Neurotraumatology Committee Report

Like so many other WFNS Ad Hoc Committees, the COVID-19 pandemic has profoundly affected the activities of the Neurotraumatology Committee since March 2020. However, the Committee has made significant progress in addressing the need for neurotrauma care worldwide.

Co-Chair Peter Hutchinson is Director of the National Institute for Health Research Global Health Research Group on Neurotrauma (NIHR GHRGN) based at the University of Cambridge in the UK. The NIHR GHRGN collaborators include groups in Brazil, Colombia, Ethiopia, India, Indonesia, Malaysia, Myanmar, Nigeria, Pakistan, South Africa, Tanzania, and Zambia. Partner organizations, in addition to the WFNS, include over a dozen groups worldwide that are dedicated to global health, surgery, and neurotrauma.

Co-Chair Tariq Khan is Dean of the Northwest School of Medicine in Peshawar, Pakistan. He and his Committee member colleagues, together with continuing medical education (CME) provider Global Neuro, produced the Virtual ICRAN 2020. Presentations for ICRAN (International Conference on Recent Advances in Neurotraumatology) were held December 5 and 6, with the virtual aspect continuing until December 20.

Following are an update on the activities of the NIHR GHRGN (grouped into four themes) and the final report on Virtual ICRAN 2020.

NIHR Global Health Research Group on Neurotrauma – Recent Activities

Theme 1

• Global Neurotrauma Outcomes Study (GNOS) – we have completed recruitment with a total of almost 1650 patients from 61 countries including very high-, high-, middle- and lowincome setting. The study is at the point of analysis. We are expecting that it will provide unprecedented data regarding the differences in epidemiology, case mix, indications for surgery, surgical resources available and outcomes following emergency surgery for head injury around the world. A number of participants have expressed a wish to continue data collection and contribute to the Global Epidemiology and Outcomes of TBI Registry (GEOTBI) which will continue to drive better and locally-owned research pertinent to improving care for traumatic brain injury in the local settings.
• Global Epidemiology and Outcomes of TBI Registry (GEO-TBI), has been delayed due to COVID – 19, however has progressed to the pilot phase (Pakistan, India, Ethiopia, South Africa and seven sites in UK), where local collections are being evaluated for achievability and sustainability. Full rollout is planned for October 2020. If successful, the GEO-TBI will be the largest database of head injury patients worldwide with coverage across all continents and development status allowing to address further locally-driven research questions and establish real-world comparative effectiveness research networks.
• One of the key areas of improvement that has been identified by the currently available databases of head injury patients admitted to hospitals in our partner countries has been prevention and pre-hospital care. Global Prevention of Neurotrauma-Road Traffic Collisions (GPONT-RTC) - this research project has led to relationships with stakeholders who are normally involved in the developing and implementing policies and strategies to reduce road traffic collisions and consequent neurotrauma (i.e. local council members, police). We are planning to produce short educational videos based on research findings and disseminate them to policymakers and members of the public through Whatsapp and Facebook. This project has allowed for training in and the application of population science research in areas where such methodologies are often lacking.

Theme 2

• In Myanmar we are involved in ongoing clinical discussion, training, and mentoring through both formal teaching and informal support. This involves a) formal neuroanatomy teaching, multi-professional intensive care teaching and training, long-term volunteer placements and mentoring, reciprocal visits, quality implement projects, and academic research projects. b) local service redesign looking at the pathway of traumatic brain injury (TBI) patients in concert with local clinical, managerial and academic leaders, c) informing healthcare policy at a local and national level on ICU provision with a focus on TBI care. The research has now been integrated through UK Aid since 2013. This has allowed research work to extend across departments – notably neurosurgery and anaesthesia/intensive care – but also across health cadres involving both physician and nurse researchers
• One of the key determinants of poor outcome in TBI at Yangon General Hospital (YGH) is the delay in neurosurgical care for polytrauma patients. We have identified solutions involving the reallocation of neurosurgical surgical staff into the ED and the equipping of ED operating rooms to perform emergency neurosurgical procedures. We have also realised that resource limitation is not the barrier to improving care they had previously perceived – changing the attitude to local service and reducing perceived dependence on overseas aid for service improvement. In addition, we have identified how proposed plans for the reconfiguration of the hospital could be augmented to improve TBI care and formed a working partnership with the architecture firm contracted to plan these developments.

Theme 3

• We have demonstrated the feasibility of recruiting patients to randomised surgical trials in India and are planning a further study based solely in LMIC.
• We have proposed a clinical trial of hinge craniotomy as a low-cost equivalent to decompressive craniectomy (DC), particularly applicable to out LMIC partners where resources and follow-up of patients following DC may be difficult. We have conducted a global survey attracting more than 200 responses from 60 countries, including 40 LMICs which has shown there is international interest in participating and randomising for the proposed trial. The trial has undergone peer review and we are in the process of securing preparing applications for additional funding from major UK funding bodies.
• In Zambia, our project to collect long-term outcome data following TBI has been extremely successful. Anecdotally, patients often find it difficult to return to clinic because of logistical and financial reasons and have expressed appreciation that our team proactively follow up their progress post-injury by telephone. Simple technological innovations we are working in many LMICs, e.g. Zambia has now included telephone and SMS follow-up protocols to daily clinic routines. Moreover, the opportunities for staff to develop as a result of our programme have been extremely well received
• The Group has commenced work with a fully funded research assistant working in Colombia to develop Beyond One Option for Treatment of Traumatic Brain Injury: A Stratified Protocol (BOOTStraP) to provide guidelines for management of head injury in LMICs. This project has the potential to impact large groups of physicians and their patients who currently do not have the ability to follow available recommendations due to limited resources.

Theme 4

• The Group has contributed significantly to training local neurosurgeons, intensive care physicians and anaesthesiologists in the partner countries. In Zambia we have delivered another training course – 1^st International Stroke Conference in Lusaka which was attended by >100 participants from Lusaka, surrounding hospitals and 7 different countries from the East and Central African Region. Curriculum development for the National Neurosurgery Training Programme in Zambia continues to be developed. The training programme has now 10 neurosurgeons of which 3 have passed membership exams to the College of Surgeons of East, Central and South Africa (COSECSA) and will be applying for RCS sponsored international fellowships based in Cambridge.
• Research network in partner countries has been established with the help of the local PIs and Research Fellows funded by the group. Currently the Group has 27 NIHR Academy members in 15 countries.
• The Group continues to provide access to BMJ Research to Publication and we have feedback from our Research Fellows confirming that the access to these online resources have had direct impact on the approach to writing papers and has been helpful in the process of getting papers published.

Click to access the final report Virtual ICRAN 2020.