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A Global Neurosurgery Approach to Reducing the Burden of Traumatic Acute Subdural Hematoma: A Narrative Review

By Mahnoor Sukaina

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Sukaina M. A global neurosurgery approach to reducing the burden of traumatic acute subdural hematoma: a narrative review. HPHR. 2021; 32.

A Global Neurosurgery Approach to Reducing the Burden of Traumatic Acute Subdural Hematoma: A Narrative Review

Abstract

This narrative review highlights the importance of timely neurosurgical interventional after a person suffers from a motor vehicle accident. Acute subdural hematomas account for 30-70% of traumatic brain injuries. The paper discusses the global burden of TBI as the forerunner of the public health problem, about 50% of the world population will acquire TBI once in their lifetime. There is a severe deficit in the global workforce to meet the neurotrauma, which becomes worse in low-income and middle-income countries especially in sub-Saharan and Southeast Asia. Indication for neurosurgical intervention depends upon several parameters such as clot thickness exceeding 10mm, midline shift greater than 5mm; which possibly increases intracranial pressure (ICP) more than 20 mmHg as a result of mass effect, and abnormal pupillary response such as asymmetrically unilateral or bilaterally dilated. Surgical procedures vary with different circumstances, which include mainly craniotomy, decompressive hemicraniectomy, and burr hole irrigation. Comparison of the outcomes of decompressive craniectomy and craniotomy are discussed under the DECRA and RESCUEicp trials. Robotic telepresence, task-shifting, and task-sharing are alternative interventional strategies and practices to carry various neurosurgical procedures by non-neurosurgeons in LMICs. Reintroduction of the survivors of MVA acquiring TBI into the society is a prime concern, therefore, various neurorehabilitation strategies are discussed. The barriers to becoming neurosurgeons by the young doctors as the core principle of infrastructure, governance by bodies such as World Health Organization and its universal health coverage initiative, and World Federation of Neurosurgical Societies efforts to balance the disparity in LMICs are discussed.

Abbreviations Used in This Paper

  • Abbreviated Injury Scale (AIS)
  • Acute Subdural Hematoma (aSDH)
  • Computerized Tomography (CT)
  • Cranioplasty (CP)
  • Decompressive Craniectomy (DC)
  • Decompressive Craniotomy (DCO)
  • Department of Transportation (DOT)
  • Extended Glasgow Score (GOS-E)
  • Glasgow Coma Scale (GCS)
  • Gross Domestic Product (GDP)
  • High-income countries (HIC)
  • Intracranial Pressure (ICP)
  • Low-income and middle-income countries (LMICs)
  • Low-income countries (LICs)
  • Motor Vehicle Accident (MVA)
  • National Institute of Health Research (NIHR)
  • Paroxysmal Sympathetic Hyperactivity (PSH)
  • Posttraumatic Agitation (PA)
  • Posttraumatic Hydrocephalus (PTH)
  • Randomized Control Trials (RCTs)
  • Subdural Hematoma (SDH)
  • Task-shifting and Task-sharing (TS/S)
  • Traumatic Brain Injury (TBI)
  • Universal Health Coverage (UHC)
  • World Federation for Neurosurgical Societies (WFNS)
  • World Health Organization (WHO)

Introduction

Worldwide, automobiles are primarily used for transportation; with only in the US about 86% of the population uses cars for commuting (Ritchter, 2019). According to the 2019’s data from the US department of transportation (DOT) Bureau of Transportation Statistics, total highway registered vehicles were 276,491,174 of which; 194,348,815 vehicles were light duty-short wheelbase, 59,456,369 light-duty vehicles were long wheelbase, and 8,596,314 motorcycles (Bureau of Transportation Statistics1, n.d.). Further investigation of 2019 data of the US DOT Bureau of Transportation Statistics, conveyed 6,756,000 crashes of automobiles, resulting in 36,096 fatalities and 2,740,000 MVA related injuries in the United States (Bureau of Transportation Statistics2, n.d.). If we calculate the total percentage of automobile crashes to the total registered highway vehicles, we receive 40.925% of the incidence report. Furthermore, according to the Centers for Disease Control and Prevention (2014), MVA was the second most cause of traumatic brain injury (TBI) related hospitalization, which accounted for 20.4% for the mean age of 18.2 years, wherea

Global Burden of TBI

A global catastrophe exists in the public health sector regarding neurosurgery and neurotrauma, where TBI is the leading global public health problem and it accounts for 27 million annual worldwide cases (Clark et al., 2020). The global burden of trauma and injuries costs more than $500 billion each year and more than 10 million injuries (Hoffman et al., 2005), and about 50% of the world population will have at least one TBI in their life (Maas et al., 2017). Meara et al. (2015) quoted 33% of world deaths that is 16.9 million lives were lost in 2010 due to the unavailability of surgical service, which is greater than the combined death by HIV/AIDS, tuberculosis, and malaria. MVA account for the quarter of entire injury-related death globally and are the worldwide leading cause of trauma-related death in males (Hoffman et al., 2005). The fact sheet from WHO (2020) quoted the figure of 1.35 million deaths that occur as a result of MVA every year, of which; more than half the deaths occur in pedestrians, cyclists, and 2-wheel motorcyclists (Hoffman et al., 2005). The report further mentions the statistics of 93% of the global MVA-related fatalities among the low and middle-income countries (LMICs), although these countries have 60% of the world vehicles only (WHO, 2020).

