Neurosurgical Facilities Research Articles

Atypical Variants of Spinal Dysraphism: A Case Series

Abstract The aim of this study is to present and discuss atypical instances of spina bifida (SB) within a Nigerian paediatric cohort, highlighting their distinctive clinicoradiological features. Additionally, a brief literature review is provided to contextualise these congenital anomalies. This series comprises eight rare cases of SB managed in a Nigerian neurosurgical facility. Additionally, a brief literature review is provided to contextualise these congenital anomalies. This case series comprises eight rare cases of SB managed in a Nigerian neurosurgical facility. Amongst these, four cases exhibited segmental spinal dysgenesis (SSD; one thoracolumbar, one lumbar, and two sacral). Each of these cases demonstrated diverse associated musculoskeletal, cutaneous, and perineal anomalies, accompanied by varying degrees of neurological dysfunction. Other cases included lipomyelomeningocele (LMMC), human tail (HT), membranous meningocele, and myeloschisis (MSS). Autonomic dysfunction was a common feature in all of the cases, whilst two of the patients presented with congenital kyphotic spinal deformity. Lower limb anomalies varied, including congenital talipes equinovarus deformity, pes planus, congenital calcaneovagus deformity, rocker bottom feet, clinodactyly, and tetrapolydactyly. Remarkably, none of the patients exhibited clinical features indicative of hydrocephalus. SSD, LMMC, HT, membranous meningocele, and MSS represent atypical forms of SB in the Nigerian paediatric population. Early neuroimaging of patients with suspected spinal dysraphism is crucial, as it may reveal a spectrum of diverse vertebral anomalies associated with this neurological condition within the African population.

DIPG-56. BRAINSTEM TUMOR BIOPSY: A SINGLE INSTITUTE EXPERIENCE OF SAFETY AND FEASIBILITY IN A LOW-MIDDLE INCOME COUNTRY (LMIC)

Abstract BACKGROUND Brainstem tumors account for 10-15% of all pediatric central nervous system tumors and carry a dismal prognosis. These include a wide spectrum of histological diagnosis therefore, in most specialized centers stereotactic biopsies for brainstem tumors are considered safe and standard practice. However, this approach continues to pose a challenge in LMIC’s. METHODS We retrospectively reviewed data of patients presenting with brainstem tumors at Aga Khan University Hospital, Pakistan, between 2014 and 2023. In addition to histopathological analysis, whole-genome sequencing and RNA sequencing were also performed on 6 tumors. RESULTS We identified 39 patients with brainstem tumors; amongst these 56.4% were females. Median age at diagnosis was 9 years (IQR: 5.1-11). Most cases presented with walking difficulty (74%) and cranial nerve palsies (46%). Median duration of symptoms was 30 days (IQR: 20-60). On imaging large proportion were intrinsic pontine tumors (53.8%) followed by brainstem (30.8%) and cerebellopontine angle (15.4%). 21 patients underwent stereotactic biopsy with 86% performed after 2016. 43% were intrinsic pontine tumors. Histopathology analysis showed a wide spectrum with diffuse midline glioma in 28% of cases, pilocytic astrocytoma, anaplastic astrocytoma and ganglioglioma in 33%, 14% and 9% of cases respectively. Rare entities identified included embryonal tumor with multilayered rosettes, atypical teratoid rhabdoid tumor and schwannoma (5%). Biopsies were uneventful in 81% of cases. Complication of biopsy in 2 patients included cranial nerve palsy and subdural hemorrhage. No patient died due to complications of biopsy. Surgical and medical management was altered in 9 patients due to availability of histological diagnosis. CONCLUSIONS We present the first study demonstrating safety and feasibility of stereotactic biopsy for brainstem tumors in LMIC. These biopsies should be considered for atypical brainstem tumors and should be performed in well-equipped tertiary neurosurgical facilities by trained neurosurgeons in LMIC.

