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

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.