Neuro-oncology access in Sub-Saharan Africa: A literature review of challenges and opportunities.

Background: Ensuring equitable access to treatments and therapies in the constantly evolving field of neuro-oncology is an imperative global health issue. With its unique demographic, cultural, socioeconomic, and infrastructure characteristics, Sub-Saharan Africa faces distinct challenges. This literature review highlights specific barriers to neuro-oncology care in the region and explores potential opportunities for enhancing access. Methods: Predetermined keyword searches were employed to screen titles and abstracts using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework. Inclusion criteria were studies published between January 1, 2003, and June 20, 2023, specifically addressing the capacity and challenges of neuro-oncology in the Sub-Saharan African region. The data sources queried were PubMed and Google Scholar. Systematic reviews and meta-analyses were deliberately excluded. All authors conducted independent screening and structured data extraction meticulously. Results: Our paper identified multiple challenges that impede access to quality treatment for brain tumors. These include constrained resources, insufficient training of healthcare professionals, certain cultural beliefs, and a general lack of awareness about brain tumors, all contributing to delayed diagnosis and treatment. Furthermore, the lack of detailed data on the incidence and prevalence of primary central nervous system tumors impairs the accurate assessment of disease burden and precise identification of areas requiring improvement. However, we discovered that ongoing research, advocacy, enhanced training, mentorship, and collaborative efforts present valuable opportunities for substantial progress in neuro-oncology access. Conclusions: While we provide a glimpse of the current state, we hope these results will help stimulate dialogue and catalyze initiatives to surmount highlighted obstacles and improve neuro-oncology outcomes across Sub-Saharan Africa.

Ney Bienvenido Arias Lora (1926-2007): The Dominican Republic's First Neurosurgeon.

BACKGROUND: Dr. Ney Bienvenido Arias Lora emerged not only as a pioneer in neurosurgery but a community leader in the Dominican Republic (DR), contributing significantly to a region where both fundamental and neurosurgical resources were scarce. This account aims to shed light on the remarkable life and career of Dr. Arias Lora, emphasizing the critical role he played in establishing and advancing neurosurgery in the DR. METHODS: This paper relies on original bibliographic materials, providing an in-depth analysis of Dr. Arias Lora's life. Through a thorough examination of his career, we aim to highlight his pioneering efforts in the Caribbeans where neurosurgical expertise was nearly nonexistent during his time. RESULTS: Dr. Arias Lora, born in 1926, and became the first neurosurgeon in the DR in 1959. He played a pivotal role in establishing the Neurosurgery Residency Program at the Hospital Salvador B. Gautier and was instrumental in the development of neurosurgery training in his home country and the Caribbeans. Beyond his medical contributions, Dr. Arias Lora served as an educator, authoring significant works, and holding prestigious academic positions. His legacy is reflected in the "Dr. Ney Arias Lora Traumatology Hospital" in Santo Domingo, a testament to his dedication to neurosurgery and public service. CONCLUSIONS: Dr. Ney Bienvenido Arias Lora's life and achievements stand as a testament to the transformative impact dedicated individuals can have on the advancement of neurosurgery. Despite the intricacies inherent in the field of neurosurgery and broader societal challenges, his story serves as an inspiration.

Samuel Frank Clarendon Ghouralal (1925-1991): Pioneering Neurosurgeon in Trinidad.

BACKGROUND: Dr. Samuel Frank Clarendon Ghouralal emerged not only as a pioneer in neurosurgery but as a community leader in Trinidad and Tobago, contributing significantly to a region where neurosurgical care was scarce. This historical account aims to shed light on the remarkable life and career of Dr. Ghouralal, emphasizing the critical role he played in establishing and advancing neurosurgery in Trinidad and Tobago. METHODS: The writing of this project was sparked by the discovery of original scientific and biographical information about Dr. Ghouralal. RESULTS: Dr. Ghouralal revolutionized Trinidad and Tobago's medical landscape, pioneering neurosurgery in a region where it was previously nonexistent. Despite initial challenges, his exceptional skills and dedication established the field, earning him the title "the Guru." His groundbreaking surgeries, including the successful brain tumor removal from an American soldier in 1957 and the critical operation on Indian cricket captain Nari Contractor in 1962, cemented his reputation as a trailblazer. Dr. Ghouralal's visionary leadership extended beyond borders, influencing neighboring countries and formalizing training programs, earning recognition from prestigious institutions like the Royal College of Surgeons in England. His service as President of the Trinidad and Tobago Medical Association and Assistant Hospital Medical Director showcased his commitment to medical governance. Having been conferred the Scroll of Honour and the Chaconia Medal (Gold), his enduring legacy persists posthumously. CONCLUSIONS: Dr. Ghouralal's life and achievements stand as a testament and inspiration to the transformative impact dedicated individuals can have on the advancement of neurosurgery throughout the world.

