Neurological Surgeons Research Articles

First person profile: Raymond Sawaya, MD: The founding chair of the neurosurgery department at The University of Texas MD Anderson Cancer Center, Dr. Sawaya has nurtured a generation of specialists and helped to advance the field.

First person profile: Raymond Sawaya, MD: The founding chair of the neurosurgery department at The University of Texas MD Anderson Cancer Center, Dr. Sawaya has nurtured a generation of specialists and helped to advance the field.

Erratum. Acute postoperative neurological deterioration associated with surgery for ruptured intracranial aneurysm: incidence, predictors, and outcomes.

"Erratum. Acute postoperative neurological deterioration associated with surgery for ruptured intracranial aneurysm: incidence, predictors, and outcomes" published on 07 Feb 2020 by American Association of Neurological Surgeons.

Pregnancy and parental leave among neurosurgeons and neurosurgical trainees.

Despite recently heightened advocacy efforts relating to pregnancy and family leave policies in multiple surgical specialties, no studies to date have described female neurosurgeons' experiences with childbearing. The AANS/CNS Section of Women in Neurosurgery created the Women and Pregnancy Task Force to ascertain female neurosurgeons' experiences with and attitudes toward pregnancy and the role of family leave policies. A voluntary online 28-question survey examined the pregnancy experiences of female neurosurgeons and perceived barriers to childbearing. The survey was developed and electronically distributed to all members of the American Association of Neurological Surgeons and Congress of Neurological Surgeons who self-identified as female in February 2016. Responses from female resident physicians, fellows, and current or retired practicing neurosurgeons were analyzed. A total of 126 women (20.3%) responded to the survey; 57 participants (49%) already had children, and 39 (33%) planned to do so. Participants overwhelmingly had or planned to have children during the early practice and senior residency years. The most frequent obstacles experienced or anticipated included insufficient time to care for newborns (47% of women with children, 92% of women planning to have children), discrimination by coworkers (31% and 77%, respectively), and inadequate time for completion of board requirements (18% and 51%, respectively). There was substantial variability in family leave policies, and a minority of participants (35%) endorsed the presence of any formal policy at their institution. Respondents described myriad unique challenges associated with pregnancy and family leave. Pregnancy and family leave pose significant challenges to the recruitment, retention, and advancement of women in neurosurgery. It is thus imperative to promote clear family leave policies for trainees and practitioners, address discrimination surrounding these topics, and encourage forethought and flexibility to tackle obstacles inherent in pregnancy and the early stages of child rearing.

Analysis of Demographic and Educational Backgrounds of Interventional Neuroradiology Fellowship Program Director Workforce in North America

PurposeTo analyse the demographics, academic background, and scholarly activity of Interventional Neuroradiology (INR)/Endovascular Surgical Neuroradiology (ESN) program directors (PDs) in the United States (US) and Canada. MethodsA list of all INR/ESN fellowships was obtained from the Accreditation Council for Graduate Medical Education, the Committee on Advanced Subspecialty Training, maintained by Society of Neurological Surgeons, the NeuroInterventional Training list website maintained by the Society of NeuroInterventional Surgery, and the Neurosurgical Fellowship Training Program Directory website maintained by the American Association of Neurological Surgeons. Online search was performed to identify PDs for these programs. Publicly available sources used to gather information about each PD included the program websites, the HealthGrades and Doximity websites, and Elsevier's Scopus database. Demographic and educational data including age, gender, educational background, subspecialty, appointment age, interval between residency completion and appointment as PD, additional degrees, academic rank, prior leadership positions, and metrics of scholarly activity were recorded. One-way analysis of variance was used to determine differences between the means of different groups. ResultsA total of 78 PDs from 72 programs were included, of which 72 (92.3%) were male with the mean age of 49.59 years (SD 7.25). Specialty division of PDs was neurosurgery (40, 51.3%), radiology (26, 33.3%), and neurology (10, 12.8%), whereas 2 PDs were dual board-certified in neurology and radiology. Twenty-five (32.1%) PDs attended an international medical school. All PDs received an MD degree or foreign equivalent, with no PD holding a DO degree. Eleven PDs received a PhD degree and 16 PDs received fellowship from a professional medical society. The mean ± SD publications, citations, and h-indexes of PDs were 111.32 ± 121.18, 2985.0 ± 1459.0 and 22.27 ± 15.45, respectively. There was no statistical difference in scholarly activity among PDs when stratified on the basis of specialty, gender, and US region. ConclusionINR/ESN PDs are predominantly male, with a majority from neurosurgery background, and thirty percent having graduated from international medical schools.

