Endovascular Management of Acute Ischaemic Stroke in Nepa

Comment
Endovascular management of acute ischaemic stroke in Nepal

Globally, acute ischaemic stroke is the leading cause of (with proximal middle cerebral artery occlusion in 14 of
disability. Disease burden is higher in low-income and 20 patients), and two patients had posterior circulation
middle-income countries (LMICs) than in high-income stroke (mid-basilar occlusion).
countries, with LMICs seeing 71% of stroke-related Most procedures were done under conscious sedation
deaths.1 Nepal is a low-income country with a per-capita (20 of 22 patients). We did a primary thrombectomy in
income of US$1034.2 Stroke is a major cause of death 13 cases and thrombectomy with bridging thrombolysis
and one of the top five causes of morbidity in Nepal, using intravenous alteplase in 9 cases. The mean
as measured by disability-adjusted life years (DALYs).3 duration of each procedure was 41 min (±23 min).
In high-income countries, mechanical thrombectomy Although two patients had subarachnoid haemorrhage
has revolutionised the management of acute ischaemic on the follow-up CT scan, none had developed a
stroke with large vessel occlusion.4 In Nepal, the symptomatic intracerebral haemorrhage. Overall, good
first mechanical thrombectomy programme was angiographic recanalisation was obtained in 20 patients
initiated in March, 2019, by a team led by a dedicated (modified thrombolysis in cerebral infarction scale
interventional neuroradiologist Dr Subash Phuyal at score of 2b or 3) and 17 patients had good functional
Grande International Hospital. In this Comment we independence at 3 months. Recanalisation success and
discuss our early insights into this programme. functional outcome were similar to those reported in
Based on initial radiological imaging studies (CT previous trials.4
angiography and MRI), 22 patients after an acute Mechanical thrombectomy is a potent intervention
ischemic stroke with large vessel occlusion underwent that improves stroke outcomes (number needed to
a mechanical thrombectomy. Of 22 patients, 9 patients treat [NNT] of 2·6 compared with NNT of 10–19 for
received bridging intravenous thrombolysis prior to thrombolysis),4,6 with the added potential of benefiting
the mechanical thrombectomy. Bridging intravenous patients who present too late for thrombolysis.
thrombolysis was done using alteplase in patients with Our initial insights indicate that thrombectomy is a
acute ischaemic stroke presenting within the time frame feasible and viable intervention to improve stroke
of 4·5 h. For patients presenting within 6 h of onset, outcomes, even in LMICs such as Nepal. However, we
thrombectomy was only done if there was no evidence carefully chose the patients who would benefit from
of pronounced ischaemia within the anterior circulation a thrombectomy and could afford the procedure.
(Alberta Stroke Program Early CT Score (ASPECTS) The study was an orchestrated and dedicated effort
of >6).5 In patients with wake-up stroke, posterior of a team comprising an experienced interventional
circulation stroke, or those presenting between 6 and neuroradiologist, neurologist, critical care physicians,
24 h after stroke onset, thrombectomy was done only anaesthesiologist, nurses, and support staff with round-
if a large penumbra was presumed (clinical-diffusion the-clock availability. All the interventions were done in
mismatch and MRI-based ASPECTS of >5). Stroke a well-equipped, single tertiary centre in Kathmandu.
severity was assessed using the National Institutes of The bigger challenge lies in replicating these
Health Stroke Scale. A non-contrast CT or MRI (diffusion- procedures and applying them to other centres across
weighted imaging and fluid-attenuated inversion the country. We foresee numerous obstacles that need
recovery) was promptly done, followed by vascular to be overcome to attain this ambitious goal. Awareness
imaging (CT or magnetic resonance angiography) to among the public and health-care workers remains poor.
assess the presence and site of the arterial occlusion. A Awareness campaigns in the community and in hospitals
CT scan was done immediately after the thrombectomy would help the patients seek health-care facilities on
and 24–48 h later. The clinical outcome was assessed at time. Ambulance availability remains inadequate and
discharge from hospital and at the 3-month follow-up, rudimentary, especially in rural areas. Geographical factors
with good functional independence being defined as a and frequent landslides limit the existing transport
modified Rankin Scale score of less than or equal to 2. system and add to the complexity of the problem.
Anterior circulation stroke was detected in 20 patients Emergency medical services that are adapted to the local
www.thelancet.com/lancetgh Vol 8 May 2020 e635

