Outcomes Following Exploratory Burr Holes for Traumatic Brain Injury in a Resource Poor Setting

Examining fall-related mortality in registries and surveillance systems in sub-Saharan Africa: a systematic review

OBJECTIVE

Fall-related injuries are a global public health concern, and trauma registries aid in collecting data to develop measures to reduce their burden on individuals and communities. The aim of this review was to provide a comprehensive overview of the reporting of fall-related mortality in trauma registries and surveillance systems in sub-Saharan Africa.

METHODS

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched eight electronic databases, and studies set in countries of sub-Saharan Africa were included if the reported data originated from a trauma registry or surveillance system and contained a measurement of fall-related mortality. Results were synthesised in a descriptive manner.

RESULTS

Of the 3574 records found, we included 21 studies in the analysis. Different definitions were inconsistently used in reporting fall-related mortality: studies reported either a percentage of fall deaths by total falls or of fall deaths by total deaths. Deaths due to falls by total falls ranged from 0.01% to 2.4% in studies with paediatric patient populations, and from 0.03% to 60% among studies not restricted to a specific age group. Reporting on other variables in relation to injury and trauma care was also inconsistent.

CONCLUSIONS

The findings of this review were heterogeneous, and variables were collected irregularly among trauma registries. This led to a broad range of results and made comparisons and deductions difficult. A more standardised data collection across registries would heighten the intercomparability of results from different studies and, therefore, facilitate usage in data-based efforts for implementing prevention and optimising care.

Time to death and its predictors among traumatic brain injury patients admitted to East Amhara comprehensive specialized hospitals, Ethiopia: retrospective cohort study

BACKGROUND

Globally, 64-74 million individuals around the world are estimated to sustain traumatic brain injury every year. Moderate and severe traumatic brain injury can lead to a lifetime physical, cognitive, emotional, and behavioral changes. There were limited studies conducted in Ethiopia regarding to traumatic brain injury mortality.

METHODS

An institutional based retrospective cohort study was conducted on 429 randomly selected traumatic brain injury patients aged 18 to 64 years who were admitted to East Amhara Comprehensive Specialized Hospitals from January 1, 2016 to December 31, 2021. Kobo toolbox was applied for data collection and exported to Stata version 17 for data processing and analysis. To estimate death free time, a Kaplan Meier failure curve was used. The Cox proportional hazards regression model was used at the 5% level of significance to determine effect of predictor variables on time to death.

RESULT

A total of 429 traumatic brain injury patients aged 18 to 64 years were included with response rate of 91.3% and 145(33.8%) were dead. Open injuries (AHR = 0.25; 95% CI: 0.18-0.36), co-existing injuries (AHR = 0.40; 95% CI: 0.24-0.66), ICU admission (AHR = 0.42; 95% CI: 0.29-0.60), arrival within 4-24 h (AHR = 3.48; 95% CI: 2.01-6.03), arrival after 24 h (AHR = 6.69; 95% CI: 3.49-12.28), subdural hematoma (AHR = 2.72; 95% CI: 1.77-4.19), serum albumin < 3.5 g/dL (AHR = 0.66; 95% CI: 0.49-0.94), moderate (AHR = 0.56; 95% CI: 0.21-0.89), and mild traumatic brain injury (AHR = 0.43; 95% CI: 0.29-0.56) were predictors of traumatic brain injury mortality.

CONCLUSION

The finding of this study showed that the mortality was 1/3rd of the total patients. Open injuries, co-existing injuries, ICU admission, arrival time (4-24 h and > 24 h), subdural hematoma, serum albumin < 3.5 g/dL and severity of traumatic brain injury (mild and moderate) were predictors of traumatic brain mortality. Therefore, working on these factors to reduce the morality of traumatic brain injury patients is very important.