The value of glial fibrillary acidic protein levels in the diagnosis and prognosis of subarachnoid hemorrhage

Background: Subarachnoid hemorrhages is an important emergency condition due to its high morbidity and mortality. Early diagnosis and rapid intervention are very important to prevent poor clinical outcome of this disease. Objective: The aim of this study was to determine the value of glial fibrillary acidic protein in the diagnosis and prognosis of subarachnoid hemorrhage. Methods: Patients presenting to the emergency department and undergoing computerized tomography and/or lumbar puncture due to suspicion of subarachnoid hemorrhage were included in this prospective study. Based on the computerized tomography–lumbar puncture results, cases were divided into subarachnoid hemorrhage group and non–subarachnoid hemorrhage control group. Subarachnoid hemorrhage patients were classified on the basis of severity of subarachnoid hemorrhage and were classified as good or poor clinical outcome groups based on Glasgow Outcome Scores. Glial fibrillary acidic protein levels were then compared. Results: A total of 111 patients were evaluated due to suspicion of subarachnoid hemorrhage and diagnosed with subarachnoid hemorrhage (n = 73) or without subarachnoid hemorrhage (n = 38). Cerebrospinal fluid glial fibrillary acidic protein levels were significantly higher in the subarachnoid hemorrhage group than in the non–subarachnoid hemorrhage group (p < 0.001) (median (25%–75%): 11.62 (2.64–68.04) and 2.26 (1.5–4.83), respectively). Serum glial fibrillary acidic protein levels of the subarachnoid hemorrhage patients with poor clinical outcomes were higher than those of subarachnoid hemorrhage patients with good clinical outcomes (p = 0.003) and cerebrospinal fluid glial fibrillary acidic protein levels were similar (p = 0.379). Glial fibrillary acidic protein levels at the time of presentation exhibited a low level of correlation with Glasgow coma score, World Federation of Neurological Surgeons scale, Hunter–Hess Scale, Ogilvy–Carter Scale, Glasgow Outcome Score, and modified Rankin score. Conclusion: Cerebrospinal fluid glial fibrillary acidic protein levels may be a valuable diagnostic parameter at the time of presentation for diagnosis of subarachnoid hemorrhage. And also serum glial fibrillary acidic protein levels may be useful in predicting subarachnoid hemorrhage patients with poor clinical outcomes.

Quality Outcomes Database Spine Care Project 2012-2020: milestones achieved in a collaborative North American outcomes registry to advance value-based spine care and evolution to the American Spine Registry.

