Neurosurgical Care Research Articles

Neurosurgery in Pakistan: Past, Present, and Future.

Since its independence from India in 1947, Pakistan has struggled with economic crises such as global debt, corruption, constant regime change, and a decades-long war against terrorism. The resulting socioeconomic barriers have stymied efforts to develop a comprehensive and equitably accessible healthcare system, especially regarding safe, timely, and affordable surgical care. This article evaluates neurosurgery's development, current state, and prospects in Pakistan, a lower-middle-income country. We performed a literature search using PubMed and analyzed relevant articles to better understand the state and landscape of neurosurgery in Pakistan. Moreover, we conducted ecological research by querying the databases of the World Bank and the Institute of Health Metrics and Evaluation to evaluate the neurological and neurosurgical disease burden in the Pakistani population. The neurosurgical workforce in Pakistan has demonstrated rapid growth over the past two decades, with approximately 450 neurosurgeons and a neurosurgeon-per-100 000 population density of 0.114. Nonetheless, access to essential neurosurgical procedures for the treatment of diseases such as stroke has been difficult to ensure, which likely contributes to Pakistan's stroke burden, ie, stroke was still the third most common cause of death in 2019, causing 21.7% of all deaths. While Pakistan's political and economic instability has adversely affected the development of neurosurgery, the field has still made great strides and demonstrates a promising future in providing equitable neurosurgical care to all Pakistan's people.

Neurosurgery in Australia's Top End: the lifesaving advantages of developing sustainable neurosurgical care in rural and remote regions.

The authors' goal was to perform a retrospective audit of all emergency cranial neurosurgery performed at the Royal Darwin Hospital in the first 5 years of the unit and to compile their data in a similar fashion to an earlier study titled "Emergency Neurosurgery in Darwin: Still the Generalist Surgeons' Responsibility," which was published in 2015. All emergency cranial neurosurgery performed by a neurosurgeon between 2017 and 2021 was identified. Data were extracted from the National Critical Care and Trauma Response Centre database. Statistical analyses were descriptive logistic regression performed using Stata version 15.1 software to examine factors associated with death. A total of 320 patients (42% Indigenous) underwent 427 emergency neurosurgeries. There were 35 emergency neurosurgeries in 2017 and 82 in 2021. The most common procedure performed was insertion of an external ventricular drain, followed by craniotomy and removal of intracranial hematoma. Mortality was 7.5% overall and 8.4% among patients with trauma. Only age proved to be a statistically significant independent risk factor for death (t = -2.95, p < 0.0041; OR 1.06, p = 0.02). Location, sex, injury severity, and presenting Glasgow Coma Scale score were not associated with death. Indigenous and non-Indigenous patients had similar outcomes. The data illustrate the importance of developing small but sustainable neurosurgical units in rural and remote areas. A dedicated neurosurgical unit at the Royal Darwin Hospital has led to an increase in the amount and variety of emergency neurosurgery performed in Darwin. Interstate transfers have reduced. This has tangible lifesaving and economic advantages.

Caregiver-reported satisfaction with pediatric movement disorder surgery.

Patient- and surrogate-reported outcomes are increasingly recognized as important and historically limited dimensions of satisfaction with medical care. Evaluating caregiver satisfaction for cerebral palsy (CP) patients with pediatric movement disorders (PMDs) remains undefined, limited by a lack of appropriate tools and the heterogeneity of the patient population. The authors identified caregiver satisfaction with the neurosurgical management of PMDs as a key quality metric and report their results across an institutional experience. A retrospective single-institution survey study was performed on caregivers of consecutive children who underwent PMD surgery from March 2022 to December 2023. The authors designed a brief 4-question satisfaction survey with dichotomous yes/no answers. The telephone survey solicited answers from primary caregivers, and contact attempts were made 3 times before labeling a nonresponder. Non-English speakers were included. The survey answers were correlated with demographic characteristics, clinical data, and complications. Descriptive statistics were performed using Excel. Seventy patients were identified in the study period with 50 associated caregivers voluntarily responding to the questionnaire (50/70 [71.4%]). Forty-six male and 24 female patients with a mean (range) age of 13.1 (2-34) years and a follow-up range of 3-20 months were included. All 50 caregivers reported satisfaction with the surgical care their child received: 100% confirmed they would refer others to the program and 94% confirmed that they would have the surgery again in retrospect. Ten caregivers (10/50 [20%]) recalled complications, but only 5 (5/50 [10%]) surgical complications resulted in hospital readmission. Caregivers were overwhelmingly satisfied with the neurosurgical care for PMDs and would recommend the functional pediatric neurosurgery program to others. A large percentage would again submit to the surgery. There is a perception disparity between caregiver- and hospital-identified complications; it may be beneficial to emphasize expected adverse effects with caregivers prior to surgery. Caregiver satisfaction remains an important quality dimension and future research may benefit from more objective metrics.

