European Medical Students' Views on Neurosurgery, with Emphasis on South-East Europe (Albania, Greece, Serbia, and Turkey).

BACKGROUND: Neurosurgery, an intricate and dynamic surgical specialty, faces challenges in attracting medical graduates. Despite its potential appeal, a decreasing trend in medical students opting for surgical specialties, including neurosurgery, is noted. This study aims to assess European medical students' perceptions of neurosurgery, focusing on South-East Europe, and address concerns about the declining interest in this field. METHODS: A comprehensive digital survey, comprising 33 questions, was distributed to 1115 medical students across 17 European countries. The survey, conducted over 9 months, gathered responses through European neurosurgical societies, the European Association of Neurosurgical Societies (EANS), and university channels. Statistical analysis utilized IBM Statistical Package for the Social Sciences, presenting data through counts, proportions, and χ2 tests. RESULTS: The study reveals that, over the survey period, 834 medical students completed the questionnaire, with a predominant representation from South-East Europe. While 43.2% of participants were considering a surgical career, neurosurgery emerged as the most preferred specialty (26.37%). Despite this interest, 80.2% reported insufficient knowledge about pursuing a neurosurgical career, with limited exposure during medical education. Concerns about work-life balance, heavy workload, and hierarchical structures were prominent among respondents. CONCLUSIONS: The findings underscore the need for targeted interventions to address concerns influencing medical students' decisions regarding neurosurgery. Improving neurosurgical education, dispelling misconceptions, and creating a supportive work environment are crucial steps to attract and retain diverse talented individuals in neurosurgery. These efforts will be vital in narrowing the gap between the demand for neurosurgeons and the number of medical graduates entering the field, ensuring a sustainable future for this essential surgical specialty.

Gender differences in work-life balance of European neurosurgeons.

Introduction: Neurosurgery is one of the most demanding medical specialties. For neurosurgeons, balancing professional activity with personal life can be challenging. Research question: To evaluate gender differences in contribution of neurosurgeons in the household and child-rearing, as well as their impact on personal life and career. Material and methods: An anonymous, electronic, 59-item web-based survey was administered to National Neurosurgical Societies of Europe, and European Member Societies of the European Association of Neurosurgical Societies (June-October 2021). Results: A total of 205 European neurosurgeons (87 females and 118 males, mean age 40.7) are included in our survey. In neurosurgery, females are significantly more likely to be alone (37.9%), while males are significantly more likely to have children (66.9%). In terms of household efforts, females spend more time than males on the same tasks. Most participants (71.2%) view gender issues as a disadvantage in career pursuing. Women feel less accepted (54.3%) and having fewer opportunities (58.6%), while men believe that pregnancy/child-rearing (65.8%) and having many roles (51.3%) are the main obstacles. Both genders (77.6%) favor more convenient working conditions for young parents.Discussion and Conclusion. In our study we found that, women neurosurgeons take more responsibilities at home, especially in the child-rearing years. Female neurosurgeons are more likely to live alone or stay childless more often compared to their male colleagues. Supportive facilities, flexible programs, universal life policies and presumably curbing of the social stereotypes are of importance to overcome gender inequities that women are still facing in neurosurgery.

Some Interesting Points of Competition of X-Ray using during the Greco-Ottoman War in 1897 and Development of Neurosurgical Radiology: A Reminiscence.

AIM: To investigate the competition of radiologic development between Turkey and Greece during the Greco-Ottoman War when the first application of X-Ray took place. MATERIAL AND METHODS: A literature review was conducted, and we searched the published papers about X-Ray using during the Greco-Turkish War in 1897. RESULTS: The use of X-Rays in the military dates to the Greco-Ottoman War in 1897, which is an important issue because X-ray was first specifically used in this war. The radiographic images were used to show the evidence of pieces of bullets and shrapnel inside the bodies of soldiers. CONCLUSION: The experience of the Ottoman Empire and Greece is important for the development of neurosurgical radiology. Both Greek and Turkish parts used the X-Ray technology before any of the risks and adverse effects were unknown. More studies are required.

Direct Consequences of Cranioplasty to the Brain: Intracranial Pressure Study.