Quality of Life and Its Associated Factors Among Children with Spina Bifida in Ethiopia: A Cross-Sectional Study to Inform Policy and Practice

Congenital myelomeningocele, or spina bifida (SB), is the predominant congenital anomaly of the central nervous system. Beyond its implications on neonatal mortality, SB impacts the long-term quality of life in affected children. This study sought to investigate the health-related quality of life (HRQoL) among children with SB treated at Ethiopia's leading pediatric neurosurgical facility. Set at Zewditu Memorial Hospital in Addis Ababa, Ethiopia, this hospital-based cross-sectional study spanned from June 30 to September 30, 2022. It incorporated 232 children, using data gathered through interviewer-led questionnaires. The HRQoL was measured using the PedsQL 4.0, a 23-item generic scale. The study's participants had a median age of 5years (interquartile range=3 to 6years). The aggregate mean scores on the PedsQL 4.0 tallied at 68.59±18.01. The lowest scores emerged from queries on school participation, whereas physical and emotional functioning registered the highest scores. Through multiple regression analyses, variables such as family income, monthly household income, number of children, and the presence of a neurogenic bladder showed strong association with HRQoL. This study fills a gap in the literature providing information on the HRQoL and its associated factors for children with SB in low-resourced settings. We champion the proactive integration of quality-of-life metrics into neurosurgical care policy and practice. Given the enduring consequences of SB, interventions honing the HRQoL can steer children toward realizing their intrinsic and enhance societal participation and contribution.

Global Neurosurgical Challenges: A Focus on Central Asia

Neurosurgical care in Central Asia is marked by significant variation across the region's five countries—Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan. This variation is influenced by factors such as limited modern technology, a shortage of neurosurgeons, and inadequate healthcare infrastructure. Despite these obstacles, there have been notable advancements in the field, particularly in Kazakhstan, where the number of neurosurgeons has increased, and specialized fields such as vascular neurosurgery and brain tumor management have seen significant progress. Other countries in the region, such as Uzbekistan, Tajikistan, and Kyrgyzstan, have also made strides in improving neurosurgical care. However, these advancements in neurosurgical care are insignificant to those seen globally which make standard neurosurgical care inaccessible to many patients in Central Asian countries due to shortages of neurosurgeons and limited facilities. The dearth of research data in some CA countries further emphasize the need for urgent intervention. Therefore, we recommend a multipronged approach involving targeted investments, policy reforms, international collaborations, and knowledge sharing is recommended to bolster neurosurgical care capabilities and expand access to essential care across Central Asia. This approach include establishing specialized neurosurgical training programs and fellowships, investing in infrastructure and technology for neurosurgical facilities, and fostering collaborations with international centers for training and research. Additionally, early introduction of neurosurgery education in medical schools, enhancing access to online education resources for neurosurgeons, and promoting the use of telemedicine for neurosurgical consultations and follow-up care are recommended

A Geospatial Analysis of the Availability, Distribution, and Accessibility of Neurosurgical Facilities, Workforce, and Infrastructure in Nigeria; and Projection Towards 2050

There has been a modest but progressive increase in the neurosurgical workforce, training, and service delivery in Nigeria in the last 2decades. However, these resources are unevenly distributed. This study aimed to quantitatively assess the availability and distribution of neurosurgical resources in Nigeria while projecting the needed workforce capacity up to2050. An online survey of Nigerian neurosurgeons and residents assessed the country's neurosurgical infrastructure, workforce, and resources. The results were analyzed descriptively, and geospatial analysis was used to map their distribution. A projection model was fitted to predict workforce targets for 2022-2050. Out of 86 neurosurgery-capable health facilities, 65.1% were public hospitals, with only 17.4% accredited for residency training. Dedicated hospital beds and operating rooms for neurosurgery make up only 4.0% and 15.4% of the total, respectively. The population disease burden is estimated at 50.2 per 100,000, while the operative coverage was 153.2 cases per neurosurgeon. There are currently 132 neurosurgeons and 114 neurosurgery residents for a population of 218 million (ratio 1:1.65 million). There is an annual growth rate of 8.3%, resulting in a projected deficit of 1113 neurosurgeons by 2030 and 1104 by 2050. Timely access to neurosurgical care ranges from 21.6% to 86.7% of the population within different timeframes. Collaborative interventions are needed to address gaps in Nigeria's neurosurgical capacity. Investments in training, infrastructure, and funding are necessary for sustainable development and optimized outcomes.