Successful control of an environmental reservoir of NDM-producing Klebsiella pneumoniae associated with nosocomial transmissions in a low-incidence setting

BackgroundThe hospital wastewater system has been reported as a source of nosocomial acquisition of carbapenemase producing Enterobacteriaceae (CPE) in various settings. Cleaning and disinfection protocols or replacement of contaminated equipment often fail to eradicate these environmental reservoirs, which can lead to long-term transmission of CPE. We report a successful multimodal approach to control a New Delhi metallo-beta-lactamase positive Klebsiella pneumoniae (NDM-KP) nosocomial outbreak implicating contamination of sink traps in a low-incidence setting.MethodsFollowing the incidental identification of NDM-KP in a urine culture of an inpatient, we performed an epidemiological investigation, including patient and environmental CPE screening, and whole genome sequencing (WGS) of strains. We also implemented multimodal infection prevention and control (IPC) measures, namely the isolation of cases, waterless patient care, replacement of contaminated P-traps and connecting pieces, and bleach and steam disinfection of sinks for 6 months, followed by patient and environmental screenings for eradication.ResultsBetween February and May 2022, five NDM-KP cases were identified in an eight-bed neurosurgical intermediate care unit. Among the eight sink traps of the unit, three were positive for NDM-KP. Patient and environmental isolates belonged to multilocus sequence typing ST-268. All isolate genomes were genetically very similar suggesting cross-transmission and a potential role of the environment as the source of transmissions. Following the introduction of combined IPC measures, no new case was subsequently detected and sink traps remained negative for NDM-KP within 6 months after the intervention.ConclusionThe implementation of multimodal IPC measures, including waterless patient care combined with the replacement and disinfection of P-traps and connecting pieces, was successful in the control of NDM-KP after eight months. In a low-incidence setting, this approach has made it possible to pursue the objective of zero transmission of carbapenemase-producing Enterobacteriaceae (CPE).

The Boston Declaration 2025: Plan and Pledges for Progress in Global Neurosurgery

Global neurosurgery has been described as the clinical and public health practice of neurosurgery with the primary purpose of ensuring timely, safe, and affordable neurosurgical care to all who need it. Global neurosurgery activities in the form of mission trips, educational partnerships, and research collaborations have been in place for decades. Still, there have been no central organizing efforts to improve the harmonization of these endeavors until recently. The 2016 Bogotà Declaration on Global Neurosurgery was the first meeting of global neurosurgery practitioners from low- and middle-income countries (LMICs) and high-income countries (HICs) to organize a consensus statement around the global gaps in neurosurgery care and goals for its future development. Since then, interest in global neurosurgery has grown dramatically among neurosurgeons, trainees, nurses, and allied professionals. Global neurosurgery has emerged as a distinct academic subspecialty within neurosurgery. However, recent evidence demonstrates that wide gaps remain in access to safe, timely, and affordable neurosurgical care. Quite as important is the current dominance of global neurosurgery discourse by HIC actors. The Boston Declaration seeks to further define a unified vision of progress as global neurosurgery continues to grow and evolve. This ambitious initiative will review existing evidence, employ on-the-ground expert experience, and seek broad inclusivity and transparency to formulate a new set of goals for global neurosurgery and a structure that shifts the agency to LMIC actors. We propose a path to developing a new consensus statement and action plan, the 2025 Boston Declaration for Global Neurosurgery.

