore surgical subspecialties during preclinical years. A multifaceted approach is imperative to recruit and retain qualified women interested in neurosurgery.

Impact of venous thromboembolism during admission for meningioma surgery on hospital charges and postoperative complications.

Surgical resection of meningiomas has been associated with high rates of venous thromboembolic events (VTE) as compared with all other intracranial tumors. There is a paucity of data regarding the clinical complications and comorbidities associated with this cohort yet the underlying pathophysiological mechanism for this tumor-specific finding remains unclear. Our goal was to determine the various impacts of VTE on meningioma surgery in a large cohort of inpatient admissions. This retrospective analysis utilized discharge data from the National Inpatient Sample (NIS) from 2002 to 2010. Patient demographics, comorbidities, length of stay, hospital charges, and postoperative complications were compared between patients with and without VTE. Of 20,259 patients, 426 (2.1%) experienced a VTE. Compared to the non-VTE cohort, patients that experienced a VTE were older (62.7 ±â€¯13.7 vs. 57.2 ±â€¯14.7; p < 0.001), were more commonly male (38.0% vs 30.1%; p = 0.001), had longer hospitalizations (18.8 vs 6.6 days; p < 0.001), and incurred significantly greater hospital charges ($195,837 vs $74,434; p < 0.001). VTE patients experienced significantly higher rates of acute postoperative complications including shock, hemorrhage, wound dehiscence, infection, intracerebral hemorrhage, hemiparesis/hemiplegia, stroke, and death during admission. Odds ratio of aforementioned postsurgical complications remained significantly higher both before and after adjusting for age and sex (all p < 0.01). Occurrence of VTE in patients undergoing meningioma resection portends greater hospital charges, most likely attributed to longer lengths of admission. Increased postoperative complications and mortality in the VTE group warrants further investigation and wariness of the surgeon when treating surgical candidates of meningioma.

Return to the Emergency Room with or without Readmission After Endoscopic Transsphenoidal Surgery in Socioeconomically Disadvantaged Patients at an Urban Medical Center.

BACKGROUND: Although reducing 30-day hospital readmissions is now a priority in neurosurgical quality improvement, postoperative emergency room (ER) visits have remained poorly understood, in particular, in populations with limited access to outpatient care. After endoscopic transsphenoidal surgery, the unique pathologic entities treated can engender a variety of surgical and metabolic complications-often dangerous, delayed, and nonspecific in presentation. We sought to characterize the causes and timing of ER visits-with or without readmission-in a socioeconomically disadvantaged population. METHODS: We reviewed all the patients undergoing ETS by our skull base team from 2009 to 2017 to determine their socioeconomic profile and causes of ER visits. For external validation, we compared our results with national data from the American College of Surgeons National Surgical Quality Improvement Program. RESULTS: Of the 229 patients, 35 (15.3%) had visited the ER within 30 days of discharge. Of these 229 patients, 21 (9.2%) were readmitted, and 109 (47.6%) were insured by Medicaid. The most common reasons for the ER visits were headache (8 of 35 [22.9%]), hyponatremia (7 of 35 [20.0%]), and epistaxis (5 of 35 [14.3%]). The most common cause for readmission was symptomatic hyponatremia (6 of 21 [28.6%]). The other reasons for readmission included meningitis (2 of 21 [9.5%]), adrenal crisis (2 of 21 [9.5%]), and cerebrospinal fluid leakage (1 of 21 [4.8%]). The average time to readmission was 10.9 days. According to the National Surgical Quality Improvement Program database, the 30-day readmission rate was 5.5%, of which 22.2% were for hyponatremia. CONCLUSION: Delayed hyponatremia accounts for a large proportion of ER visits and unplanned readmissions. Close follow-up with diligent, multidisciplinary care might reduce the number of ER visits and readmission in this population.

Transbasal versus endoscopic endonasal versus combined approaches for olfactory groove meningiomas: importance of approach selection.

OBJECTIVE There has been much debate regarding the optimal surgical approach for resecting olfactory groove meningiomas (OGMs). In this paper, the authors analyzed the factors involved in approach selection and reviewed the surgical outcomes in a series of OGMs. METHODS A retrospective review of 28 consecutive OGMs from a prospective database was conducted. Each tumor was treated via one of 3 approaches: transbasal approach (n = 15), pure endoscopic endonasal approach (EEA; n = 5), and combined (endoscope-assisted) transbasal-EEA (n = 8). RESULTS The mean tumor volume was greatest in the transbasal (92.02 cm3) and combined (101.15 cm3) groups. Both groups had significant lateral dural extension over the orbits (transbasal 73.3%, p < 0.001; combined 100%), while the transbasal group had the most cerebral edema (73.3%, p < 0.001) and vascular involvement (66.7%, p < 0.001), and the least presence of a cortical cuff (33.3%, p = 0.019). All tumors in the combined group were recurrent tumors that invaded into the sinonasal cavity. The purely EEA group had the smallest mean tumor volume (33.33 cm3), all with a cortical cuff and no lateral dural extension. Gross-total resection was achieved in 80% of transbasal, 100% of EEA, and 62.5% of combined cases. Near-total resection (> 95%) was achieved in 20% of transbasal and 37.5% of combined cases, all due to tumor adherence to the critical neurovascular structures. The rate of CSF leakage was 0% in the transbasal and combined groups, and there was 1 leak in the EEA group (20%), resulting in an overall CSF leakage rate of 3.6%. Olfaction was preserved in 66.7% in the transbasal group. There was no significant difference in length of stay or 30-day readmission rate between the 3 groups. The mean modified Rankin Scale score was 0.79 after the transbasal approach, 2.0 after EEA, and 2.4 after the combined approach (p = 0.0604). The mean follow-up was 14.5 months (range 1-76 months). CONCLUSIONS The transbasal approach provided the best clinical outcomes with the lowest rate of complications for large tumors (> 40 mm) and for smaller tumors (< 40 mm) with intact olfaction. The role of EEA appears to be limited to smaller, appropriately selected tumors in which olfaction is already absent. EEA also plays an important adjunctive role when combined with the transbasal approach for recurrent OGMs invading the sinonasal cavity. Careful patient selection using an individualized, tailored strategy is important to optimize surgical outcomes.