Neurocritical Care Organization in the Low-Income and Middle-Income Countries

Hemanshu Prabhakar^#¹, Abhijit V Lele^#², Indu Kapoor³, Charu Mahajan³, Gentle S Shrestha⁴, Chethan Venkatasubba Rao⁵, Jose I Suarez⁶, Sarah L Livesay⁷, Faraz Shafiq⁸, Konstantin Popugaev⁹, Dhania Santosa¹⁰, Obaidullah Naby Zada¹¹, Wanning Yang¹², Hosne Ara Nisha¹³, Julio C Mijangos-Mendez¹⁴, Peter Kaahwa Agaba¹⁵, Juan Luis Pinedo Portilla¹⁶, Yalew Hasen Tuahir¹⁷, Puvanendiran Shanmugam¹⁸, Yanet Pina Arruebarrena¹⁹, Walter Videtta²⁰, Sebastián Vásquez-García²¹, M Samy Abdel Raheem²², Fasika Yimer²³, Llewellyn C Padayachy²⁴, Luis Silva Naranjo²⁵, Pedro Arriaga²⁶, Chann Myei²⁷, Sarah Shali Matuja²⁸, Tarig Fadalla²⁹, Tanuwong Viarasilpa³⁰, Ganbold Lundeg³¹, Halima M Salisu-Kabara³², Samuel Ern Hung Tsan³³, Simon P Gutierrez³⁴, Leroy P Yankae³⁵, Aidos Konkayev³⁶, Nophanan Chaikittisilpa³⁷, Gisele Sampaio³⁸, Tuan Van Bui³⁹, Geraldine Seina L Mariano⁴⁰, Gisselle Aguilar Sabillon⁴¹, Pablo Blanco⁴², Williams Ortiz⁴³, Angel Jesus Lacerda Gallardo⁴⁴, Oguzhan Arun⁴⁵, Kalaivani Mani⁴⁶

Affiliations

¹ Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India. prabhakaraiims@yahoo.co.in.
² Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA.
³ Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India.
⁴ Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal.
⁵ Departments of Neurology and Neurosurgery and Center for Space Medicine, Baylor College of Medicine, Houston, TX, USA.
⁶ Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁷ Department of Adult and Gerontological Nursing, Rush University, Chicago, IL, USA.
⁸ Department of Anaesthesiology, The Aga Khan University, Karachi, Pakistan.
⁹ Anaesthesia and Intensive Care, Burnazian State Research Centre, Moscow, Russia.
¹⁰ Department of Anesthesiology and Reanimation, Dr Soetomo General Academic Hospital, Surabaya, Indonesia.
¹¹ Department of Anesthesia, French Medical Institute for Mothers and Children, Kabul, Afghanistan.
¹² Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
¹³ Square Hospital Limited, Dhaka, Bangladesh.
¹⁴ Department of Medical Clinics, University Centre for Health Sciences, University of Guadalajara, Guadalajara, Mexico.
¹⁵ Department of Anaesthesia and Intensive Care, Mulago National Superspecialized Referral Hospital, Kampala, Uganda.
¹⁶ Department of Emergency and Critical Care, Almanzor Aguinaga Asenjo Hospital, Chiclayo, Peru.
¹⁷ Debre Tabor University, Debra Tabor, Ethiopia.
¹⁸ Intensive Care Unit, Peradeniya Teaching Hospital, Peradeniya, Sri Lanka.
¹⁹ Intensive Care Unit Department, Greater Accra Regional Hospital, Accra, Ghana.
²⁰ Department of Intensive Care, Posadas Hospital, Buenos Aires, Argentina.
²¹ Neurosciences and Intensive Care Department, Clínica del Country, Bogotá, Colombia.
²² Department of Anaesthesiology and Intensive Care, Asyut University Hospitals, Asyût, Egypt.
²³ Department of Medical Sciences, Hage Geingob Campus School of Medicine, University of Namibia, Windhoek, Namibia.
²⁴ Brain Tumor and Translational Neuroscience Centre, Department of Neurosurgery, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa.
²⁵ Intensive Care Unit, Hospital General Ambato, Ambato, Ecuador.
²⁶ Critical Care, Karl Heusner Memorial Hospital, Belize City, Belize.
²⁷ Department of Anaesthesia and Intensive Care, Defence Services General Hospital, Yangon, Myanmar.
²⁸ Department of Internal Medicine, Catholic University of Health and Allied Sciences, Mwanza, Tanzania.
²⁹ Department of Neurosurgery, Soba University Hospital, Khartoum, Sudan.
³⁰ Division of Critical Care, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
³¹ Department of Critical Care and Anaesthesia, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia.
³² Anesthesiology/Intensive Care Unit/Theatres, Aminu Kano Teaching Hospital, Kano, Nigeria.
³³ Department of Anaesthesiology and Intensive Care, Faculty of Medicine and Health Sciences, University of Malaysia, Sarawak, Malaysia.
³⁴ Intensive Care, Hospital de Especialidades Materno Infantile, La Paz, Bolivia.
³⁵ Department of Neurology, University Teaching Hospitals, Lusaka, Zambia.
³⁶ Department of Anesthesia and Intensive Care, Astana Medical University, Astana, Kazakhstan.
³⁷ Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol, Bangkok, Thailand.
³⁸ Department of Neurology, Universidade Federal de São Paulo and Hospital Israelita Albert Einstein, São Paulo, Brazil.
³⁹ Neurosurgical Intensive Care Unit, Cho Ray Hospital, Ho Chi Minh City, Vietnam.
⁴⁰ Critical Care Services, St. Luke's Medical Centre, Quezon City, Philippines.
⁴¹ Hospital Mario Catarino Rivas, San Pedro Sula, Honduras.
⁴² Hospital Dr Luis Razetti, Barcelona, Anzoátegui, Venezuela.
⁴³ Hospital Ingavi, San Lorenzo, Paraguay.
⁴⁴ Hospital General Docente Roberto Rodríguez Fernández, Morón, Cuba.
⁴⁵ Department of Anesthesiology and Reanimation, Faculty of Medicine, Selcuk University, Konya, Turkey.
⁴⁶ Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India.

