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Background In the 1960s, less than 10% of medical school graduates were women. Today, almost half of all medical school graduates are women. Despite the significant rise in female medical school graduates, there continues to be a large gender gap in most subspecialties, particularly surgical subspecialties such as neurosurgery. Objective The purpose of our study was to assess the factors contributing to differences in the academic ranks of male and female staff in academic neurosurgery programs in Canada and the United States (US). Methods Data about women in academic neurosurgery was collected from a number of sources, including Fellowship and Residency Electronic Interactive Database (FREIDA), Accreditation Council for Graduate Medical Education (ACGME), Canadian Resident Matching Service (CaRMS) FRIEDA, ACGME, CaRMS, Pubmed, and Scopus, to create a database of all neurosurgeons in the US and Canada. The analysis included neurosurgeons in academic and leadership ranks and also the H index, citations, publications, citations per year, and publications per year. Results Women represent only 12% of neurosurgeons in the US and Canada. When gender is further analyzed by academic appointment, women represent just over 12% of neurosurgeons at the assistant and associate professor levels (15.44% and 13.27%, respectively) but significantly less at the full professor level (5.84%). Likewise, only 7.45% of women hold first-in command leadership positions while 4.69% hold second-in-command positions within their institutions. Conclusions The existing data shows that women are significantly under-represented in academic neurosurgery. Lack of role models, experience, limited scientific output, and aspirations of a controlled lifestyle could be the potential contributing factors.