Parenthood and neurosurgery in Europe, a white paper from the European association of neurosurgical societies' diversity in neurosurgery committee, part II - practice with children.

Introduction: In the first part of this White Paper, the European Association of Neurosurgical Societies (EANS) Diversity in Neurosurgery Committee (DC) addressed the obstacles faced by neurosurgeons when planning to have a family and practice during pregnancy, attempting to enumerate potential, easily implementable solutions for departments to be more family-friendly and retain as well as foster talent of parent-neurosurgeons, regardless of their gender identity and/or sexual orientation. Attrition avoidance amongst parent-neurosurgeons is at the heart of these papers. Research question: In this second part, we address the obstacles posed by practice with children and measures to mitigate attrition rates among parent-neurosurgeons. For the methodology employed to compose this White Paper, please refer to Supplementary Electronic Materials (SEM) 1. Materials and methods: For composing these white papers, the European Association of Neurosurgical Societies (EANS)'s Diversity Committee (DC) recruited neurosurgeon volunteers from all member countries, including parents, aspiring parents, and individuals without any desire to have a family to create a diverse and representative working group (WG). Results: In spite of the prevailing heterogeneity in policies across the continent, common difficulties can be identified for both mothers and fathers considering the utilization of parental leave. Discussion and conclusion: Reconciliation of family and a neurosurgical career is challenging, especially for single parents. However, institutional support in form of childcare facilities and/or providers, guaranteed lactation breaks and rooms, flexible schedule models including telemedicine, and clear communication of policies can improve working conditions for parent-neurosurgeons, avoid their attrition, and foster family-friendly work environments.

Cystic Dilatation of the Ventriculus Terminalis: Examining the Relevance of the Revised Operative Classification Through a Systematic Review of the Literature, 2011-2021.

The literature features limited evidence on the natural history of the cystic dilatation of the ventriculus terminalis (CDVT) and its response to treatment. The goal of this study is to ascertain which impact the revised operative classification of CDVT had on the management of patients diagnosed over the past 10 years.Ten new clinical articles presenting a total of 30 cases of CDVT were identified and included for qualitative analysis. Two take-home messages can be identified: (1) Adequate consideration should be given to designing national pathways for referral to tertiary centers with relevant expertise in the management of lesions of the conus medullaris, and (2) we suggest that type Ia should be, at least initially, treated conservatively, whereas we reckon that the signs and symptoms described in types Ib, II, and III seem to benefit, although in some patients only partially, from surgical decompression in the form of cystic fenestration, cyst-subarachnoid shunting, or both.While the level of evidence gathered in this systematic review remains low because the literature on CDVT consists only of retrospective studies based on single-center series (level of evidence 4 according to the Oxford Centre for Evidence-Based Medicine (OCEBM)), the strength of recommendation for adopting the revised operative classification of CDVT is moderate.

The role of genetic and epigenetic factors in determining the risk of spinal fragility fractures: new insights in the management of spinal osteoporosis.

Osteoporosis predisposes patients to spinal fragility fractures. Imaging plays a key role in the diagnosis and prognostication of these osteoporotic vertebral fractures (OVF). However, the current imaging knowledge base for OVF is lacking sufficient standardisation to enable effective risk prognostication. OVF have been shown to be more prevalent in Caucasian patient cohorts in comparison to the Eastern Asian population. These population-based differences in risk for developing OVF suggest that there could be genetic and epigenetic factors that drive the pathogenesis of osteoporosis, low bone mineral density (BMD) and OVF. Several genetic loci have been associated with a higher vertebral fracture risk, although at varying degrees of significance. The present challenge is clarifying whether these associations are specific to vertebral fractures or osteoporosis more generally. Furthermore, these factors could be exploited for diagnostic interpretation as biomarkers [including novel long non-coding (lnc)RNAs, micro (mi)RNAs and circular (circ)RNAs]. The extent of methylation of genes, alongside post-translational histone modifications, have shown to affect several interlinked pathways that converge on the regulation of bone deposition and resorption, partially through their influence on osteoblast and osteoclast differentiation. Lastly, in addition to biomarkers, several exciting new imaging modalities could add to the established dual-energy X-ray absorptiometry (DXA) method used for BMD assessment. New technologies, and novel sequences within existing imaging modalities, may be able to quantify the quality of bone in addition to the BMD and bone structure; these are making progress through various stages of development from the pre-clinical sphere through to deployment in the clinical setting. In this mini review, we explore the literature to clarify the genetic and epigenetic factors associated with spinal fragility fractures and delineate the causal genes, pathways and interactions which could drive different risk profiles. We also outline the cutting-edge imaging modalities which could transform diagnostic protocols for OVF.

