Neuropathology practice in India: a survey of the current status of diagnostics and training in tertiary care centres.

Neuropathology has been in existence as a speciality in India since the 1950s. Its practice has kept pace with the developments in the field, paralleling advancements in neurosurgery and neurosciences, especially in tertiary care centres. This nationwide survey, conducted across 52 centres, provides a comprehensive analysis of diagnostic infrastructure, training opportunities, and challenges in the practice of neuropathology. The results reveal variability in institutional setups, access to advanced diagnostic tools, and availability of training programs, reflecting a mixed landscape of progress and unmet needs. The majority of surveyed centres (78.8%) integrate neuropathology within general pathology, limiting its specialised focus. Only 17.3% recognise neuropathology as a distinct speciality, with only two functioning as independent departments. Training opportunities are gradually increasing. The Neuropathology Society of India has been instrumental in bridging some of the training gaps. Availability of in-house diagnostic facilities for workup of central nervous system (CNS) neoplastic lesions as per World Health Organization (WHO) CNS5 classification varies widely, with immunohistochemistry (IHC) being the most widely employed technique. Advanced molecular diagnostics, such as next-generation sequencing (NGS) are restricted to a few centres, while DNA methylation profiling is not available in-house in any of the surveyed centres. This limitation forces many institutions to outsource advanced testing, often at a significant financial burden to patients. Resource stratification reveals that 42.3% of surveyed centres are at resource level III, where surrogate IHC molecular markers are available and 32.7% are at resource level IV, with additional availability of basic molecular techniques such as fluorescence in situ hybridisation (FISH) and/or Sanger sequencing. Only 17.3% have advanced molecular techniques such as NGS and are at resource level V. Facilities to evaluate biopsies for diagnosis of non-neoplastic disorders such as neuromuscular diseases, infections, neurodegenerative and neurometabolic disorders are available in 82.3% of centres surveyed. Although muscle and nerve biopsies are performed in a large number of centres, in-house advanced molecular genetic diagnoses are limited to only three and electron microscopy to only seven centres. Comprehensive diagnostics for epilepsy, infections, and neurodegenerative diseases are concentrated in only a few of the tertiary care centres. Autopsies are being performed in 31 centres. Bio-banking and brain banking initiatives, although promising, remain largely confined to academic or research-driven projects. This survey thus highlights achievements in diagnostics and training, while emphasising the pressing need for a multifaceted approach for further improvement of neuropathology and thereby the quality of patient care in India. The survey reveals that although neuropathology services and training in India at tertiary care centres is better than at several other lower middle-income countries (LMICs), there is a need to increase infrastructure and training opportunities equitably. Strategic investment in molecular diagnostic facilities and digital pathology platforms, expanded training programs, and the recognition of neuropathology as a distinct speciality are critical for further improvement. Additionally, reducing financial burden on patients and expanding research infrastructure will be critical to advancing the field. Establishment of zonal nodal centres for referrals and collaboration between centres, both within India and globally, can further help address the disparities. Addressing all these issues will require concerted policy decisions at the governmental level along with the formulation of government supported programs and funding strategies.