The Quality Outcomes Database (QOD), formerly known as the National Neurosurgery Quality Outcomes Database (N2QOD), was established by the NeuroPoint Alliance (NPA) in collaboration with relevant national stakeholders and experts. The overarching goal of this project was to develop a centralized, nationally coordinated effort to allow individual surgeons and practice groups to collect, measure, and analyze practice patterns and neurosurgical outcomes. Specific objectives of this registry program were as follows: "1) to establish risk-adjusted national benchmarks for both the safety and effectiveness of neurosurgical procedures, 2) to allow practice groups and hospitals to analyze their individual morbidity and clinical outcomes in real time, 3) to generate both quality and efficiency data to support claims made to public and private payers and objectively demonstrate the value of care to other stakeholders, 4) to demonstrate the comparative effectiveness of neurosurgical and spine procedures, 5) to develop sophisticated 'risk models' to determine which subpopulations of patients are most likely to benefit from specific surgical interventions, and 6) to facilitate essential multicenter trials and other cooperative clinical studies." The NPA has launched several neurosurgical specialty modules in the QOD program in the 7 years since its inception including lumbar spine, cervical spine, and spinal deformity and cerebrovascular and intracranial tumor. The QOD Spine modules, which are the primary subject of this paper, have evolved into the largest North American spine registries yet created and have resulted in unprecedented cooperative activities within our specialty and among affiliated spine care practitioners. Herein, the authors discuss the experience of QOD Spine programs to date, with a brief description of their inception, some of the key achievements and milestones, as well as the recent transition of the spine modules to the American Spine Registry (ASR), a collaboration between the American Association of Neurological Surgeons and the American Academy of Orthopaedic Surgeons (AAOS).

Erratum. Screening duplex ultrasonography in neurosurgery patients does not correlate with a reduction in pulmonary embolism rate or decreased mortality.

"Erratum. Screening duplex ultrasonography in neurosurgery patients does not correlate with a reduction in pulmonary embolism rate or decreased mortality" published on 25 Oct 2019 by American Association of Neurological Surgeons.

Erratum. The T2-FLAIR-mismatch sign as an imaging biomarker for IDH and 1p/19q status in diffuse low-grade gliomas: a systematic review with a Bayesian approach to evaluation of diagnostic test performance.

"Erratum. The T2-FLAIR–mismatch sign as an imaging biomarker for IDH and 1p/19q status in diffuse low-grade gliomas: a systematic review with a Bayesian approach to evaluation of diagnostic test performance" published on May 2020 by American Association of Neurological Surgeons.

Coronavirus Disease 2019 (COVID-19) and Neurosurgery: Literature and Neurosurgical Societies Recommendations Update

BackgroundSince January 2020, when the pathogen causing the coronavirus disease was identified in humans, the literature on coronavirus disease 2019 (COVID-19) has grown exponentially to more than 4000 publications. There is the need to provide an update for each single medical discipline, including neurosurgery, to be used by single professionals or to be distributed through the neurosurgical community and to be used by governments in designing new scenario of care.MethodsA review of the MEDLINE database was performed on April 13, 2020. Search terms included “COVID-19,” “neurosurgery,” and “surgery.” A review of documents published on the webpage of the WFNS (World Federation of Neurosurgical Societies) and of the 5 continental associations of neurosurgical societies, AANS (American Association of Neurological Surgeons), AASNS (Asian Australasian Society of Neurological Surgeons), CAANS (Continental Association of African Neurosurgical Societies), EANS (European Association of Neurosurgical Societies), and FLANC (Latin American Federation of Neurosurgical Societies), representing the 119 national neurosurgical societies around the world, was performed.ResultsThe literature search yielded 38 results that were manually reviewed. Fourteen manuscripts were considered eligible. They described suggestions and considerations to optimize care of neurosurgical patients, editorials on operational models, perspectives from neurosurgical departments, letters to the editor describing experiences on how to help medical staff to be prepared in advance for pandemic situations, and descriptions of regional or departmental models and/or organizational schemes. The webpages of the searched societies reported a total of 57 documents.ConclusionsThe neurosurgical scientific community has promptly reacted to the COVID-19 outbreak by producing a growing number of documents that could serve as guidance for neurosurgeons all over the world. Neurosurgical societies will represent the key institutions for guiding the neurosurgical community to overcome the COVID-19 crisis.

