Purpose STAT proteins play a key role in several cellular functions related to cell development, differentiation, proliferation, and survival. Persistent STAT activation due to somatic STAT5b N642H gain-of-function mutation is a rare mechanism of STAT dysregulation that results in hypereosinophilia, frequent infections, leukemias, and pulmonary diseases. Herein, we describe a case of a child with a rare early onset STAT5b gain-of-function disease treated with targeted JAK inhibition who developed a cranial Mycobacterium avium osteomyelitis. Methods A 3-year-old male with a known STAT5b gain-of-function mutation presented with a 10-day history of a firm, immobile, non-painful cranial mycobacterium mass with dural infiltration located anterior to the coronal suture. Stepwise management finalized with complete resection of the lesion with calvarial reconstruction. A case-based literature review was performed evaluating all patients with this mutation who developed cranial disease. Results The patient was symptom and lesion-free at 1 year since surgical resection and initiation of triple mycobacterial pharmacotherapy. Our literature review demonstrated the rarity of this disease, as well as other presentations of this disease in other patients. Conclusion Patients with STAT5b gain-of-function mutations have attenuated Th1 responses and are treated with medications, such as JAK inhibitors, which further inhibit other STAT proteins that regulate immunity against rare infectious entities, such as mycobacterium. Our case highlights the importance of considering these rare infections in patients on JAK inhibitors and with STAT protein mutations. Possessing a clear mechanistic understanding of this genetic mutation, its downstream effect, and the consequences of treatment may enhance a physician’s diagnostic and clinical management of similar patients in the future.

In 2019, the World Federation of Neurosurgical Societies (WFNS) established an ad hoc Global Neurosurgery Committee (GNC) to coordinate its global efforts to promote equitable neurosurgical care. Medical students have been essential to the GNC since its first generation (“GNC 1.0”). We describe the integration of medical students in GNC 1.0 and provide suggestions on the incorporation of medical students into the second-generation GNC (“GNC 2.0”).

The Global Neurosurgery Committee (GNC) of the World Federation of Neurosurgical Societies (WFNS) launched the Global Action Plan during the 2016 Bogota Declaration on Global Neurosurgery in Colombia in order to coordinate efforts and bring neurosurgeons around the world to address unmet neurosurgical care. The Global Action Plan contains five objectives: Amplify, Align, Advance, Assimilate and Advocate for neurosurgical care. In this paper, we present the goals and the work of the Advance team. The goal of the Advance objective was to “A. Map research output by region and themes, B. Establish one or more Global Neurosurgery research grant and/or award mechanisms, C. Advocate for Global Neurosurgery category/sections in major neurosurgery journals (3 or more by 2021), D. Establish funding mechanisms for training in future leaders in the public health practice of Global Neurosurgery (2 or more by 2021), E. Inclusion of Global Neurosurgery Sessions in major neurosurgery meetings (>75% by 2021), F. Establish a mentoring relationship between editorial board members from HIC and LMICs (>1 by 2021), and G. Establish a mentoring relationship between authors from HIC and LMICs (>1 by 2021).

The World Federation of Neurosurgical Societies (WFNS), the governing body for national and regional neurosurgical societies worldwide, established the ad hoc Global Neurosurgery Committee (GNC) in 2019. This international board of neurosurgeons collaborated virtually in pursuit of defined goals and targets related to neurosurgical equity. We summarize the work of the WFNS GNC, highlight the role of virtual collaboration in global surgery, and delineate best practices for virtual collaboration in global surgery.

Pituitary abscess is a rare condition that can result from a primary infection of the pituitary gland or secondarily to an existing pathology. While there are prior prior prior reported cases of secondary pituitary abscesses, we present the first operative video detailing management of this uncommon disease entity. We present the case of a 36-year-old male with a history of a known pituitary adenoma who was found to have a pituitary abscess. The patient underwent an expanded endoscopic endonasal approach for abscess evacuation and tumor resection. The patient recovered well, with gradual return of right extra-ocular movements and full return of right vision. At 1 year post-operatively, he had returned to work with no restrictions. A discussion of the presenting symptoms; risks, benefits, and alternatives to surgical intervention; and an overview of the known cases of secondary pituitary abscesses is presented. Operative video from the case is reviewed, in addition to relevant radiologic imaging, pre-operatively, and at 1 year post-operatively.