^# Contributed equally.

PMID: 39920547
DOI: 10.1007/s12028-025-02210-7

Neurocritical Care Organization in the Low-Income and Middle-Income Countries

Hemanshu Prabhakar et al. Neurocrit Care. 2025 Aug.

. 2025 Aug;43(1):141-156.

doi: 10.1007/s12028-025-02210-7. Epub 2025 Feb 7.

Authors

Affiliations

¹ Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India. prabhakaraiims@yahoo.co.in.
² Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA.
³ Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India.
⁴ Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal.
⁵ Departments of Neurology and Neurosurgery and Center for Space Medicine, Baylor College of Medicine, Houston, TX, USA.
⁶ Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁷ Department of Adult and Gerontological Nursing, Rush University, Chicago, IL, USA.
⁸ Department of Anaesthesiology, The Aga Khan University, Karachi, Pakistan.
⁹ Anaesthesia and Intensive Care, Burnazian State Research Centre, Moscow, Russia.
¹⁰ Department of Anesthesiology and Reanimation, Dr Soetomo General Academic Hospital, Surabaya, Indonesia.
¹¹ Department of Anesthesia, French Medical Institute for Mothers and Children, Kabul, Afghanistan.
¹² Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
¹³ Square Hospital Limited, Dhaka, Bangladesh.
¹⁴ Department of Medical Clinics, University Centre for Health Sciences, University of Guadalajara, Guadalajara, Mexico.
¹⁵ Department of Anaesthesia and Intensive Care, Mulago National Superspecialized Referral Hospital, Kampala, Uganda.
¹⁶ Department of Emergency and Critical Care, Almanzor Aguinaga Asenjo Hospital, Chiclayo, Peru.
¹⁷ Debre Tabor University, Debra Tabor, Ethiopia.
¹⁸ Intensive Care Unit, Peradeniya Teaching Hospital, Peradeniya, Sri Lanka.
¹⁹ Intensive Care Unit Department, Greater Accra Regional Hospital, Accra, Ghana.
²⁰ Department of Intensive Care, Posadas Hospital, Buenos Aires, Argentina.
²¹ Neurosciences and Intensive Care Department, Clínica del Country, Bogotá, Colombia.
²² Department of Anaesthesiology and Intensive Care, Asyut University Hospitals, Asyût, Egypt.
²³ Department of Medical Sciences, Hage Geingob Campus School of Medicine, University of Namibia, Windhoek, Namibia.
²⁴ Brain Tumor and Translational Neuroscience Centre, Department of Neurosurgery, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa.
²⁵ Intensive Care Unit, Hospital General Ambato, Ambato, Ecuador.
²⁶ Critical Care, Karl Heusner Memorial Hospital, Belize City, Belize.
²⁷ Department of Anaesthesia and Intensive Care, Defence Services General Hospital, Yangon, Myanmar.
²⁸ Department of Internal Medicine, Catholic University of Health and Allied Sciences, Mwanza, Tanzania.
²⁹ Department of Neurosurgery, Soba University Hospital, Khartoum, Sudan.
³⁰ Division of Critical Care, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
³¹ Department of Critical Care and Anaesthesia, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia.
³² Anesthesiology/Intensive Care Unit/Theatres, Aminu Kano Teaching Hospital, Kano, Nigeria.
³³ Department of Anaesthesiology and Intensive Care, Faculty of Medicine and Health Sciences, University of Malaysia, Sarawak, Malaysia.
³⁴ Intensive Care, Hospital de Especialidades Materno Infantile, La Paz, Bolivia.
³⁵ Department of Neurology, University Teaching Hospitals, Lusaka, Zambia.
³⁶ Department of Anesthesia and Intensive Care, Astana Medical University, Astana, Kazakhstan.
³⁷ Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol, Bangkok, Thailand.
³⁸ Department of Neurology, Universidade Federal de São Paulo and Hospital Israelita Albert Einstein, São Paulo, Brazil.
³⁹ Neurosurgical Intensive Care Unit, Cho Ray Hospital, Ho Chi Minh City, Vietnam.
⁴⁰ Critical Care Services, St. Luke's Medical Centre, Quezon City, Philippines.
⁴¹ Hospital Mario Catarino Rivas, San Pedro Sula, Honduras.
⁴² Hospital Dr Luis Razetti, Barcelona, Anzoátegui, Venezuela.
⁴³ Hospital Ingavi, San Lorenzo, Paraguay.
⁴⁴ Hospital General Docente Roberto Rodríguez Fernández, Morón, Cuba.
⁴⁵ Department of Anesthesiology and Reanimation, Faculty of Medicine, Selcuk University, Konya, Turkey.
⁴⁶ Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India.