Serum exosomes miR-206 and miR-549a-3p as potential biomarkers of traumatic brain injury

Traumatic brain injury (TBI) is one of the leading causes of death and disability worldwide. However, effective diagnostic, therapeutic and prognostic biomarkers are still lacking. Our research group previously revealed through high-throughput sequencing that the serum exosomes miR-133a-3p, miR-206, and miR-549a-3p differ significantly in severe TBI (sTBI), mild or moderate TBI (mTBI), and control groups. However, convincing experimental evidence is lacking. To solve this problem, we used qPCR in this study to further verify the expression levels of serum exosomes miR-133a-3p, miR-206 and miR-549a-3p in TBI patients. The results showed that the serum exosomes miR-206 and miR-549a-3p showed good predictive value as biomarkers of TBI. In addition, in order to further verify whether serum exosomes miR-206 and miR-549a-3p can be used as potential biomarkers in patients with TBI and to understand the mechanism of their possible effects, we further determined the contents of SOD, BDNF, VEGF, VEGI, NSE and S100β in the serum of TBI patients. The results showed that, serum exosomes miR-206 and miR-549a-3p showed good correlation with BDNF, NSE and S100β. In conclusion, serum exosomes miR-206 and miR-549a-3p have the potential to serve as potential biomarkers in patients with TBI.

Current trends and challenges: The landscape of perioperative mortality in intracranial surgeries in low- and middle-income settings: A narrative review

Background and Aims

Intracranial surgeries are pivotal in treating cerebral pathologies, particularly in resource-limited contexts, utilizing techniques such as craniotomy, transsphenoidal approaches, and endoscopy. However, challenges in low and middle income countries (LMICs), including resource scarcity, diagnostic delays, and a lack of skilled neurosurgeons, lead to elevated perioperative mortality (POM). This review seeks to identify major contributors to these challenges and recommend solutions for improved patient outcomes in neurosurgical care within LMICs.

Methods

This review examines POM in LMICs using a detailed literature search, focusing on studies from these regions. Databases like PubMed, EMBASE, and Google Scholar were utilized using specific terms related to "intracranial surgery," "perioperative mortality," "traumatic brain injuries," and "LMICs." Inclusion criteria covered various study designs and both pediatric and adult populations while excluding stand-alone abstracts and case reports.

Results

POM rates for intracranial surgeries differ widely across many low and middle-income regions: Africa sees rates from 2.5% to 39.1%, Asia between 3.6% and 34.8%, and Latin America and the Caribbean have figures ranging from 1.3% to 12%. The POM rates in LMICs were relatively higher compared to most first-world countries. The high POM rates in LMICs can be attributed to considerable delays and compromises in neurosurgical care delivery, exacerbated by late diagnoses and presentations of neurosurgical pathologies. This, coupled with limited resources, underdeveloped infrastructure, and training gaps, complicates intracranial disease management, leading to elevated POM.

Conclusion

Intracranial POM is a pronounced disparity within the neurosurgical field in LMICs. To mitigate intracranial POM, it is imperative to bolster healthcare infrastructure, amplify personnel training, foster global partnerships, and harness technologies like telemedicine. Tackling socioeconomic obstacles and prioritizing early detection through sustained funding and policy shifts can substantially enhance patient outcomes.

Neuro damage control: current concept and civilian applications

Damage control (DC) initially referred to abbreviated (<1 h) surgical procedures to control abdominal hemorrhage in severe trauma patients, to avoid the 'bloody vicious circle' of hypothermia-coagulopathy-acidosis-hypocalcemia. Progressively, the concept was extended to pre-hospital and peri-operative surgical and non-surgical trauma care. The DC strategy can be applied either in a single severe trauma patient at risk of progression toward the bloody vicious circle or in case of limited or overwhelmed health resources (deprived environment, mass casualties, etc.). DC strategies in neurological casualties have improved over the last decade in military neurosurgeons, but remain poorly codified in civilian settings. In this comprehensive review, we summarize the current concept of neuro-DC, which includes surgical and medical care for neurological injuries as part of a DC strategy. Neuro-DC basically consists in: (i) preventing secondary brain injury; (ii) controlling intracranial bleeding; (iii) controlling intracranial pressure; (iv) limiting contamination of compound wounds; and (v) achieving secondary anatomical restoration.