OBJECTIVE:Medical journals have a role in promoting representation of neurosurgeons who speak primary languages other than English. We sought to characterize the language of publication and geographic origin of neurosurgical journals, delineate associations between impact factor (IF) and language and geographic variables, and describe steps to overcome language barriers to publishing. METHODS:Web of Science, Scopus, and Ulrich's Serial Analysis system were searched for neurosurgery journals. The journals were screened for relevance. Language of publication, country and World Health Organization region, World Bank income status and gross domestic product, and citation metrics were extracted. RESULTS:Of 867 journals, 74 neurosurgical journals were included. Common publication languages were English (52, 70.3%), Mandarin (5, 6.8%), and Spanish (4, 5.4%). Countries of publication for the greatest number of journals were the United States (23, 31.1%), United Kingdom (8, 10.8%), and China (6, 8.1%). Most journals originated from the Americas region (29, 39.2%), the European region (28, 37.8%), and from high-income countries (n = 54, 73.0%). Median IF was 1.55 (interquartile range [IQR] 0.89-2.40). Journals written in English (1.77 [IQR 1.00-2.87], P = 0.032) and from high-income countries (1.81 [IQR 1.0-2.70], P = 0.046) had highest median IF. When excluding outliers, there was a small but positive correlation between per capita gross domestic product and IF (β = 0.021, P = 0.03, R2 = 0.097). CONCLUSIONS:Language concordance represents a substantial barrier to research equity in neurosurgery, limiting dissemination of ideas of merit that currently have inadequate outlets for readership. Initiatives aimed at increasing the accessibility of neurosurgical publishing to underrepresented authors are essential.

Introduction: Pituitary macroadenomas are the most commonly identified suprasellar mass in adults and are typically benign and demonstrate slow growth. However, the presence of a high Ki-67 proliferation index (>3%) has been shown to be associated with more rapid growth, infiltration of adjacent tissue, and resistance to standard therapy, which significantly impacts management strategies. Due to the lack of information available on imaging characteristics of macroadenomas with high Ki-67 indices, we sought to determine whether the presence of cystic change on MRI and/or tumor volume are associated with a high Ki-67 index.

Purpose: Stereotactic Radiosurgery (SRS) is an effective option for incompletely resected or recurrent pituitary adenoma. Herein, we evaluated the characteristics and outcomes of patients undergoing SRS for pituitary adenoma using a national cancer registry. Methods: National Cancer Database (NCDB) was queried for patients diagnosed with pituitary adenoma and treated with SRS between 2004 and 2017. Patients were grouped based on whether their treatment consisted of SRS alone or SRS plus a surgical procedure. Demographic, clinical, and treatment characteristics were compared between the two groups. Kaplan Meier survival curves and cox-regression analyses were performed to evaluate the impact of treatment type on survival. Results: A total of 1,625 patients who had undergone SRS for pituitary adenoma were identified. Of these, 1,189 (73.2%) also underwent a surgical procedure. Compared to patients undergoing SRS plus surgery, patients undergoing SRS alone were more likely to be older (> 65: 43.3%, n = 189 vs 14.4%, n = 171; p < 0.001), have smaller tumors (<= 3 cm; 92.1% vs 65.4%, p < 0.001), and have delayed treatment (days from diagnosis to treatment; 98 +/- 123.4 vs 39.8 +/- 67.2, p < 0.001). The five-year survival rate for the standalone SRS group was found to be 79.3% (95% CI 75.1-83.8), which was significantly lower compared to that for patients undergoing SRS following surgical resection (94.2% (95% CI 92.7-95.7)) (p < 0.001). Conclusion: Our analyses indicate that a treatment regimen consisting of surgery plus SRS is associated with lower mortality compared to SRS alone, despite its association with larger, more complex tumors.