Current Applications of the Three-Dimensional Printing Technology in Neurosurgery: A Review.

In the recent years, three-dimensional (3D) printing technology has emerged as a transformative tool, particularly in health care, offering unprecedented possibilities in neurosurgery. This review explores the diverse applications of 3D printing in neurosurgery, assessing its impact on precision, customization, surgical planning, and education. A literature review was conducted using PubMed, Web of Science, Embase, and Scopus, identifying 84 relevant articles. These were categorized into spine applications, neurovascular applications, neuro-oncology applications, neuroendoscopy applications, cranioplasty applications, and modulation/stimulation applications. 3D printing applications in spine surgery showcased advancements in guide devices, prosthetics, and neurosurgical planning, with patient-specific models enhancing precision and minimizing complications. Neurovascular applications demonstrated the utility of 3D-printed guide devices in intracranial hemorrhage and enhanced surgical planning for cerebrovascular diseases. Neuro-oncology applications highlighted the role of 3D printing in guide devices for tumor surgery and improved surgical planning through realistic models. Neuroendoscopy applications emphasized the benefits of 3D-printed guide devices, anatomical models, and educational tools. Cranioplasty applications showed promising outcomes in patient-specific implants, addressing biomechanical considerations. The integration of 3D printing into neurosurgery has significantly advanced precision, customization, and surgical planning. Challenges include standardization, material considerations, and ethical issues. Future directions involve integrating artificial intelligence, multimodal imaging fusion, biofabrication, and global collaboration. 3D printing has revolutionized neurosurgery, offering tailored solutions, enhanced surgical planning, and invaluable educational tools. Addressing challenges and exploring future innovations will further solidify the transformative impact of 3D printing in neurosurgical care. This review serves as a comprehensive guide for researchers, clinicians, and policymakers navigating the dynamic landscape of 3D printing in neurosurgery.

Disparities in neurosurgical care: Using length of stay to evaluate efficiency of care in New York City hospitals

Objective: We sought to analyze public and private hospital patient cohorts in New York City (NYC) to assess differences in hospital access and outcomes from 2009-2022.Methods: Inpatient neurosurgical discharges, as determined by APR-DRG codes, from 2009-2022 were aggregated for seven NYC hospitals, four private and three public, via the Statewide Planning and Research Cooperative System (SPARCS). Statistical analyses (Z-tests) were performed in Python.Results: 325,351 patients were identified, 223,361 private and 101,990 public. Private hospitals had lower high-severity to low-severity and higher high-mortality to low-mortality risk ratios relative to public hospitals (p &lt; .001). Public hospitals treated a higher proportion of stroke and trauma (p &lt; .001). Average length of stay (LOS) was shorter at private hospitals compared to public (5.3 vs. 7.1 days, p &lt; .001). Statistical significance remained when stratifying for illness severity and elective versus non-elective surgery status. Interestingly, cranial trauma cases were associated with a longer LOS in private hospitals relative to public (7.9 vs. 5.7 days, p &lt; .001).Conclusions: While many factors influence outcomes in private versus public hospitals, LOS can mark the efficiency of care. LOS was shorter at private hospitals in all instances except with cranial trauma. Care efficiency is important for hospital reimbursement, which can directly impact available resources for patient care. These findings emphasize the need to further analyze patient accessibility to neurosurgical care at private hospitals and the resources necessary to support neurosurgical practices within public hospitals.