The Deficit in the Special Neurosurgical Workforce to Meet the Demand

Dewan et al. (2018) mentioned that 13.8 million neurosurgical cases develop each year of which 80% arise in low and middle-income countries. To meet this enormous demand there are only 49,940 neurosurgeons available globally that deals with 13.8 million new operative cases and 22.6 million new consultative cases annually (Dewan et al.,2018). Therefore, creating a deficit of 5.2 million in neurosurgical care excluding the trivial and nonessential cases performed by neurosurgeons particularly in high-income countries (HICs) (Dewan et al., 2018). Dewan et al. (2018) further estimated an additional 22,626 neurosurgeons to fill the deficit, as the greatest deficit is in Southeast Asia where essential 2.5 million cases go unattended alone out of 5.2 million global unmet cases that result in either death or disability. Ratan et al. (2019) estimated 1 million trauma-related death annually in India, of which, over half the deaths are due to head injury. There are only 1,400 certified neurosurgeons in the population of 1.2 billion, of which, 80% of the specialist doctors live in urban areas, and patients have to travel hundreds of kilometers to seek a neurosurgeon, therefore, losing the golden hour of the trauma (Ratan et al., 2019). Corley, Lepard et al. (2019) found that patients should be in 4 hours facility at least to provide timely intervention after meeting the trauma. Rubiano et al. (2020) estimated that in Columbia, 70% of the death in violence cases and 90% of death in MVA is due to the TBI.

The Disparity Amongst Different Regions

Hoffman et al. (2005) differentiated the demographical disparity among the outcome of MVA, where a long-term disability is greater in rural areas as compared to urban where morbidity and mortality from the brain and spinal injury preponderates. Hoffman et al. (2005) further compared that newly founded countries in Europe come under middle-income countries represents the highest mortality due to neurotrauma, whereas, high-income countries including North America, Western Europe, and Australia/ New Zealand reveals the lowest rates.

The Disparity In the Neurosurgery Workforce

Dewan et al. (2018) estimated disparity amongst the global neurosurgery workforce where 56% of the neurosurgeons reside in LMICs to meet with the total 82% of neurosurgical global case volume; which is slightly less than 4.9 million operative cases annually (Corley, Lepard et al., 2019). Furthermore, Africa alone accounts for 15% of the global neurosurgical volume whereas there is less than 1% availability of neurosurgeons by the African hospitals and healthcare network (Dewan et al., 2018). Africa has nearly 2 million cases annually as compared to the US and Canada that has 665,000 annual combined cases (Dewan et al., 2018).  The number of neurosurgeons per population also varies where Japan having 7495 neurosurgeons in 127,131,800 population, and thirty-three countries have no neurosurgeon (Mukhopadhyay et al. 2019). The neurosurgeon density also varies according to the region, where the global mean is 1 neurosurgeon per 230,000 population (Mukhopadhyay et al., 2019), while in the EU one neurosurgeon per 99,152 population (Reulen et al., 2009). Karekezi et al. (2020) highlighted the efforts by the World Federation of Neurosurgical Societies (WFNS) and Rabat Training Center in sub-Saharan Africa; which represents 17% of the world land and 14% of the world population, that increased the number of neurosurgeons from 79 in 1998 to 369 in 2016, therefore, shifting the ratio from 1 neurosurgeon per 6 million to 1 per 2.62 million. Fuller et al. (2016) quoted the figure of 565 neurosurgeons for the entire African continent, of which in East Africa there are only 27 neurosurgeons in the population of 270 million, hence, with the ratio of a neurosurgeon to the inhabitant of 1 is to 10 million. Due to regional difference, there is a disparity in the participation of the global neurosurgical trials such as less than 10% of TBI patients from LMIC were included in the RESCUEicp trial (Hutchinson et al., 2016; Mohan et al., 2021), while no patients from LMIC were included in DECRA trial (Cooper et al., 2011; Mohan, et al., 2021).

Subdural Hematoma and Its Association with Automobile Crash

McCafferty et al. (2018) claim that in the US, one-third of trauma-related deaths are caused by head injury. Urban et al. (2012) estimated the figure of 1.7 million worldwide individuals that had TBI due to involvement in MVA, which often leads to acute subdural hematoma (aSDH) and can be fatal. 

 

According to Lavrador et al. (2018), 50% to 60% of subdural hematoma are categorized under aSDH. There are two classifications of traumatic aSDH pathophysiology; burst lobe syndrome, which is brain contusion and intracerebral hematoma (ICH) communicates with subdural space, or trauma-induced rupturing of bridging veins within subdural space, which leads to leakage and stasis of blood, hence, causing SDH (Lavrador et al.,2018). Further, SDH is classified into acute, subacute, and chronic, concerning the interval of injury. Acute SDH occurs in a timeframe of fewer than 72 hours, following the accident (Stone et al., 1983). Subacute hematoma is a further complication of aSDH arising from four days to twenty-one days, following TBI (Ha et al. 2018). A chronic subdural hematoma can arise within twenty-one days, mostly in the older age group, regardless of aSDH (Ha et al. 2018).

Mechanism of aSDH

Gusmão et al. (2003) correlate aSDH with automobile crash head injury, the mechanism of SDH in a crash accident is strongly associated with accelerating inertia, producing the most intense and severely fatal head injury. Further complications may arise from traumatic accelerating injuries such as extradural hematoma, cerebral contusion, and hypoxic brain injury. When the head is in momentum in the direction of the speeding motor vehicle, abrupt cessation of speed by a motor vehicle crash results in brain compression to the skull in the direction of accelerating force.

 

Subdural space occupies between two meningeal layers of the brain, arachnoid mater, and dura mater that is embryonically derived from neural crest cells. Bridging veins connect the blood supply from the surface of the brain to the dura matter (Pierre L et al,2020). An initial clinical picture would show hematoma by rupturing of bridging veins in subdural space, excavation of blood within subdural space, producing bruises, a shear strain on the white matter of the brain (Rush, 2011; Iliescu et al., 2015). Urban et al. (2012) discussed the importance of the impact and intensity of crashes on neuroanatomical regions concerning the MVA. Direct coup injury is associated with front side accident, which is largely confined to falx cerebri, whereas, far and near side crash observes countercoup injury. Injury in far and near side crashes involving lateral convexities of the brain results in greater SDH volume.

