The Dawn of a New Era Neurointervention

With the advent of neurointervention services in Nepal, we are able to provide the most advanced endovascular treatment for the ailments of the blood vessels of brain without having to open the skull. This has revolutionized the treatment of the two common, yet life-threatening, neurological conditions—aneurysms and strokes.

Before surgery, Kaushila with a giant aneurysm. After Neurointervention treatment having fully recovered.

An aneurysm happens when the wall of the blood vessel inside the depth of the brain becomes weak. This results in the formation of small sacs in the artery that has a very high risk of rupture. Earlier, the only treatment available for an aneurysm was an arduous brain surgery—drilling of the skull to cut it open, retracting the brain to reach its depths, and operating on the blood vessels using a microscope. With the availability of advanced neurointervention services, this life-threatening condition is treated by inserting a fine catheter from one’s thigh. The catheter is negotiated carefully through the arteries of the body, and into the delicate vessels of the brain to treat the aneurysm through coiling. Multiple research trials and subsequent follow-up studies have established coiling of the cerebral aneurysm as the standard of care, as the length of hospital stay as well the risk of complications, is lower. One such trial, the International Subarachnoid Trial (ISAT) completed in 2002 showed that trans-luminal coiling had a better treatment outcome than open surgery.

Kaushila Rana, 79, from Parbat district, had been suffering from headache, which was slowly beginning to affect her vision. As her children lived abroad, she had no support within her immediate family. Her nephew eventually offered help and took her around several hospitals. However, she was left without a diagnosis or treatment. Finally, they ended up at UDM- NINAS where her condition was diagnosed. She had a giant aneurysm, which was pressing on the nerve of her eyelid. Our team was able to treat her condition in the cathlab with the most advanced flow diversion stent, relieving her of headache as well as restoring her vision.

Similarly, the second condition, stroke, is a medical emergency that is sometimes also called a brain attack. It occurs when blood vessels in the brain become narrowed or clogged with fatty deposits called plaque (ischemic stroke) or when a blood vessel in the brain bursts (hemorrhagic stroke). In either case, blood flow to the brain is cut off, leading to damage or death of the brain cells. Once brain cells die, they generally do not regenerate, and devastating damage may occur, resulting in physical, cognitive, and mental disabilities. It is reported that approximately two million brain cells die every minute till the blood flow to the brain is restored. It is crucial, therefore, that proper blood flow and oxygen supply to the brain be restored as soon as possible.

Things must move quickly once the patient with stroke arrives at the hospital. The emergency doctors determine what type of stroke the patient has with the help of an advanced scan soon after arrival. There are only two modalities to treat ischemic stroke. If the patient arrives at the hospital within four-and-a-half hours of the onset of symptoms, thrombolysis is performed, where intravenous medications are used to dissolve the blood clot. Nonetheless, ‘time is brain’, and every effort must be made to reduce the time delay. If the patient arrives later, mechanical thrombectomy is the only treatment option available. In this procedure, the patient is taken to the cathlab and a micro-catheter negotiated from the femoral artery till it reaches the offending blood clot obstructing the major artery in the brain. The clot is carefully retrieved and pulled outside the body. This re-establishes the blood flow, reverting the paralysis, and giving patients a second lease on life. It is crucial that the signs of stroke are recognized and the patient is brought to the hospital without wasting any time.

The above pictures show the blocked artery, the removed offending blood clot, and the re-established blood circulation in the brain.

More than 11 million ischemic strokes occur worldwide each year, of which more than half occur in low- and middle-income countries. Globally, stroke is the second-leading cause of death and the third-leading cause of death and disability combined. In Nepal, stroke accounts for nearly 9.46 % of the total deaths. It is estimated that 50,000 people are afflicted, and 15,000 people die from stroke annually. Stroke is particularly dangerous in developing countries like Nepal, where there is a general lack of awareness about the condition, coupled with the paucity of services and the availability of expertise.

Mechanical thrombectomy was not offered at any hospital in Nepal up to the year 2018, because of the absence of trained personnel. To address the ever-increasing problem, dedicated complete neurointervention care was started in 2019 in Nepal.

Dr. Subash Phuyal, Nepal’s first fully trained neurointerventionalist—a doctor who has specialized in radiology and has had further training for three years in neurointervention—performed the first successful mechanical thrombectomy. Over time, more advanced equipment like the BiPlane cathlab has been made available, allowing for complex and advanced neurointervention procedures to be performed.

Although the incidence of ischemic stroke increases with age, an estimated 10 to 20 % of these events occur in younger people who are 18 to 50 years of age. Recent publications report an increasing incidence of stroke in young adults. Compared with stroke in older people, stroke in the young has a disproportionately large economic impact, as it leaves the victims disabled during their most productive years.

Sushma Ghale, on the right, represents the above group. This 25-year-old housewife from Dhading presented at the emergency department of our hospital. She had lost her ability to speak or move the right half of her body for the last three hours. An immediate brain scan showed the occlusion of a large blood vessel in the brain. She was rushed to the cathlab and a mechanical thrombectomy was performed. Our team was able to successfully retrieve the clot, and she was transferred to the ICU for recovery. Upon examination the following morning, she was conscious and had regained strength in her limbs and her speech. She was discharged a few days later having no neurological deficits.

This is Sushma, two days after mechanical thrombectomy. She would have remained paralyzed for the rest of her life had the neurointervention services not been available.
Neurointervention team at Upendra Devkota Memorial National Institute of Neurological and Allied Sciences, Neuro Hospital Bansbari, Kathmandu.

 

 

 

It is, therefore, of utmost importance to create awareness not only about the treatment options, but also for the prevention of stroke.

 

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