OPTIC PATHWAY GLIOMAS AFTER TRANSITIONING INTO ADULTHOOD – AN INSTITUTIONAL EXPERIENCE

Abstract AIMS Optic pathway gliomas (OPG) are rare tumors affecting the optic nerve and the chiasm that occur predominantly during childhood and are generally managed by pediatric neurosurgeons/ pediatric oncologists. Prognosis is quite good for these benign tumors, and many patients survive into adulthood. While clinical care for these patients in childhood is well-standardized, the clinical course of patients with OPG after transitioning into adulthood is not well studied.We herein aimed to characterize patients with OPG diagnosed in childhood after transitioning into adult neurosurgical care in order in order to ellucidate the clinical course of OPG in adulthood and to identify potential problems with clinical care of these special patients in adult neurosurgery or neuro-oncology services. METHOD Clinical and radiographical data from adult patients (&amp;gt; 16 years of age) with OPG diagnosed in childhood and treated in our institution were collected from patient charts. Descriptive statistics and outcome analysis were performed using commercial statistical software. RESULTS Of 124 patients with OPG diagnosed in childhood, 35 patients transitioned into adulthood. The population included equal distribution of male (18, 51.4%) vs female (17, 48.6%) patients. Median age at diagnosis was 8.0 years (range 0.5 – 15.0) and median age at last follow up was 20.8 years (range 17.1 – 38.6). 12 patients were positive for NF (34.3%). 9 patients had undergone surgery for the OPG (25.7%), 11 had chemotherapy (31.4%) and 15 (42.8%) had received radiotherapy. 8 patients showed an endocrine deficiency (22.9%), 4 hypothalamic dysfunction (11.4%) and 8 cognitive/behavioral difficulties (22.9%). Visual acuity impairment was detected in 12 patients (34.3%). 9 patients experienced recurrence (25.7%). CONCLUSION Patients with OPG transition into adulthood frequently and experience a wide range of clinical problems. Close neurosurgical/neuro-oncology specialist follow-up is recommendable.

Postoperative wound care protocol prevents surgical site infection after craniotomy.

Postoperative wound care after craniotomy is not standardized. Evaluate the impact of a standardized post-craniotomy wound care protocol on surgical site infection (SSI). Prospective quasi-experimental single-center intervention cohort study involving adult patients undergoing craniotomy at a 461-bed academic medical center in Orange County, California from January 2019-March 2023 (intervention) compared to January 2017-December 2018 (baseline). A postoperative neurosurgical wound care protocol was developed involving chlorhexidine cloths to remove incisional clots and to clean the surgical incision and adjacent hair after craniotomy surgery. Protocol adherence was monitored by routine inpatient surveillance of wounds and photo-documentation for real-time feedback to surgeons and nursing staff. Impact of the intervention was assessed using multivariable regression models. There were 3560 craniotomy surgeries and 62 (1.7%) SSIs; 1251 surgeries and 30 (2.4%) SSIs during baseline, and 2309 surgeries and 32 (1.4%) SSIs during intervention. Process evaluation after implementation found significant decreases in incisional clots, erythema, drainage, and unclean hair. In multivariable analysis, the intervention was associated with fewer SSI (odds ratio (OR): 0.5 (0.3, 0.9), P = 0.02). A standardized post-craniotomy wound care protocol involving cleaning of the incision and adjacent hair, including removal of incisional clots with chlorhexidine cloths was effective in reducing the risk of SSI.

Marine bioactives: a new frontier in neurosurgical therapeutics.

Bioactives derived from marine sources are opening up new therapeutic opportunities for neurosurgery. These include tissue regeneration, neuroprotection, and infection control. These molecules derived from extreme marine conditions have generated new modes of action, for example, selective inhibition of voltage-gated ion channels and influencing pathways of neuroinflammation. Representative examples include chitosan for nerve regeneration, conotoxins for pain modulation, and fucoidan for neuroprotection. Despite therapeutic promise, major challenges remain: those of sustainable sourcing and regulatory validation. This letter points up the potential of marine bioactives to change neurosurgical care and challenges the brain communities to work together across disciplines in order to make that happen.

The Low-Income and Middle-Income Countries' Perspective on Global Neurosurgery Collaborations.