Clinical Examination and Diagnosis

Glasgow Come Scale (GCS)

Developed in 1974, GCS is the significantly most widely used standard indicator for the evaluation and assessment of TBI (Matis & Birbilis, 2008). GCS assists in finding the conscious status of the injured patient, therefore, providing a better assessment option for the clinician. The score of 13-15 on the scale is classified as mild, 9-12 as moderate, and 3-8 as severe (McCafferty et al. 2018). Pupillary examination for size and light reactivity is vital for the prognosis of brain function and risen intracranial pressure (ICP), further, a neurological examination should be done (McCafferty et al. 2018).

Abbreviated Injury Scale (AIS)

Initially introduced in 1971, AIS is a widely used gold standard score-based analysis of TBI (Carroll et al., 2010), with updates and revisions coming at intervals including in AIS-1998, AIS-2005, Updated 2008, and AIS-2015. AIS for TBI is a six-digit classification of the injury starting with prefix 14, and scored on the scale of 1-6, with 1 as minor injury and 6 as virtually unsurvivable injury (Morris et al., 2008). AIS-2005 is used to assess the severity and size of TBI such as distinguishing the volume and size of hematoma (Carroll et al.2010).

Significance of Diagnostic Neuroimaging

Computerized Tomography (CT) scans are an extensively used diagnostic tool for the confirmation of SDH by volume of clotted blood and size. The immediate phase shows a “swirled” appearance and iso-dense, indicating the continuing excavation of blood without formation of clot and intermixing of serum of already started lodged blood clots (Rao et al., 2016). Further, Rao et al. (2008) found the early phase possibly divulges the formation of concave and crescent-shaped clots, which begin to hypo-dense on CT-scan with increasing intervals. Besides, Magnetic Resonance Imaging (MRI) is more accurate in the detection of SDH, considering the variation in intensities of clots and adjacent parts, T2-weighted images (T2WI), has proven to be approximately 95% sensitive (Rao et al., 2016).

Midline Shift as an Indicator for the Assessment of aSDH

A study by Kotwica (1993) illustrated the poor prognosis and lethal clinical outcome of greater midline shift and cerebral contusion in CT-scan. Valadka et al. (2000) discussed the direct correlation of midline shift with the decreased cerebral metabolic rate of oxygen CMRO2, which is the utilization of oxygen by the brain according to its requirements, to maintain its metabolic and physiochemical activities (Clarke & Sokoloff, 1999). According to Urban et al. (2012), the clinical significance of midline shift by increased ICP of the brain produces cerebral edema. Clot thickening less than 0.6cm accounts for subdural hematoma with AIS severity code 3, which is considered fatal, a bilateral and huge clot of greater than 1cm thickness accounts for pronounced SDH of AIS severity code 5 (Urban et al., 2012).

Case Study

Rybkin et al. (2018) discuss a case study of a 19 year of male who came with MVA, initially, he underwent a radiological examination that showed a fine CT scan indicating no intracranial bleeding with a GCS score of 15. He was administered a single dose of Aspirin 325mg for the treatment of the blunt head injury. After observing him for several hours, he developed aggravating cephalgia and a single episode of vomiting. Repeated CT scan revealed a visible right-sided SDH. The case study by Rybkin et al. (2018) strongly emphasizes the need for admitting patients under observation if they come after obtaining MVA, regardless of the initial remarkable impressions of the CT-scan, adequate GCS, or asymptomatic status of the patient, as the SDH may have late-onset.

Indication for Surgical Intervention

Around 30% to 70% MVA comes in the domain of neurosurgery; because of brief association with head injuries (Elliott, 1957), which makes neurosurgery a viable or in some cases a necessary option for the treatment of aSDH. The assessment is made based on a CT scan showing clot thickness exceeding 10mm or presenting midline shift more than 5mm even with adequate GCS (Bullock et al., 2006; McCafferty et al., 2018).  Bullock (2006) suggested that ICP observation becomes mandatory to make an operative decision in comatose patients presenting with GCS below 9 and anisocoria.

 

Surgery must be performed in comatose patients with a decline in GCS by 2 or more during the interval of injury and observation, along with abnormal pupillary response on examination such as dilated, fixed, non-reactive to light reflex, or showing asymmetry. Prompt surgical intervention must be done to evacuate SDH with ICP surpassing 20mmHg (Bullock et al. 2006; McCafferty et al. 2018).

Surgical Procedures

Various surgical procedures can be done to evacuate hematoma, including; burr hole trephination, subtemporal decompressive craniectomy, decompressive hemicraniectomy, twist drill craniostomy. Treatment options vary with circumstances, such as the result of the CT scan and clinical interpretation, surgeon’s skills, brain edema, comorbidities, age, and neurological condition(s) (Bullock et al. 2006). A report by Fomchenko et al. (2018) demonstrates that craniotomy is required for ICP more than 20 mmHg, producing mass effects accompanying brain edema. A craniotomy is recommended in declining GCS of less than 8, with midline shift greater than 5mm. This evacuates the clot by elevating the bone flap temporarily, whereas, decompressive hemicraniectomy is majorly performed to reduce the high ICP, by removing the bone flap and requires second surgery for cranioplasty (Chen et al., 2011). Decompressive craniectomy and craniotomy, both convey equal importance in acute SDH with low GCS, while a slight difference by Chen et al. (2011) report suggests greater mortality associated with decompressive craniectomy in comparison with craniotomy. Subdural evacuation port system with twist drill craniostomy; a minimally invasive operation, is not recommended for acute SDH, hence, preferred for chronic SDH. While 100% termination of clot and only 3.2% recurrence is reported with burr hole irrigation in SDH. (Fomchenko et al. 2018)

 

Early intervention is crucial for better clinical outcome, Karibe et al. (2014) quoted figures from the study by Seelig et. al. that clot evacuation within 4 hours span has shown 30% mortality, further extension in the interval, exceeding than 4 hours demonstrated the fatality to rise thrice to 90%. However, according to a report by Tien et al. (2011), minimal difference in craniotomy outcome was observed in patients, who had done it within 4 hours and after 4 hours. However, an early arrival in “Golden Hour after trauma” has vital importance for better clinical outcomes and may reduce the probability of death in MVA related TBI (Tien et al., 2011).