Factors in Residency Decision Making for Female Neurosurgery Applicants

Neurosurgery remains a specialty with one of the largest gender gaps in the United States. Neurosurgery residency programs are highly motivated to attract the best female candidates in an effort to improve their program diversity, but no studies currently exist that examine the factors of highest importance to female applicants for neurosurgery residency selection. The purpose of this study was to determine factors that female neurosurgery residents used when selecting their residency. A 2-part survey was sent to female neurosurgical residents by e-mails collected from the American Association of Neurological Surgeons directory and residency program websites. The survey asked participants to score 17 characteristics of residency programs in terms of importance and then asked them to rank their top 5 most influential factors when selecting a neurosurgery residency. The most important factors included variety/number of cases, camaraderie and happiness of current residents, early surgical/clinical experience, and academic reputation. The least important factors included gender diversity of faculty and residents, number of female residents, number of female faculty, and attitudes toward maternity leave. Efforts to increase female applicants in neurosurgery residency programs should focus on highlighting some more universal, non-gender-related factors, such as happiness and camaraderie among residents and anticipated clinical experiences, as opposed to showcasing features that would seemingly appeal to female applicants, such as maternity leave and number of current female faculty or residents.

Ultra-Early Versus Early Aneurysm Surgery After Subarachnoid Hemorrhage: A Retrospective Outcome Analysis

Abstract Object The timing of definitive management of ruptured intracranial aneurysms has been the subject of considerable debate, although the benefits of early surgery (until 72 hours postictus) are widely accepted. The aim of the present study is to evaluate the potential benefit of ultra-early surgery (until 24 hours) when compared with early surgery, in those patients who were treated by surgical clipping at the Neurosurgery Department of the Coimbra Hospital and University Centre. Methods A 17-year database of consecutive ruptured and surgically treated intracranial aneurysms was analyzed. Outcome was measured by the Glasgow Outcome Scale (GOS). Baseline characteristics were analyzed by the Fisher exact test, the chi-squared and Mann-Whitney tests. Logistic regression was used to assess the impact of good grade according to the World Federation of Neurological Surgeons (WFNS) scale and ultra-early surgery in a good GOS outcome. Results 343 patients who were submitted to surgical clipping in the first 72 hours post-ictus were included, 165 of whom have undergone ultra-early surgery. Demographics and preoperative characteristics of ultra-early and early surgery patients were similar. Good-grade patients according to the WFNS scale submitted to ultra-early surgery demonstrated an improved GOS at discharge and at 6 months. Poor-grade patients according to the WFNS scale submitted to ultra-early surgery demonstrated an improved GOS at discharge. Conclusions Ultra-early surgery for aneurysmal subarachnoid hemorrhage patients improves outcome mainly on good-grade patients. Efforts should be made on the logistics of emergency departments to consider achieving treatment on this timeframe as a standard of care.

Cerebral vascular malformations and their imaging modalities.

Cerebrovascular malformations are uncommon diverse group of dysmorphic vascular communications that may occur sporadically or as part of genetic syndromes. These include non-neoplastic lesions such as arteriovenous malformations (AVM), cavernous malformations (CM), developmental venous anomalies (DVA), and telangiectasias as well as others like arteriovenous fistulas (AVF), vein of Galen malformations (VOGM), and mixed or unclassified angiomas. These lesions often carry a high degree of morbidity and mortality often requiring surgical or endovascular interventions. The field of cerebrovascular anomalies has seen considerable advancement in the last few years. Treatment and management options of various types of brain anomalies have evolved in neurological, neurosurgical, and neuro-interventional radiology arena. The use of radiological imaging studies is a critical element for treatment of such neurosurgical cases. As imaging modalities continue to evolve at a rapid pace, it is imperative for neurological surgeons to be familiar with current imaging modalities essential for a precise diagnosis. Better understanding of these cerebrovascular lesions along with their associated imaging findings assists in determining the appropriate treatment options. In the current review, authors highlight various cerebrovascular malformations and their current imaging modalities.

Dynamics of outcome after aneurysmal subarachnoid hemorrhage.