Clinical Utility of Near-Infrared Device in Detecting Traumatic Intracranial Hemorrhage: A Pilot Study Toward Application as an Emergent Diagnostic Modality in a Low-Resource Setting

Limited computed tomography (CT) availability in low- and middle-income countries frequently impedes life-saving neurosurgical decompression for traumatic brain injury. A reliable, accessible, cost-effective solution is necessary to detect and localize bleeds. We report the largest study to date using a near-infrared device (NIRD) to detect traumatic intracranial bleeds. Patients with confirmed or suspected head trauma who received a head CT scan were included. Within 30 min of the initial head CT scan, a blinded examiner scanned each patient's cranium with a NIRD, interrogating bilaterally the frontal, parietal, temporal, and occipital quadrants Sensitivity, specificity, accuracy, and precision were investigated. We recruited 500 consecutive patients; 104 patients had intracranial bleeding. For all patients with CT-proven bleeds, irrespective of size, initial NIRD scans localized the bleed to the appropriate quadrant with a sensitivity of 86% and specificity of 96% compared with CT. For extra-axial bleeds >3.5mL, sensitivity and specificity were 94% and 96%, respectively. For longitudinal serial rescans with the NIRD, sensitivity was 89% (< 4 days from injury: sensitivity: 99%), and specificity was 96%. For all patients who required craniectomy or craniotomy, the device demonstrated 100% sensitivity. NIRD is highly sensitive, specific, and reproducible over time in diagnosing intracranial bleeds. NIRD may inform neurosurgical decision making in settings where CT scanning is unavailable or impractical.

Burr hole as a management for extra axial hematomas in a low-resource setting

INTRODUCTION AND IMPORTANCE

In a low-resource setting, the availability of neurosurgeons and neurosurgical equipment for neurosurgery has proved to be a challenge for the management of extra-axial hematomas hence general surgeons perform burr hole surgeries for emergencies.

CASE PRESENTATION

We share our experience with three patients who presented with extra-axial hematomas and managed successfully in our institute with craniostomy as the surgical approach.

CLINICAL DISCUSSION

Traumatic brain injury is a major global health burden as it is a leading cause of death among the middle-aged population. Mortality associated with brain injury is highest in low- and middle-income countries. From our experience, we had good outcome in terms of improved Glasgow Coma Scale and overall clinical status in those who underwent burr hole surgery for extra axial hematoma.

CONCLUSION

The need for neurosurgeons in sub-Saharan Africa is high but training comes at a cost hence general surgeons can perform life-saving emergency procedures with good outcomes.

Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

BACKGROUND

Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.

METHODS

We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.

FINDINGS

Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49).

INTERPRETATION

Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

FUNDING

National Institute for Health Research Global Health Research Group.

How to manage traumatic brain injury without invasive monitoring?

PURPOSE OF REVIEW

Severe traumatic brain injury (TBI) is an extremely serious health problem, especially in low-middle income countries (LMICs). The prevalence of severe TBI continues to increase in LMICs. Major limitations in the chain of care for TBI patients are common in LMICs including suboptimal or nonexistent prehospital care, overburdened emergency services, lack of trained human resources and limited availability of ICUs. Basic neuromonitoring, such as intracranial pressure, are unavailable or underutilized and advanced techniques are not available.

RECENT FINDINGS

Attention to fundamental principles of TBI care in LMICs, including early categorization, prevention and treatment of secondary insults, use of low-cost technology for evaluation of intracranial bleeding and neuromonitoring, and emphasis on education of human resources and multidisciplinary work, are particularly important in LMICs. Institutional collaborations between high-income and LMICs have developed evidence focused on available resources. Accordingly, an expert group have proposed consensus recommendations for centers without availability of invasive brain monitoring.

SUMMARY

Severe TBI is very prevalent in LMIC and neuromonitoring is often not available in these environments. When intracranial pressure monitors are not available, careful attention to changes on clinical examination, serial imaging and noninvasive monitoring techniques can help recognize intracranial hypertension and effectively guide treatment decisions.

