Fellowship at Home: A Model for Expanding Neurosurgical Capacity in Low- and Middle-Income Countries

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Publication Details

Journal
Neurosurgery
Published
2026-09-18
DOI
https://doi.org/10.1227/neu.0000000000004216
Primary Topic
Global Health and Surgery
Type
article
Field-Weighted Citation Impact
0.00
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article

Fellowship at Home: A Model for Expanding Neurosurgical Capacity in Low- and Middle-Income Countries

Nirav J. Patel, Lucia Rivera‐Lara, R. Moser, Linda Liverani et al.
Neurosurgery
Global Health and Surgery
article

Fellowship at Home: A Model for Expanding Neurosurgical Capacity in Low- and Middle-Income Countries

Nirav J. Patel, Lucia Rivera‐Lara, R. Moser, Linda Liverani, Silvia D. Vaca, Roberto Labin, Pablo Maidana, Jose Kuzli
article en

Abstract

BACKGROUND AND OBJECTIVES: Short-term global neurosurgical missions and off-site fellowships rarely achieve durable independence in low-resource settings. Sustainable capacity building requires longitudinal, locally embedded training that integrates technical skill with system development. The objective of this study was to evaluate whether a locally embedded "Fellowship at Home" model could establish sustainable independent cerebrovascular surgical capacity and identify factors associated with success. METHODS: We established a longitudinal partnership (2022-present) between Brigham and Women's Hospital and Hospital de Itauguá in Paraguay to develop a comprehensive cerebrovascular program through a model termed "Fellowship at Home." The goal was independent, safe practice. The program combines iterative in-country microsurgical training, development of neuroanesthesia and neurocritical care, and implementation of standardized operative and perioperative systems, reinforced by continuous virtual mentorship. A defining strategy was deliberate focus on a single high-complexity "anchor pathology." Brain arteriovenous malformations were selected because their safe treatment requires the full integration of advanced anesthesia, microsurgery, imaging, operative technology, and critical care. RESULTS: Over 3 years, 18 brain arteriovenous malformation (bAVM) resections were performed collaboratively without preoperative embolization, of which 13 were Spetzler-Martin grade II to IV. This resulted in transition to independent practice, with 14 bAVMs subsequently resected by the local neurosurgeon, of which 4 were Spetzler-Martin grade III to IV. Systems built to support bAVM care translated across the local program, with aneurysm clipping volume increasing from <60 cases annually before 2022 to >100 cases by 2025. CONCLUSION: Focusing on a single complex "anchor pathology" can serve as a catalyst for system-wide capability building. The Fellowship at Home model demonstrates that durable, high-level neurosurgical capacity in low- and middle-income countries can be achieved through continuity, co-ownership, and embedded training. Analysis of this partnership identified recurring determinants of success, including local leadership, longitudinal mentorship, multidisciplinary systems development, and progressive operative autonomy, which may inform future capacity-building initiatives.

Neurosurgery
Brigham and Women's Hospital (US), Harvard University (US), University of Massachusetts Chan Medical School (US), Hospital Nacional Cayetano Heredia (PE), Stanford Health Care (US), Stanford University (US)
Openalex Percentile: Top 8%
Global Health and Surgery
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