Service Delivery of Decompressive Craniectomy, Craniotomy, Decompressive Craniotomy

DECRA Trial

A trial took place between 2002 to 2010 with the convention of bifrontotemporoparietal decompressive craniectomy (DECRA) to manage patients with severe diffused TBI that was unresponsive to first-tier medical management. The patients enrolled in the trial based on ICP greater than 20mmHg for the duration of above fifteen minutes within one hour period. Although the bifrontotemporoparietal DC decreased the ICP, mechanical ventilation duration and median days of ICU stay, it had more long-term (6-month follow-up) worse outcome on the Extended Glasgow Outcome Scale GOS-E either resulting in 19% mortality in DC versus 18 % in the standard medical treatment group, or a vegetative state or severe disability that require assistance. (Cooper et al., 2011; Honeybul, Ho, & Lind, 2013; Hutchinson et al., 2016). Possible explanations could be an axonal stretch due to expansion of the brain outside the domain of the skull cavity, altered cerebral blood flow, and metabolism. (Cooper, et al., 2011). The DECRA trial was further reevaluated between the 6–12-month period for severe diffuse TBI and refractory intracranial hypertension using the International Mission for Prognostic and Analysis of Clinical Trial (IMPACT) model for baseline TBI severity, conveyed that the procedure offers increased vegetative state and no better clinical outcome in comparison with the standard medical treatment group. (Cooper et al., 2020)

RESCUEicp Trial

In contrast to the DECRA trial, RESCUEicp, a randomized trial conducted by the University of Cambridge and the EUROPEAN Brain Injury Consortium, for evaluating outcomes of craniectomy as a last-tier intervention with increased ICP of >25mmHg between 1 hour and 12 hours in comparison with standard medical treatment group, the trail also include unilateral intervention, unlike DECRA. Convention of decompressive craniectomy for refractory intracranial hypertension due to TBI results in decrement of TBI related deaths (26.9% surgical group vs. 48.9% in the standard medical group); reduced time of discharge, ICP, and time in ICU; also improved Extended Glasgow Outcome Scale (GOS-E) (Hutchinson et al., 2006; Hutchinson et al., 2016). However, it is frequently associated with an increase in a vegetative state, upper severe disability, and lower severe disability in comparison with the standard medical treatment group (Hutchinson et al., 2016).

RESCUE aSDH Trial

A survey conducted in UK and Ireland demonstrated that the majority of neurosurgeons does DC in 25% of cases of aSDH (Kolias et al., 2013). Data from a retrospective cohort study from the 91 patients shows that 56% of the patient receiving DC for evacuation of the SDH while the rest getting craniotomy (Kolias et al., 2016). The study concluded that patients receiving primary DC had lesser morbidity as compare to the craniotomy. Therefore, this cohort study encouraged the convention of pragmatic, multicentered and randomized control RESCUE aSDH trial, by NIHR Global Research Group on Neurotrauma (http://www.rescueasdh.org/), which compared two groups for aSDH surgery; decompressive craniectomy vs craniotomy and measured the clinical outcomes based on GOS-E at 12 months after TBI as a protocol of IMPACT model (Hutchinson, et al., 2021). The study is concluded recently in April 2021; therefore, no current evidence is available on the comparative efficacy of the study. Rush et al. (2016) in their original national retrospective cohort study analyzed over sixty thousand cases of aSDH, and concluded that craniectomy has a significantly higher mortality rate and longer hospital stay as compared to craniotomy, along with patient going with craniectomy were discharged to skilled nurse or rehabilitation.

The Alternative Surgical Procedure in LMICs

A survey conducted by NIHR Global Health Research Group on Neurotrauma in collaboration with WFNS introduced a cost-effective alternative surgical approach to address TBI and aSDH. The survey concluded that more than 68% of neurosurgeons in LMIC opt for hinge craniotomy also known as decompressive craniotomy (DCO) as a surgical procedure for TBI and greatly considered for aSDH in LIC, proven to control increased ICP. Decompressive craniotomy allows bone flap to hinge or “float” to help in relieving ICP and does not require second cranioplasty surgery. However, the expert panel in the committee suggested that DCO with ICP monitoring can be a beneficial alternative to DC. The high cost of neurosurgery itself restricts many patients in LMICs to opt for DC as it requires two surgeries, which may be beyond their affordability (Mohan, et al., 2021). As data quotes 55 million to 69 million people in LIC suffer TBI, due to economic disparities they are deprived of basic trauma care, hence, DCO is beneficial for public health and affordable (Mohan et al., 2021; Weiss et al., 2020).

Mohan et al. (2021) studied that DCO is more often a preferred neurosurgical option especially in aSDH in LMICs, the three indicators that quantify DCO are; aSDH with GCS 9-12, aSDH with contusions and GCS 9-12, and aSDH with contusions and GCS 3-8. Kolias et al. (2018) discussed circumstances when DC is used; first, unilateral hemicraniectomy for aSDH with comatose patients and brain swelling, second, comatose patients with parenchymal hemorrhage or contusions (usually frontotemporal) and substantial mass effect with midline shift >5mm, third, patients undergone craniotomy for the evacuation of intracranial hematoma but their ICP remains unstable, fourth, closed TBI with diffuse brain swelling.