Co-secreting growth hormone and prolactin pituitary adenomas, which comprise a considerable portion of all growth hormone-secreting adenomas, can be characterized into three distinct subtypes. In this report, we present a case of a monomorphous mammosomatotroph cell adenoma successfully treated with transsphenoidal surgical resection. A 38-year-old female presented to clinic with a 1-year history of galactorrhea and oligomenorrhea. This was on the background of a 4-year history of insulin intolerance and acromegaly, notably of the hands and feet. At the time of presentation, the patient had a reported body mass index (BMI) of 34.28 kg/m2 and an elevated blood pressure (BP) of 128/78 mmHg. It was suspected at this stage that the patient had a growth hormone (GH) and prolactin (PRL) co-secreting pituitary adenoma. Head MRI confirmed the presence of a pituitary adenoma measuring 1.0 × 1.2 × 1.3 cm. Clinically, the sequence of symptoms suggested a monomorphous mammosomatotroph cell adenoma, with definitive diagnosis requiring an oral glucose tolerance test (OGTT) and histological tissue sampling for tumor typing. Transsphenoidal surgery (TSS) is indicated for symptomatic microadenomas and non-invasive macroadenomas. A TSS approach was recommended despite the patient’s relatively small-sized tumor. Though it was not required for our patient, adjuvant therapy such as octreotide and cabergoline may be implemented post-operatively to prevent recurrence and, in the case of residual tumor, radiosurgery or additional surgical resection may be implemented for symptomatic relief. At this time, however, research proving the effectiveness of medical therapy over TSS for the treatment of monomorphous mammosomatotroph adenomas is lacking. For those who are unable to undergo surgery, more work is needed in this field to determine the effectiveness of medical treatment for this specific type of tumor.

To the Editor: Traumatic brain injury (TBI) affects roughly 69 million individuals per year, many of who reside in low- and middle-income countries (LMICs).1 While there exist several limitations to treating TBI in LMICs, many can be properly addressed if given the attention and focus required to usher in change. Case in point, the governing body of neurotrauma literature is produced in high-income countries (HICs), which pose additional constraints in settings with limited medical equipment, health infrastructure, and available staff, as seen in several LMICs.1-3 In addition, approximately 23 300 additional neurosurgeons are required to address more than 5 million essential neurosurgical cases that are unmet annually, all of which occur in LMICs.4 We believe operationalizing global neurosurgery research in neurosurgical journals can serve to bridge this gap and provide a space for leaders across the world to share pearls of knowledge toward reducing the global burden of neurological diseases and disorders, including TBI. Fortunately, there is a growing movement to ensure the provision of timely, safe, and affordable neurosurgical care to all individuals who require it. In 2015, the Lancet commission on surgery published an article that brought attention to the need for neurosurgical enhancement on a global scale.5 This group offered targets focusing on increasing access to surgery and expanding knowledge of barriers to equitable care in LMICs by the year 2030. Still, inequities in access to neurosurgical care remain rampant, stressing a need for targeted efforts as potential remedy. Global Neurosurgery has gained significant momentum as evident by the upward trend of peer-reviewed abstracts and articles submitted and published in neurosurgical journals. A PubMed search of the phrase “global neurosurgery” displays an ascending trend with 3 published articles in 2015, 42 articles in 2018, and 82 in the year 2020.6 This positive trend speaks to the impact of efforts made by communities such as The Lancet, the World Federation of Neurosurgical Societies (WFNS), Global Neurosurgery Committee (GNC), American Association of Neurological Surgeons (AANS), and many other organizations aimed at strengthening neurosurgery globally. Global neurosurgery conferences provide additional unique opportunities to connect partners in LMICs and HICs to develop education, advocacy, and policy. Importantly, the rise in the digital world amid the COVID-19 pandemic has enabled participants—particularly from LMICs—to overcome barriers such as visa acquisition, funding for travel and lodging, and time away from school and/or work.7,8 In addition to conferences, research fosters wide-ranging partnerships virtually by permitting collaboration anchored by shared goals, shared discoveries, and the inclusion of perspectives with others worldwide. Journal publications mitigate barriers to learning in LMICs, though paywalls continue to remain a barrier. Nevertheless, the pursuit of equity inherent in global neurosurgery involves deconstructing those barriers that directly and indirectly further disparities in access to and quality of care. Although existing efforts to minimize these disparities are commendable, focused measures remain necessary. Consideration of the variety of factors contributing to inequity and the interplay between them is essential to develop initiatives that are effective, scalable, and easily assessed. Specifically, the role of research in reducing disparities is key. In HICs, research efforts underpin developments in access to and quality of neurosurgical care—efforts to be mirrored in countries with less access to neurosurgical capacity. Global neurosurgery research serves to advance strategies to improve neurosurgical care and the health system at large. We suggest the incorporation of a “Global Neurosurgery” section or category into neurosurgical journals to highlight research regarding strategies for developing sustainable neurosurgical training models, augmenting neurosurgical clinical and research capacity, and strengthening health systems through policy and advocacy. Understanding local neurosurgical epidemiology drives the development of contextually appropriate models of neurosurgical practice. Consideration of social determinants of health allows neurosurgeons to highlight and address areas of inequity. Increasing representation of global neurosurgery research in journals is particularly important to provide neurosurgeons with the capability and platform to work with policymakers in developing capacity for the training of neurosurgeons and delivery of neurosurgical care. Additionally, these sections may strengthen research capacity in LMICs, allowing the discovery of further innovative solutions to ameliorate the neurosurgical burden of disease. Patients suffering from TBI experience a range of syndromes that ultimately impact their social, political, and economic life.9,10 The ability to properly care for TBI, therefore, can indicate the strength of a nation's healthcare system. As global neurosurgery continues to mature from its infancy just a few years ago, it has become apparent that addressing the neurosurgical burden of disease requires a multimodal strategy. A key element of such a strategy is the expansion of global neurosurgery research. An accessible and engaging global neurosurgery section in neurosurgical journals will solidify the position of global neurosurgery in the intellectual framework of neurosurgery research, facilitate the reduction of existing disparities, and catalyze further efforts toward producing the highest quality of care in resource-limited settings. Funding This study did not receive any funding or financial support. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