Access to neurosurgical care is limited in low-income and middle-income countries (LMICs) and in marginalized communities in high-income countries (HICs). International partnerships represent one possible means of addressing this issue. Insights from surgeons in HICs have been explored, but data from LMICs' counterparts are scarce. We aimed to study the perspectives of neurosurgeons and trainees from LMICs regarding global neurosurgery (GN) collaborations and interests, motivators, and challenges in participating. An online survey was conducted targeting neurosurgeons and trainees from LMICs. The survey explored demographics, previous experiences, ongoing activities, interests, and barriers related to GN activities. Data were collected between July 2022 and December 2022 and analyzed. Responses involved 436 individuals. The most represented region (25%) was sub-Saharan Africa, and most respondents were male (87.8%) aged 35-49 years. Interest in GN was high, with 91% after its developments. Most respondents (96.1%) expressed interest in training, professional, or research experience in HICs, but only 18.1% could cover the expenses. A majority (73.2%) strongly agreed to return to their home country for work after HIC training. Ongoing HIC-LMIC partnerships were reported by 27.8% of respondents. Clinical exposure emerged as the most relevant motivating factor (87%), while financial concerns, lack of opportunities, and lack of program support were identified as important barriers. Funding and dedicated time were highlighted as the most crucial facilitators. Understanding the perspectives of neurosurgeons and trainees from LMICs is essential to expanding HICs-LMICs collaborations and improving access to neurosurgical care worldwide. Financial support and targeted interventions are needed to address barriers and promote equitable partnerships in GN.

The History and Current State of Neurosurgery in the Republic of Moldova: Celebrating the 25th Anniversary of the Founding of the Department of Neurosurgery

Five billion people worldwide lack access to safe, timely, and affordable surgical and anesthesia care. This deficit is greatest in low- and middle-income countries, especially for specialty surgical services including neurosurgery, due to insufficient personnel, resources, and infrastructure. The southeastern European nation of the Republic of Moldova is one such middle-income country. Discussions with key individuals involved in neurosurgical care in Moldova were conducted to characterize the history and current state of neurosurgery in Moldova. Via a process of chain referral sampling, all practicing neurosurgeons in Moldova were invited to participate in the execution and authorship of this project. Developing from origins in the Soviet Union, neurosurgery became part of the national health system in the 1940s, with the creation of the first neurosurgery department in 1999. Eleven hospitals, including eight public and three private, offer neurosurgical services, with 239 beds and 5330 cases performed in 2023. Most attending neurosurgeons and residents are male, but this is changing as women comprise over one-third of residents in training. There is one neurosurgery residency program and a 2-year fellowship in endovascular neurosurgery in Moldova, with further fellowship training received outside of the country. CT and MRI are available at most centers. This article provides the first-ever description of the history and current state of neurosurgery in Moldova and presents key recommendations to guide the international neurosurgery community in developing neurosurgical care in countries with an unmet need.

PDOC-02 SUB-SAHARAN AFRICAN EXPERIENCE OF NEUROSURGICAL-ONCOLOGIC CARE: CHALLENGES AND BARRIERS ENCOUNTERED AT 7 CANCER TREATMENT CENTERS

Abstract BACKGROUND Wide disparities in neurosurgical-oncologic care and treatment outcomes exists globally despite recent improvements in diagnostics and cancer therapy. To better understand the challenges to neurosurgical-oncologic care in low resource settings, we collected data on national neurosurgery capacity and hospital diagnostic and treatment capacity across 7 national referral hospitals in 7 countries Sub-Saharan Africa (SSA). METHODS A 42-item self-administered questionnaire was distributed to partner neurosurgeons at the 7 sites via REDCap in April 2023 to provide country and hospital level capacity data on neurosurgical-oncologic care. RESULTS Neurosurgical and neurosurgical-oncologic care was reported to be available in a limited number of provinces/states/regions in 6 out of the 7 countries. The neurosurgery and pediatric neurosurgery workforce density across the 7 countries ranged between 0.03 – 0.67 per 100,000 and 0 – 0.05 per 100,000 respectively. Three hospitals had no pediatric ICU with the remaining four having between 2-8 bed-capacity pediatric ICU. One hospital did not have both CT and MRI scanner available and relied solely on private diagnostic facilities for neuroimaging. Histopathology services were largely limited to basic hematoxylin and eosin (H&amp;E) and/or advanced histopathology staining. Molecular subtyping was available at only one hospital. None of the 7 hospitals had neurocritical care expertise, neuroradiologist, or neuropathologist. Four hospitals had a pediatric anesthesiologist. Only one hospital had a neuro-oncologist, but none had a pediatric neuro-oncologist. Both adjuvant chemotherapy and radiotherapy was unavailable at 3 hospitals. Rehabilitation was largely limited to basic physical and occupational therapy at all 7 hospitals. Although all 7 countries had a multiple health payer system, the payment structure differed across the 7 hospitals for different neurosurgical-oncologic services with patients making out-of-pocket payments for all services in some cases. Financial constraint was reported as a major barrier to care. CONCLUSION System-level interventions are needed to strengthen neurosurgical-oncologic care capacity in SSA.

