Neurocritical Care Organization in Low- and Middle-Income Countries

Academic Background and Problem Statement

Neurocritical care (NCC) has rapidly evolved over the past few decades as a distinct subspecialty of critical care medicine. Evidence shows that patients with acute brain injuries have significantly improved outcomes when treated in dedicated units by specialized teams. Although NCC is well-established in high-income countries (HICs), it remains in its early stages in many low- and middle-income countries (LMICs).

Significant disparities exist between HICs and LMICs regarding access to essential resources, such as intensive care unit (ICU) beds, neuroimaging, clinical laboratories, neurosurgical capacity, and medications for managing complex neurological conditions. In LMICs, there is an acute shortage of healthcare workers trained to manage neurologic emergencies, with subspecialized NCC expertise largely absent. These resource limitations create barriers to delivering effective NCC, and limited information exists regarding the current state of NCC capacity in LMICs.

Although the Point Prevalence in Neurocritical Care (PRINCE) study conducted by the Neurocritical Care Society (NCS) aimed to provide a global overview of NCC practices, its findings primarily reflected the experience of large academic centers in high-resource settings, with minimal representation from LMICs. Therefore, the results of the PRINCE studies cannot be fully extrapolated to LMICs, where the challenges are markedly different.

This study focuses exclusively on NCC practices in resource-limited settings to address this gap. By expanding upon the PRINCE study findings and contextualizing them for LMICs, researchers aim to understand the organization of NCC in these countries. Although not all hospitals providing NCC services were included, they believe this will provide valuable insights into resource allocation, disease burden, and potential areas for research. Ultimately, this information can help LMICs prioritize resources and develop strategies to improve care for patients with neurological injuries, who often face higher morbidity and mortality compared to those in HICs.

Source of the Paper and Author Profiles

This study was conducted by researchers from 45 different institutions, including Hemanshu Prabhakar from the All India Institute of Medical Sciences (New Delhi, India) and Abhijit V. Lele from the Harborview Medical Center, University of Washington (Seattle, WA, USA). The paper was published in Neurocritical Care in 2025.

Research Process and Methodology

Study Population and Sample Size

This study employed a cross-sectional survey method, collecting data from 408 healthcare providers across 42 LMICs. The data covered the presence of dedicated neurointensive care units (NICUs), workforce composition, access to critical care technologies, and adherence to evidence-based protocols.

Data Collection and Analysis

Data were collected online using Google Forms and analyzed using Stata 18.0 software. Descriptive statistics were used to summarize the data. Differences among geographical regions were assessed using the Kruskal-Wallis test, while economic strata differences based on World Bank classification were analyzed using Pearson’s χ² test.

Survey Design and Distribution

The research team adapted the case report form originally developed for the PRINCE study by the NCS. The steering committee reviewed and modified it to fit resource-limited settings. National representatives recruited participants through informal networking, emails, and social media platforms like WhatsApp groups and critical care society mailing lists. Each national representative distributed the survey link to relevant institutions and colleagues within their country.

Research Findings

Infrastructure and Resource Allocation

The study found that only 36.8% of respondents reported having dedicated NICUs, with the highest proportion in the Middle East (100%) and the lowest in Sub-Saharan Africa (11.5%). Access to critical care technologies, such as portable computed tomography (CT) scanners, was very limited, especially in low-income countries (LICS), where the availability of portable CT scanners was zero. Additionally, reliance on anesthesia residents for 24-hour care was widespread.

Workforce Shortages

The study revealed significant workforce shortages in LMICs, with many institutions relying on anesthesia residents for round-the-clock care. Nurse-to-patient ratios were generally 1:2 across regions but were 1:3 in Europe and Central Asia. Advanced practice providers (APPs) were most scarce in LICS.

Adherence to Guidelines and Protocols

Adherence to guidelines for acute ischemic stroke (AIS) and traumatic brain injury (TBI) was 61.7% and 55.6%, respectively, with the highest rates in Latin America and the Caribbean (LAC) at 72% and 73%. Upper-middle-income countries (UMICs) had higher adherence rates (66% and 60%), while lower rates were observed in LICS (22% and 32%).

Access to Technological Resources

Access to portable CT scanners and tele-intensive care unit (tele-ICU) services was very limited in LMICs. Only 9.3% of respondents reported having portable CT scanners, with a rate of 19.3% in UMICs, and none in LICS. Tele-ICU services were available in just 14.9% of institutions overall, with a higher rate of 21.3% in UMICs.

Conclusions and Implications

Study Conclusion

This study highlights critical gaps in infrastructure, workforce, and technology in LMICs but also underscores opportunities for improvement. Strategic investments in NICU capacity, workforce development, and affordable technologies are unmet needs in resource-limited settings. These findings offer a roadmap for policymakers and global health stakeholders to prioritize neurocritical care and reduce disparities in patient outcomes globally.

Research Value

This study emphasizes the organization, resources, and adherence to protocols in NCC in LMICs, revealing significant gaps in infrastructure, workforce, and standardized guideline adherence. Despite challenges, the results provide key opportunities to improve care delivery, focusing on infrastructure building, workforce development, and technology access. These findings are crucial for policymakers, health ministries, and frontline providers in making decisions about resource allocation and system reforms.

Research Highlights

1. Uneven Infrastructure: Distribution of NICUs is highly uneven, particularly with severe shortages in Sub-Saharan Africa.
2. Workforce Shortages: Reliance on anesthesia residents for 24-hour care is common, and APPs are especially scarce in LICS.
3. Low Guideline Adherence: Adherence to AIS and TBI guidelines is higher in UMICs but lower in LICS.
4. Limited Technological Resources: Access to portable CT scanners and tele-ICU services is very limited, especially in LICS.

Looking Forward

The findings have important implications for global health policy. Strengthening NCC systems in LMICs not only improves patient outcomes but also promotes global health equity. Regardless of location, all patients with neurological emergencies deserve the best possible care. Targeted interventions can build a global NCC system that serves all patients, regardless of their geographic or economic circumstances.