In this observational study, we analyzed and described the dynamics of the outcome after aneurysmal subarachnoid hemorrhage (SAH) in a collective of 203 cases. We detected a significant improvement of the mean aggregate modified Rankin Score (mRS) in every time interval from discharge to 6 months and up to 1 year. Every forth to fifth patient with potential of recovery (mRS 1-5) at discharge improved by 1 mRS point in the time interval from 6 month to 1 year (22.6%). Patients with mRS 3 at discharge had a remarkable late recovery rate (73.3%, p = 0.000085). Multivariate analysis revealed age ≤ 65 years (odds ratio 4.93; p = 0.0045) and “World Federation of Neurological Surgeons” (WFNS) grades I and II (odds ratio 4.77; p = 0.0077) as significant predictors of early improvement (discharge to 6 months). Absence of a shunting procedure (odds ratio 8.32; p = 0.0049) was a significant predictor of late improvement (6 months to 1 year), but not age ≤ 65 years (p = 0.54) and WFNS grades I and II (p = 0.92). Thus, late recovery (6 month to 1 year) is significant and independent from age and WFNS grade.

A Survey of Applicant Views Regarding the Neurosurgical Fellowship Application Process

The process of fellowship selection remains unclear and heterogeneous among subspecialties in neurosurgery. We surveyed neurosurgical residents applying for subspecialty fellowships about their experiences to evaluate the process and find areas for improvement. We distributed an online, nationwide survey to 153 U.S. neurosurgical residents (postgraduate years 5-7) identified via the American Association of Neurological Surgeons resident database. Sixty-nine residents responded to the survey, representing a variety of subspecialties. Most residents applied for 2-5 programs (45%) and completed 2-5 interviews (45%). The primary methods of finding fellowships were via word of mouth (68%) and faculty mentors (67%), followed by Web sites and reaching out to fellowship directors (54%) and online database searching (46%). Although many residents applied for fellowships in postgraduate year 5 of training (39%), there was significant variability in times for interviews and offer letters. Most residents accepted their first offer (75%). Most respondents (93%) believed that national neurosurgical societies should help improve the fellowship application process, with reasons including a common application and due dates (29%), fellowship database with program details (29%), and improved coordination of interviews (23%). Regarding a nationalized match system, residents were roughly split among opposed (38.6%), neutral (26.3%), and supportive (35.1%). These survey results suggested that the neurosurgical fellowship application process could be improved by a common application, public listing of programs, standardized dates for application, and improved coordination of interviews. Residents are generally supportive of having an improved organization of the match and/or a national fellowship match.

Prognostic factors varying with age in patients with aneurysmal subarachnoid hemorrhage

With the advent of an aging society, more elderly patients with aneurysmal subarachnoid hemorrhage (aSAH) have been treated. We investigated if prognostic factors differ with age in aSAH patients. In a prospectively maintained aSAH database at multiple institutions from 2013 to 2016, 238 patients who underwent clipping or coiling for a ruptured aneurysm within 48 h of onset were divided into elderly (≥75 years; 57 patients) and non-elderly groups, or categorized into 4-age groups (<54, 55–64, 65–74, and ≥75 years). Prognostic factors and clinical characteristics were retrospectively analyzed. The elderly group had a higher incidence of pre-morbidities, co-morbidities, poor admission World Federation of Neurological Surgeons (WFNS) grades, modified Fisher grade 4, and resultantly 90-day poor outcomes (modified Rankin scale [mRS] 3–6). Multivariate logistic regression analyses revealed that independent determinants for poor outcomes were hypertension and modified Fisher grade 4 in the elderly group, and admission WFNS grades IV–V, systemic complications, non-procedural cerebral infarction and shunt-dependent chronic hydrocephalus in the non-elderly group. The 4-age group analyses showed that higher age group was more frequently associated with the prognostic factors. As higher age itself causes poor outcomes and more association of prognostic factors, prognostic factors in elderly patients may be rather limited.