James Franklin Osman Adewale Ishola Mustaffah: Ghana's First Neurosurgeon.

BACKGROUND: This historical narrative examines the early life of Dr. James Franklin Osman Adewale Ishola Mustaffah and his pivotal role in laying the foundations and advancing the field of neurosurgery in Ghana. METHODS: The creation of this project was driven by the exploration of original scientific and bibliographical works concerning Dr. Mustaffah. It details his initial endeavors to shape the landscape of neurosurgery in Ghana and Africa. RESULTS: This historical account follows the remarkable journey of Dr. Mustaffah, spanning from his early education in Ghana, through his college years and medical training in London, to his distinguished career in neurosurgery. It explores his groundbreaking position as the first Ghanaian neurosurgeon and his contributions to establishing neurosurgery as a recognized practice in Ghana. We commemorate the life and legacy of Dr. Mustaffah, a visionary neurosurgeon whose profound influence has motivated numerous medical professionals in Africa and beyond. CONCLUSIONS: This article illuminates the extraordinary life and lasting legacy of Dr. Mustaffah, a pioneering neurosurgeon whose contributions have significantly shaped the trajectory of neurosurgical practice in Ghana and throughout Africa.

Presentation, management, and outcomes of pediatric hydrocephalus in Africa: a systematic review and meta-analysis of 12,355 patients.

OBJECTIVE: The prevalence, management, and outcomes of hydrocephalus remain underexplored in Africa. This study aimed to analyze demographic and clinical features, evaluate treatment strategies, and assess neurological outcomes of pediatric hydrocephalus in Africa. METHODS: A systematic review of the literature using the PubMed, Google Scholar, and Web of Science electronic databases was completed according to the PRISMA guidelines to identify articles describing pediatric patients in Africa with hydrocephalus. RESULTS: Seventy-four retrospective and prospective studies and 33 case reports involving 12,355 patients were included. In 54 retrospective articles reporting patient demographics, 53.8% (3926/7297) were male with a mean age of 12.3 months. Nineteen studies reported macrocephaly (80.2%, 1639/2043) as the most common presentation. The etiology of hydrocephalus was reported as postinfectious (41.0%, 2303/5614) across 27 articles and congenital (48.6%, 1246/2563) in 10 articles. Eleven articles reported 46.7% (609/1305) of patients had communicating hydrocephalus while 53.3% (696/1305) had obstructive hydrocephalus. Diagnostic imaging included CT (76.1%, 2435/3202; n = 29 articles), ultrasonography (72.9%, 2043/2801; n = 15 articles), and MRI (44.8%, 549/1225; n = 11 articles). In 51 articles, 83.1% (7365/8865) of patients had ventriculoperitoneal shunting (VPS) while 33 articles described 54.1% (2795/5169) receiving endoscopic third ventriculostomy (ETV) for hydrocephalus surgical management. Postoperative complications included sepsis (6.9%, 29/421; n = 4 articles), surgical site infections (5.1%, 11/218; n = 4 articles), and CSF leaks (2.0%, 15/748; n = 8 articles). Shunt-related complications included infections (4.3%, 117/2717; n = 21 articles) and blockages (4.1%, 34/829; n = 6 studies). In 15 articles, 9.0% (301/3358) of patients with shunts had revisions. The mean follow-up duration was 18.9 ± 16.7 months with an overall mortality rate of 7.4% (397/5383; n = 29 articles). In the analysis of comparative studies, the 160 patients undergoing ETV demonstrated significantly higher odds of a successful operation (OR 1.54, 95% CI 0.51-4.69; p = 0.03) and neurological improvement at last follow-up (OR 3.36, 95% CI 0.46-24.79; p < 0.01) compared with the 158 who received VPS, but no significant differences were observed for complications and mortality between the two groups (p > 0.05). CONCLUSIONS: This review offers a comprehensive summary of pediatric hydrocephalus in Africa, highlighting shunting as the primary treatment. However, the observed variations across studies highlight the need to establish standardized guidelines for reporting patient characteristics, management strategies, and outcomes to ensure consistency and comparability in articles.

African Women in Neurosurgery: An Exploration of Historical Perspectives, Current Realities, and Future Prospects.

