Epilepsy Surgery in Low and Low Middle-Income Countries and a Proposed Program Framework

Introduction: The International Global Action Plan on Epilepsy and Other Neurological Disorders (IGAP) promotes the landscape of epilepsy care worldwide over the next decade. Disadvantaged populations in low and low middle-income countries (LMIC) currently lag years behind their high-income counterparts in access to surgical care. The objective of this study is to further characterize the state of surgery in these areas with relative paucity of healthcare resources.

Methods: A systematic review among three databases (MEDLINE, Embase, and Scopus) were searched between inception to October 2023. Studies reporting surgical epilepsy programs in LMIC countries were included.

Results: Of 555 publications, 16 studies met inclusion criteria. A total of 7,185 patients with drug-resistant epilepsy underwent surgical intervention in seven countries. 26% of patients were pediatric. The most common procedure performed was a lesionectomy (60%) followed by a focal resection (47%), anterior temporal lobectomy (47%), and corpus callosotomy (40%). The common personnel included in these programs were neurologists, nurses trained in EEG administration and neurosurgeons. There was heterogeneity in the training of providers, many of these providers trained in high-income countries (63%). Pre-surgical workup included vEEG (80%) and neuroimaging primarily with CT scans. Financial burden is a major limitation to establishing comprehensive programs in LMIC, with epilepsy surgery costs ranging from $1,200-$22,000. It is suggested that methods to mitigate costs should be considered.

Conclusion : Surgical epilepsy programs are feasible in low-income countries: examples show a stepwise approach should be employed starting with simple cases and then moving to more complex cases as experience grows. With the global urgency to address epilepsy, these findings are important to motivate interventions in resource strained environments.