Defining pediatric neurosurgery in low-income countries: a cross-sectional study in Ethiopia.

Pediatric neurosurgical practice is prevalent in most low- and lower-middle-income countries but lacks comprehensive documentation of practice patterns, demographics, and case variety. This study aimed to present the current state of pediatric neurosurgery in Ethiopia, including workforce characterization, case variety, and relevant procedures. A survey was developed and distributed to all Ethiopian fully trained neurosurgeons (n = 50). Survey questions assessed sociodemographic variables, level of training, case variety, and neurosurgical practice. Statistical analysis was conducted to describe the current practice of pediatric neurosurgery. A total of 45 neurosurgeons responded (90%). Three respondents (7%) were women. There was only 1 fellowship-trained pediatric neurosurgeon, while most neurosurgeons were general neurosurgeons who served a pediatric patient population. Most neurosurgeons (56%) worked in the capital city, Addis Ababa, while another 13% worked in other urban settings. The top three indications for a pediatric neurosurgical procedure were neural tube defects (NTDs) (96%), hydrocephalus (93%), and trauma (60%). NTD-associated hydrocephalus was the most common hydrocephalus type seen (71%). The most common procedure for hydrocephalus was shunt insertion (96%). A prenatal diagnosis of NTD was made in < 10% of cases, as reported by 84% of respondents. The study highlights Ethiopia's need for more pediatric neurosurgeons. Suggested strategies to facilitate subspecialty training include the establishment of a fellowship program facilitated by the implementation of a nationwide pediatric neurosurgery registry. Promoting efforts for early diagnosis and treatment of pediatric conditions coupled with NTD prevention initiatives could improve pediatric neurosurgical care in Ethiopia.

Cerebral Microcirculation: Progress and Outlook of Laser Doppler Flowmetry in Neurosurgery and Neurointensive Care.

Laser Doppler flowmetry (LDF) is a well-established technique for the investigation of tissue microcirculation. Compared to skin, the use in the human brain is sparse. The measurement of cerebral microcirculation in neurointensive care and during neurosurgery is challenging and requires adaptation to the respective clinical setting. The aim of the review is to present state of the art and progress in neurosurgery and neurointensive care where LDF has proven useful and can find clinical importance in the investigation of cerebral microcirculation. The literature in the field is summarized and recent technical improvements regarding LDF systems and fiber optical probe designs for neurosurgical and neurocritical care described. By combining two signals from the LDF unit, the measurement of the microcirculation (Perfusion) and gray whiteness (TLI) of the brain tissue, the full potential of the device is achieved. For example, a forward-looking LDF-probe detects high-risk hemorrhage areas and gray-white matter boundaries along intraoperative trajectories during stereotactic neurosurgery. Proof of principles are given for LDF as a guidance tool in deep brain stimulation implantation, brain tumor needle biopsies, and as long-term monitoring device in neurocritical care. With well-designed fiber optical probes, surgical fixation, and signal processing for movement reduction, LDF monitoring of the cerebral microcirculation is successful up to 10 days. The use of LDF can be combined with other physiological measurement techniques, for example, fluorescence spectroscopy for identification of glioblastoma during tumor surgery. Fiber optics can also be used during magnetic resonance imaging (MRI). Despite the many advantages, fiber optical LDF has not yet reached its full potential in clinical neuro-applications. Multicenter studies are required to further evaluate LDF in neurosurgery and neurointensive care. In conclusion, the present status of LDF in neurosurgery and neurointensive care has been reviewed. By combining Perfusion and TLI with tailored probe designs the full potential of LDF can be achived in measuring cerebral microcirculation. This includes guidance during DBS implantation and needle biopsies, and long-term monitoring in neurocritical care.