Angioarchitecture Classification and Treatment Modalities of Craniocervical Junction Arteriovenous Fistulas: A Cohort Study of 155 Patients.

Craniocervical junction (CCJ) arteriovenous fistulas (AVFs) are rare. Variability in clinical manifestations and treatment strategies for CCJ AVFs stems from differences in their angioarchitecture. Our study aims to categorize CCJ AVFs based on their angioarchitecture and explore the associated clinical features and treatment modalities for distinct CCJ AVF types. The authors conducted a retrospective analysis of patients with CCJ AVFs treated at a single neurosurgical facility over the past decade. These patients were classified based on the angioarchitecture of their CCJ AVFs. The analysis included an evaluation of angioarchitecture, clinical characteristics, treatment strategies, and outcomes. The study included 155 patients, with a median age of 56 years, collectively manifesting 165 CCJ AVFs. Our classification identified 4 distinct CCJ AVF types: epidural AVFs (19 [11.5%]), dural AVFs (98 [59.4%]), radicular AVFs (33 [20.0%]), and perimedullary AVFs (15 [9.1%]). Further differentiation was applied based on the presence of pial feeders. The predominant fistula location was at cervical-1 (77.0%). Ascending intradural drainage (52.7%) and descending intradural drainage (52.1%) were frequently observed drainage patterns. Patients with dural AVF predominantly presented with venous hypertensive myelopathy, whereas patients with other types of CCJ AVFs showed a higher incidence of subarachnoid hemorrhage (P = .012). Microsurgery was the predominant treatment, applied in the management of 126 (76.4%) AVFs, whereas 8 (4.8%) AVFs exclusively underwent interventional embolization and 25 (15.2%) received a combination of interventional embolization and microsurgical treatment. CCJ AVFs can be distinguished based on the fistula location and the arterial feeders. Currently, microsurgery stands as the preferred treatment strategy for CCJ AVFs, whereas interventional embolization plays a distinctive role in cases with specific angioarchitecture or as a pretreatment measure before microsurgery.

Frequency and predictors of decompressive craniectomy in ischemic stroke patients treated by mechanical thrombectomy in the ETIS registry

Background and aimsMechanical thrombectomy (MT) for patients with acute ischemic stroke (AIS) is usually performed in a comprehensive stroke center with on-site neurosurgical expertise. The question of whether MT can be performed in a primary stroke center without a neurosurgical facility is debated. In this context, there is a need to determine the frequency, delay and predictors of neurosurgical procedures in patients treated by MT. This study aims to determine these factors. MethodsIn total, 432 patients under 60years old, diagnosed with an acute ischemic stroke with a large vessel occlusion and treated by MT between January 2018 and December 2019 in six French stroke centers, were selected from the French clinical registry ETIS. Univariate and multivariate logistic regression models were used to identify predictive factors for decompressive craniectomy. ResultsAmong the 432 included patients, 43 (9.9%) patients with an anterior circulation infarct underwent decompressive craniectomy. Higher admission NIHSS (OR: 1.08 [95% CI: 1.02–1.16]), lower ASPECT (OR per 1 point of decrease 1.53 [1.31–1.79] P<0.001) and preadmission antiplatelet use (OR: 3.03 [1.31–7.01]) were independent risk factors for decompressive craniectomy. The risk of decompressive craniectomy increases to more than 30% with an ASPECT score<4, an NIHSS>16, and current antiplatelet use. ConclusionIn this multicenter registry, 9% of acute ischemic stroke patients (<60years old) treated with MT, required decompressive craniectomy. Higher NIHSS score, lower ASPECT score, and preadmission antiplatelet use increase the risk of subsequent requirement for decompressive craniectomy.