BACKGROUND: Gender disparities remain a significant issue, particularly impacting African women in the field of neurosurgery. METHODS: Databases, articles, and perspectives were reviewed to identify challenges faced by African Women in Neurosurgery (AWIN), and explore solutions for recruitment, retention, and career advancement of AWIN. RESULTS: In 1982, Africa saw its first female neurosurgeon, with the first female president of the World Federation of Neurosurgical Societies appointed 4 null decades later. Presently, the continent hosts 245 female neurosurgeons, with North Africa comprising the majority at 76.3%, with Algeria notably contributing 72.2% of this total. Southern Africa contributes 7.8%, while West Africa, East Africa, and Central Africa contribute 6.5%, 6.1%, and 3.3%, respectively. Thirteen countries lack neurosurgeons entirely and 30 out of the 54 African nations face shortages of female neurosurgeons, with distributions as follows: North Africa (1-country), Southern Africa (6-countries), West Africa (8-countries), East Africa (9-countries), and Central Africa (6-countries). Our analysis mapped the distribution of 245 AWIN across the African regions and examined the professional trajectories and achievements of 17 pioneering AWIN. Additionally, we compiled registries for: 1) 76 neurosurgical training programs across 26 African countries, 2) organizations tackling gender disparities in neurosurgery, and 3) recommendations to promote AWIN across governmental, community, and academic spheres. CONCLUSIONS: To boost AWIN representation in neurosurgery, concerted and comprehensive efforts are vital. Collaboration among medical schools, training programs, and governments is key to fostering diversity and inclusivity in African neurosurgical settings.

Hussein Suleiman Abusalih (1930-2021): First Neurosurgeon and Former Minister of Health of Sudan.

BACKGROUND: This historical account reviews the course and lasting impact of Dr. Hussein Suleiman Abusalih (October 5, 1930 to December 6, 2021) in neurosurgery. METHODS: The conception of this project was sparked by the discovery of original scientific and bibliographical information about Dr. Abusalih, a prolific neurosurgeon and political figure in his home country of Sudan. This project aims to thoroughly describe the impact of Dr. Abusalih in his home country and in the field of neurosurgery. RESULTS: From humble beginnings, Dr. Abusalih traveled extensively to pursue his passions in education and medicine. He received his neurosurgical training with Dr. Ahmed El-Banhawi of Ain Shams University. Afterward, he returned to Sudan to become the nation's first neurosurgeon and formed the first neurosurgical department in the country in addition to being appointed as the Minister of Health of Sudan. Partnering with several neuroscientists and fellow physicians, Dr. Abusalih was one of the founders of the Pan African Association of Neurological Sciences and worked extensively for various indigenous populations. As a prolific researcher and educator, Dr. Abusalih authored many presentations, publications, and various books, such as "Inside the Ministry of Health" and "Neurosurgery in the Seventies." Dr. Abusalih was a prominent figure in both medical and political fields. CONCLUSIONS: Our article provides a look into the life and impact of Dr. Abusalih as a prominent political pioneer and the first neurosurgeon in Sudan.

Emanuel Olatunde Alaba Olanrewaju Odeku (1927-1974): First African Neurosurgeon Trained in the United States and Establisher of the National and West African Postgraduate Medical Colleges.

BACKGROUND: In this comprehensive historical account, the authors delve into the remarkable trajectory of Dr. Latunde E. Odeku, a pioneering figure in neurosurgery. METHODS: The inspiration for this project was ignited by the discovery of the original scientific and bibliographic materials of Latunde Odeku, a renowned Nigerian neurosurgeon and the first African neurosurgeon in history. Following a thorough review of the literature and information available on Dr. Odeku, we have compiled a comprehensive and detailed analysis of his life, work, and legacy. RESULTS: This paper begins by introducing his childhood and early education in Nigeria, highlights his journey through medical school and residency in the United States, and follows his career and role in establishing the first neurosurgical unit in West Africa. We celebrate the life and legacy of Latunde Odeku, a trailblazing neurosurgeon whose contribution has inspired generations of medical professionals in Africa and around the world. CONCLUSIONS: This article sheds light on the remarkable life and achievements of Dr. Odeku and his trailblazing work for generations of doctors and researchers.

Understanding the Ghanaian Neurosurgical Literature: A Scoping Review and Bibliometric Analysis.

