Reducing the Gap in Neurosurgical Education in LMICs: A Report of a Non-Profit Educational Program.

INTRODUCTION: Central to neurosurgical care, neurosurgical education is particularly needed in low- and middle-income countries (LMICs), where opportunities for neurosurgical training are limited due to social and economic constraints and an inadequate workforce. The present paper aims (1) to evaluate the validity and usability of a cadaver-free hybrid system in the context of LMICs and (2) to report their learning needs and whether the courses meet those needs via a comprehensive survey. METHODS: From April to November 2021, a non-profit initiative consisting of a series of innovative cadaver-free courses based on virtual and practical training was organized. This project emerged from a collaboration between the Young Neurosurgeons Forum of the World Federation of Neurological Societies (WFNS), the NIHR Global Health Research Group on Neurotrauma, and UpSurgeOn, an Italian hi-tech company specialized in simulation technologies, creator of the UpSurgeOn Box, a hyper-realistic simulator of cranial approaches fused with augmented reality. Over that period, 11 cadaver-free courses were held in LMICs using remote hands-on Box simulators. RESULTS: One hundred sixty-eight participants completed an online survey after course completion of the course. The anatomical accuracy of simulators was overall rated high by the participant. The simulator provided a challenging but manageable learning curve, and 86% of participants found the Box to be very intuitive to use. When asked if the sequence of mental training (app), hybrid training (Augmented Reality), and manual training (the Box) was an effective method of training to fill the gap between theoretical knowledge and practice on a real patient/cadaver, 83% of participants agreed. Overall, the hands-on activities on the simulators have been satisfactory, as well as the integration between physical and digital simulation. CONCLUSIONS: This project demonstrated that a cadaver-free hybrid (virtual/hands-on) training system could potentially participate in accelerating the learning curve of neurosurgical residents, especially in the setting of limited training possibilities such as LMICs, which were only worsened during the COVID-19 pandemic.

Needs, Roles, and Challenges of Young Asian Neurosurgeons.

BACKGROUND: Asia has a marked shortage of neurosurgical care, with approximately 2.5 million critical cases left untreated. The Young Neurosurgeons Forum of the World Federation of Neurosurgical Societies surveyed Asian neurosurgeons to identify research, education, and practice. METHODS: A cross-sectional study using a pilot-tested e-survey was circulated to the Asian neurosurgical community from April to November 2018. Descriptive statistics were used to summarize variables pertaining to demographics and neurosurgical practices. The chi-square test was used to explore the relationship between World Bank income level and variables on neurosurgical practices. RESULTS: A total of 242 responses were analyzed. Respondents were mostly from the low- and middle-income countries (70%). Most represented institutions were teaching hospitals (53%). More than 50% of the hospitals had between 25and 50 neurosurgical beds. Access to an operating microscope (P = 0.038) or image guidance system (P = 0.001) appeared to increase in correlation to a higher World Bank income level. Limited opportunities for conducting research (56%) and hands-on operating opportunities (45%) were leading challenges in daily academic practice. The leading challenges were limited numbers of intensive care unit beds (51%), inadequate or absent insurance coverage (45%), and lack of organized perihospital care (43%). Inadequate insurance coverage decreased with increasing World Bank income levels (P < 0.001). Organized perihospital care (P = 0.001), regular magnetic resonance imaging access (P = 0.032), and equipment necessary for microsurgery (P = 0.007) increased with higher World Bank income levels. CONCLUSIONS: Improving neurosurgical care hinges on regional and international collaboration and national policies to ensure universal access to essential neurosurgical care.

Needs, Roles, and Challenges of Young Latin American and Caribbean Neurosurgeons.

BACKGROUND: Barriers to neurosurgery training and practice in Latin American and Caribbean countries (LACs) have been scarcely documented. The World Federation of Neurosurgical Societies Young Neurosurgeons Forum survey sought to identify young neurosurgeons' needs, roles, and challenges. We present the results focused on Latin America and the Caribbean. METHODS: In this cross-sectional study, we analyzed the Young Neurosurgeons Forum survey responses from LACs, following online survey dissemination through personal contacts, social media, and neurosurgical societies' e-mailing lists between April and November 2018. Data analysis was performed using Jamovi version 2.0 and STATA version 16. RESULTS: There were 91 respondents from LACs. Three (3.3%) respondents practiced in high-income countries, 77 (84.6%) in upper middle-income countries, 10 (11%) in lower middle-income countries, and 1 (1.1%) in an unclassified country. The majority (77, or 84.6%) of respondents were male, and 71 (90.2%) were younger than 40. Access to basic imaging modalities was high, with access to computed tomography scan universal among the survey respondents. However, only 25 (27.5%) of respondents reported having access to imaging guidance systems (navigation), and 73 (80.2%) reported having access to high-speed drills. A high GDP per capita was associated with increased availability of high-speed drills and more time dedicated to educational endeavors in neurosurgery, such as didactic teaching and topic presentation (P < 0.05). CONCLUSIONS: This survey found that neurosurgery trainees and practitioners of Latin America and the Caribbean face many barriers to practice. These include inadequate state-of-the-art neurosurgical equipment, a lack of standardized training curricula, few research opportunities, and long working hours.

