Endovascular management of acute ischaemic stroke in Nepal

Globally, acute ischaemic stroke is the leading cause of disability. Disease burden is higher in low-income and middle-income countries (LMICs) than in high-income countries, with LMICs seeing 71% of stroke-related deaths.1Feigin VL Forouzanfar MH Krishnamurthi R et al.Global and regional burden of stroke during 1990–2010: findings from the Global Burden of Disease Study 2010.Lancet. 2014; 383: 245-254Summary Full Text Full Text PDF PubMed Scopus (2635) Google Scholar Nepal is a low-income country with a per-capita income of US$1034.2The World BankGDP per capita (current US$) – Nepal.https://data.worldbank.org/indicator/NY.GDP.PCAP.CD?locations=NPDate: 2018Date accessed: February 9, 2020Google Scholar Stroke is a major cause of death and one of the top five causes of morbidity in Nepal, as measured by disability-adjusted life years (DALYs).3Shaik MM Loo KW Gan SH Burden of stroke in Nepal.Int J Stroke. 2012; 7: 517-520Crossref PubMed Scopus (15) Google Scholar In high-income countries, mechanical thrombectomy has revolutionised the management of acute ischaemic stroke with large vessel occlusion.4Goyal M Menon BK van Zwam WH et al.Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials.Lancet. 2016; 387: 1723-1731Summary Full Text Full Text PDF PubMed Scopus (3955) Google Scholar In Nepal, the first mechanical thrombectomy programme was initiated in March, 2019, by a team led by a dedicated interventional neuroradiologist Dr Subash Phuyal at Grande International Hospital. In this Comment we discuss our early insights into this programme. Based on initial radiological imaging studies (CT angiography and MRI), 22 patients after an acute ischemic stroke with large vessel occlusion underwent a mechanical thrombectomy. Of 22 patients, 9 patients received bridging intravenous thrombolysis prior to the mechanical thrombectomy. Bridging intravenous thrombolysis was done using alteplase in patients with acute ischaemic stroke presenting within the time frame of 4·5 h. For patients presenting within 6 h of onset, thrombectomy was only done if there was no evidence of pronounced ischaemia within the anterior circulation (Alberta Stroke Program Early CT Score (ASPECTS) of >6).5Pexman JH Barber PA Hill MD et al.Use of the Alberta Stroke Program Early CT Score (ASPECTS) for assessing CT scans in patients with acute stroke.AJNR Am J Neuroradiol. 2001; 22: 1534-1542PubMed Google Scholar In patients with wake-up stroke, posterior circulation stroke, or those presenting between 6 and 24 h after stroke onset, thrombectomy was done only if a large penumbra was presumed (clinical-diffusion mismatch and MRI-based ASPECTS of >5). Stroke severity was assessed using the National Institutes of Health Stroke Scale. A non-contrast CT or MRI (diffusion-weighted imaging and fluid-attenuated inversion recovery) was promptly done, followed by vascular imaging (CT or magnetic resonance angiography) to assess the presence and site of the arterial occlusion. A CT scan was done immediately after the thrombectomy and 24–48 h later. The clinical outcome was assessed at discharge from hospital and at the 3-month follow-up, with good functional independence being defined as a modified Rankin Scale score of less than or equal to 2. Anterior circulation stroke was detected in 20 patients (with proximal middle cerebral artery occlusion in 14 of 20 patients), and two patients had posterior circulation stroke (mid-basilar occlusion). Most procedures were done under conscious sedation (20 of 22 patients). We did a primary thrombectomy in 13 cases and thrombectomy with bridging thrombolysis using intravenous alteplase in 9 cases. The mean duration of each procedure was 41 min (±23 min). Although two patients had subarachnoid haemorrhage on the follow-up CT scan, none had developed a symptomatic intracerebral haemorrhage. Overall, good angiographic recanalisation was obtained in 20 patients (modified thrombolysis in cerebral infarction scale score of 2b or 3) and 17 patients had good functional independence at 3 months. Recanalisation success and functional outcome were similar to those reported in previous trials.4Goyal M Menon BK van Zwam WH et al.Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials.Lancet. 2016; 387: 1723-1731Summary Full Text Full Text PDF PubMed Scopus (3955) Google Scholar Mechanical thrombectomy is a potent intervention that improves stroke outcomes (number needed to treat [NNT] of 2·6 compared with NNT of 10–19 for thrombolysis),4Goyal M Menon BK van Zwam WH et al.Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials.Lancet. 2016; 387: 1723-1731Summary Full Text Full Text PDF PubMed Scopus (3955) Google Scholar, 6Brunström M Carlberg B Thrombolysis in acute stroke.Lancet. 2015; 385: 1394-1395Summary Full Text Full Text PDF PubMed Scopus (10) Google Scholar with the added potential of benefiting patients who present too late for thrombolysis. Our initial insights indicate that thrombectomy is a feasible and viable intervention to improve stroke outcomes, even in LMICs such as Nepal. However, we carefully chose the patients who would benefit from a thrombectomy and could afford the procedure. The study was an orchestrated and dedicated effort of a team comprising an experienced interventional neuroradiologist, neurologist, critical care physicians, anaesthesiologist, nurses, and support staff with round-the-clock availability. All the interventions were done in a well-equipped, single tertiary centre in Kathmandu. The bigger challenge lies in replicating these procedures and applying them to other centres across the country. We foresee numerous obstacles that need to be overcome to attain this ambitious goal. Awareness among the public and health-care workers remains poor. Awareness campaigns in the community and in hospitals would help the patients seek health-care facilities on time. Ambulance availability remains inadequate and rudimentary, especially in rural areas. Geographical factors and frequent landslides limit the existing transport system and add to the complexity of the problem. Emergency medical services that are adapted to the local resources can help in early transportation of patients. Trained experts and well-equipped hospitals are rare. The local government needs to prioritise stroke management and collaborate with local neurological centres, experts, and dedicated international funding bodies to improve health care and strengthen local policies. Most patients cannot afford a mechanical thrombectomy. Adequate health insurance policies need to be created so that this intervention becomes affordable to most patients. Comprehensive stroke centres, with 24 h availability of all stroke interventions, need to be linked with other stroke centres by a well-defined system of communication and patient transport. Resource-appropriate implementation of so-called telestroke services (rapid online assessment networks to treat patients with stroke) can be helpful. Also, the small number of experts needs to increase. With all these approaches, expanding thrombectomy services is feasible and achievable.7McDermott M Skolarus LE Burke JF A systematic review and meta-analysis of interventions to increase stroke thrombolysis.BMC Neuro. 2019; 19: 86Crossref Scopus (21) Google Scholar, 8Nepal G Yadav JK Basnet B Shrestha TM Kharel G Ojha R Status of prehospital delay and intravenous thrombolysis in the management of acute ischemic stroke in Nepal.BMC Neurol. 2019; 19: 155Crossref PubMed Scopus (23) Google Scholar We declare no competing interests.

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