Geographical Distribution of Neurosurgeons and Emergency Neurosurgical Services in Pakistan

According to the World Federation of Neurosurgical Societies (WFNS), a minimum neurosurgery workforce density should be 1 per 200,000 population for optimum access to neurosurgical care. Pakistan lags behind in the number of neurosurgeons, and disproportionate geographical distribution further increases disparity. Our objective was to geographically map the density of neurosurgeons and emergency neurosurgical services (ENS) in Pakistan. This survey was circulated among 307 neurosurgeons. Data were analyzed using SPSS v21. The number of neurosurgeons and ENS were plotted on the population density map using ArcGIS Pro 3.0.0 software. Three hundred and seven neurosurgeons working at 74 centers responded to our survey (93.3% coverage). The current density of neurosurgeons in Pakistan is 0.14/100,000. The 2 more populous provinces, Punjab and Sindh, have 42.3% (130) and 35.8% (110) neurosurgeons, respectively. They also housed nearly 3 quarters of all the neurosurgery centers in urban districts. Karachi and Lahore accommodate 135 (44%) of all the country's neurosurgeons, having 0.29 and 0.51 neurosurgeons/100,000 respectively. Management of traumatic brain injury is offered at 65 centers (87.8%). Nearly all centers are equipped with computed tomography (CT) scan machine (74; 97%), but magnetic resonance imaging (MRI) facility is available at 55 (72%) centers and 37 (49%) centers have angiography suites. Sixty nine centers (93.2%) have C-arm fluoroscopes available. The geographical mapping of neurosurgeons and neurosurgical facilities is highly skewed towards urban centers, increasing disparity in access to timely neurosurgical emergency services. Four times more neurosurgeons are required in Pakistan to bridge the gap in neurosurgical workforce.

Addressing The Traumatic Brain Injury Crisis In Thailand: Analysis Of National Access To Neurosurgical Facilities Utilizing Geospatial Mapping (P1-5.028)

<h3>Objective:</h3> We aim to assess the accessibility to neurosurgical centers in Thailand for the management of traumatic brain injury (TBI) using a novel approach of geospatial mapping in low-middle income countries. Additionally, we seek to address issues of priority setting in hospital site selection accounting for national insurance schemes. <h3>Background:</h3> Road traffic injuries are among the leading causes of death in Thai youth. TBI accounts for 65% of all motorcycle-crash fatalities. In recent years, the proportion of TBI patients has more than doubled, resulting in excessive burden of disease currently unmet by epidemiological strategy. <h3>Design/Methods:</h3> Mapping neurosurgical accessibility in 77 provinces using population level data, spatial ancillary data, and reverse geocoding was conducted using ArcGIS. Mock-scenarios in which patients would have to be transferred to other hospital sites per the national insurance scheme were also assessed for the top-10 provinces with highest burden of disease. <h3>Results:</h3> The percentage of the population with access to a neurosurgical facility within the golden hour is 22.6%, with the greatest disparity occurring in the northern border regions, where access time averages 180 minutes and only 12.3% of the population has access to neurosurgical care. Mock-scenarios analysis revealed that the current allocation of provincial hospital care accessible to a patient injured in a region to which they do not have access results in 78.2% excess delayed care. <h3>Conclusions:</h3> With nearly 54 million people living too far away from a neurosurgical facility, that equates to 15,410 unnecessary deaths, given Thailand’s high rate of mortality for TBI patients. The limitations of addressing this epidemiological gap include a lack of a national ambulance system with protocolized approaches to TBI management, brain-drain of neurosurgeons, and a lack of 24/7 neurosurgical care, which suggests that our findings may show an even larger disparity of care. <b>Disclosure:</b> Mr. Mahajan has nothing to disclose. Wuttipong Tirakotai has nothing to disclose.

Ailing neurosurgical services in rural Africa

Ailing neurosurgical services in rural Africa

Letter: The State of Cerebrovascular Care in Africa.

Letter: The State of Cerebrovascular Care in Africa.

