Global Neurotrauma Outcome Study Update Webinar

Course Title Global Neurotrauma Outcome Study (GNOS) Update Webinar
Course Date May 12, 2019
Televised By Neurosurgical TV
Organized By Asian Medical Students & Residents Society for Neurosurgery (AMSRS)
Sponsors None
Content Type Online Lectures
Presenters Franco Servadei (Italy)
Peter Hutchinson (UK) )
Tariq Khan (Pakistan) )
David Clark (UK)
Iype Cherian (Nepal))
Raja Krishnankutty (India))
Participants Online Panel (30 participants around the world); Offline Panel Viewers up to 200

The  Asian  Medical  Students  &  Residents  Society  for  Neurosurgery,  as  part  of the  Social  Media, Communications  and  disseminations  member  of  the  Global  Neurotrauma  Outcome  Study  (GNOS) organized an update webinar to provide an insight of the on-goings in what is to be one of the largest global neurotrauma study to date. Organized by its President, Dr Hira Burhan, the webinar was comprised of lectures and interactive talks by eminent Principal Investigators and study leads. The entire webinar was broadcast on Neurosurgical TV and available for free viewership.

The President of the World Federation of Neurosurgical Societies, Prof Franco Servadei, opened the session reviewing overall global neurosurgical needs in terms of disparity in availability of neurosurgeons and instruments between high income countries (HICs) and low- and middle-income countries (LMICs). He emphasized the role of WFNS to improve the current status of neurosurgery by supporting education through full-time and short-period training courses. This, along with the economic support of WFNS, has helped increase the number of neurosurgeons in Africa five-fold since 1998. Moreover, organizing WFNS educations courses as 3D cinema lectures has enabled a better learning medium for young neurosurgeons and trainees. Education via the web is an excellent alternative, especially for neurosurgeons coming from countries where commuting is difficult.  However, as Prof Servadei made note, it is important to consider the long learning curve that is depicted easier in videos than in real practice. The efforts of ACNS, AMSRS, and the contributions of Profs Yoko Kato and Cherian  were also appraised. They  mentioned various sources on online education and Neurosurgical TV emerging as one major contributor lately.

In his concluding remarks, Prof Servadei mentioned the importance of data acquisition and proper research in order to establish protocols for intervention. With 40% of the population residing in LMICs, accounting for the majority of neurotrauma cases, less than 5% of the available data comes from LMICs, whereas studies from US & Europe (HICs) are the data used to establish protocols.

The Principal Investigator of GNOS, Prof Peter Hutchinson from Cambridge, provided details on the NIHR Global Health Research Group on Neurotrauma. The rising rates of deaths following road injuries is the largest cause of TBI, and the subsequent hypoxia and hypovolemia are contributors to mortality. The importance of pre-hospital care and strategies to implement them are crucial to address this alarming rise. Prof Hutchinson presented the history and establishment of the Global Health Research Group on Neurotrauma - funded by the UK Government with the aim of creating a global partnership for global problems. This follows a 4-tier theme; GNOS is based on Theme 1 – mapping of global neurotrauma. This study is a snapshot to a more descriptive GEO-TBI that will establish an international TBI registry.

While talking about the advances in neurosurgery, Prof Hutchinson introduced the development of infra-scanners, that can act as hand-held CT imaging devices, and non-invasive ICP monitors. However, these resources seem to be far out of reach for countries where basic neurosurgical facilities are lacking, as pointed by one of the panelists from Cameroon, who shed light on the poor pre-hospital care in their region. It was unanimously concluded to prioritize prevention and involve the government to facilitate the provision of basic resources to these areas.