Threading the Needle: When a Cranial Burr Hole Is Palliative Therapy

Subdural hematoma (SDH) impacts up to 58.1 per 100,000 individuals aged ≥65 years. Some patients or proxies elect to focus exclusively on comfort care treatments, whereas others may consider surgical procedures such as a craniotomy or cranial trephination (burr hole) to relieve intracranial pressure. The central lesson of this case report is that the burr hole is a potential palliative care treatment in terms of experiences and outcomes, even among very old adults provided they have excellent baseline function. We present a case of a 95-year-old woman presenting to the emergency department with acute on chronic SDH and aphasia. Neurosurgical consultation and cranial trephination reversed her aphasia, and she continues to live independently with good function three years postsurgery. We discuss how the burr hole is consistent with a palliative care approach as well as the value of interdisciplinary discussions of minimally invasive neurosurgical interventions with potential for enhancing quality of life.

The Burden of Traumatic Brain Injury in Sub-Saharan Africa: A Scoping Review

BACKGROUND

Despite the growing incidence of traumatic brain injury (TBI) in Sub-Saharan Africa, there is yet to be a study to map the current burden of the disease on the continent. This scoping review aims to outline the literature on TBI.

METHODS

This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews. A search string was developed to identify studies relating to TBI epidemiology, management, and outcomes. The search was applied to Medline, Embase, and Global Medicus Index.

RESULTS

In total, 107 studies were included in the final analysis. More than one half originated from South Africa. Seventy-five studies were published in 2013 or later. Studies recruited a median of 115 patients: 83.5 male and 31 female. TBI affected all age groups (range = 0-105 years) and sexes but was more common among young males aged 20-40. Road traffic accidents caused TBI in a median of 71 patients. Other major causes included assault (median = 39.5) and falls (median = 12.5). Craniectomies were the most commonly reported surgical treatment (18.7%) followed by burr holes (7.5%). Four studies (3.7%) reported delays in seeking neurotrauma care, with delays in reaching a neurotrauma facility and delays in receiving care being reported in 15 studies (14%) each. Glasgow Outcome Scale score was reported in 28 (26.1%) studies, whereas quality of life measures were reported in 2 (1%). Younger age was associated with favorable outcomes.

CONCLUSIONS

There is an increased need for TBI research, education, and training in Sub-Saharan Africa. This will aid stakeholders in optimizing patient management and outcome.

Surgical intervention and patient factors associated with poor outcomes in patients with traumatic brain injury at a tertiary care hospital in Uganda

OBJECTIVE

The purpose of this study was to investigate whether neurosurgical intervention for traumatic brain injury (TBI) is associated with reduced risks of death and clinical deterioration in a low-income country with a relatively high neurosurgical capacity. The authors further aimed to assess whether the association between surgical intervention and acute poor outcomes differs according to TBI severity and various patient factors.

METHODS

Using TBI registry data collected from a national referral hospital in Uganda between July 2016 and April 2020, the authors performed Cox regression analyses of poor outcomes in admitted patients who did and did not undergo surgery for TBI, with surgery as a time-varying treatment variable. Patients were further stratified by TBI severity using the admission Glasgow Coma Scale (GCS) score: mild TBI (mTBI; GCS scores 13-15), moderate TBI (moTBI; GCS scores 9-12), and severe TBI (sTBI; GCS scores 3-8). Poor outcomes constituted Glasgow Outcome Scale scores 2-3, deterioration in TBI severity between admission and discharge (e.g., mTBI to sTBI), and death. Several clinical and demographic variables were included as covariates. Patients were observed for outcomes from admission through hospital day 10.

RESULTS

Of 1544 patients included in the cohort, 369 (24%) had undergone surgery. Rates of poor outcomes were 4% (n = 13) for surgical patients and 12% (n = 144) among nonsurgical patients (n = 1175). Surgery was associated with a 59% reduction in the hazard for a poor outcome (HR 0.41, 95% CI 0.23-0.72). Age, pupillary nonreactivity, fall injury, and TBI severity at admission were significant covariates. In models stratifying by TBI severity at admission, patients with mTBI had an 80% reduction in the hazard for a poor outcome with surgery (HR 0.20, 95% CI 0.04-0.90), whereas those with sTBI had a 65% reduction (HR 0.35, 95% CI 0.14-0.89). Patients with moTBI had a statistically nonsignificant 56% reduction in hazard (HR 0.44, 95% CI 0.17-1.17).