BACKGROUND: Research serves to bolster clinical neurosurgery by critically assessing various disease pathologies, while identifying important challenges and opportunities. However, there is limited information on the landscape of the Ghanaian neurosurgical literature. METHODS: A scoping review and bibliometric analysis was conducted in accordance with PRISMA guidelines. PubMed, Embase, Global Index Medicus, and Web of Science electronic databases were searched from inception until December 21, 2021 for English language articles about neurosurgery in Ghana. RESULTS: 927 articles were identified and 66 were ultimately included in the analysis. A majority of them, 42.4%, were retrospective cohort studies, with 62.1% published after 2010. There were no randomized controlled or basic science studies. Most articles were published in the West African Journal of Medicine (24.2%) and non-infectious/non-traumatic spinal pathology was the most commonly discussed topic (22.7%); 66.7% of articles included only authors affiliated with Ghanaian institutions, and international collaborators frequently originated from the United States (15.9%). Only 22.7% of the manuscripts reported a funding source. Commonly reported challenges included limited sample sizes, delays in diagnosis and treatment, and lack of proper diagnostic tools and specialized care. CONCLUSIONS: This review revealed that while the Ghanaian academic neurosurgery output has been increasing over time, these have been limited to cohort studies largely assessing spine pathology. The Ghanaian neurosurgical research environment may be bolstered by an increase in research funding, the establishment of longitudinal clinical databases, training in research methodology, increased incentives for researchers, strengthening of research collaborative networks, and increased engagement of neurosurgical trainees in research.

Brain Tumor Programs in Asia and Africa: Current Status, Challenges, and Future Perspectives.

OBJECTIVE: To assess the status of brain tumor programs in Asia and Africa and propose comprehensive evidence-based short- and long-term measures for improving the existing systems. METHODS: A cross-sectional analytical study was conducted in June 2022 by the Asia-Africa Neurosurgery Collaborative. A 27-item questionnaire was designed and distributed to gain insight into the status and future directions of brain tumor programs in Asia and Africa. Six components of brain tumor programs were identified-surgery, oncology, neuropathology, research, training, and finances-and assigned scores of 0-14. The total scores allowed subclassification of each country into levels of brain tumor program from I to VI. RESULTS: A total of 110 responses from 92 countries were received. These were subdivided into 3 groups: group 1, countries with response from neurosurgeons (73 countries); group 2, countries with no neurosurgeons (19 countries); and group 3, countries without a neurosurgeon response (16 countries). The components associated with the highest level of brain tumor program were surgery, neuropathology, and oncology. Most countries in both continents had level III brain tumor programs with a mean surgical score of 2.24. The major lag between each group was with respect to the advances in neuropathology and financial support. CONCLUSIONS: There is an urgent need to improve and develop existing and nonexistent neuro-oncology infrastructure, personnel, and logistics in countries across the continents, especially for the countries with no neurosurgeons.

Assessment of the Neurosurgical Capacity in Ghana: Challenges and Opportunities.

BACKGROUND: Low- and middle-income countries experience numerous challenges in the provision of neurosurgical care. However, limited information exists on the neurosurgical workforce and the constraints under which care is delivered in Ghana, West Africa. METHODS: A 19-item survey assessing neurosurgical workforce, infrastructure, and education was administered to Ghanaian consultant neurosurgeons and neurosurgeon trainees between November 8, 2021, and January 20, 2022. The data were analyzed using summary descriptions, and qualitative data were categorized into themes. RESULTS: There were 25 consultant neurosurgeons and 8 neurosurgical trainees (from 2 training centers) identified at 11 hospitals in Ghana totaling a workforce density of 1 neurosurgeon per 1,240,000. Most neurosurgical centers were located in Accra, the capital city. Almost half of the population did not have access to a hospital with a neurosurgeon in their region. Of hospitals, 82% had in-house computed tomography and/or magnetic resonance imaging scanners. In the operating room, most neurosurgeons had access to a high-speed drill (91%) but lacked microscopes and endoscopic sets (only 64% and 36% had these tools, respectively). There were no neurointensivists or neurological intensive care units in the entire country, and there was a paucity of neurovascular surgeries and functional neurosurgical procedures. CONCLUSIONS: The provision of neurosurgical care in Ghana has come a long way since the 1960s. However, the neurosurgical community continues to face significant challenges. Alleviating these barriers to care will call for systems-level changes that allow for the prioritization of neurosurgical care within the Ghanaian health care system.

Reporting morbidity associated with pediatric brain tumor surgery: are the available scoring systems sufficient?