ABSTRACT: Intracranial pressure (ICP) is a crucial factor that we need to take into account in all major pathophysiological changes of the brain after decompressive craniectomy (DC) and cranioplasty (CP). The purpose of our study was to check ICP values before and after cranioplasty and its relation to various parameters (imaging, demographics, time of cranioplasty, and type of graft) as well as its possible relation to postsurgical complications. The authors performed a prospective study in which they selected as participants adults who had undergone unilateral frontotemporoparietal DC and were planned to have cranioplasty. Intracranial pressure was measured with optical fiber sensor in the epidural space and did not affect cranioplasty in any way.Twenty-five patients met the criteria. The mean vcICP (value change of ICP) was 1.2 mm Hg, the mean ΔICP (absolute value change of the ICP) was 2.24 mm Hg and in the majority of cases there was an increase in ICP. The authors found 3 statistically significant correlations: between gender and ΔICP, Δtime (time between DC and CP) and vcICP, and pre-ICP and ±ICP (quantitative change of the ICP).Μale patients tend to develop larger changes of ICP values during CP. As the time between the 2 procedures (DC and CP) gets longer, the vcICP is decreased. However, after certain time it shows a tendency to remain around zero. Lower pre-ICP values (close to or below zero) are more possible to increase after bone flap placement. It seems that the brain tends to restore its pre-DC conditions after CP by taking near-to-normal ICP values.

Post-Cranioplasty Complications: Lessons From a Prospective Study Assessing Risk Factors.

ABSTRACT: Complication rate related with cranioplasty is described as very high in most of relevant studies. The aim of our study was to try to identify possible factors, that could predict complications following cranioplasty. The authors hypothesized that some physical characteristics on the preoperative brain computed tomography (CT) scan can be predictive for complications.The authors carried out a prospective observational study. All patients were adults after decompressive craniectomy, planned for cranioplasty and had a brain CT scan the day before cranioplasty. Our data pool included demographics, reason of craniectomy, various radiological parameters, the time of cranioplasty after craniectomy, the type of cranioplasty bone flap, and the complications.Twenty-five patients were included in the study. The authors identified statistically significant correlation between time of cranioplasty after craniectomy and the complications, as well as between the type of cranioplasty implant and the complications. There was statistically significant correlation between complications and the distance of the free brain surface from the level of the largest skull defect dimension - free brain surface deformity (FBSD). Moreover, the correlation between FBSD and the time of cranioplasty was statistically significant.It seems that for adult patients with unilateral DC the shorter time interval between craniectomy and cranioplasty lowers the risk for complications. The risk seems to be decreased further, by using autologous bone flap. Low values of the FBSD increase the risk for complications. This risk factor can be avoided, by shortening the time between craniectomy and cranioplasty.

Clipping versus coiling in posterior circulation intracranial aneurysms: a meta-analysis.

BACKGROUND: Posterior circulation intracranial aneurysm (IA) treatment remains challenging, due to the anatomy of the area and the high rupture possibility. Endovascular treatment seems to be more suitable for these aneurysms, but studies focused on endovascular treatment demonstrate a high rate of re-intervention needing. A meta-analysis might offer a clearer view, being useful in a more effective treatment planning. METHODS: A systematic search was performed, using the PubMed database platform. The final article pool contained 20 articles. Studied parameters were operative mortality, late mortality, permanent neurologic deficit (PND), and the need for re-intervention (Re-int). We divided patients into two subgroups, those with ruptured and those with unruptured aneurysm. Statistical analysis was performed using appropriate software. RESULTS: In the total population (645 patients), there was a superiority of coiling over clipping in terms of PND and of coiling in terms of Re-int. As regards mortality, there was no clear superiority of one method over the other. CONCLUSIONS: The current study came to the conclusion that there is a superiority of coiling over clipping in terms of PND. On the other hand, clipping seems to be superior to coiling in terms of the need for re-intervention. As regards mortality (both operative and late), there is no clear superiority of one method over the other. Studying subgroups of patients (ruptured and unruptured posterior circulation IAs), in terms of PND, there is no superiority of one method over the other. The same goes for Op-Mo on ruptured aneurysms.

The value of the identification of predisposing factors for post-traumatic amnesia in management of mild traumatic brain injury.

