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Subash Phuyal, MD, DM
Department of Neuro imaging and Interventional Neuroradiology, Upendra Devkota Memorial National Institute of Neurological and Allied Science

Gentle S Shrestha, MD, FACC, EDIC, FCCP, FNCS
Associate Professor, Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal

Nepal is a small country located in south Asia, with diverse geography ranging from Himalayan regions in the north to plain terrains in the south. It is fully landlocked, bordered by China to the north and India to the south, east, and west. Nepal is a developing country with a population of approximately twenty-nine million people of diverse cultural, ethnic, religious, and lingual backgrounds. Nepal has eight of the ten highest peaks in the world, including the tallest peak, Mount Everest. Despite being gifted with natural resources and a rich cultural background, Nepal is disadvantaged in terms of its available health facilities. The nation has a gross national income (GNI) per capita of USD 1190 as of 2020 and is categorized as a lower-middle income nation according to the World Bank.

Globally, stroke is the second-leading cause of death and third-leading cause of death and disability combined (1), with two-thirds of all stroke cases occurring in developing countries (2). We have a high incidence of ischemic stroke in Nepal, where stroke accounts for nearly 9.5% of all deaths. It is estimated that 50,000 people  are afflicted with stroke every year, with 15,000 people dying from stroke annually (3). This burden is further aggravated by a lack of available resources and trained experts. Although stroke treatment has been recently revolutionized after multiple trials proved the efficacy of mechanical thrombectomy in patients with emergent large-vessel occlusion, the procedure was not offered at any center in Nepal up until 2018 due to a lack of trained personnel and limited resources. Neuro-interventional care was initiated in Nepal in 2019, and the first successful mechanical thrombectomy in the country was performed that March by a team led by interventional neuroradiologist Dr. Subash Phuyal.

This team of trained experts subsequently introduced the service to several of the large hospitals in Kathmandu. Over the last few years, the team has performed about 640 procedures, including over 100 interventions for intracranial aneurysms and over 100 mechanical thrombectomies for acute large vessel occlusions, with outcomes comparable to international standards. This success is attributable to the orchestrated efforts of an interventional neuro-radiologist together with a trained team of neurologists, emergency physicians, anesthesiologists, intensivists, nurses, and other allied staff. This team-based approach has allowed for comprehensive stroke care from the emergency room to hospital discharge. The role of a dedicated critical care team proved especially pivotal in optimizing patient outcomes following neurointervention.

However, there have been multiple challenges along the way. Due to a lack of public awareness as well as the country’s unique geography and primitive roads and transportation infrastructure, most patients with stroke delay seeking health care attention. These factors limit the potential impact of acute interventions like alteplase and mechanical thrombectomy. To mitigate this, there have been ongoing efforts to raise public awareness through social media, as well as efforts to improve existing systems of pre-hospital transportation. Still, even when patients arrive at a hospital within the time window for intervention, many do not receive intervention due to cost constraints, while many hospitals lack stroke management protocols and dedicated stroke teams. We envision the development of local stroke protocols that link central tertiary level hospitals to multiple peripheral hub hospitals as a way to streamline stroke referrals and ultimately improve system-wide stroke care. Efforts are also ongoing to collaborate with local governments for the provision of funding to facilitate timely interventions.

Additionally, setting up a modern angiography suite with biplane imaging and modalities specific to  various endovascular treatments is costly. We have attempted to improvise by leveraging existing cardiac cath labs with built-in single plane angiography and training radiology technicians to rapidly switch between different angiography planes to circumvent the limitations of single plane machines (Fig 1.). To cut down on the cost of mechanical thrombectomy, we use only an aspiration catheter in every first pass attempt rather than using the Solumbra technique (Fig. 2). Despite these cost-cutting measures, we are nevertheless able to attain satisfactory outcomes, and have brought down procedure-related costs by almost 50%.

A lack of trained health care workers also remains a major limitation. We envision training first-line health care workers and developing sustainable training programs locally to grow clinical neuroscience services nationwide. Nepal is already conducting post-graduate training programs in neurology and neurosurgery, and we aim to expand training programs further to include the fields of neurocritical care, neuroanesthesiology, neuroradiology, and neurointervention. Our goal is to continue to improve the treatment of patients requiring neurointervention in the coming years, and to further expand our services throughout the country.

Figure 1: A neurointerventional procedure performed in a biplane cath lab in Kathmandu, Nepal

Figure 2: Left internal carotid anteroposterior (A) and lateral (D) angiogram showed occlusion of the proximal M2 and branches (black arrow). Roadmap anteroposterior (B) and lateral (E) images showing an aspiration catheter at the site of occlusion (*). Post-mechanical thrombectomy anteroposterior (C) and lateral (F) angiogram showed complete (TICI3) recanalization (black arrow).  

References

1. Feigin VL, Stark BA, Johnson CO, et al. Global, regional, and national burdern of stroke and its risk factors, 1990-2019: a systematic analysis for the global burden of disease study 2019. Lancet Neurol. 2021;20:795-820.
2. Bender M, Jusufovic E, Railic V, et al. High burden of stroke risk factors in developing country: the case study in Bosnia- Herzegovina. Mater Sociomed. 2017;29:277-9.
3. Shaik MM, Loo KW, Gan SH. Burden of Stroke in Nepal. Int J Stroke. 2012;7:517-20.