Parenthood and neurosurgery in Europe a white paper from the European Association of Neurosurgical Societies' Diversity in Neurosurgery Committee Part I - Family Planning and Practice during Pregnancy.

Introduction: Family and work have immensely changed and become intertwined over the past half century for both men and women. Additionally, alongside to traditional family structures prevalent, other forms of families such as single parents, LGBTQ + parents, and bonus families are becoming more common. Previous studies have shown that surgical trainees regularly leave residency when considering becoming a parent due to the negative stigma associated with pregnancy during training, dissatisfaction with parental leave options, inadequate lactation and childcare support, and desire for greater mentorship on work-life integration. Indeed, parenthood is one of the factors contributing to attrition in surgical specialities, neurosurgery not being an exception. Research question: The Diversity in Neurosurgery Committee (DC) of the European Association of Neurosurgical Societies (EANS) recognizes the challenges individuals face in parenthood with neurosurgery and wishes to address them in this white paper. Materials and methods: In the following sections, the authors will focus on the issues pertaining to family planning and neurosurgical practice during pregnancy in itemized fashion based on an exhaustive literature search and will make recommendations to address the matters raised. Results: Potential solutions would be to further improve the work-family time ration as well as improving working conditions in the hospital. Discussion and conclusion: While many obstacles have been quoted in the literature pertaining to parenthood in medicine, and in neurosurgery specifically, initiatives can and should be undertaken to ensure not only retention of colleagues, but also to increase productivity and job satisfaction of those seeking to combine neurosurgery and a family life, regardless of their sexual identity and orientation.

Representation of minorities in European neurosurgical leadership.

Introduction: Ethnic diversity has significantly increased within European countries since World War II for several reasons. However, there continues to be a contrasting lag in leadership positions within healthcare circles, and neurosurgery is no exception. Under-representation of minorities is a contributory factor to recurring problems of healthcare inequality. Research question: The European Association of Neurosurgical Societies (EANS) Diversity Committee (DC) set out to examine trends in underrepresented minority (URM) representation in leadership positions across Europe. Material and methods: Data on the race and ethnicity of departmental heads across the units in the European nations was collated. We defined the term 'ethnic minority' in line with the criteria set by the European Commission against Racism and Intolerance (ECRI). The percentage of URM among the European neurosurgical units was analysed against the demographics of the respective countries to assess whether there was a corresponding association. Results: The percentage of URM representation was low across most European countries. Countries with the highest immigration rates e.g. Great Britain and Germany had the highest rates of representation within the neurosurgical leadership in comparison to other countries. The Balkan states had zero rates of URM representation within the neurosurgical leadership. Discussion and conclusion: Our findings demonstrate that URM representation in neurosurgical leadership across European countries is significantly low. Selection policies, training curricula and recruitment processes aimed at improving health inequality are necessary. Further studies are needed to elucidate the factors contributing to the low participation of URM in neurosurgical leadership.

Cystic dilatation of the ventriculus terminalis: A narrative review.

Introduction: The terminal ventricle, also known as the fifth ventricle, is a tiny relic cavity in the conus medullaris of the human spinal cord. Our purpose in bringing attention to this condition is to get the word out about the signs and symptoms, diagnostic hurdles, and therapeutic options available for it. Methods: All relevant studies involving patients diagnosed with ventriculus terminalis (VT) were retrieved from PubMed, Google Scholar, and Scopus. Studies published in complete English language reports were included. The terms VT, terminal ventricle, and 5th ventricle. Age, gender, presenting symptoms, magnetic resonance imaging findings, treatment, and outcome of patients with ventriculus terminalis were all included and recorded. Results: The average age of the patients was 39 years, and there were 13 men among them (14.4%). Motor deficits and sciatica were the most commonly reported symptoms in 38 and 34 patients (42.2%, 37.7%), respectively. In 48 patients (53.3%), cyst fenestration was performed, and in 25 patients (27.7%), myelotomy was performed. Fifty-eight patients (64.4%) saw a reduction in cyst size after surgery. The majority of patients reported an improvement in their symptoms in 64 cases (51.1%), with only three cases (3.3%) reporting a worsening. Conclusions: In cases where the VT is the source of symptoms such as motor, sensory, or bladder dysfunction, surgical intervention is recommended. This review compiles information from the available literature to shed light on the anatomy, clinical presentation, imaging, and treatment options for this variant. It also aims to pinpoint any potential drawbacks or restrictions connected to the surgical techniques.