Cranioplasty

Iaccarino et al. (2021) discussed the proceedings from the consensus meeting by International Conference on Recent Advances in Neurotraumatology (ICRAN) endorsed by WFNS on posttraumatic cranioplasty (CP) following DC for TBI in which the cranial vault is reconstructed. The meeting discussed measures to take while undergoing CP including reconstruction of cranial defects, prevention or treatment of extracerebral fluid collection, altered cerebrospinal fluid, psychological disturbances and rehabilitation, and sinking sink flap syndrome. During the meeting the committee discussed various types of materials that can be used; first, autologous bone, is commonly used due to biocompatibility and lower material cost, however, it may have bone flap resorption (BFR) complications, which may require reoperation. Second, polymethylmethacrylate (PMMA) that is non-absorbable, radiolucent and comes in inexpensive liquid form to encompass easy moldable feature, it also comes in 3D solid prosthetic to eliminate the complications of an exothermic reaction. Third, titanium, which has the advantages of hardness and stability due to mesh and 3d porous features, however, expensiveness, radiopacity, difficulty in molding, and non-physiological heat conduction are the disadvantages. Fourth, relatively newer polyetheretherketone (PEEK) is inert, durable, and possesses a lower risk of postoperative new-onset seizures but the literature lacks research on its efficacy and complications. Fifth, porous hydroxyapatite constitutes the material for bone grafting, the advantages include osteoconductivity and biocompatibility, but disadvantages are prosthetics fracture in the first few months of the implant.

Financial Cost of Cranioplasty

The financial costs for the CP implants may start from 10,000 USD, commercial 3D printers cost ranges between 37,000 USD- 310,000 USD, which is out beyond the affordability for patients in LMICs (Morales-Gómez et al., 2018). There is no data available for customizing computer-designed cranioplasty in LMIC, however, it is most needed in poor resource LMIC due to the increased proportion of TBI incidence. A study by Morales-Gómez et al. (2018) contributed to relieve the global burden of neurosurgery especially in LMIC by introducing the notion of computerized 3Dprinter, cost-effective, open software-generated implant, or cranioplasty costs 2,500 USD to 3,500 USD.

Timely Intervention in Neurosurgery Can Save Lives

Timely neurosurgical intervention in the case of TBI can have a significant improvement in the outcome and neurosurgical procedures for neurotrauma specifically in the evacuation of traumatic aSDH, while the elevation of depressed skull fractures should be essentially available worldwide on an emergency basis (Mass et al., 2017; Clark et al., 2020). However, due to a deficit in the availability of neurosurgeons, there is another non-neurosurgeon workforce that can perform surgeries for neurotrauma. Vespa et al. (2007) discussed the importance of robotic telepresence in the case of neurocritical care patients, as it can provide a timely assessment and intervention, therefore, increasing the prospects of improvement in the case of neurotrauma. Vespa et al. (2007) estimated the latency for robotic telepresence on an average takes 9.2 +/- 9.3 minutes compared to conventional face-to-face that takes 218 +/- 186 minutes, for the brain ischemia the robotic is 7.8 +/- 2.8 versus 152 +/- 85 minutes, and elevated ICP is 11 +/-14 versus 108 +/- 55 minutes. The study by Vespa et al. (2007) also discussed that robotic telepresence is highly effective in cases with acute problems of brain ischemia and elevated ICP after TBI, it also reduces the length of ICU stay in subarachnoid hemorrhage and brain trauma, therefore, substantially reducing the ICU cost more than $1.1 million. Rubiano et al. (2015) proposed several interventional strategies based on different global studies to reduce the impact of trauma; a term for the global burden for all the disease in context with the LMICs, these include using hyperosmolar fluids, resuscitation reducing strategies, means for data collection, capacity building for neurotrauma education, dissemination of education and techniques for injury prevention, and using prophylactic hypothermia for the treatment. 

Neurotrauma Burden and Deficit Access to Neurosurgery in LMICs

Meara et al. (2015) discussed the outcomes of the Lancet Commission on Global Surgery 2030 that pose as the challenges in providing surgical care in LMICs, including worst access to surgical care when needed in LMICs to around 5 billion people, 81 million cases of tremendous health expenditures on accessing surgical and anesthesia care in LMICs, 143 million additional neurosurgical interventions are needed in LMICs to prevent death and disability but due to the poor access the fatalities and disabilities are higher, an urgent and accelerated investment is needed in scaling-up the surgical service in LMICs otherwise it will cost a loss of revenue of US $12.3 trillion until 2030. Hoffman et al. (2005) discussed several reasons regarding the devastating neurotrauma-related injuries in LMICs. These include but are not limited to poor roads that transfer a neurotrauma patient to the hospital, it also includes poor access to emergency services in rural versus urban areas (Hoffman et al., 2005). Fuller et al. (2016) discussed the limitations and challenges in fulfilling neurological capacity in LMICs where there is a shortage of skilled workforce in dealing with the neurotrauma, also access to electricity and clean water in the hospitals are other significant challenges in lower-income countries or middle-income rural areas.