Academic neurosurgery in Nepal: Present status and future directions

IntroductionThe establishment of local neurosurgery training programs in Nepal has proven critical for the expansion of the discipline across the country. This paper aims to describe the evolution, current status, challenges, and future directions of academic neurosurgery in Nepal. Research questionWhat is the current status and international standing of academic neurosurgery in Nepal? Material and methodsInformation related to growth and development in Nepal was obtained from universities and regulatory bodies in Nepal. Variables described are the current number of neurosurgeons, the number of neurosurgical centers and centers with accreditation for training, the description of existing training models, the number of graduates, and the contribution of Nepalese neurosurgeons to world literature. ResultsFormal neurosurgical training started in Nepal in 1999. Of 67 hospitals with neurosurgical facilities, 10 (14.9%) are accredited. Three training models (MCh, NBMS, and FCPS) currently exist. Of 116 neurosurgeons currently practicing in the country, 47 (40.5%) are homegrown. The contribution of the Nepalese neurosurgical community to the world includes the training of the first two Maldivian neurosurgeons and an increasing presence in world neurosurgical literature. ConclusionsAlthough comparable to other countries with similar economies, Nepal still faces some challenges to the sustainability and further developments of Neurosurgery. Continued concerted efforts will help Nepalese neurosurgeons achieve the goal of securing self-reliance in neurosurgical education.

Questionnaire Survey of Neurointerventional Simulation Training in the Japanese Society for Neuroendovascular Therapy.

Simulation training has focused on education and practical training. However, the adoption rate of neurointerventional simulation training in Japan is unknown. Therefore, we sent a questionnaire survey form to consulting specialists from the Japanese Society for Neuroendovascular Therapy (JSNET) to clarify the actual simulation training situation and compare the differences between university hospitals and general hospitals in Japan. The questionnaire survey was conducted in 243 neurosurgical training facilities that had JSNET consulting specialists between May 31, 2021 and July 31, 2021. The questionnaire survey forms were distributed by Google Forms. A total of 162 facilities responded to the survey (response rate: 66.7%; 35.2% from university hospitals and 64.8% from general hospitals). The adoption rate for simulation training was 53.7%, and it was significantly higher in the university hospitals than in the general hospitals (64.9% vs. 47.6%, p = 0.035). On the simulation effectiveness survey, more than 80% of respondents answered that the simulation training was a useful tool for upskill training. The open-ended question on interventional simulation training showed that there are limiting factors such as financial constraints. Additionally, respondents expressed a desire for a standard neurointerventional simulation training and education program. The adoption rate for simulation training was 53.7% in the training facilities of JSNET, and it was higher in the university hospitals than in the general hospitals. Most of the respondents answered that simulation training is an effective tool to improve neurointerventional skills. They also requested the establishment of simulation training programs and simulation tools.

Private vs public care for intracranial tumours: Findings from Pakistan.

To observe the patient characteristics and centres providing neuro-oncological care in public and private health hospitals in Pakistan. The Pakistan Association of Neuro-oncology carried out a retrospective, cross-sectional study in 2019 on patients admitted to 32 hospitals in Pakistan, with dedicated neurosurgical facilities. Patients with a histopathological diagnosis of an intracranial tumour were included. Public health care facilities catered for 84% patients with ages between 20 and 60 years and children having intracranial tumours. Private centres were utilised by 66.7% patients from the upper socioeconomic sector. More patients were lost to follow-up in the public sector (n = 784) versus in the private sector (n = 356). Mortality was also higher in the public sector hospitals, (13.9%) as compared to 9.6% in the private sector. Public and private sector health services for neuro-oncological care in Pakistan still have a long way to go to cover the gaps for unmet needs. Strengthening health systems for brain tumour care is imperative to increase both the access to care and the quality of care to fulfil this need.

Preoperative Visual Impairment in Vestibular Schwannoma Patients: An Overlooked Entity of Developing World.

