Stroke burden has significantly increased in the past decade, particularly in low and middle-income countries, accounting for over 85% of stroke-related morbidity and mortality globally. Pakistan is the fifth most populous country in the world. However, the epidemiological data regarding stroke is sparse. A cross-sectional integrated population health survey found a high prevalence of 1.2% stroke per annum, with patients younger than their Western counterparts, leading to increased functional disability and economic losses. Yet, fewer than 200 neurologists share the burden of this rising epidemic, and only a handful of centers are capable of Intravenous thrombolysis (IVT) and Mechanical Thrombectomy (MT).
The history of neurointervention in Pakistan is fairly new. In the year 2000, a radiologist in Pakistan began performing myelography and direct puncture carotid angiography in one of the top public hospitals in Lahore. However, it was not until 2015 when international faculty members Prof Ossama Mansour and Dr. Husnain Haider Shah performed the country's first mechanical thrombectomy. The College of Physicians and Surgeons Pakistan (CPSP), the leading government healthcare center responsible for medical development in Pakistan, does not have a fellowship program for neuro-intervention. Pakistani foreign healthcare specialists and neuro-interventional societies; Middle East North Africa Stroke & Interventional Neurotherapies Organization (MENA-SINO) Society, MT 2020 – Stroke: Vascular and Interventional Neurology (SVIN) and The European Society of Minimally Invasive Neurological Therapy (ESMINT) Society all have played significant roles in the development of this specialty in Pakistan.
Since 2015, the MENA-SINO society has been a vital element in the development of neuro intervention in Pakistan, including yearly neuro intervention workshops with foreign faculties. The goal is to bring all specialties and stakeholders together under one roof. It is a comprehensive stroke and neuro-intervention workshop that includes live patients in the angiography suite as well as case-based discussions. Faculties throughout the country, including neurologists, neurosurgeons, radiologists, medical physicians, and staff members, attend these seminars and build an international network while learning. Under the umbrella of MENA-SINO, its remote fellowship program is also structured in collaboration with Alexandria University Egypt. Doctors enrolled are taught the fundamentals of angiography and stroke intervention. This partnership can assist in sharing Pakistan's massive neuro-intervention burden by providing advanced training.
Prof. Adnan Siddiqui is the Director of the Neuroendovascular Fellowship program at the University at Buffalo, New York. In 2017, he conducted a live workshop on two flow diverter cases which were the first cases done Pakistan. It was an extended workshop with vigorous discussions and case scenarios. His visit gave way to new corridors for newcomers in the field. Since 2017, many Pakistani physicians have visited him in Buffalo for observer-ship and he has been distantly mentoring many Pakistani neuro-interventionalists. Remote mentoring is being done through WhatsApp groups and case-based discussions. During this period, Prof. Adnan helped lay the foundational ideas for Neurointervention training programs and fellowships with special emphasis on developing parts of the world. Due to his efforts, the first Stroke Centre was established in the country, and not only has he trained the Chair of the department but he also initiated a training program in the same center.
ESMINT has started diplomas in stroke intervention and neuro intervention. The neuro intervention diploma is a ray of hope to many who work in South Asian countries where fellowship programs are not available. In 2022-2023, there were 7 candidates from Pakistan attending the European Diploma in Ischemic Stroke Intervention (EDSI) course. The EDSI certification gives basic knowledge about anatomy and tools to learn advanced neurointervention. Virtual fellowship and distant mentorship programs are part of this process and breakthrough educational structure offered by ESMINT. Prof Ashfaq Shuaib, Dr. Taimoor, and Dr. Farid Suri are the coordinators of the Association of Physicians of Pakistani Descent of North America (APPNA) organization, which launched a nine-month-long online stroke fellowship program three years ago. Under the umbrella of APPNA MERIT, almost 30 graduates are already trained and working at different places in Pakistan.
MT 2020+ is an effort of SVIN, a global movement to provide access to mechanical thrombectomy regardless of resources or geography. In 2019, Pakistan became a member of MT 2020+. We have accomplished incredible things under the auspices of MT2020, the most important of which is to bring all stakeholders, specialties, and health-related government authorities under one roof. MT 2020 has given a platform for the launch of a national MT campaign encompassing all four provinces. Our list now includes stroke coordinators from all four provinces who operate independently through this platform. Many ground-breaking efforts were made, including frequent MT workshops in various regions of the country, including remote locations to familiarize doctors and patients with MT. Local training programs range from distant locations to large hubs where neuro-intervention is done. We've won platinum medals, and this relationship is one of the best things that has ever happened to our community.
Personal efforts of a few Pakistanis working at prestigious medical centers in the United States have done an outstanding job in changing the neuro-intervention landscape in Pakistan. Dr Fazal Zaidi affiliated with MT2020, is a US regional liaison. In his capacity working at the University of Toledo, he along with Dr. Hisham Sallahudin became members of the international visiting faculty in stroke centers; they frequently visit Pakistan to perform complex neuroendovascular procedures. Both of them have started online proctorships through audio-visual systems to help to do live stroke cases, due to their efforts they have successfully launched the biggest Stroke Intervention program in one of the hospitals in Pakistan where all stroke services are provided free of charge. I feel the future of neuro intervention is bright in Pakistan and as more people train, they will help play a significant role in the fight against the rising burden of stroke. While we still have a lot to improve in the interventional neurology space, we hope that our successes can inspire other neurologists in developing countries on ways to train and improve stroke care for their patients.
About the Authors:
Saima Ahmad:
Dr. Saima Ahmad MBBS, DMRD, MSc, EDSI is Pakistan’s first female neuro-interventional
radiologist who has graduated from Fatimah Jinnah Medical University. She started her
efforts towards developing an acute stroke care program in 2019 and is recognized by many
national and international stroke societies for her work. As a board member of the MENA-
SINO Society and MT2020, she is actively engaged in research, and webinars and published
over 50 publications. One of her biggest aspirations is to develop neuro-interventional facilities in low-resource settings and stroke programs in LMICs.
Dileep Yavagal:
Dr. Dileep R. Yavagal is the Chief of Endovascular Division, Director of Interventional
Neurology and Co-Director of Neuroendovascular Surgery and Clinical Professor of
Neurology and Neurosurgery at the University of Miami & Jackson Memorial Hospitals. He
is also the Director of NeuroStem Cell Division at the Interdisciplinary Stem Cell Institute.
Dr. Yavagal is an international thought leader in endovascular therapy for ischemic and
hemorrhagic stroke.
Fazal Zaidi:
Dr. Fazal Zaidi is an Associate Professor of Neurology at the University of Toledo and
Director Interventional Neurology Service at ProMedica Toledo Hospital. He is also Director
Neurology Network at ProMedica Neuroscience.