^# Contributed equally.

PMID: 39920547
DOI: 10.1007/s12028-025-02210-7

Abstract

Background: This study aimed to assess the organization, infrastructure, workforce, and adherence to protocols in neurocritical care across low- and middle-income countries (LMICs), with the goal of identifying key gaps and opportunities for improvement.

Methods: We conducted a cross-sectional survey of 408 health care providers from 42 LMICs. The survey collected data on the presence of dedicated neurointensive care units, workforce composition, access to critical care technologies, and adherence to evidence-based protocols. Data were analyzed using descriptive statistics, and comparisons were made across different geographical regions (East Asia and the Pacific, Europe and Central Asia, Latin America and the Caribbean, the Middle East and North Africa, and South Asia and sub-Saharan Africa) and economic strata [low-income countries (LICs), lower middle-income countries (LoMICs), and upper middle-income countries (UMICs)].

Results: Only 36.8% of respondents reported access to dedicated neurointensive care units: highest in the Middle East (100%), lowest in sub-Saharan Africa (11.5%), highest in LoMICs (42%), and lowest in LICs (13%). Access to critical care technologies, such as portable computed tomography scanners (9.3%; UMICs 11%, LICs 0%) and tele-intensive care unit services (14.9%; UMICs 19%, LICs 10%), was limited. Workforce shortages were evident, with many institutions relying on anesthesia residents for 24-h care. Adherence to protocols, including those for acute ischemic stroke (61.7%) and traumatic brain injury (55.6%), was highest in Latin America and the Caribbean (72% and 73%, respectively) and higher in UMICs (66% and 60%, respectively) but remained low in LICs (22% and 32%, respectively).

Conclusions: The study highlights critical gaps in infrastructure, workforce, and technology across LMICs, yet it also underscores the potential for improvement. Strategic investments in neurointensive care unit capacity, workforce development, and affordable technologies are an unmet need in resource-limited settings. These findings offer a road map for policymakers and global health stakeholders to prioritize neurocritical care and reduce the disparities in patient outcomes globally.

Keywords: Intensive care unit; Low-income countries; Middle-income countries; Neurocritical care; Organization; Protocols.

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Conflict of interest statement

Conflicts of interest: None of the authors have any conflict of interest. Ethical Approval/Informed Consent: Ethical approval for this study was obtained from the Institute Ethics Committee (IEC) at the All India Institute of Medical Sciences, New Delhi, India. Participating institutes in the various low- and middle-income countries sought clearance from their respective ethics committees, facilitated by the national coordinators who received the final protocol, IEC approval letter, and related documents.

References

1. Prust ML, Mbonde A, Rubinos C, Shrestha GS, Komolafe M, Saylor D, et al. Providing neurocritical care in resource-limited settings: challenges and opportunities. Neurocrit Care. 2022;37(2):583–92.
1. Shrestha GS, Lamsal R. Neurocritical care in resource-limited settings. J Neurosurg Anesthesiol. 2020;32(4):285–6.
1. Shrestha GS, Goffi A, Aryal D. Delivering neurocritical care in resource-challenged environments. Curr Opin Crit Care. 2016;22(2):100–5.
1. Shrestha GS, Nepal G, Prabhakar H, Prust ML. Cost-effectiveness of neurocritical care in settings with limited resources. Lancet Glob Health. 2023;11(9): e1343.
1. Gonçalves B, Rynkowski C, Turon R, Charris N, Miranda F, de Caro V, et al. Clinical characteristics and outcomes of patients with aneurysmal subarachnoid hemorrhage: a prospective multicenter study in a middle-income country. Neurocrit Care. 2023;38(2):378–87.

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Neurocritical Care Organization in the Low-Income and Middle-Income Countries

Affiliations

Neurocritical Care Organization in the Low-Income and Middle-Income Countries

Authors

Affiliations

Abstract

Conflict of interest statement

References

MeSH terms

LinkOut - more resources

Full Text Sources

Medical