CONCLUSIONS

In this setting, the association between surgery and rates of poor outcomes varied with TBI severity and was influenced by several factors. Patients presenting with mTBI had the greatest reduction in the hazard for a poor outcome, followed by those presenting with sTBI. However, patients with moTBI had a nonsignificant reduction in the hazard, indicating greater variability in outcomes and underscoring the need for closer monitoring of this population. These results highlight the importance of accurate, timely clinical evaluation throughout a patient's admission and can inform decisions about whether and when to perform surgery for TBI when resources are limited.

Incidence and predictors of mortality among patients with head injury admitted to Hawassa University Comprehensive Specialized Hospital, Southern Ethiopia: A retrospective follow-up study

Introduction

Head injury is the leading cause of morbidity and mortality throughout the world, especially in resource-limited countries including Ethiopia. However, little is known about the mortality rate and its predictors among these patients in Ethiopia. Thus, the study aims to assess the incidence rate of mortality and its predictors among patients with head injury admitted at Hawassa University Comprehensive Specialized Hospital.

Methods

Institutional based retrospective follow-up study was conducted among 1220 randomly selected head injury patients admitted from July 2017 to July 2019. Bivariable and multivariable Cox regression models were fitted to identify the predictors of mortality. Proportionality assumption was tested by a global test based on the Schoenfeld residuals test.

Results

The incidence of the mortality rate was 2.26 (95%CI: 1.9–2.6) per 100-person day observation. The independent predictors of time to death were age above 65 years (AHR:3.49, 95%CI:1.63, 7.48), severe TBI (AHR: 8.8, 95%CI:5.13, 15.0), moderate TBI (AHR:3, 95%CI:1.73,5.31), hypotension (AHR:1.72, 95%CI: 1.11,2.66), hypoxia (AHR:1.92, 95%CI: 1.33,2.76), hyperthermia (AHR:1.8, 95%CI: 1.23,2.63) and hypoglycemic (AHR:1.94, 95%CI: 1.34, 2.81) positively associated with mortality, while underwent neurosurgery was negatively associated with mortality (AHR: 0.25, 95% CI: 0.11,0.53).

Conclusion

The incidence of mortality rate among head injury patients was high. Older age, moderate and severe TBI, hypotension and hypoxia at admission, neurosurgical procedure, and the episode of hyperthermia and hypoglycemia during hospitalization were the independent predictors of mortality among head injury patients. Therefore, intervention to reduce earlier deaths should focus on the prevention of secondary brain insults.

Trends in head injury associated mortality in Malawi

BACKGROUND

To address the problem of surgical workforce deficiencies in Malawi, we partnered with local institutions to establish a surgical residency-training and educational program for local surgeons in 2009. While this program has improved trauma-associated outcomes, it is unclear whether, without additional system improvements, the management of traumatic brain injury (TBI) has similarly advanced. This study sought to describe trends of TBI-associated in-hospital trauma mortality at a tertiary trauma center in sub-Saharan Africa.

METHODS

We conducted a retrospective analysis of all patients recorded in the Kamuzu Central Hospital trauma surveillance registry in Lilongwe, Malawi, from 2012 through 2017. Modified Poisson regression modeling was used to compare the risk ratio of TBI associated in-hospital death each year compared to the year 2012, after adjusting for relevant covariates.