Task Shifting and Task Sharing Strategies to Deal with the Deficit in the Neurotrauma Workforce

Ratan et al. (2019) and Fuller et al. (2016) in separate LMICs research regarding India and Africa respectively, discussed that efforts are been made to train the non-neurosurgeon workforce in providing adequate training to deal with neurotrauma including providing safe anesthesia, education, and training, with the purpose of the trained individuals returning to their places to help the local community. Karekezi et al. (2020) mention concerning the WFNS program that the trained individuals returning to their countries. Nevertheless, the deficit remains and more significant efforts need to be done at the global level to deal with neurotrauma in LMICs without the involvement of the neurosurgeons, but with the help of another workforce including trauma surgeons, anesthetist, skilled medical nursing staff, rehabilitation, and injury prevention educationists.

How Does TS/S Affect Patient Care?

Robertson et al. (2020) discussed the practice of task-shifting and task-sharing (TS/S) in the context of LMICs that involves carrying out neurosurgeries by non-specialists in emergency cases. Around 43% percent of the LMICs have reported that TS/S is currently in practice, which involves doing the neurosurgical intervention including burr holes, craniotomy and craniectomy for hematoma evacuation, external ventricular drain, ventriculoperitoneal shunt, and other neurosurgical procedures by general practitioners, general surgeons, nonphysician providers, and neurosurgeons without board certification (Robertson et al., 2020). Task-shifting in neurosurgery is the transfer of neurosurgical tasks to the less qualified and less trained workforce, whereas, task sharing is team efforts between a more qualified workforce to less qualified ones, while the less qualified workforce keeps the expert in the loop for better clinical outcomes (Robertson et al., 2020).

 

Rubiano et al. (2020) created several algorithms using the Delphi method to improve the decision making for TS/S, by providing a pictorial representation on the availability of resources and the outcomes based on the situation, perhaps, they created a Bootstrap (Beyond One Option for the Treatment of Traumatic Brain Injury: A stratified protocol). Rubiano et al. (2020) used various available protocols such as Glasgow Coma Scale, Richmond agitation-sedation Scale (RASS), and series of questions 1 to 13 with each question has a table and a supporting algorithm. Dewan et al. (2018) discussed that benefit versus risk ratio should be measured in performing the TS/S such as the relatively straightforward emergency evacuation of extradural hematomas and placing shunt for hydrocephalus.

Unavailability of Standardized Instruments in LMICs

Hutchinson (2019) discussed the consensus outcome of the meeting held in Cambridge, UK by NIHR, WFNS, and AO/Global Neuro that lack of standard therapeutics to control ICP post-TBI might not be available to maintain patient’s health in LMIC. The summary of statements regarding DC in LMIC follows that lack of generalized data from LMIC. Results from DECRA and RESCUEicp cannot be implemented for clinical practice at their site, however, the decision of DC by case attending neurosurgeon after recent CT-Scan is recommended, moreover for the welfare of patients it is permissible to convey DC by expert surgeons where no neurosurgeon is available (Hutchinson, 2019). Karekezi et al. (2020) discussed that in the Sub-Saharan region there is a severe deficiency of diagnostic imaging and standardized instruments. Hofman et al. (2005) discussed that in LMICs, the low-cost diagnostics and availability of neuroimaging can improve the diagnosis of TBI patients. To meet this deficiency, WFNS until December 2018 had dispatched 241 neurosurgical sets to LMICS across the globe.

Neurorehabilitation Role in Post TBI Care

One of the important goals of providing timely neurosurgical intervention is not only to reduce mortality but also the reintroduction of the patients into normal life post-trauma. However, long-term disability and neuropsychological complications are an active debate amongst the researchers with the consensus on the need for neurorehabilitation post-TBI (Seely et al., 2009). Sarajuuri et al. (2005) discussed that patients suffering from TBI may pose psychological, emotional, and behavioral disturbances, which special neurorehabilitation programs can improve the psychosocial functioning (89%) in neurotraumatic patients with moderate to severe TBI as compare to conventional rehabilitation program (55%).

 

Oberholzer and Müri (2019) discussed that neurorehabilitation is not same irrespective of the etiology of the injury, and different brain injury requires different neurorehabilitation. Thus, medical aspects should be taken into account while devising strategies and programs for neurorehabilitation. Mass et al. (2017) discussed categories of neurorehabilitation; restitutional strategies focus on repetitive patterns and exercises, compensatory strategies focus on using tools and gadgets to repair the cognitive shortcomings, and adaptive strategies focus on remolding perception to improve self-efficacy.

 

Oberholzer and Müri (2019) classified different medical aspects for the TBI; first, Disorders of Consciousness that may include vegetative state or unresponsiveness wakeful syndrome and minimally consciousness state. There is a clear understanding that neurorehabilitation may not be applicable or ineffective in the domain of disorders of the consciousness. Second, Paroxysmal Sympathetic Hyperactivity (PSH) which patients may exhibit symptoms of hypertension, arrhythmias, hyperthermia, diaphoresis, dystonia, increased spasticity, could be a response to external stimuli. Since there is no definite diagnosis that may involve clinical features of the symptoms, neurorehabilitation in PSH can be challenging and needs a tailored program. Third, Posttraumatic Agitation (PA), which is a subcategory of delirium in which patient shows agitated, paranoid, disinhibited, and labile, patients in acute phases of TBI may exhibit 35% to 96% PA. Oberholzer and Müri (2019) mention that diagnosis of PA is the diagnosis of exclusion, which is given after ruling out all medical and neurologic causes. Neurorehabilitation for PA requires the use of standard and diminish external stimuli, a comfortable sleeping environment, a uniformity in visitor and medical team, and a pharmacological medication regimen. Non-selective beta-blockers (propranolol, pindolol) and neuroleptics (carbamazepine, valproate) may be effective medications to control agitation, aggression, and irritability. Fourth, Posttraumatic Hydrocephalus (PTH), a common and treatable complication during the management of TBI, with an incidence of 0.7% to 29%. Clinical, neuroimaging, radiology, and physiological criteria are considered for the incursion of the diagnosis, which is divided into two types; communicating or non-communicating PTH. If timely not intervened with the rehabilitation, then PTH may result in complicated and severe medical issues and risk factors. Fifth, Posttraumatic Neuroendocrine Disorders, which may manifest due to pituitary lesions encountered during the TBI; in which the pituitary gland remains susceptible due to blood supply is compromised within sella turcica (Oberholzer & Müri, 2019). Hypopituitarism has a high risk of prevalence (50-80%), along with growth hormone deficiency, adrenocorticotropic hormone deficiency, hyperprolactinemia, diabetes insipidus, syndrome of inappropriate antidiuretic hormone (SIADH), reduction of serum thyroid-stimulating hormone, gonadotropic insufficiency, somatotropic insufficiency, and corticotropic insufficiency.