The Chair of the WFNS Neurotrauma Committee, Prof Tariq Khan from Pakistan, talked about current neurotrauma care from the LMIC perspective. The lack of awareness and implementation of preventive strategies is perhaps the major contributor to the high rate of TBI in LMICs, coupled with gunshot and mass casualty disasters that add to the burden. The availability of ambulances with trained staff and personnel will reduce morbidity and mortality. What is important in LMICs is the provision of basic skills and equipment in neurosurgical setups rather than sophisticated gadgets to monitor ICP, for example, noted Prof Khan. Timely intervention to address hypoxia and hypovolemia can help. Rehabilitation is another important factor affecting long-term prognosis. Compared with HICs, the initial outcomes were similar in LMICs; however, over a long-term period of 6 months, the HICs had much better rates of recovery and prognosis. This can be achieved by training family members and continuing follow-up care.

The GNOS will help provide a platform to contribute LMIC data  that will help in devising global protocols, said Prof Khan. Setting minimal standards of care are important for guidelines - a target of the WFNS Neurotrauma Committee, which has partnered with ThinkFirst to develop preventive strategies for neurotrauma.  As  the  host  of  the  upcoming  ICRAN  2019  in  Peshawer,  Prof  Khan  announced  the comprehensive recommendations for management of brain and spine injuries will be discussed then.

Dr David Clark, Clinical Research Fellow at NIHR, discussed the current status of the GNOS study. Dr Clark went through in detail the GNOS questionnaire, which is comprised of two parts: the patient data, and the site data to access the facilities available at the participating centers. To date, GNOS has had 108 participating centers from 50 countries. Out of these, 9 were in sub-Saharan Africa and 5 countries were from conflict/post-conflict zones (including Iraq, Syria, and Libya). In terms of HDI (Human Development Index): 67 countries belonged to very high and high HDI, whereas 42 came from medium to low HDI.

Of all procedures recorded in GNOS, the majority were evacuation of supratentorial EDH. Of interest to  the  investigators,  there  were cases  of cisternostomy  reported  in  the  study  - a  new spectrum  of neurotrauama management.   Dr Clark urged more centers to participate and noted the role of young trainees and medical students in helping disseminate the study in their respective centers.

Following  with  the  reports  on  neurotrauma  and  GNOS,  a  session  to  describe  experiences  from participating centers was held. Prof Iype Cherian, eminent skull base neurosurgeon from Nepal, shared his experience with GNOS and the road to progress in cisternostomy for TBI. Prof Cherian expressed his interest  in  advances  in  neurosurgery  itself  per  se ,  rather  than  advances  in  tools  and  gadgets  for monitoring and diagnosis. He described how important it is to manage the progressive sequel of TBI and identify patients suitable to undergo cisternostomy in moderate to severe brain injury. He demonstrated the surgical steps of cisternostomy and what to expect in a very tense brain, the extradural maneuvers of brain unlocking, and the amount of retraction needed in a tense brain. Prof Cherian shared his cases and  outcomes  as  well  as  those  from  China  and  India.  He  highlighted  the  fact  that  consensus  on neurotrauma revolves around achieving the best patient outcome. Hence, debates for choice of surgery should be focused on the best patient care. The recognition of cisternostomy by the GNOS investigators, who have put this as an option for treatment of TBI, was appreciated by Prof Cherian. He concluded with the importance of training on the microscope, particularly for residents and young neurosurgeons to master the skills needed to perform a cisternostomy.

The last talk was by Dr Raja Krishnankutty from South India, who outlined the hurdles a participating center in India encounters to enroll in GNOS, and tips on how to register successfully. Despite India being one of the largest contributors of TBI and having a huge population, it does not have a single center registered for GNOS. This is due to the extensive paperwork - a hurdle for many interested in GNOS. Dr Raja outlined all the steps needed to enroll in GNOS - a great help in disseminating the study in India.

The webinar was successfully concluded with a short question and answer session from attending panelists and viewers – helping to promote the study among its viewers.

AMSRS is thankful to the WFNS leadership for their time and effort - and AMSRS looks forward to organizing further webinars to promote GNOS.  Further information about the GNOS study can be found by visiting:


President, AMSRS

August 2022