OBJECT: To identify the risk factors for post-traumatic amnesia (PTA) and to document the incidence of PTA after mild traumatic brain injuries. METHODS: This was a prospective study, affecting mild TBI (mTBI) (Glasgow Coma Scale 14-15) cases attending to the Emergency Department between January 2009 and April 2012 (40 months duration). Patients were divided into two groups (Group A: without PTA, and Group B: with PTA, and they were assessed according to the risk factors. RESULTS: A total of 1762 patients (males: 1002, 56.8%) were meeting study inclusion criteria [Group A: n = 1678 (83.8%), Group B: n = 84 (4.2%)]. Age, CT findings: (traumatic focal HCs in the frontal and temporal lobes or more diffuse punctate HCs, and skull base fractures), anticoagulation therapy and seizures were independent factors of PTA. There was no statistically significant correlation between PTA and sex, convexity fractures, stroke event, mechanism of mTBI (fall +/or beating), hypertension, coronary heart disease, chronic smokers and diabetes (p > 0.005). CONCLUSION: CT findings: (traumatic focal HCs in the frontal and temporal lobes or more diffuse punctate HCs and skull base fractures), age, seizures and anticoagulation/antiplatelet therapy, were independent factors of PTA and could be used as predictive factors after mTBI.

Could IGF-I levels play a neuroprotective role in patients with large vestibular schwannomas?

AIM: To evaluate the possible superiority of outcome in patients with elevated IGF-I levels after vestibular schwannoma (VS) resection. PATIENTS & METHODS: This retrospective study included 65 patients (34 male, 52.3%) with VS operated in between January 2009 and April 2014 (follow-up 3.2 ± 0.7 years). Preoperative or postoperative IGF-I levels were identified for each patient. RESULTS: Patients were divided into two groups: Group A (small size tumor), 56 patients; and Group B (large size tumor), 9 cases. IGF-I levels in Group A (195.8 ± 32.9 ng/ml) were compared with those of Group B (242.2 ± 22.2 ng/ml) and were found to have statistically significant difference (p = 0.001). CONCLUSION: Increased IGF-I levels could hold a key role in nerve recovery in patients undergoing surgical resection of large VS.

Anterior cervical spine surgery-associated complications in a retrospective case-control study.

Anterior cervical spine procedures have been associated with satisfactory outcomes. However, the occurrence of troublesome complications, although uncommon, needs to be taken into consideration. The purpose of our study was to assess the actual incidence of anterior cervical spine procedure-associated complications and identify any predisposing factors. A total of 114 patients undergoing anterior cervical procedures over a 6-year period were included in our retrospective, case-control study. The diagnosis was cervical radiculopathy, and/or myelopathy due to degenerative disc disease, cervical spondylosis, or traumatic cervical spine injury. All our participants underwent surgical treatment, and complications were recorded. The most commonly performed procedure (79%) was anterior cervical discectomy and fusion (ACDF). Fourteen patients (12.3%) underwent anterior cervical corpectomy and interbody fusion, seven (6.1%) ACDF with plating, two (1.7%) odontoid screw fixation, and one anterior removal of osteophytes for severe Forestier's disease. Mean follow-up time was 42.5 months (range, 6-78 months). The overall complication rate was 13.2%. Specifically, we encountered adjacent intervertebral disc degeneration in 2.7% of our cases, dysphagia in 1.7%, postoperative soft tissue swelling and hematoma in 1.7%, and dural penetration in 1.7%. Additionally, esophageal perforation was observed in 0.9%, aggravation of preexisting myelopathy in 0.9%, symptomatic recurrent laryngeal nerve palsy in 0.9%, mechanical failure in 0.9%, and superficial wound infection in 0.9%. In the vast majority anterior cervical spine surgery-associated complications are minor, requiring no further intervention. Awareness, early recognition, and appropriate management, are of paramount importance for improving the patients' overall functional outcome.

Clipping Versus Coiling in Anterior Circulation Ruptured Intracranial Aneurysms: A Meta-Analysis.

OBJECTIVE: To evaluate open surgical versus endovascular repair of anterior circulation ruptured intracranial aneurysms based on operative mortality, permanent neurologic deficit, late mortality, and need for reintervention. METHODS: This meta-analysis included articles published since December 6, 2016, that compared outcomes of the 2 methods. Extracted data were organized in a standard table format, including first author, country, covered study period, publication year, number of patients and patients at follow-up, operative mortality rate (with 30 days from treatment), permanent neurologic deficit (appearing after surgery), late mortality (after 1 month), and reintervention (surgery or coiling) for both groups of patients. Follow-up was at least 1 year. RESULTS: There were 8 articles that matched our study criteria. The study population was 628 patients; 374 were treated with surgical clipping, and 254 were treated with endovascular coiling. Pooled results showed no statistically significant difference between the 2 groups in terms of operative mortality, permanent neurologic deficit, late mortality, and need for reintervention. CONCLUSIONS: Selection of the appropriate procedure must be made on the basis of the special characteristics of each case.

