Brazil's Neurosurgical Paradox: Advanced Capacity Amid Territorial Inequity

Neurosurgical care has undergone remarkable technological advancement over recent decades, yet equitable access remains uneven across health systems. This study examines the structural determinants of neurosurgical access in Brazil, a middle-income country with a universal public health system (Sistema Único de Saúde), highlighting the paradox between workforce expansion and persistent territorial inequities. Between 2015 and 2025, Brazil's neurosurgical workforce increased by 50.9%, rising from 2875 to 4340 specialists, with national density growing from 1.43 to 2.04 per 100 000 inhabitants. Despite this expansion, marked regional disparities persist, with 53.4% of neurosurgeons concentrated in the Southeast and only 5.5% in the North. Geographic and infrastructural inequalities contribute to the emergence of "neurosurgical deserts", where care is formally available but functionally inaccessible because of distance, limited referral systems, and insufficient hospital capacity. Arteriovenous malformations serve as a sentinel condition illustrating these disparities. Although patients in metropolitan areas benefit from early diagnosis and multimodal treatment, those in peripheral regions often present with hemorrhage because of delayed access to imaging and specialized care. These differences underscore how system organization directly influences clinical outcomes. Brazil exemplifies a broader pattern in middle-income countries, where technological sophistication coexists with fragmented system integration. Addressing these inequities requires coordinated policy interventions, including redistribution of the workforce, development of regional neurovascular networks, telemedicine integration, and investment in comprehensive care infrastructure. Transforming universal coverage into effective access depends on measurable equity metrics and integrated system design, ensuring timely and high-quality neurosurgical care across diverse geographic settings.