BACKGROUND:Social media use in neurosurgery remains an understudied phenomenon. Our study aims to examine the global membership and engagement of the prominent Neurosurgery Cocktail Facebook group with over 25,000 neurosurgeons and trainees worldwide, specifically during the COVID-19 pandemic. METHODS:Neurosurgery Cocktail's numbers of members, posts, comments, and reactions were collected from December 2019 to November 2020. Anonymized aggregate data of members' characteristics, including age, sex, and country of origin in November 2020, were also obtained. The most engaging posts in November 2020 were categorized into topics by a majority consensus of 3 reviewers. RESULTS:The average number of members steadily increased from 21,266 in December 2019 to 25,218 in November 2020. In November 2020, 18.8% of members were women, and 71.3% were between 25-44 years old. With members from 100 countries, 77.9% are from low- and middle-income countries, with the highest representation from India, Egypt, and Brazil. After the COVID-19 pandemic declaration, daily engagement peaked in April 2020 with a daily average of 41.63 posts, 336.4 comments, and 1914.6 reactions before returning to pre-pandemic levels. Among the 99 top posts in November 2020, the majority (56.5%) were classified as "interesting cases," with "education-related" as the second-most common topic (16.2%). CONCLUSIONS:Neurosurgery Cocktail has shown steady growth since its creation. The COVID-19 pandemic was correlated with a spike in activity without lasting impact. The group demonstrates social media's potential for knowledge exchange and promoting organic international collaborations.

Background Endovascular therapy is known to achieve a high rate of recanalization in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) and is currently the standard of care. Hemorrhagic conversion is a severe complication that may occur following AIS in patients undergoing endovascular thrombectomy (EVT). There is a scarcity of data on the risk factors related to HV in post-EVT patients, especially those who develop symptomatic hemorrhagic conversion. The main objective of our study is to identify independent predictors of radiographic and symptomatic hemorrhagic conversion in our diverse patient population with multiple baseline comorbidities that presented with AIS and were treated with EVT as per the most updated guidelines and practices. Methodology This is a retrospective chart review in which we enrolled adult patients treated with EVT for AIS at a comprehensive stroke center in the Bronx, NY, over a four-year period. Bivariate analyses followed by multiple logistic regression modeling were performed to determine the independent predictors of all and symptomatic hemorrhagic conversion. Results A total of 326 patients who underwent EVT for AIS were enrolled. Of these, 74 (22.7%) had an HC, while 252 (77.3%) did not. In total, 25 out of the 74 (33.7%) patients were symptomatic. In the logistic regression model, a history of prior ischemic stroke (odds ratio (OR) = 2.197; 95% confidence interval (CI) = 1.062-4.545; p-value = 0.034), Alberta Stroke Program Early CT Score (ASPECTS) of <6 (OR = 2.207; 95% CI = 1.477-7.194; p-value = 0.019), and Thrombolysis in Cerebral Infarction (TICI) 2B-3 recanalization (OR = 2.551; 95% CI = 1.998-6.520; p-value=0.045) were found to be independent predictors of all types of hemorrhagic conversion. The only independent predictor of symptomatic hemorrhagic conversion on multiple logistic regression modeling was an elevated international normalized ratio (INR) (OR = 11.051; 95% CI = 1.866-65.440; p-value = 0.008). Conclusions History of prior ischemic stroke, low ASPECTS score, and TICI 2B-3 recanalization are independent predictors of hemorrhagic conversion while an elevated INR is the only independent predictor of symptomatic hemorrhagic conversion in post-thrombectomy patients.

