"To Operate" Versus "Not to Operate" in Low-Resource Settings: Example of Aneurysm Surgery in Rural Iran and Impact of Mastery of Neurosurgical Anatomy.

BACKGROUND: Subarachnoid hemorrhage (SAH) has a global incidence of 9/100,000. In low-resource settings, where neurosurgical capacity is diminished through fewer human and technological resources, neurosurgeons may not be prepared to operate on aneurysm cases in emergent situations. We report a patient presented with aneurysmal SAH in rural Iran, creating the dilemma of the will for the neurosurgeon. We discuss the impact of the knowledge of neurosurgical anatomy on the resolution of this dilemma.

CASE DESCRIPTION: A 30-year-old female presented with aneurysmal SAH to a remote medical facility in rural Iran. A safe and fast referral to a nearby vascular neurosurgery center was not available. A contrasted computed tomography (the only available imaging modality) revealed a carotid bifurcation aneurysm. The situation was explained to the patient and family, and they decided to proceed with surgery. With the minimum technical radiological and surgical equipment available, the surgeon managed to successfully treat the patient, aided by his mastery of the neurosurgical anatomy. The patient was discharged without any complication.

CONCLUSIONS: We highlight the importance of mastery of neurosurgical anatomy, which was critical in achieving a favorable patient outcome. The necessity of developing low-cost platforms to enhance neurosurgical anatomy learning in neurosurgical residency programs of low-resource regions and countries is discussed.