Imaging in Craniofacial Disorders With Special Emphasis on Gradient Echo Black-Bone and Zero Time Echo MRI Sequences.

Context: The well-known effects of ionizing radiation on brain cells have been a major driving force toward the use of non-ionizing methods of imaging in both elective and emergency settings. Pediatric neurosurgery has certainly leveraged on this shift in clinical practice, however patients with craniofacial disorders could not fully benefit from the adoption of magnetic resonance imaging (MRI) because computed tomography (CT) scans still retain superior imaging power on bone tissue. Aims: To explore the knowledge available on the use of MRI as surrogate for CT scan in the assessment of craniosynostosis. Settings and Design: A scoping review was designed to identify landmark studies and ongoing clinical trials exploring the accuracy of MRI-based bone imaging in the preoperative planning of pediatric patients with craniosynostosis. Materials and Methods: A total of 492 records were screened from Pubmed, Ovid Medline, Scopus, and Cochrane Library databases; while 55 records were retrieved from ClinicalTrials.gov register. Only clinical studies revolving around the use of Gradient Echo Black-Bone (BB) and Zero Time Echo (ZTE) MRI sequences for the preoperative planning of pediatric craniosynostosis were retained for inclusion. Results and Conclusions: This review identified only five clinical studies reporting a high accuracy of MRI-based 3D bone reconstruction in 47 pediatric candidates to surgical correction of craniosynostosis. Although promising, limited evidence (Level IV) exist that BB and ZTE MRI could help in the surgical planning for craniosynostosis management. The results of two ongoing randomized clinical trials, which are actively enrolling patients, will hopefully help answering this research question.

A scoping review on the challenges, improvement programs, and relevant output metrics for neurotrauma services in major trauma centers.

Background: For a neurotrauma unit to be defined as a structured neurotrauma service (NS) the following criteria must be satisfied: A dedicated neurointensive care unit, endovascular neuroradiology, in-hospital neurorehabilitation unit and helicopter platform within the context of a Level I trauma center. Designing an effective NS can be challenging, particularly when considering the different priorities and resources of countries across the globe. In addition the impact on clinical outcomes is not clearly established. Methods: A scoping review of the literature spanning from 2000 to 2020 meant to identify protocols, guidelines, and best practices for the management of traumatic brain injury (TBI) in NS was conducted on the US National Library of Medicine and National Institute of Health databases. Results: Limited evidence is available regarding quantitative and qualitative metrics to assess the impact of NSs and specialist follow-up clinics on patients' outcome. Of note, the available literature used to lack detailed reports for: (a) Geographical clusters, such as low-to-middle income countries (LMIC); (b) clinical subgroups, such as mild TBI; and (c) long-term management, such as rehabilitation services. Only in the last few years more attention has been paid to those research topics. Conclusion: NSs can positively impact the management of the broad spectrum of TBI in different clinical settings; however more research on patients' outcomes and quality of life metrics is needed to establish their efficacy. The collaboration of global clinicians and the development of international guidelines applicable also to LMIC are warranted.

The Flight of Icarus: A Preliminary Study of the Emotional Correlates of Hubris in Gerontological Nurses during the SARS-CoV-2 Pandemic.

Persons in leadership positions are more likely to manifest hubristic symptomatology, the longer the person exercises power and the greater the power they exercise. No data exists for healthcare staff, such as nurses and more specifically for gerontological nurses who exercise power on their colleagues as well as older persons. This study aims to examine whether there are emotional correlates of gerontological nurses' experienced hubris when serving in a leadership position, and to investigate possible gender differences during SARS-CoV-2 pandemic, a little investigated period regarding its emotional aspects on healthcare professionals. Gerontological nurses in leadership positions completed Job Affect Scale, Emotional Labour Scale, Emotion Regulation Questionnaire, Generalized Immediacy Scale, General Index of Job Satisfaction, Maslach Burnout Inventory, Wong-Law Emotional Intelligence Scale, State-Anxiety-Inventory, Perceived Cohesion Scale, and a 5-point Likert scale measuring hubristic attributes. No statistically significant differences were found between male and female nurses regarding the abovementioned classic administered emotional scales and hubris. The analyses yielded only a negative correlation between negative affect and hubris. This research provides for the first time data regarding gerontological nurses in leadership positions, suggesting that various negative and positive emotional variables do no directly relate to hubristic symptoms for this group of healthcare professionals. As hubristic behaviors and their dangerous consequences are found not to be related to abovementioned emotional variables, researchers and hospital managers should consider and focus on other indices in their attempt to prevent such phenomena.