RESULTS

87,295 patients were recorded into the KCH Trauma Registry. 3,393 patients with TBI were identified, and most TBI patients were young males. In 2013 (RR 0.66, 95% CI 0.48, 0.92) and 2014 (RR 0.57, 95% CI 0.41, 0.79), the adjusted risk ratio of in-hospital death decreased compared to 2012 when adjusted for age, sex, initial AVPU score, transfer status, and multisystem trauma. However, the adjusted risk ratio of mortality in 2015 (0.73, 95% CI 0.53, 1.02) plateaued, with relatively minor improvements in 2016 (0.72, 95% CI 0.54, 0.97) and 2017 (0.71, 95% CI 0.53, 0.96).

CONCLUSIONS

A decrease in TBI associated mortality was associated with the establishment of a residency and educational training program for general surgery. This program increased available surgeons, improved critical care and trauma training, and integrated some neurosurgical training. However, improvements in outcomes plateaued in the last few years of the study, despite these enhancements to surgical care. The general surgery workforce must be supplemented with improved neurosurgical services and neurocritical care to decrease TBI-related mortality.

Mapping Global Neurosurgery Research Collaboratives: A Social Network Analysis of the 50 Most Cited Global Neurosurgery Articles

Social network analysis of bibliometric data evaluates the relationships between the articles, authors, and themes of a research niche. The network can be visualized as maps composed of nodes and links. This study aimed to identify and evaluate the relationships between articles, authors, and keywords in global neurosurgery. The authors searched global neurosurgery articles on the Web of Science database from inception to June 18, 2020. The 50 most cited articles were selected and their metadata (document coupling, co-authorship, and co-occurrence) was exported. The metadata were analyzed and visualized with VOSViewer (Centre for Science and Technology Studies, Leiden University, The Netherlands). The articles were published between 1995 and 2020 and they had a median of 4.0 (interquartile range [IQR] = 5.0) citations. There were 5 clusters in the document coupling and 10 clusters in the co-authorship analysis. A total of 229 authors contributed to the articles and Kee B. Park contributed the most to articles (14 publications). Backward citation analysis was organized into 4 clusters and co-occurrence analysis into 7 clusters. The most common themes were pediatric neurosurgery, neurotrauma, and health system strengthening. The authors identified trends, contributors, and themes of highly cited global neurosurgery research. These findings can help establish collaborations and set the agenda in global neurosurgery research.

An evaluation of outcomes in patients with traumatic brain injury at a referral hospital in Tanzania: evidence from a survival analysis

OBJECTIVE

The purpose of this study was to determine if patients with traumatic brain injury (TBI) in low- and middle-income countries who receive surgery have better outcomes than patients with TBI who do not receive surgery, and whether this differs with severity of injury.

METHODS

The authors generated a series of Kaplan-Meier plots and performed multiple Cox proportional hazard models to assess the relationship between TBI surgery and TBI severity. The TBI severity was categorized using admission Glasgow Coma Scale scores: mild (14, 15), moderate (9-13), or severe (3-8). The authors investigated outcomes from admission to hospital day 14. The outcome considered was the Glasgow Outcome Scale-Extended, categorized as poor outcome (1-4) and good outcome (5-8). The authors used TBI registry data collected from 2013 to 2017 at a regional referral hospital in Tanzania.

RESULTS

Of the final 2502 patients, 609 (24%) received surgery and 1893 (76%) did not receive surgery. There were significantly fewer road traffic injuries and more violent causes of injury in those receiving surgery. Those receiving surgery were also more likely to receive care in the ICU, to have a poor outcome, to have a moderate or severe TBI, and to stay in the hospital longer. The hazard ratio for patients with TBI who underwent operation versus those who did not was 0.17 (95% CI 0.06-0.49; p < 0.001) in patients with moderate TBI; 0.2 (95% CI 0.06-0.64; p = 0.01) for those with mild TBI, and 0.47 (95% CI 0.24-0.89; p = 0.02) for those with severe TBI.

CONCLUSIONS

Those who received surgery for their TBI had a lower hazard for poor outcome than those who did not. Surgical intervention was associated with the greatest improvement in outcomes for moderate head injuries, followed by mild and severe injuries. The findings suggest a reprioritization of patients with moderate TBI-a drastic change to the traditional practice within low- and middle-income countries in which the most severely injured patients are prioritized for care.