We sought to establish a comprehensive imaging score indicating the likelihood of higher WHO grade meningiomas pre-operatively. All surgical intracranial meningioma patients at our institution between 2014 and 2018 underwent retrospective chart review. Preoperative MRI sequences were reviewed, and imaging features were included in the score based on statistical and clinical significance. Point values for each significant feature were assigned based on the beta coefficients obtained from multivariate analysis. The imaging score was calculated by adding up the points, for a total score of 0 to 5. The predictive ability of the score to identify higher-grade meningiomas was evaluated. Ninety patients, 50

Introduction: Pituitary apoplexy is generally caused by hemorrhage of a benign pituitary tumor. However, in this report, we identify two previously healthy middle-aged patients presenting with chronic pituitary insufficiency and suspected pituitary adenomas but found intraoperatively to have infarcted or hemorrhagic necrotic pituitary glands without histopathological evidence of neoplastic cells, newly termed here as burnt-out pituitary glands.

BACKGROUND:The global burden of neurosurgical disease is substantial, particularly in low- and middle-income countries (LMICs). Medical conferences are important in connecting those from LMICs to those from high-income countries for support and serve as an educational and networking tool. In this study, we sought to quantitatively assess the incorporation of global neurosurgery topics in international conferences related to the neurosurgical specialty.METHODS:A database of major international neurosurgical conferences, from the conference of a group of 9 major neurosurgical societies, that had global neurosurgery featured from 2015 to 2020 was created. We then did a retrospective analysis to study the characteristics of these conferences ranging from geographic location to number to different components of the conferences.RESULTS:There was an increase in the number of conferences with global neurosurgery since 2015. This, in addition to the occurrence of 3 wholly global neurosurgery-related conferences in recent years, is promising and suggests growth in the field. However, 52.6% of conferences took place in North American or European countries, the majority of which were high-income countries. Furthermore, a majority of the presence of global neurosurgery was in the form of individual talks (54.5%) as opposed to plenaries or sessions.CONCLUSIONS:The preponderance of conferences in North America and Europe can pose barriers for those from LMICs including travel time, expenses, and visa problems. As global neurosurgery becomes an increasing part of the global health movement, we hope that these barriers are addressed. Conferences may become an even stronger tool to promote equity in neurosurgical education and practice.

Introduction: Endovascular thrombectomy (EVT) is a well-established treatment of acute ischemic stroke. Variability in outcomes among thrombectomy patients results in a need for patient centered approaches to recovery. Identifying key factors that are associated with outcomes can help prognosticate and direct resources for continued improvement post-treatment. Thus, we developed a comprehensive pre-dictive model of short-term outcomes post-thrombectomy. Methods: This is a retro-spective chart review of adult patients who underwent EVT at our institution over the last four years. Primary outcome was dichotomized 90-day mRS (mRS 0-2 v mRS 3-6). Bivariate analyses were conducted, followed by logistic regression modelling via a backward-elimination approach to identify the best fit predictive model. Results: 326 thrombectomies were performed; 230 cases were included in the model. In the final predictive model, adjusting for age, gender, race, diabetes, and presenting NIHSS, pre-admission mRS = 0-2 (OR 18.1; 95% 3.44-95.48; p < 0.001) was the strongest predictor of a good outcome at 90-days. Other independent pre-dictors of good outcomes included being a non-smoker (OR 5.4; 95% CI 1.53-19.00; p = 0.01) and having a post-thrombectomy NIHSS<10 (OR 9.7; 95% CI 3.90-24.27; p < 0.001). A decompressive hemicraniectomy (DHC) was predictive of a poor out -come at 90-days (OR 0.07; 95% CI 0.01-0.72; p = 0.03). This model had a Sensitivity of 79%, a Specificity of 89% and an AUC=0.89. Conclusion: Our model identified low pre-admission mRS score, low post-thrombectomy NIHSS, non-smoker status and not requiring a DHC as predictors of good functional outcomes at 90-days. Future works include developing a prognostic scoring system.

