Despite advances in issues related to gender equity, barriers to recruiting and retaining women in neurosurgery continue to exist. At the same time, the overall projected shortage of neurosurgeons suggests that women will be vital to the long-term success of the field. Attracting women to neurosurgery can capitalize on strategies, such as mentoring, teaching leadership and negotiating skills, and job sharing or dual training tracks to name a few, that would benefit both men and women passionate about pursuing neurosurgery. Ultimately, personal and institutional accountability must be evaluated to ensure that the best and brightest candidates, regardless of gender, are recruited to neurosurgical programs to promote the health of our challenging but most satisfying profession.

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Background: Distal anterior cerebral artery (DACA) aneurysms are rare and their surgical treatment presents some unique difficulties. In this report, we present our experience of cases with DACA aneurysms. Materials and Methods: Among 80 patents with cerebral aneurysm operated on in the three-year period, 15 patients (18.75%) had DACA aneurysms, who were studied retrospectively. We analyze the specific clinical and radiological features, surgical strategies and prognostic factors affecting the surgical outcomes of these DACA aneurysms. Results: There were 10 male and 5 female patients harboring 16 DACA aneurysms. All patients presented with subarachnoid hemorrhage, 11 patients (73%) had intracerebral hematoma in their initial CT scan and four of them had associated intraventricular hemorrhage. Thirteen of the ruptured DACA aneurysms (86%) were small in size (less than 7 mm in diameter). Three patients (20%) had other associate aneurysms. In 14 patients (93%), a unilateral interhemispheric approach was used in their treatment, while pterional approach was used in one patient. Eleven patients (73%) had favorable outcomes and only one patient (7%) died. The follow-up data suggested that poor admission grade and initial Intracerebral hematoma (ICH) on brain scan portend an unfavorable prognosis. Conclusions: DACA aneurysms are usually small even when ruptured, they are usually associated with ICH more frequently than intracranial aneurysms in other locations. They should be aggressively treated even if very small because of their tendency to early rupture.

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Penetrating head injury is a potentially life-threatening condition. Penetrating head injuries with impacted object (weapon) are rare. The mechanism of low velocity injury is different from high velocity missile injury. Impacted object (weapon) in situ poses some technical difficulties in the investigation and management of the victims, and if the anticipated problems are not managed properly, they may give rise to serious consequences. The management practice of eight patients with impacted object in situ in context of earlier reported similar cases in literature is presented.

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Background: There has been longstanding controversy over the use of magnesium sulfate infusion in the medical management of aneurysmal subarachnoid hemorrhage (SAH). Several clinical trials evaluating the beneficial effects of magnesium on cerebral vasospasm and their poor outcome have been published. However, results from the majority of these studies have been inconclusive. This meta-analysis was performed to evaluate the effectiveness of magnesium on patient outcomes after aneurysmal SAH. Materials and Methods: PubMed and the Cochrane library were searched for controlled clinical trials assessing the efficacy of magnesium sulfate infusion after aneurysmal SAH. Eight studies consisting of 936 patients were included. Results: There was a decreased risk of poor outcome at 3-6 months after SAH in magnesium treatment groups when compared to placebo [0.78 (95% CI 0.66-0.93)]. Poor outcome was defined as severe disability, persistent vegetative state, or death, as measured by the Glasgow outcome scale (GOS), extended Glasgow outcome scale (GOSE) or modified Rankin scale (mRS). The risk of mortality after SAH was unaffected by magnesium treatment [RR 0.68 (95% CI 0.58-1.27)]. Conclusion: Magnesium sulfate infusion decreases risk of poor outcome after aneurysmal SAH. Current studies in the literature do not suggest a role for magnesium sulfate in mortality reduction after SAH.

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Carotid cavernous fistula (CCF) is an abnormal arteriovenous communication in the cavernous sinus. Direct CCF results from a tear in the intracavernous carotid artery. Typically, it has a high flow and usually presents with oculo-orbital venous congestive features such as exophthalmos, chemosis, and sometimes oculomotor or abducens cranial nerve palsy. Indirect CCF generally occurs spontaneously with subtle signs. We report a rare case of spontaneous direct CCF in childhood who did not have the usual history of craniofacial trauma or connective tissue disorder but presented with progressive chemosis and exophthalmos of the right eye. This report aims also to describe the safety and success of transvenous embolization with coils of the superior ophthalmic vein and cavernous sinus through the inferior petrosal sinus.

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Background: Surgical treatment of extramedullary craniovertebral and upper cervical tumors differs essentially, depending on the peculiarities of their localization. Materials and Methods: In the Spinal Department of the Institute of Neurosurgery during the period from 2000 to 2010, 96 patients with ventral and ventrolateral intradural extramedullary craniovertebral tumors and tumors of upper cervical localization were examined and operated. Results: The patients were distributed as follows. Tumors of the craniovertebral localization: These are neoplasms spreading in rostral direction up to the boundary of the lower third of the clivus and in caudal direction up to the upper edge body of the axis (C0-C1) - 12 patients; tumors at the C1-C2 level: 28 patients; and tumors at the C1-C2-C3 level: 56 patients. The tumors were divided into ventral (60) and ventrolateral (36). Conclusion: Therefore, the adequate choice of a surgical approach first depends on the localization of the tumor, its size and the extent to which it has spread. In most cases of extramedullary ventrolateral tumors of craniovertebral and upper cervical localization, far lateral and posterolateral approaches are the most optimum and the least traumatic. The extreme lateral approach is advisable in cases of big size ventral craniovertebral tumors.

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Intrathecal baclofen (ITB) has been found to be helpful not only for spasticity but also for unconsciousness in a vegetative patient. This is the first case of ITB in Nepal, and here we discuss the effectiveness of ITB for spasticity in a patient in vegetative state. We also discuss about a simple technique for ITB used in Nepal where baclofen pump is not available. Here, we present a case of a 40-year-old male patient who had severe head injury with diffuse axonal injury treated conservatively. He went on to a vegetative state and subsequently developed severe spasticity of all the limbs. ITB was started under the guidance of one of the authors , Prof. Taira. Baclofen was injected to the spinal intrathecal space through a catheter which is used for spinal anesthesia. Spasticity improved significantly and his higher mental function also showed signs of improvement. He finally became fully conscious and well oriented. ITB is very useful in cases of severe spasticity and vegetative condition, a state of unconsciousness lasting longer than a few weeks. Even with a simple technique in the absence of baclofen pump, ITB can be used with its optimum effect.

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On November 22, 2010, a simulation-based hands-on education course for medical staff in the neurosurgical fields was held in 8 ^th Asian Congress of Neurological Surgeons (ACNS) in Kuala Lumpur, Malaysia. The present education course called Primary Neurosurgical Life Support (PNLS) course had been started by the Japan Society of Neurosurgical Emergency since 2008. This report summarizes the international version of PNLS course in 8 ^th ACNS.

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In a world with rapidly changing technologies in the field of neurosurgery, Japan leads the world in many subspecialities like vascular neurosurgery. Apart from this, neuro-oncology and spinal surgeries are also among the premium quality operations performed in the region. I would like to share my experience of spending 3 months at the Fujita Health University, Nagoya, Japan, and the rich expertise and technologies encountered during the period, which made me understand Neurosurgery in a better way.

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