According to which factors in severe traumatic brain injury craniectomy could be beneficial.

BACKGROUND: To investigate the clinical outcome at 101 patients undergoing decompressive craniectomy (DC) after severe traumatic brain injury (TBI). METHODS: Age, Glasgow Coma Scale (GCS) at the time of intubation, and the intraoperative intracranial pressure (ICP) were recorded. Formal DC was performed in all cases and the square surface of bone flap was calculated in cm(2) based on the length and the width from computed tomography scan. RESULTS: The difference of good neurological recovery (Glasgow outcome score 4-5), between patients with ICP ≤20 mmHg, GCS ≥5, age ≤60 years, and bone flap ≥130 cm(2) and those with ICP >20 mmHg, GCS <5, age >60 years, and bone flap <130 cm(2), was statistically significant. CONCLUSION: Although the application of DC in severe TBI is controversial and the population in this study is small, our study demonstrates the threshold of the specific factors (patient age, ICP and GCS on the day of the surgery and the size of the bone flap) which may help in the decision of performing DC. Furthermore, this study proves that the different combinations and mainly at the same time involvement of all prognostic parameters (age <60, GCS <5, bone flap ≥130 cm(2), and ICP ≤20 at time of DC surgery) allow a better outcome.

Posttraumatic Hydrocephalus after Decompressive Craniectomy in 126 Patients with Severe Traumatic Brain Injury.

OBJECTIVE: Severe traumatic brain injuries (TBIs) occur frequently. In some of these patients decompressive craniectomy (DC) must be performed. Posttraumatic hydrocephalus (PTH) can develop after TBI further damaging the brain. DC is considered to be one of the causes of PTH. This study defines the incidence of PTH in TBI patients who underwent DC and tries to determine associated factors. MATERIALS AND METHODS: We conducted a retrospective study (2009-2013) that included 126 patients with severe TBI and DC. The collected data were demographics, the craniectomy size, the presence or absence of hydrocephalus, the need for changing the opening pressure of the valve of the cerebrospinal fluid (CSF) shunt or replacing all or parts of the CSF shunt, and the interval between cranioplasty and shunt placement. We excluded patients with additional intraventricular hemorrhage and those with bilateral or bifrontal DC. RESULTS: Ten of the 126 patients (7.9%) developed PTH and were treated with a CSF shunt. There was no statistical correlation between development of PTH and age or sex, but a statistically significant correlation between development of PTH and the size of DC. CONCLUSION: Our study suggests that PTH development is multifactorial and shows that PTH is not that rare. We showed a correlation between craniectomy size and the incidence of PTH.

Motive related positivity: decision-making during a prisoners' dilemma task.

The neural mechanisms underlying decision-making to cooperate or defect were investigated using event-related potentials during an iterated computer Prisoner's Dilemma task, adapted to induce working memory operation. Event-related potentials from 64 leads of 22 participants were recorded during 90 trials and averaged depending on the condition of cooperation and defect. The P200 component of the event-related potentials provided evidence for activation differences between cooperation and defect. Cooperation elicited significantly increased P200 activation at parieto-occipital leads, while defect activated primarily the prefrontal electrodes. Functional mapping using Low Resolution Electromagnetic Tomography indicated that in the 150-180 ms time window Brodmann areas 19 (precuneus) and 17 (lingual gyrus), exhibited increased activation during cooperation, while Brodmann area 6 (precentral gyrus) exhibited increased activation when participants defected. In conclusion, the current study provides evidence that cooperation and defect elicit different brain activation at specific loci and within specific time windows.

Temporal processing dysfunction in schizophrenia as measured by time interval discrimination and tempo reproduction tasks.

OBJECTIVE: Time perception deficiency has been implicated in schizophrenia; however the exact nature of this remains unclear. The present study was designed with the aim to delineate timing deficits in schizophrenia by examining performance of patients with schizophrenia and healthy volunteers in an interval discrimination test and their accuracy and precision in a pacing reproduction­replication test. METHODS: The first task involved temporal discrimination of intervals, in which participants (60 patients with schizophrenia and 35 healthy controls) had to judge whether intervals were longer, shorter or equal than a standard interval. The second task required repetitive self-paced tapping to test accuracy and precision in the reproduction and replication of tempos. RESULTS: Patients were found to differ significantly from the controls in the psychoticism scale of EPQ, the proportion of correct responses in the interval discrimination test and the overall accuracy and precision in the reproduction and replication of sound sequences (p < 0.01). Within the patient group bad responders concerning the ability to discriminate time intervals were associated with increased scores in the Positive and Negative Syndrome Scale (PANSS) and in the Brief Psychiatric Rating Scale (BPRS) in comparison to good responders (p < 0.01). There were no gender effects and there were no differences between subgroups of patients taking different kinds or combinations of drugs. CONCLUSIONS: Analysis has shown that performance on timing tasks decreased with increasing psychopathology and therefore that timing dysfunctions are directly linked to the severity of the illness. Different temporal dysfunctions can be traced to different psychophysiological origins that can be explained using the Scalar Expectancy Theory (SET).