Lack of Neurorehabilitation Access in LMICs

Hyder et al. (2007) discussed the burden of TBI to be excruciating in LMICs, and different across HICs from rural to the urban range, where estimates are, 80% of global disabled people live in LMICs, only 2% have access to neurorehabilitation. Neurorehabilitation may involve the use of technology such as virtual reality software, telerehabilitation, robotic stimulation, non-invasive brain stimulation can be useful and inexpensive options in LMICs (Platz & Sandrini, 2020). Platz and Sandrini (2020) mentioned that the neurorehabilitation team may involve physicians, physiotherapists, occupational therapists, speech and language therapists, psychologists, nurses, and social workers that work as a unit to use their extensive skills, knowledge, and learning for the better patient outcome. The affordability and pay make a significant difference among HICs and LMICs, where the former has on an average 900 physiotherapists per 1 million population, and the latter has less than 10 physiotherapists in Sub-Saharan and Southeast Asian regions. Similarly, in HICs, there are over three hundred speech and language therapists per million population while in LICs African countries there exists none.

The Disparity in Research Publication among HIC and LMIC Countries

A study conducted comparative differences in the conduction of randomized control trials (RCTs) in HIC and LMIC from 2003 to 2016. Which stated that 73.3% of RCTs were held in HIC whereas only 8.8% of trials were conducted in LMIC countries excluding China, as whole 71 trials out of 106 were alone held in China. The huge neurosurgery research gap between HIC and LMIC due to a reduced mean sample size possibly due to lack of resources, single-center studies, and a smaller number of enrollment sites. Lack of academic research limits the expansion of advanced neurosurgical access to LIC. Therefore, it is suggestive to invest in research projects in LMIC to generate accurate data. (Griswold, et al., 2020)

 

Efforts to improve neurosurgical service delivery in LIC are increasing after the Lancet Commission of Global Surgery in 2015, acceptance of global surgery is sufficiently increasing neurosurgery research in LIC. It is suggestive to gain access to technologies for e-publication and expanding networking with HIC to collaborate in research publication. To increase in literature from LIC, Global neurosurgery communities offered multiple educational and training opportunities to LMIC, such as the Harvard Program for Global Neurosurgery and Social Change, the American Association of Neurological Surgeons, The Foundation for International Education in Neurosurgery, and Oregon Health Science and University. (Weiss, et al., 2020)

Infrastructure

Dewan et al. (2018) estimated around 23,300 additional neurosurgeons would be needed by 2030 all in LMICs, the young professionals believe that need for the neurosurgeons is already fulfilled in HIC, whereas, in LMICs there are several foremost barriers for the attainment of the specialization in neurosurgery. Robertson, Gnanakumar, et al. (2020) discussed the barriers to entry by the residents, fellows, and those consultants who have an interest in becoming neurosurgeons.

 

These barriers revolve around several themes such as lack of accessibility to books, journals, researches, teaching materials, mentors, guidance from mentors, and a limited number of trained neurosurgeons (Robertson, Gnanakumar, et al., 2020). Several respondents to Robertson, Gnanakumar, et al. (2020) study mentioned that lack of surgical and diagnostic equipment, surgical training, ICU beds, and neurosurgical beds restricts the learning opportunities. While several young professionals believe that the demand versus supply of neurosurgeons is already met and not many additional neurosurgeons are required. A final category of barrier that young neurosurgeons find is lack of guidance from seniors, bullying, harassment, and exhausting working hours that make a poor work-life balance and personal-family relationship issues.

Governance

Universal Health Coverage

In 2015 WHO member states passed a resolution to make health coverage universally accessible to everyone, of which, surgical care and anesthesia are the key components. This encouraged member states to create a national plan for surgical care, which 37 member states have either completed or in the completion stage within 4 years of passing the resolution. The next is WHO’s Thirteenth General Programme of Work (GPW 13) that aims to achieve three important agendas during 2019-2023 time; which WHO refers to as triple billion targets. This will make efforts to reach a billion people each for universal health coverage (UHC), protection during health emergencies, and better health and well-being of people, and its progress will be measured using sustainable development goals (SDG). WHO describes UHC as a policy where everyone around the world can receive the health services they need without hindrances from financial difficulty. It allows an individual to acquire a complete scope of quality health services from the diagnosis to the treatment. The medical necessity should not exhaust an individual’s funds and savings, and instead, drag the person either into a loan or selling off the earning, which otherwise is for the family and children.  UHC does not provide free medical, surgical, and anesthesia services, it provides a framework on what services are covered and how are they funded (Universal Health Coverage [UHC], 2021).

 

Corley, Barthélemy et al. (2019) recommended the encouragement of health ministry leadership in LMICs to engage in neurotrauma prevention and care by the development of nationwide traffic rules and their enforcement to avoid MVA due to drunk driver, exceeding the speed limit, unfastened seatbelts, child restrained, and bike riders without a helmet. Helmet law should be given utmost priority and anyone violating the law should be penalized to relieve from the global burden of TBI (Corley, Barthélemy et al., 2019). Similarly, occupational safety and wearing of protective gear to avoid injury after falling should be implemented.

