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The Dawn of a New Era: The Rise of Neuro-intervention in Nepal

Nowadays, the systematic application of neuro-interventional radiology in treating stroke has the potential to significantly limit its burden, especially in high-income countries. Yet, as documented by the Global Stroke Fact Sheet published by the World Stroke Organization, the incidence of stroke has risen by 70% from 1990 to 2019, with a proportional increase in the global number of deaths and disability-adjusted life years (DALYs), especially in low- and middle-income countries. Therefore, it was not long ago that Nepal, a developing country with challenges of its own, started experiencing that burden. Although we do not have the exact data on stroke incidence and prevalence in Nepal, it is estimated that 50,000 people per year are afflicted with stroke, and among these people, nearly 30% of people die from stroke annually. Stroke is the third leading cause of death and the leading cause of disability in Nepal. This number is on the rise. If we compare with the previous data, stroke-related deaths in our country have increased by 40% between 2009 and 2022. So, these facts and statistics point toward a greater need for skilled personnel and better availability of proper treatment and interventions in this field. However, as there were no trained doctors, neuro-interventional capacity was non-existent in Nepal until a few years back.


In 2019, we performed the first case of mechanical thrombectomy (MT) on a 50-year-old patient, finally making a breakthrough in the field. Going back the memory lane, the whole scenario is still engraved inside my mind. While the patient made it to the hospital within the therapeutic window and with a lot of hope, it didn’t take them long to realize the financial deficit this procedure would put them into. However, despite several unforeseen barriers, we went ahead with MT and had an excellent outcome in the end, which became a light of hope for many more cases to come. It is dumbfounding how a disease considered to likely leave its remnants in the form of disability can be cured completely. Further, the outcome shows that it is not just the number of lives that are saved in such a short interval, but the huge impact on improving someone’s quality of life and those who care for them.


However, our initial years in establishing neuro-intervention in Nepal were a struggle. At the time, neuro-interventional radiologists were involved in treating a handful of patients with large vessel occlusion (LVO) acute stroke with minimal resources available, which were limited to fluoroscopy in a single-plane cardiac catheterization lab instead of dedicated bi-plane catheterization labs that we have today. Although a few catheterization labs were available, they were limited to performing cardiac procedures, making it nearly impossible to offer a standard of intervention to patients with stroke due to LVO. In addition, a lack of trained supporting staff inside the theater and hardware were other factors that caused a setback in providing sufficient service.


Regarding my own journey, until a few years back, I was the only neuro-interventional radiologist in the country performing thrombectomies. During this period, I took upon the role of organizing workshops to educate other health workers about the subject, as a jump start to widening its scope further down the line. But although there has been a rise in the number of interventional radiologists, setting up a catheterization lab and building a new team is a constant challenge. Nevertheless, our team of experts has managed to introduce the necessary equipment, and hospitals have set up catheterization labs. Over the years overcoming all the obstacles, our team has done over 1000 procedures, among which around 250 are coiling for ruptured/unruptured aneurysms and around 150 are mechanical thrombectomy procedures for large artery strokes. Slowly with time, new neuro-interventionalists are joining us with proper training, which has increased the number of procedures while decreasing the burden of stroke.


Besides the above-mentioned challenges in setting up the neuro-intervention capacity, there are additional systemic obstacles we faced. First of all, stroke treatment including neuro-intervention is time-dependent. So, the prehospital delay – the delay in time between the symptom onset to the arrival at point-of-care – is a significant barrier we face. Reasons for that include a low level of awareness about stroke treatment, lack of centralized ambulance services, difficult geographical terrain, poor roads, and unprecedented landslides in hilly regions. Moreover, often overlooked is the financial constraint, as most of the population is unable to afford the care. A typical mechanical thrombectomy procedure costs approximately 4500 USD. This is extremely expensive for the majority of the Nepali population in the absence of insurance services. Therefore, even if they present within the proper time window, chances are that the procedure will be deferred.


Neuro-interventional procedure in Biplane Catheterization Lab at Upendra Devkota Memorial-National Institute of Neurological and Allied Sciences, Bansbari, Kathmandu, Nepal.


Overall, I believe that starting a neuro-intervention facility is a big challenge in a low-resource setting like Nepal and an even bigger challenge for patients to afford the services. Such endeavors must be supported by the government. Although the setup cost is high, there are long-term savings in the timely treated stroke patients who can enjoy economic and social independence. These can be supplemented further by health education and training of healthcare workers for proper diagnosis, patient preparation, timely referral, and follow-up. To overcome these challenges, our team has a plan to form a foundation where a certain percentage of their salary is saved for people in need.



(A) Left internal carotid anterioposterior angiogram showed occlusion of proximal M1 MCA and branches. (B) Post Mechanical thrombectomy anterioposterior angiogram showed complete (TICI3) recanalization.


 



Dr. Subash Phuyal, MBBS, MD, DM is Nepal’s first neuro-interventional radiologist, who graduated from All India Institute of Medical Sciences, New Delhi, India. He started the first-ever mechanical thrombectomy program in Nepal in 2019 and was recognized for his work by the Nepal Stroke Association for this work. Currently, he is the head of the department of Interventional Neuroradiology at Upendra Devkota Memorial National Institute of Neurological and Allied Sciences (UDM NINAS) in Bansbari, Nepal. As a board member of the research committee at UDM NINAS, Dr. Phuyal has been actively engaged in research and has published over 50 research articles in peer-reviewed journals. One of his aspirations has been to generate awareness about stroke among the general public and he has been able to fulfill that promise by conducting seminars and workshops and being vocal about it on social media platforms.


Twitter: @dr_phuyal



Dr. Anisha Pandey, MBBS is a medical graduate from the Kist Medical College Teaching Hospital in Nepal, affiliated to Tribhuvan University in 2019. She works as a Medical Officer alongside Dr. Phuyal at Grande International Hospital and helps manage stroke cases in the Intensive Care Unit (ICU). She aspires to continue her career in the field of critical care medicine in the future. Throughout her journey, she has developed an interest in stroke care management and hopes to pursue this area of neurology in her future.




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