Diffusion of Technology in the Teaching of Neuroanatomy in Times of Pandemic: A Medical and Academic Perspective on Learning.

The Covid-19 pandemic has caused major changes in many sectors of society worldwide. The issue of medical education stands out since it had to adapt to the rules of social isolation, ensuing discussions about the computerization of teaching methodology, particularly in neuroanatomy. In particular, the latter showed satisfactory adaptability to new technologies and highly promising learning results. During this review, we aim to evaluate the current state of neuroanatomy teaching and evaluate the possibilities of incorporating technology into teaching-learning of human anatomy in a post-pandemic world.

Decompressive Craniectomy for Malignant Ischemic Stroke: An Institutional Experience of 145 Cases in a Brazilian Medical Center.

BACKGROUND: Malignant ischemic stroke (MIS) occurs in a subgroup of patients with cerebrovascular accident who sustain massive or significant cerebral infarction. It is characterized by neurological deterioration owing to progressive edema, raised intracranial pressure, and cerebral herniation. Decompressive craniectomy (DC) is a surgical technique that can be used to treat select cases of this condition in the presence of medically refractory intracranial hypertension. This study aimed to identify prognostic factors associated with clinical outcome, including timing of the procedure, and postoperative mortality. METHODS: We analyzed surgical characteristics associated with prognosis in 145 patients who underwent DC secondary to MIS between 2013 and 2018, assessing clinical outcome at discharge and 6 and 12 months after discharge. Our inclusion criteria were DC secondary to MIS in adult patients with raised intracranial pressure signs. RESULTS: Our analysis showed that although patients from cities >100 km from the neurosurgical center had a worse prognosis, only the surgical head side (left vs. right, P = 0.001), hospitalization length (P < 0.001), and earlier timing of procedure (P < 0.001) were statistically relevant in having worse outcomes. CONCLUSIONS: Patients in whom more time passed from presentation to the neurosurgical procedure, owing to living in a distant city or taking more time to be seen by a specialist, tended to have a worse prognosis. The timing of procedure, surgical side, and hospitalization length were independent predictors in determining the prognosis of patients who underwent DC after an MIS.

Pediatric Gunshot Head Injury: Prevalence of Prognostic Factors in Surgical Patients: An Institutional Experience in Ten Years.

This article aims to evaluate the predictive factors of morbidity and mortality in pediatric patients who suffered gunshot wounds to the head. We reviewed a series of 43 patients who were admitted to a referential neurosurgical hospital between 2010 and 2019. Data from 43 patients who underwent a surgical treatment in our institution were collected, and the following parameters were considered in the analysis: the initial Glasgow Coma Scale (GCS), age, sex, bullet entry site, and bullet trajectory. Computed tomography (CT) scans at admission, complications, midline crossing, and Glasgow score scale at the time of discharge (Glasgow Outcome Scale; GOS) were also factored in. Male sex corresponded to 90.7% of cases (N = 39), and 16-17 years of age was the most common age (60.5%). The frontal region was the most common entry site (41.9%), followed by the parietal wall and occipital entry. Penetrating trajectory was shown in 48.8% of cases, perforation/transfixing in 39.5%, and tangential in 11.6%. CT showed that sinking is the most common alteration (74.4%), followed by cerebral contusion (44.2%). According to the GOS, 23.3% died, 23.3% were classified by an unfavorable outcome (GOS, 2-3), and 53.5% a favorable outcome (GOS, 4 and 5). In our study, there was a significant association between the low GCS scores on admission and low GOS (1-3; p = 0.001) at time of discharge. Patients with wounds that crossed the midline also had a significant association with low GOS (p = 0.014) in our clinical experience. We concluded that low GCS scores at admission and children with a wound that crosses the midline are predictive factors of high mortality and morbidity, in our clinical experience.

SARS-CoV-2 and Nervous System - Neurological Manifestations in Patients With COVID-19: A Systematic Review.

Coronavirus (CoV) is a virus infectious disease with a considerable spectrum of clinical presentations. Symptoms ranged from asymptomatic infection to severe pneumonia that may lead to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and several clinical complications. Neurologic symptoms related to CoV have been described recently in the literature. The relationship between SARS-CoV-2 and the central nervous system (CNS) is still not clear. This review aimed to reveal the current knowledge regarding CNS manifestation in SARS-CoV-2. A systematic literature review was carried out to identify the particularities of coronavirus disease 2019 (COVID-19) in patients with CNS involvement, using the PubMed database between January 1, 2020 and April 30, 2020. Conference papers, reviews, published letters, editorials, studies in pregnant women and children, and studies only reporting on a specific factor were excluded. An initial search included as many as 83 articles. Out of the 83 screened articles, 32 were selected for full-text review. Sixteen studies were excluded because they did not analyze nervous system involvement in SARS-CoV-2 infection. Thus, 16 papers were included in this review. There were three retrospective studies and 13 case reports/series of cases. Data from the current literature reveal that patients who suffer from a severe illness have more CNS involvement, neurological symptoms (i.e., dizziness, headache) and an association with strokes. The severe patients had higher D-dimer and C-reactive protein levels than non-severe patients and presented multiple organ involvement, such as serious liver, kidney and muscle damage.