 

Robertson et al. (2020) discussed that official governing bodies such as the local ministry of health should predefine the procedures and circumstances where TS/S can be implemented. Also, a strict monitoring body and surveillance system be used to refrain unskilled or inexperienced people to perform neurosurgery for their self-interest.  

Endorsement of the twinning approach lies to term working simultaneously “together” as a team including LMIC neurosurgeons, nurses, technical staff, anesthesiologists. A single surgeon visits to train and teaches local surgeons at health care faculties, not only surgeons are trained but also staff and paramedics involved in health care delivery (Fuller et al., 2016). 

Funding

The Lancet Neurology Commission estimated the $400 billion global economic cost of the TBI, which encompasses 0.5% of international GDP (Maas et al.,2017). Oberholzer & Müri (2019) discussed that the economic impact of TBI and long-term disability with the prevalence of 3.2 to 5.3 million people in the US is 221 billion USD. The actual impact is far beyond the numbers as it may involve families of the affected individual. Hoffman et al. (2005) discussed that governmental and private funding in HIC creates opportunities for the companies to create low-cost technologies and imaging guidance that may accelerate the improvement and reintroduction of the TBI patient. Dewan et al. (2018) discussed that imaging services such as MRI may be costly for the diagnosis of TBI in LMICs, therefore, creating a gap in definitive diagnosis. Funding is required from the governing bodies, institutions, and committees in HICs for sharing the burden of providing the relief to LMICs in terms of diagnostic imaging, training of the workforce, procurement of the material and resources, educational training for injury prevention, research, and providing global health insurances to share the burden in LMICs with those who cannot afford the neurosurgery. The UK National Institute of Health Research (NIHR) funded trial referred to as RESCUEaSDH (Randomised Evaluation of Surgery with Craniectomy for patients Undergoing Evacuation of Acute Subdural Haematoma) that compares between craniotomy vs decompressive craniectomy for surgical treatment of acute subdural hematoma.

Cost of aSDH and Its funding

A study by Wesson et al. (2014) calculated the cost of trauma care and treatment in LMICs. The direct medical cost of each hospitalization ranged from 14 USD to 17,400 USD, with an average median cost of 291 USD, the cost increases to 14 folds when including direct medical and indirect medical costs of injury 4,085 USD. Dijck et al. (2019) studied the in-patient hospital cost of patients with severe TBI, the results showed the costs were quite expensive which ranged from 2,130 USD to 401,808 USD, depending upon during of stay at the hospital and type of intervention used to treat the patient. A study by Kalanithi et al. (2011) demonstrated that the average hospital cost for aSDH increased to 67% from 1993-2006, the average hospital cost for patients admitted with aSDH is 47,315 USD.

Conclusion

Neurosurgery holds a firm position in public health initiatives. Most motor vehicle accidents may result in mild to severe traumatic brain injury, which mostly develops acute subdural hematoma, for which prompt evaluation as per protocol is necessary even if the patient is not showing any complications. Lodged clotted hematomas cannot be left inside the skull, thereby, operation by neurosurgeons and timely removal of clot or other surgical techniques could diminish the severity and chances of morbidity, or acquired long-term disability caused by TBI.

 

Although the global burden of TBI costs 0.5% of the world GDP, there exists a severe shortage in a global neurosurgical workforce that makes the prevalence of the disease further challenging especially in LMICs. Primary surgical options to evacuate aSDH are decompressive craniectomy, craniotomy, and decompressive craniotomy, each with its complications and necessities.  Furthermore, the DCO procedure is recommended in LIC due to its cost-effectiveness and good clinical outcome. Due to the unavailability of the required workforce, non-neurosurgeons can perform the necessary lifesaving surgeries through the practice of task-shifting and task-sharing. Reconstruction of the skull by cranioplasty has its significance and necessity, however, there exist different materials each with its pros and cons. 

 

To maintain the balance and reduce the disparity amongst HIC and LMICs steps should be taken to improve the data collection of literature in LMICs and increase in collaboration of neurosurgical professionals in these regions to communicate and resolve issues by sending health aid and suggestions to improve the burden of global neurotrauma. WHO, WFNS, and NIHR has taken positive public health initiatives to strengthen the domain of neurosurgery by introducing different programs such as universal health coverage by WHO, residency programs by WFNS and Rabat Medical Center, and funding different trials such as RESCUEasdh. These governances not only result in distributing the global burden of the disease but also opens opportunities for the people to receive healthcare that otherwise could be beyond the affordability in LMICs.

 

Neurorehabilitation plays a significant role in post-TBI care and the well-being of the patients; however, different strategies are required to cope up with the agitation, irritability, cognitive impairment, and behavioral disturbances in the patients. This field still needs supporting literature and practices, especially in terms of diagnosis due to the nature of TBI can be different, which can change the course of the rehabilitation.

 

Regardless of the need and shortage of the neurotrauma workforce, there exist barriers that undermine the efforts of the young doctors, fellows, and consultants to pursue the highly in-demand specialty. These barriers include access to the learning resources, lack of support in terms of career counseling, challenging nature of work, unavailability of the surgical experience, and mentorship by existing neurosurgeons. Therefore, efforts should be made at the global level that shapes the focus of the young doctors, residents, fellows, and consultants to pursue this field.

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About the Author

Mahnoor Sukaina

Manhhoor Sukaina, a student at Karachi Medical and Dental College, descirbes herself as a “very enthusiastic and ambitious to serve the community through my knowledge, research capabilities and clinical acumen.” She currently is preparing for USMLE step 1 and foreseeing residency in the U.S.