Integration of Palliative Care in Neurosurgical Critical Care : Insights from a Single-Center Perspective.

Palliative care is a specialized approach designed to enhance the quality of life for both patients and their families, offering patient-centered care through comprehensive assessment and care planning. However, the integration of palliative care within neuro-critical care settings has been relatively understudied. This descriptive study aims to identify the characteristics, palliative care needs, and outcomes of patients referred to palliative care services during admission to the neurosurgical intensive care unit (NS-ICU). A retrospective analysis of adults admitted to the NS-ICU at a referral hospital between December 2019 and December 2021 was conducted. The study focused on those referred to the inpatient palliative care team with diagnoses of non-traumatic brain hemorrhage, traumatic brain injury, or brain neoplasm. Excluded were patients who died before palliative care consultation or lacked sufficient information. The investigation assessed demographic and clinical characteristics at consultation, along with post-consultation hospital outcomes derived from medical records and interview notes. In this study involving 38 enrolled patients, the median age was 65, with 42.1% females. The most prevalent diagnosis was non-traumatic brain hemorrhage (47.4%). Reasons for palliative care consultation included psychosocial support (95%), goal-of-care discussions (68%), decision-making support (50%), and communication facilitation (39%). The median time from NS-ICU admission to consultation was 3.5 days (range: 1-8 days), and all interviews involved family members. Key decision topics encompassed mechanical ventilation (23.7%) and tracheostomy (21.1%). Patient preferences for life-sustaining treatment could be estimated in only 47.4% of cases, often resulting in treatment disagreement. Among the 38 patients, 26 (68.4%) died during admission. Before the consultation, full code status, partial code status, and comfort care alone were reported as 32%, 66%, and 2%, respectively; post-consultation, these figures shifted to 11%, 42%, and 47%, respectively. Palliative care was predominantly sought for psychosocial support and discussions concerning goals of care. Despite challenges in ascertaining patient treatment preferences, palliative care consultations proved invaluable in aiding family members and facilitating treatment decision-making. Our study suggests the potential integration of palliative care within neuro-critical care, contributing to a heightened utilization of comfort care at the end-of-life.

Head injury management in road accident patients: a case report

Objective: To examine recovery outcomes for patients with head injuries from road traffic accidents (RTAs), focusing on neurosurgical care. Methodology: We studied patients admitted to our hospital with head injuries from RTAs. This included a case study of a 55-year-old man severely injured in a road accident, highlighting neuropsychological assessments and treatment outcomes. Results: The case report presents the successful recovery of a 55-year-old patient who sustained severe head injuries from a road traffic accident. Following neurosurgical intervention to remove blood clots and comprehensive neuropsychological therapy, the patient showed significant improvement in memory and cognitive functions. The outcomes demonstrate a positive response to the integrated treatment approach, with the patient regaining substantial normalcy in life over the course of three months. Conclusion: The case of a 55-year-old patient highlights the challenges and outcomes of treating severe head injuries resulting from RTAs. Key findings include the importance of immediate and appropriate neurosurgical care and neuropsychological support.

E kaua e hoki i te waewae tūtuki, ā, apā anō hei te ūpoko pakaru - a systematic review of neurosurgical disease and care for Māori in New Zealand.

