Letter: Capacity Building for Surgical Epilepsy Care in Ukraine

To the Editor:

The epilepsy treatment gap in low- and middle-income countries (LMICs) remains a significant problem deserving greater attention. With epilepsy affecting roughly 1% of the global population,¹ we believe that the most optimal approach to improving epilepsy care and specifically addressing the surgical treatment gap is capacity building for neurosurgeons and neurologists. The rapid growth of global neurosurgery has enabled practical and durable contributions to neurosurgical care in various LMICs.² Burgeoning international collaborations between physicians serve as an ideal platform to address drug-resistant epilepsy (DRE) in underserved areas. Our experience in Ukraine since 2016 through the Co-Pilot Project has provided us with a number of important lessons that may guide initiatives in other countries.³

Direct operative assistance as a mechanism for hands-on collaboration can be profoundly valuable for long-term success. We have arranged more than 15 trips for neurosurgeons from the United States to actively assist in various operations, including functional hemispherotomy and temporal lobectomy in addition to lesionectomy and vagus nerve stimulator implantation.³ Our colleagues in Ukraine have since independently performed complex epilepsy procedures, such as functional hemispherotomy, multilobar disconnections (eg, posterior quadrant disconnection), temporal lobectomy, and callosotomy with excellent outcomes. In addition to operating, we have provided consultations for patients with DRE in various clinics throughout Ukraine (in Kyiv, Lutsk, Mukachevo, and other cities) and participated in conferences and multidisciplinary epilepsy meetings to discuss indications for surgery.

Provision of surgical equipment can be impactful but is most appropriate when tailored to specific needs. In the context of epilepsy, we aimed to bolster capabilities for the performance of intracranial electroencephalography (icEEG). In 2021, we provided an EEG amplifier to Dr Kostiantyn Kostiuk at the Romodanov Neurosurgery Institute in Kyiv as a first step toward routine performance of icEEG. Of course, being able to perform icEEG would significantly increase the cohort of surgical candidates by allowing operations for patients with negative or subtle MRI findings. Although we would like to promote the use of stereo-EEG, regulatory laws for implantable equipment (such as depth electrodes) prevent or complicate the acquisition of certain items in Ukraine. Thus, knowledge of the local neurosurgical landscape when working with surgeons in the country is an essential component of supplying operative equipment.

Because we are not able to be present in Ukraine frequently throughout the year, novel mechanisms for extending our aid have been incorporated into our collaboration. We regularly host a virtual, quarterly epilepsy conference with Ukrainian neurosurgeons and epileptologists to collectively discuss specific cases that require guidance or showcase outcomes of independently performed surgeries. In addition, Ukrainian neurosurgeons remain in contact with us to discuss cases as necessary. With time, it is clear that our partners in Ukraine are becoming increasingly more comfortable with complex epilepsy surgeries.

Finally, we have facilitated educational apprenticeships for Ukrainian neurosurgeons in the United States, which are not unlike the multiple opportunities offered by international surgical organizations, such as the European Association of Neurosurgical Societies, World Federation of Neurosurgical Societies, and Foundation for International Education in Neurological Surgery. Following their lead, we have specifically arranged multiple fellowship opportunities where Ukrainian neurosurgeons have been able to gain time and experience serving as laboratory fellows in cadaveric microsurgical laboratories at US institutions (which is important because hands-on access to cadaveric specimens in Ukraine is presently limited by current federal rules/regulations). In other instances, sponsored clinical fellowships with pediatric epilepsy have been arranged. We are also seeking to organize additional fellowship opportunities with our colleagues in Europe. Collectively, this exposure has been critical in advancing the skills of Ukrainian neurosurgical providers.

Our experience in Ukraine thus far provides a number of valuable lessons. Similar long-term, capacity-building collaborations can be recapitulated in other LMICs to help foster the development of high-quality surgical epilepsy centers. We believe that such initiatives serve as important steps to ensure that patients with DRE can attain advanced neurosurgical care and have a high chance for seizure freedom anywhere in the world.