Challenges and opportunities for effective data collection in global neurosurgery: traumatic brain injury surveillance experience in Malawi

Global health research can transform clinical and surgical practice worldwide. Partnerships between US academic centers and hospitals in low- and middle-income counties can improve clinical care at the host institution hospital and give the visiting institution access to a large volume of valuable research data. Recognizing the value of these partnerships, the University of North Carolina (UNC) formed a partnership with Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. The Department of Neurosurgery joined the partnership with KCH and designed a Head Trauma Surveillance Registry. The success of this registry depended on the development of methods to accurately collect head injury data at KCH. Since medical record documentation is often unreliable in this setting, data collection teams were implemented to capture data from head trauma patients on a 24-hours-a-day, 7-days-a-week basis. As data collection improved, pilot groups tested methods to collect new variables and the registry expanded. UNC provided onsite and remote oversight to strengthen the accuracy of the data. Data accuracy still remains a hurdle in global research. Data collection teams, oversight from UNC, pilot group testing, and meaningful collaboration with local physicians improved the accuracy of the head trauma registry. Overall, these methods helped create a more accurate epidemiological and outcomes-centered analysis of brain injury patients at KCH to date.

Development of a Three-dimensional Printed Emergent Burr Hole and Craniotomy Simulator

Patients with a traumatic head injury (THI) require immediate surgical intervention, as rapidly expanding intracranial hematomas can be imminently life-threatening, not permitting transfer time to neurosurgical care in a tertiary care center. In rural and remote areas, where neurosurgeons may not be readily available, surgical intervention by Community General Surgeons (CGS) may be required. Currently, the CGS in Newfoundland and Labrador (NL) do not have access to, or have experience training with, an emergent burr hole/craniotomy (EBHC) simulator. One of the barriers is the availability of inexpensive and reliable simulators to practice these skills. Therefore, a low-cost, three-dimensional (3D) printed EBHC simulator was designed and 3D-printed by MUN Med 3D (St John's, NL).

The aim of this technical report is to assess the need for such simulator in rural and remote healthcare centers and report on the iterative development of the EBHC simulator. The 3D-printed EBHC simulator developed by MUN Med 3D was utilized during a general surgery workshop at the 26^th Annual Rural and Remote Medicine Conference in St. John’s, NL. A total of six 3D-printed EBHC simulators were provided for the hour and a half workshop. At the end of the workshop, 16 participants were asked to provide feedback on the need for this simulator in their rural or remote environment as well as feedback on the physical attributes. The feedback received from the participants was overall positive, informative, and supported the need for the 3D-printed EBHC simulator.

Notes on the Recent History of Neuroscience in Africa

Neuroscience began with neuroanatomy and neurosurgery in Egypt more than 5000 years ago. Knowledge grew over time and specialized neurosurgery centers were established in north Africa in the eleventh century. However, it was not until the twentieth century that neuroscience research became established in sub-Saharan Africa. In most African countries, clinical research focused on understanding the rationale and improving treatment of epilepsy, infections, nutritional neuropathies, stroke and tumors. Significant advances were made. In the twenty-first century, African knowledge expanded to include all branches of neuroscience, contributing to genetic, biochemical and inflammatory determinants of brain disorders. A major focus of basic neuroscience research has been, and is, investigation of plant extracts, drugs and stress in animal models, providing insight and identifying potential novel therapies. A significant event in the history of African neuroscience was the founding of the Society of Neuroscientists of Africa (SONA) in 1993. The International Brain Research Organization (IBRO) supported SONA conferences, as well as workshops and neuroscience training schools in Africa. Thanks to their investment, as well as that of funding agencies, such as the National Institutes of Health (NIH), International Society for Neurochemistry (ISN), World Federation of Neurosurgical Societies (WFNS), World Federation of Neurology (WFN) and the International League Against Epilepsy (ILAE), neuroscience research is well-established in Africa today. However, in order to continue to develop, African neuroscience needs continued international support and African neuroscientists need to engage in policy and decision-making to persuade governments to fund studies that address the unique regional needs in Africa.