The Royal Australasian College of Surgeons (RACS) Te Rautaki Māori cites the need for more research dedicated to health equity in surgery for Māori. However, the gaps in research for Māori in surgery have not yet been highlighted. This review is the first in a series of reviews named Te Ara Pokanga that seeks to identify these gaps over all nine surgical specialties. The aim of this study was to assess neurosurgical disease incidence and perioperative outcomes for Māori at any point from referral through to the postoperative period. A systematic review of Māori neurosurgical disease and care for Māori in NZ was performed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement assisted study selection and reporting. Kaupapa Māori (Māori-centred) research methodology and the Māori Framework were utilized to evaluate Māori research responsiveness. Nine studies were included in this review. All studies were retrospective cohort studies and only two studies had at least one Māori clinical or academic expert named on their research team. Therefore, only one study was deemed responsive to Māori. Studies assessing long-term outcomes from the management of neurosurgical disease for Māori and patient and whānau experiences of neurosurgical care are lacking. This study indicates the limited scope of research conducted for Māori in neurosurgery. The broader clinical implications of this review highlight the need for good quality research to investigate access to and long-term outcomes from the management of neurosurgical disease for Māori.

Practical pearls for management of cranial injury in the developing world.

Traumatic brain injury (TBI) remains a leading cause of morbidity and mortality, with approximately 69million individuals affected globally each year, particularly in low- and middle-income countries (LMICs) where neurosurgical resources are limited. The neurocognitive consequences of TBI range from life-threatening conditions to more subtle impairments such as cognitive deficits, impulsivity, and behavioral changes, significantly impacting patients' reintegration into society. LMICs bear about 70% of the global trauma burden, with causes of TBI differing from high-income countries (HICs). The lack of equitable neurosurgical care in LMICs exacerbates these challenges. Improving TBI care in LMICs requires targeted resource allocation, neurotrauma registries, increased education, and multidisciplinary approaches within trauma centers. Reports from successful neurotrauma initiatives in low-resource settings provide valuable insights into safe, adaptable strategies for managing TBI when "gold standard" protocols are unfeasible. This review discusses common TBI scenarios in LMICs, highlighting key epidemiological factors, diagnostic challenges, and surgical techniques applicable to resource-limited settings. Specific cases, including epidural hematoma, subdural hematoma, subarachnoid hemorrhage, and cerebrospinal fluid leaks, are explored to provide actionable insights for improving neurosurgical outcomes in LMICs.

Innovative External Cranial Devices for Protecting a Craniectomy Site: A Scoping Review on Noninvasive Approaches for Patients Awaiting Cranioplasty.

Decompressive craniectomy (DC) is a commonly performed procedure to alleviate high intracranial pressure. To enhance patient quality of life and minimize complications after DC in patients awaiting cranioplasty (CP), multidisciplinary teams have designed and implemented external protective prototypes, including 3-dimensional printing and plaster models, whenever feasible. The aim of this scoping review was to assess the evidence available on innovative external cranial devices that protect the craniectomy site for patients who have undergone DC while awaiting CP in high-income countries and low- and middle-income countries. This scoping review was conducted following the methodology outlined by the Joanna Briggs Institute. Searches were performed in databases such as MEDLINE, Embase, Web of Science, Scielo, Scopus, and World Health Organization Global Health Index Medicus. Patent documents were also searched in Espacenet, Google Patents, and World Intellectual Property Organization. This scoping review included external protective devices for adult patients who underwent DC and CP, while invasive devices were excluded. A total of 9 documents described external cranial devices, with 7 of them led by researchers from high-income countries, including the United States (n = 4), Singapore (n = 1), the United Kingdom (n = 1), and Hong Kong SAR, China (n = 1). Among these devices, 77.7% (n = 7) were created using 3-dimensional printing, while 22.3% (n = 2) were developed through plaster hand modeling. The individual study results were summarized. Sustainable Development Goal (SDG) 3, SDG 9, and SDG 10 play a crucial role in the advancement of innovative strategies to ensure access to essential neurosurgical care, reduce global disparities in treatment outcomes, mitigate postoperative complications, and provide life-saving interventions. This scoping review provides fundamental evidence for multidisciplinary teams involved in designing noninvasive innovations to minimize the risks associated with post-DC complications. It is anticipated that more cost-effective models, particularly in low- and middle-income countries, can be implemented based on the findings of this review.