Objective Visual impairment in vestibular schwannomas is an underreported entity. The plethora of literature focuses primarily on facial and hearing preservation. This study aims to describe our experience and find the possible reasons for visual impairment. Materials and Methods This is a retrospective observational study. We evaluated 114 patients with vestibular schwannoma, operated during 2015 to 2020. Eight parameters were studied-age, gender, maximum tumor size, hydrocephalus, economic status, duration of symptoms, visual loss, and ease of access to the tertiary neurosurgical facility. JASP software (version 0.14.1, Amsterdam) was used for statistical analysis. Results A total of 42/114 (36.84%) patients had a varying degree of impairment. Patients with impaired vision had significantly larger tumors (4.31 vs. 4.12 cm, p = 0.02), longer duration of symptoms (19.14 vs. 16.45 months, p = 0.02), hydrocephalus ( p = 0.03), and were from remote areas ( p = 0.009). In stepwise logistic regression analysis, longer duration of symptoms and difficult access to neurosurgical facility stand out as decisive factors for visual impairment. The follow-up data were available for 35/42 (83.33%) cases of visual impairment. Vision improved in 14/35 (40%) of cases. Vision improved in a significantly higher number of patients when a preoperative ventriculoperitoneal shunt was placed ( p = 0.03). Conclusion The visual handicap occurs in a significant number of patients with vestibular schwannoma. Delayed arrival at the neurosurgical facility due to difficult access appears to be the primary factor leading to blindness. Strengthening our healthcare systems in rural areas would go a long way in the timely detection and prevention of blindness in such cases.

Facial nerve function and general outcome of patients operated for cerebellopontine angle tumors in Addis Ababa, Ethiopia, a retrospective study

IntroductionCerebellopontine angle (CPA) tumors consist of 10% of brain tumors. Surgical outcome is measured using functional status and cranial nerve preservation. MethodA hospital based retrospective cross-sectional descriptive study was done between August 31, 2015 and August 31, 2020. Fifty-five patients operated in the study period were enrolled in this study. Our study used House Brackmann Scale and Extended Glasgow Outcome Score. Fisher’s extract test was used to identify factors associated with outcome. P value < 0.05 was considered significant. ResultThe mean age of the study participants was 36.64 years with male predominance (52.7%). Hearing loss (85%) was the commonest presentation. The mean tumor size was 4.4 cms ± 1.02. The tumors were operated through Retro-sigmoid approach without neurophysiologic monitoring. Post-operative CT scan shows GTR in 77.8%. At one year there were 66.7% patients with good facial nerve outcome, 20.8% with acceptable outcome and 12.5% with poor outcome. The post op GOS-E showed GOS-E of 8 in 25.5% and GOS-E of 7 in 23,6% of the patients. The operative mortality was high and predictors of mortality were postoperative infections (P =.003) and pre-operative facial palsy(P <.001) ConclusionOur patients presented with larger tumor sizes. The rate of functional facial nerve preservation was low and the researchers advocate for improved microsurgical techniques and acquiring neuromonitoring to improve outcome. Health facilities evaluating the patients initially should have a systemic approach to diagnose the patients earlier and refer to a capable neurosurgical facility. The overall outcome was acceptable and surgery is a better option for the management of cerebellopontine angle tumors in our set-up.

Immediate postoperative complications of sellar suprasellar lesions operated via pterional approach

Objective: In neurosurgical facilities, lesions that occur in the sella turcica and suprasellar area are frequently encountered. Different complications have been documented in the past studies following surgical management of sellar suprasellar lesions. This study's rationale was to get data from our local population on complications related to the transcranial approach for sellar suprasellar lesions. The study aimed to determine the immediate (within one week) postoperative complications of sellar suprasellar lesions operated via a pterional approach&#x0D; Material and Methods: This descriptive case series study was conducted from June 2019 to June 2020 at the neurosurgical facility lady reading hospital Peshawar. A total of 117 patients, meeting inclusion criteria irrespective of gender, diagnosed with the sellar suprasellar lesion between 18 to 60 years of age operated through a pterional approach. Post-op patients were followed for seven days to access main outcome measures such as CSF leak and diabetes insipidus.&#x0D; Results: CSF leak found in 7.7% (n = 9) of patients while diabetes insipidus was detected in 14.5% (n = 17) patients. Gender and age-based stratification showed no statistically significant difference for both postoperative complications.&#x0D; Conclusion: Diabetes insipidus was a more frequent postoperative complication in patients undergoing the pterional approach for sellar suprasellar lesions followed by CSF leak. However, no statistically significant correlation was observed between different age groups and gender for all these complications.