Interpretation of Evidence-based Guidelines on Role of Emerging and Investigational Therapies for Treatment of Adults with Metastatic Brain Tumors Published by CNS in 2019

脑转移瘤是成人最常见的颅内肿瘤之一。美国神经外科医师大会（Congress of Neurological Surgeons, CNS）曾于2010年发布《脑转移瘤治疗的循证医学指南》，为脑转移瘤的规范化治疗奠定了基础。基于近年来新型疗法的进展，该学会在原指南基础上，回顾分析最新文献，制定了2019版《成人脑转移瘤治疗中新兴及试验性疗法的系统回顾和循证指南》，对高强度聚焦超声、激光间质热疗、放射增敏、免疫调节、分子靶向药物等新型治疗方法进行了讨论。本文将就新指南作一介绍和解读。

A human amygdala site that inhibits respiration and elicits apnea in pediatric epilepsy.

BACKGROUNDSeizure-induced inhibition of respiration plays a critical role in sudden unexpected death in epilepsy (SUDEP). However, the mechanisms underlying seizure-induced central apnea in pediatric epilepsy are unknown.METHODSWe studied 8 pediatric patients with intractable epilepsy undergoing intracranial electroencephalography. We recorded respiration during seizures and during electrical stimulation mapping of 174 forebrain sites. A machine-learning algorithm was used to delineate brain regions that inhibit respiration.RESULTSIn 2 patients, apnea coincided with seizure spread to the amygdala. Supporting a role for the amygdala in breathing inhibition in children, electrically stimulating the amygdala produced apnea in all 8 subjects (3-17 years old). These effects did not depend on epilepsy type and were relatively specific to the amygdala, as no other site affected breathing. Remarkably, patients were unaware that they had stopped breathing, and none reported dyspnea or arousal, findings critical for SUDEP. Finally, a machine-learning algorithm based on 45 stimulation sites and 210 stimulation trials identified a focal subregion in the human amygdala that consistently produced apnea. This site, which we refer to as the amygdala inhibition of respiration (AIR) site includes the medial subregion of the basal nuclei, cortical and medial nuclei, amygdala transition areas, and intercalated neurons.CONCLUSIONSA focal site in the amygdala inhibits respiration and induces apnea (AIR site) when electrically stimulated and during seizures in children with epilepsy. This site may prove valuable for determining those at greatest risk for SUDEP and as a therapeutic target.FUNDINGNational Institute of Neurological Disorders and Stroke - Congress of Neurological Surgeons, National Institute of General Medical Sciences, Roy J. Carver Charitable Trust.

A comparison of endovascular strategies in the treatment of ruptured vertebral artery aneurysms

BackgroundContemporary management of ruptured vertebral artery dissecting aneurysms (VADA) has evolved beyond proximal parent artery occlusion (PPAO) to include endovascular trapping (ET) of the diseased segment and vessel preserving stent treatments. The aim of this retrospective cohort study was to assess the outcomes of patients with ruptured VADAs who underwent endovascular management with trapping of the diseased segment as the first-line treatment approach. MethodsWe evaluated an institutional database of patients with ruptured VADAs who were treated at Auckland City Hospital from 1998 to 2017. Baseline and outcomes data were analyzed. High-grade SAH was defined as a World Federation of Neurological Surgeons or a Hunt and Hess grade of IV-V. Favorable outcome was defined as a modified Rankin Scale of 0–2. ResultsThe study cohort was comprised of 45 ruptured VADA patients with a mean age of 50 years. The mean follow-up duration was 12.9 months. ET of the diseased segment was performed in 32 cases (71.1%), PPAO of the VA was performed in 12 cases (26.7%) and reconstruction using a flow diverting stent was performed in 1 case (2.2%). The overall procedural complication rate was 13%, including procedural neurological morbidity in 4.4%. At last follow-up, no further aneurysm filling was seen in any case, and 77.8% had a favorable outcome. ConclusionET affords a favorable risk to benefit profile for patients with ruptured VADAs. ET remains a reasonable option for ruptured VADAs in patients with sufficient collateral supply to the vertebrobasilar system.