Effect of frequency deviance direction on performance and mismatch negativity.

The mismatch negativity (MMN) component of the auditory event-related potential is associated with automatic perceptual inference concerning changes in auditory stimulation. Recent studies have addressed the question whether performance and MMN is affected by the direction of frequency deviance. In the present study, the frequency MMN and performance is investigated during an auditory identification task. Specifically, we examined the effect of positive and negative differences between the present stimulus and the previous response frequencies on performance as well as on the characteristics of stimulus-locked ERPs and brain activation maps. The results show that frequency deviants creating mismatch conditions increase the likelihood of error commission. The decrease in performance achieves statistical significance in the case of positive frequency deviants. In the latter case, ERP amplitude values of the Fz electrode at 164 ms after stimulus onset are statistically larger for mismatch as opposed to no-mismatch condition. This corresponds to significance differences in the activation maps at Brodmann area 11, superior frontal gyrus, and the frontal lobe. The present findings revealed dissociations in behavioral and ERP responses in the processing of positive and negative frequency deviance, lending support to the notion that MMN is more sensitive to increments than to decrements in frequency.

Mismatch task conditions and error related ERPs.

BACKGROUND: The N200 component of event related potentials (ERPs) is considered an index of monitoring error related responses. The aim of the present work was to study the effect of mismatch conditions on the subjects' responses in an auditory identification task and their relation to the N200 of stimulus-locked ERPs. METHODS: An auditory identification task required to correctly map a horizontal slider onto an active frequency range by selecting a slider position that matched the stimulus tone in each trial. Fourteen healthy volunteers participated in the study and ERPs were recorded by 32 leads. RESULTS: Results showed that the subjects' erroneous responses were equally distributed within trials, but were dependent on mismatch conditions, generated by large differences between the frequencies of the tones of consecutive trials. Erroneous trials showed a significantly greater negativity within the time window of 164-191 ms after stimulus, located mainly at the Cz and Fz electrodes. The LORETA solution showed that maximum activations, as well as maximum differences, were localized mainly at the frontal lobe. CONCLUSIONS: These findings suggest that the fronto-central N200 component, conceived an index of "reorientation of attention", represents a correlate of an error signal, being produced when representation of the actual response and the required response are compared. Furthermore the magnitude of the amplitude of the N200 rests on the relation between the present and the previous stimulus.

Behavioral and brain pattern differences between acting and observing in an auditory task.

BACKGROUND: Recent research has shown that errors seem to influence the patterns of brain activity. Additionally current notions support the idea that similar brain mechanisms are activated during acting and observing. The aim of the present study was to examine the patterns of brain activity of actors and observers elicited upon receiving feedback information of the actor's response. METHODS: The task used in the present research was an auditory identification task that included both acting and observing settings, ensuring concurrent ERP measurements of both participants. The performance of the participants was investigated in conditions of varying complexity. ERP data were analyzed with regards to the conditions of acting and observing in conjunction to correct and erroneous responses. RESULTS: The obtained results showed that the complexity induced by cue dissimilarity between trials was a demodulating factor leading to poorer performance. The electrophysiological results suggest that feedback information results in different intensities of the ERP patterns of observers and actors depending on whether the actor had made an error or not. The LORETA source localization method yielded significantly larger electrical activity in the supplementary motor area (Brodmann area 6), the posterior cingulate gyrus (Brodmann area 31/23) and the parietal lobe (Precuneus/Brodmann area 7/5). CONCLUSION: These findings suggest that feedback information has a different effect on the intensities of the ERP patterns of actors and observers depending on whether the actor committed an error. Certain neural systems, including medial frontal area, posterior cingulate gyrus and precuneus may mediate these modulating effects. Further research is needed to elucidate in more detail the neuroanatomical and neuropsychological substrates of these systems.