Historical overview of the Department of Neurosurgery at Yonsei University College of Medicine in the Republic of Korea.

Originally founded in 1885, Gwanghyewon later became the Severance Hospital (named after philanthropist Louis Severance, who supported and funded the construction of a modern hospital) and Yonsei University College of Medicine. The Department of Neurosurgery at Severance Hospital was established in 1957, and its residency program began in 1961. Currently, the Department of Neurosurgery has 34 professors and 17 fellows; specialties include vascular, functional, pediatric, tumor, skull base, and spine neurosurgery. With its state-of-the-art neurosurgical facilities and services, the Department of Neurosurgery has developed into a department of excellence within the Yonsei University Health System. In this vignette, the authors present a historic overview of the Department of Neurosurgery.

Neurosurgery in Ethiopia: A New Chapter and Future Prospects

Inequitable access to surgical care is most conspicuous in low-income countries (LICs), such as Ethiopia, where infectious diseases, malnutrition, and other maladies consume the lion's share of the available health resources. The aim of this article was to provide an update on the current state of neurosurgery in Ethiopia and identify targets for future development of surgical capacity as a universal health coverage component in this East African nation. Publicly available data included in this report were gathered from resources published by international organizations. A PubMed search was used for a preliminary bibliometric analysis of scholarly output of neurosurgeons in Ethiopia and other low-income countries. Statistical analysis was used to determine the correlation between the number of neurosurgeons and academic productivity. Neurosurgeon density has increased >20-fold from 0.0022 to 0.045 neurosurgeons per 100,000 population between 2006 and 2020. The increase in neurosurgeons was strongly correlated with an increase in total publications (P < 0.001) and the number of new publications per year (P= 0.003). Despite recent progress, the availability of neuroimaging equipment remains inadequate, with 38 computed tomography scanners and 11 magnetic resonance imaging machines for a population of 112.07 million. The geographic distribution of neurosurgical facilities is limited to 12 urban centers. Ethiopian neurosurgery exemplifies the profound effect of international partnerships for training local surgeons on progress in low-income countries toward improved neurosurgical capacity. Collaborations that focus on increasing the neurosurgical workforce should synchronize with efforts to enhance the availability of diagnostic and surgical equipment necessary for basic neurosurgical care.

Temporal Delay in Neurosurgical Patients and Outcome in a Tertiary Care Center in Nepal.

Neurosurgery is a field where time from the incident to get treatment is very crucial. In low-income countries, the referral system is not well developed. In our country, a proper referral system is in the initial phase of development. We conducted a study assessing the number of visits a neurosurgery patient made before finally reaching to our center. This is a prospective observational study involving seventy patients, conducted at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Demographic characteristics, neurological diagnosis, and numbers of other centers the patients visited and outcome at discharge and in one month was assessed. Thirty-five (50%) patients were males. Thirty-three (47.1%) patients were admitted due to head injury and 13 (18.5%) were diagnosed with subarachnoid hemorrhage. Surgery was done in 32 (45.7%) patients. Fifty-three (75.7%) patients were transferred from other hospitals. Out of 53 patients, 30 (56.6%) and 17 (32%) had visited to one and two hospitals respectively. Unavailability of the neurosurgery facility was the main reason (77.4%) for the transfer. Overall mortality was 12.9%. The trend for mortality and length of hospital stay was higher in the group who visited other centers before coming to us than those who came directly. Visiting multiple hospitals where there is no neurosurgical service available is an important reason for delay. There is a need to develop neurosurgical facilities in the different parts of the country along with establishment of an effective referral mechanism.