Association of Tortuous Common Carotid Artery with Abnormal Distribution of the Ansa Cervicalis: A Case Report.

In the current study, we display a rare association of an aberrant innervation of the sternocleidomastoid muscle by the ansa cervicalis (AC) with a tortuous common carotid artery (TCCA). In specific, in a male cadaver we observed on the right side of the cervical region, a nerval branch of remarkable size originating from the most distal part of the AC's superior root and after piercing the superior belly of the omohyoid muscle innervated the distal portion of the sternocleidomastoid muscle. Furthermore, we noticed a tortuous course of the initial part of the right common carotid artery. We discuss the surgical significance of the awareness of AC's variations during neurotisation of the recurrent laryngeal nerve in cases of its damage, as well as the importance of aberrant innervation of the sternocleidomastoid muscle by AC for the preservation of muscle's functionality after accessory nerve's damage. Furthermore, we highlight the fact, that the knowledge of the relatively uncommon variant, such as TCCA is crucial for the physician in order to proceed more effectively in differential diagnosis of a palpable mass of the anterior cervical region or deal with symptoms such as dyspnea, dysphagia or symptoms of cerebrovascular insufficiency.

Neuro-Ophthalmological Manifestations Of Septo-Optic Dysplasia: Current Perspectives.

Septo-optic dysplasia (SOD), also known as de Morsier syndrome, is a rare congenital disorder belonging to the group of mid-line brain malformations. Despite the highly variable phenotypic penetration, its classical triad include a) optic nerve hypoplasia (ONH), b) agenesis of septum pellucidum and corpus callosum, and c) hypoplasia of the hypothalamo-pituitary axis. SOD has stringent diagnostic criteria requiring 2 or more features of the classic triad, therefore it represents a separate entity from other conditions such as ONH and achiasmia syndromes which share only some of these aspects, or SOD plus syndrome which is characterized by additional cortical abnormalities. Starting from its etiology and epidemiology, this narrative review focuses on the management of SOD patients, including their diagnosis, treatment and follow-up. To date, SOD is not curable; nonetheless, many of its symptoms can be improved through a tailored approach, consisting of hormonal replacement, corrective ophthalmological surgery and neuropsychological support.

Primary Gliosarcoma of the Cerebellum in a Young Pregnant Woman: Management Challenges and Immunohistochemical Features.

BACKGROUND: Gliosarcoma (GS) represents a rare, high-grade (WHO Grade IV), central nervous system neoplasm, characterized by a very poor prognosis. Similar to other high-grade gliomas, GS affects mainly adults in the 5th-7th decade of life and presents a higher incidence in males. The most reported locations of GS are the temporal lobe and the frontal lobe, while only eight cases of GS originating from the posterior cranial fossa are reported in the literature. CASE DESCRIPTION: We report the first case occurring during pregnancy in a 33-year-old patient. Diagnosis was obtained on the 15th week of gestation when patient presented with signs and symptoms of life-threatening raised intracranial pressure. Surgical excision was followed by early recurrence and eventually disease progression because the patient refused adjuvant treatment to save her fetus. CONCLUSIONS: GS should be considered in the differential diagnosis of posterior cranial fossa tumors with radiological features of meningioma or glioblastoma, even in young patients. To this regard, sarcomas, solitary fibrous tumors, and even metastases should be considered, especially in light of the tendency of GS to give rise to extracranial localizations. Whenever an aggressive management with radical excision and adjuvant treatment is not safely achievable, disease progression is likely to be unavoidable.

Costoclavicular Joint: An Osteological Study on Clavicles with Clinical Relevance.

Introduction The current study aims to detect the incidence of occurrence of a morphological variant of the impression for the costoclavicular ligament, that is a faceted apophysis of the clavicle which participates in the formation of an aberrant joint, the so-called costoclavicular joint. Methods A material of 208 dry clavicles, 107 of right and 101 of left side derived from an osteological collection, was examined in order to detect the likely presence of facet apophysis at the clavicular area of impression for the costoclavicular ligament. Results We observed three cases of oval-shaped faceted apophysis, thus an incidence of 1.44%, two in right clavicles and one in left clavicle. Conclusion The awareness of such a rare joint, thus the costoclavicular joint, is important for the physician, since such a joint may be mistaken for occupying space lesion, induce pain when it is osteoarthritic and decrease the costoclavicular space leading to difficulties in subclavian vein catheterization.