The neurosurgical curriculum: Which procedures are essential?

ObjectiveTraditionally, neurosurgery is a competitive field. Throughout the years, the surgical armamentarium has been subject to change, e.g. due to the rise of indications for gamma knife, functional or endovascular surgery. Furthermore, due to modern day issues among residents, such as work hour restrictions (WHRs) and prevalence of burn-out, may require contemporary modifications of the neurosurgical curriculum. By the means of this cross sectional research, the current curriculum is evaluated. MethodsIn September 2019, a 21-question survey was mailed to members of the Congress of Neurological Surgeons using SurveyMonkey. The survey consisted out of 3 parts: demographics of the respondents, respondent‘s neurosurgical residency and opinions on essential procedures. ResultsAfter the two reminders, 578 members responded resulting in a response rate of 7.3%. Respondents had a mean residency program of 7 years (range 3 to 12 years). Of the residents, 87.5% had a weekly WHR of 80 h per week. A minority (43.8%) felt WHRs would limit the chances of residents to master surgical techniques.Neurotraumatical procedures such as decompression of subdural (91.5%) and epidural (91.3%) hematoma‘s, ventriculoperitoneal shunt insertion (86.9%), Chiari decompression (81.4%) and cervical discectomy (81.4%) were the procedures respondents mastered the most. This in contrast to endovascular procedures (67.9%), percutaneous endoscopic lumbar discectomy (48.5%) and deep brain stimulation (34%), in which respondents were less proficient. ConclusionsThe current study gives an evaluation of different neurosurgical curricula and aimed to identify which surgical procedures are deemed as essential by neurosurgeons worldwide. Functional neurosurgery is the field in which most neurosurgeons required more instruction. Neuroendovascular and Gamma knife surgery were subspecializations in which neurosurgeons were less proficient but also specializations that were deemed more desirable to be known during residency.

Pediatric neurosurgery training during residency in the United States: a program director survey.

Pediatric neurosurgery is a core component of neurosurgical residency training. Pediatric case minimums are established by the Neurosurgery Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME). Case minimums, by themselves, allow for great variability in training between programs. There are no prior data on how the residency programs meet these requirements. The authors' objective was to gather information on pediatric neurosurgical education among the ACGME-accredited neurosurgery training programs in order to shape further pediatric neurosurgical educational efforts. A 25-question survey about pediatric neurosurgical education was created by the Education Committee of the Section on Pediatric Neurological Surgery of the American Association of Neurological Surgeons/Congress of Neurological Surgeons and distributed to program directors of all 111 ACGME-accredited neurosurgery training programs. The response rate was 77% (86/111). In 55% of programs the residents are rotated to a responder-designated "freestanding" children's hospital, and 39% of programs rotate residents to a children's hospital within a larger adult hospital or a general hospital. There are 4 or fewer pediatric neurosurgical faculty in 91% of programs. In 12% of programs less than 100 cases are performed per year, and in 45% more than 500 are performed. In 31% of responding neurosurgery residency programs there is also a pediatric neurosurgery fellowship program supported by the same sponsoring institution. Seventy-seven percent of programs have at least one specific pediatric neurosurgery rotation, with 71% of those rotations occurring during postgraduate year 3 and 50% occurring during postgraduate year 4. The duration of pediatric rotation varies from no specific rotation to more than 1 year, with 48% of residents spending 4-6 months on a pediatric rotation and 12% spending 7-11 months. Last, 17% of programs send their residents to external sites sponsoring other residency programs for their pediatric rotation. There is great variety between neurosurgery training programs with regard to resident education in pediatric neurosurgery. This study's data will serve as a baseline for future studies, and the authors hope the findings will guide further efforts in pediatric neurosurgical education in residency training programs.