Introduction: The current gold standard for evaluating functional impairment of pituitary tumors is Humphrey visual field (HVF) testing. However, optical coherence tomography (OCT) may serve as an alternative in predicting return of visual function in postoperative surgically resected patients diagnosed with a pituitary adenoma.

Introduction Endovascular therapy is known to achieve a high rate or recanalization in patients with acute ischemic stroke (AIS) and is currently a standard part of emergent care. Hemorrhagic Conversion (HC) is a severe complication that may occur following ischemic stroke in patients who undergo a thrombectomy procedure. There is scarce data on the risk factors related to hemorrhagic conversion in patients who undergo mechanical thrombectomy. In our study, we sought to gain information on clinical characteristics and predictors associated with HC in patients treated with an endovascular intervention following AIS. Methods We conducted a retrospective analysis of a population of adult patients treated with endovascular therapy for AIS at a primary stroke center in the Bronx, NY between January 2016 and February 2020. Bivariate and logistic regression analyses were performed to determine the predictors and impact on clinical outcome for patients who experienced Hemorrhagic Conversion, and for those who experienced symptomatic Hemorrhagic Conversion. Results A total of 325 patients who underwent endovascular therapy for AIS were identified. Of these, 74 (22.8%) were observed to have hemorrhagic conversion, and 251 (77.2%) had no hemorrhagic conversion. Of those diagnosed with hemorrhagic conversion, 25 (33.8%) were found to be symptomatic. Bivariate analysis of presenting labs and vital signs showed no association with HC. In logistic regression analyses, a history of prior stroke (OR 3.23; 95% CI 1.53-6.81), ASPECTS score <6 (OR 3.311; 95% CI 1.01-10.86), and TICI 2B-3 (OR: 4.372; 95% CI 1.39-13.78) were found to be independent predictors of hemorrhagic conversion. In the symptomatic hemorrhage group, a TICI (2B-3) recanalization (OR: 0.138; 95% CI .028-.673) was found to be the only independent predictor. Conclusion History of prior stroke, radiographic evidence of infarct burden, and radiographic success of thrombectomy may be considered significant predictors for hemorrhagic conversion following AIS in patients who undergo mechanical thrombectomy. Disclosures A. Boyke: None. K. Javed: None. J. Dardick: None. I. Naidu: None. J. Ryvlin: None. D. Kadaba: None. N. Haranhalli: None.

-BACKGROUND: Neurotrauma is a leading cause of morbidity and mortality around the world. Assessment of injury prevention and prehospital care for neurotrauma patients is necessary to improve care systems. -METHODS: A 29-question electronic survey was devel-oped based on the Enhancing the Quality and Transparency Of health Research (EQUATOR) checklist to assess neuro-trauma policies and laws related to safety precautions. The survey was distributed to members of World Health Orga- -ization regions that were considered to be experienced medical authorities in neurosurgery and traumatic brain injury. -RESULTS: There were 82 (39%) responses representing 46 countries. Almost all respondents (95.2%) were within the neurosurgical field. Of respondents, 40.2% were from high-income countries (HICs), and 59.8% were from low-and middle-income countries (LMICs). Motor vehicle accidents were reported as the leading cause of neuro-trauma, followed by workplace injury and assault. Of re-spondents, 84.1% reported having a helmet law in their country. HICs (4.38 +/- 0.78) were ranked more likely than LMICs (2.88 +/- 1.34; P = 0.0001) to enforce helmet laws on a scale of 1-10. Effectiveness of helmet laws was rated as 3.94 +/- 0.95 out of 10. Measures regarding prehospital care varied between HICs and LMICs. Patients in HICs were more likely to use public emergency ambulance trans-portation (81.8% vs. 42.9%; P = 0.0004). All prehospital personnel having emergency training was also reported to be more likely in HICs than LMICs (60.6% vs. 8.7%; P = 0.0001). -CONCLUSIONS: When injuries occur, timely access to neurosurgical care is critical. A focus on prehospital com-ponents of the trauma system is paramount, and policy-makers can use the information presented here to implement and refine health care systems to ensure safe, timely, affordable, and equitable access to neurotrauma care.