OBJECTIVE: Complications in pediatric neurooncology surgery are seldom and inconsistently reported. This study quantifies surgical morbidity after pediatric brain tumor surgery from the last decade in a single center, using existing morbidity and outcome measures. METHODS: The authors identified all pediatric patients undergoing surgery for an intracranial tumor in a single tertiary pediatric neurosurgery center between January 2008 and December 2018. Complications between postoperative days 0 and 30 that had been recorded prospectively were graded using appropriate existing morbidity scales, i.e., the Clavien-Dindo (CD), Landriel, and Drake scales. The result of surgery with respect to the predetermined surgical aim was also recorded. RESULTS: There were 477 cases (364 craniotomies and 113 biopsies) performed on 335 patients (188 males, median age 9 years). The overall 30-day mortality rate was 1.26% (n = 6), and no deaths were a direct result of surgical complication. Morbidity on the CD scale was 0 in 55.14%, 1 in 10.69%, 2 in 18.66%, 3A in 1.47%, 3B in 11.74%, and 4 in 1.05% of cases. Morbidity using the Drake classification was observed in 139 cases (29.14%). Neurological deficit that remained at 30 days was noted in 8.39%; 78% of the returns to the operative theater were for CSF diversion. CONCLUSIONS: To the authors' knowledge, this is the largest series presenting outcomes and morbidity from pediatric brain tumor surgery. The mortality rate and morbidity on the Drake classification were comparable to those of published series. An improved tool to quantify morbidity from pediatric neurooncology surgery is necessary.

Pattern of intracranial tumours in a tertiary hospital in Ghana.

OBJECTIVE: This study seeks to describe the pattern of intracranial tumours in Korle Bu Teaching Hospital (KBTH) based on patient demographics, clinical presentation, spatial distribution of tumour and histological findings. METHOD: The study design is retrospective and descriptive. Data was obtained from the clinical records of patients with intracranial tumours treated in our neurosurgery unit between January 2010 to December 2015, and histology reports obtained from the histopathology unit. Patients with intracranial tumours without definitive histological diagnosis were excluded. RESULTS: Of the 102 histologically diagnosed brain tumours, out of 335 brain tumour cases seen in the period under review, 58 (56.9%) were females and 44 (43.1%) were males (p = 0.031). Gliomas were the commonest intracranial tumours - 39(38.2%) followed by Meningiomas 37(36.2%) and Pituitary Adenoma - 9(8.8%). Astrocytoma was the commonest type of Glioma comprising 30(77%) of the 39 cases. Meningotheliomatous meningioma was the commonest type of meningioma with 11 (29.7%) of 37 cases. Of the 39 Gliomas 17(43.6%) were males and 22(56.4%) were females, while for the Meningioma 17(46%) were males and 20(54%) were females. The commonest symptom was headache (64%) and the commonest tumour location was supratentorial (77.5%). The crude incidence rate of intracranial tumours in this study was 1.34 per 100,000 populations per year. CONCLUSION: Gliomas are the commonest intracranial tumours seen in our series. Overall, females were more commonly affected than males in most brain tumours in this series, including both gliomas and meningiomas. FUNDING: Not declared.

Teaching and sustainably implementing awake craniotomy in resource-poor settings.

OBJECTIVE: Awake craniotomy for brain tumor resection has the benefit of avoiding a general anesthetic and decreasing associated costs (e.g., intensive care unit beds and intravenous line insertion). In low- and middle-income countries, significant resource limitations for the system and individual make awake craniotomy an ideal tool, yet it is infrequently used. We sought to determine if awake craniotomy could be effectively taught and implemented safely and sustainably in low- and middle-income countries. METHODS: A neurosurgeon experienced in the procedure taught awake craniotomy to colleagues in China, Indonesia, Ghana, and Nigeria during the period 2007-2012. Patients were selected on the basis of suspected intraaxial tumor, absence of major dysphasia or confusion, and ability to tolerate the positioning. Data were recorded by the local surgeons and included preoperative imaging, length of hospital admission, final pathology, postoperative morbidity, and mortality. RESULTS: Awake craniotomy was performed for 38 cases of suspected brain tumor; most procedures were completed independently. All patients underwent preoperative computed tomography or magnetic resonance imaging. In 64% of cases, patients remained in the hospital <10 days. The most common pathology was high-grade glioma, followed by meningioma, low-grade glioma, and metastasis. No deaths occurred, and no case required urgent intubation. The most common perioperative and postoperative issue was seizure, with 1 case of permanent postoperative deficit. CONCLUSIONS: Awake craniotomy was successfully taught and implemented in 6 neurosurgical centers in China, Indonesia, Ghana, and Nigeria. Awake craniotomy is safe, resource-sparing, and sustainable. The data suggest awake craniotomy has the potential to significantly improve access to neurosurgical care in resource-challenged settings.