Comment
resources can help in early transportation of patients. Department of Neuroimaging and Interventional Radiology (SP, KD),
Department of Neurology (RP, VKR), Department of Neurosurgery (RBA, AT,
Trained experts and well-equipped hospitals are rare. The GS), Department of Critical Care Medicine (SPA), and Department of
local government needs to prioritise stroke management Orthopaedics (CRP), Grande International Hospital, Kathmandu, Nepal;
Department of Anaesthesiology, Tribhuvan University Teaching Hospital,
and collaborate with local neurological centres, experts, Kathmandu 44600, Nepal (GSS); Department of Neurology, Upendra Devkota
and dedicated international funding bodies to improve Memorial National Institute of Neurological and Allied Sciences, Kathmandu,
Nepal (LT); and Department of Neurology, Norvic International Hospital,
health care and strengthen local policies. Most patients Kathmandu, Nepal (PJ)
cannot afford a mechanical thrombectomy. Adequate 1 Feigin VL, Forouzanfar MH, Krishnamurthi R, et al. Global and regional
health insurance policies need to be created so that burden of stroke during 1990–2010: findings from the Global Burden of
Disease Study 2010. Lancet 2014; 383: 245–54.
this intervention becomes affordable to most patients. 2 The World Bank. GDP per capita (current US$) – Nepal. 2018. https://data.
worldbank.org/indicator/NY.GDP.PCAP.CD?locations=NP (accessed
Comprehensive stroke centres, with 24 h availability of all Feb 9, 2020).
stroke interventions, need to be linked with other stroke 3 Shaik MM, Loo KW, Gan SH. Burden of stroke in Nepal. Int J Stroke 2012;
7: 517–20.
centres by a well-defined system of communication and 4 Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy
patient transport. Resource-appropriate implementation after large-vessel ischaemic stroke: a meta-analysis of individual patient
data from five randomised trials. Lancet 2016; 387: 1723–31.
of so-called telestroke services (rapid online assessment 5 Pexman JH, Barber PA, Hill MD, et al. Use of the Alberta Stroke Program
networks to treat patients with stroke) can be helpful. Early CT Score (ASPECTS) for assessing CT scans in patients with acute
stroke. AJNR Am J Neuroradiol 2001; 22: 1534–42.
Also, the small number of experts needs to increase. With 6 Brunström M, Carlberg B. Thrombolysis in acute stroke. Lancet 2015;
all these approaches, expanding thrombectomy services 385: 1394–95.
7 McDermott M, Skolarus LE, Burke JF. A systematic review and meta-analysis
is feasible and achievable.7,8 of interventions to increase stroke thrombolysis. BMC Neuro 2019; 19: 86.
We declare no competing interests. 8 Nepal G, Yadav JK, Basnet B, Shrestha TM, Kharel G, Ojha R. Status of
prehospital delay and intravenous thrombolysis in the management of
Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open acute ischemic stroke in Nepal. BMC Neurol 2019; 19: 155.
Access article under the CC BY-NC-ND 4.0 license.
Subash Phuyal, Raju Poudel, *Gentle S Shrestha,

Kapil Dawadi, Vivek K Rauniyar, Lekhjung Thapa,
Rupendra B Adhikari, Amit Thapa, Gopal Sedain,
Subhash P Acharya, Pankaj Jalan, Chakra R Pandey
[email protected]
e636 www.thelancet.com/lancetgh Vol 8 May 2020

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Endovascular management of acute ischaemic stroke in Nepal

www.thelancet.com/lancetgh Vol 8 May 2020 e635

Subash Phuyal, Raju Poudel, *Gentle S Shrestha,

e636 www.thelancet.com/lancetgh Vol 8 May 2020

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