Medicosnext
Dr. Pukar Singh Pakhrin
He is a consultant neurologist currently working in the Department of Neurology at UDM-NINAS. His areas of interest include headache and pain, stroke, epilepsy and neuromuscular disorders. He has numerous papers published in international journals as well as national health magazines including an article titled “Prevention of stroke” in an earlier issue of Medicosnext. Apart from being an astute neurophysician, he is a vocalist and lead guitarist of the official musical band of UDM-NINAS “Mastiska” and has performed at various concerts and musical events. The author would like to thank Dr. Chirayu Regmi (Resident, Department of Neurology) for his insights and contribution to the article.
Stroke, a sudden disruption of blood flow to the brain, has been a devastating human affliction for millennia. Our understanding and ability to combat it have undergone a revolutionary transformation, particularly in the last 50 years, shifting from helpless observation to targeted, life-saving interventions. This journey, however, is not uniform across the globe. In our country, which is marked by a rugged geography and limited resources, the fight against stroke is a story of resilience, incremental progress, and persistent inequities. This article traces the remarkable evolution of stroke diagnosis and management, from ancient misconceptions to modern precision medicine, with a focus on Nepal’s unique challenges and innovations.
Ancient Origins and Early Misconceptions
The history of stroke begins with Hippocrates (c. 400 BC), who coined the term “apoplexy” (meaning “struck down with violence”) to describe the sudden paralysis characteristic of stroke. He attributed it vaguely to an accumulation of humors. Galen (c. 200 AD) further described apoplexy but still lacked understanding of its vascular nature. It wasn’t until Johann Jacob Wepfer (1620–1695) conducted autopsies and identified cerebral hemorrhage and arterial blockages as causes of apoplexy that the vascular origins of stroke were recognized. Yet, for centuries, stroke remained a clinical diagnosis, with treatment limited to supportive care and rudimentary rehabilitation.
In Nepal, stroke care mirrored this historical trajectory but with added complexity. Traditional healers and basic clinical assessments were the norm, with little distinction between ischemic and hemorrhagic strokes. Care was fragmented, and advanced neurology services were confined to Kathmandu, leaving rural populations underserved.
The Imaging Revolution: A Global Leap, A Nepali Delay
The advent of imaging technologies revolutionized stroke diagnosis globally. Sir Godfrey Hounsfield’s invention of the computed tomography (CT) scanner in 1972 allowed for rapid differentiation between ischemic and hemorrhagic strokes, a critical step for treatment decisions. By the late 1970s, CT was widely used in hospitals worldwide. Magnetic resonance imaging (MRI), pioneered in the 1970s and refined with diffusion-weighted imaging (DWI) in the 1990s, further enhanced the ability to detect early ischemic changes and identify salvageable brain tissue.
In Nepal, however, the imaging revolution arrived decades later. The first CT scanner was installed at Bir Hospital in Kathmandu in 1988, and by 2025, although many CT scanning services are available, they are mostly concentrated in urban hubs like Kathmandu, Pokhara, and Biratnagar. Rural and mountainous regions often lack access entirely, leading to diagnostic delays of over 24 hours. MRI technology, first introduced at Tribhuvan University Teaching Hospital (TUTH) in 2000, remains relatively scarce, almost all in only major cities. Advanced techniques like DWI and perfusion imaging are rarely available outside Kathmandu, perpetuating disparities in stroke care.
The Dawn of Acute Reperfusion Therapies: Global Milestones, Nepali Adaptations
The ability to visualize stroke pathology paved the way for targeted treatments. In 1995, the NINDS rt-PA Stroke Study demonstrated that intravenous thrombolysis with Alteplase (tPA) within three hours of the onset of ischemic stroke significantly improved outcomes, leading to its FDA approval in 1996. The treatment window later expanded to 4.5 hours. Mechanical thrombectomy, revolutionized by stent retrievers in 2015, has become the standard of care for large vessel occlusions (LVOs), with treatment windows extending up to 24 hours using advanced imaging.
Nepal’s journey with these therapies is one of delayed adoption and persistent barriers. Intravenous tPA for stroke was first administered in Nepal in 2012 by Prof Devkota, a neurosurgeon himself. Its use however, remains limited. Most patients present beyond the treatment window, and the cost of tPA (approximately NPR 60,000–100,000) is prohibitive for many. Mechanical thrombectomy, introduced at select centers in Kathmandu around 2018–2019, is performed sporadically, with fewer than 200 procedures annually nationwide. The cost (NPR 800,000–1,200,000) and the scarcity of trained neurointerventionalists (fewer than 10 nationwide) further restrict access.
Current State of Stroke Care: A Tale of Two Realities
Globally, modern stroke management is a highly coordinated, time-sensitive endeavour. Public awareness campaigns like BEFAST (Balance, Eyes, Face, Arms, Speech, Time), rapid emergency medical services (EMS) triage, and designated stroke centers ensure swift diagnosis and treatment. Advanced imaging, including CT angiography (CTA) and MR DWI, guides decisions on thrombolysis and thrombectomy. Comprehensive stroke centers and telestroke networks provide 24/7 access to specialized care, while early rehabilitation and aggressive secondary prevention are cornerstones of recovery.
In Nepal, however, stroke care is a tale of two realities. In urban hubs, CT is the first-line diagnostic tool, with CTA and CTP available in select centers. Yet, in rural areas, clinical diagnosis predominates, and patients may travel hours for a CT scan. Thrombolysis is administered in about 10 hospitals, primarily in Kathmandu and Pokhara, but fewer than 5% of ischemic stroke patients receive it. Thrombectomy is rare, and rehabilitation services are underdeveloped. Systemic innovations, such as the Nepal Stroke Project’s 2019 clinical guidelines and training workshops for thrombolysis, offer hope, but geographic barriers, resource shortages, and financial burdens continue to hinder progress.
There is however, hope in the innovation and technological strides, that the country is making. The first Hyper Acute Stroke Unit was established in the country at UDM-NINAS in 2019. With the installation of the Bi-plane Catheterisation Lab, MRI based protocol driven care available round the clock, strides in rehabilitation services are making comprehensive stroke services possible. Additional stroke units at Bir Hospital, TUTH, and Patan Hospital, and pilot telestroke program are extending expertise to rural areas.
Future Directions: Tailoring Solutions to Nepal’s Context
Nepal’s fight against stroke demands solutions tailored to its unique challenges:
– Prehospital Systems: Training community health workers and EMS on stroke recognition is critical.
– Hub-and-Spoke Networks: Strengthening referral pathways from rural districts to stroke-ready centers can reduce delays.
– Affordable Innovation: Exploring low-dose tPA protocols and negotiating cost reductions for advanced therapies are essential.
– Rehabilitation: Community-based rehabilitation using local resources can bridge gaps in care.
– Policy Reforms: Including stroke drugs and procedures in national insurance and investing in preventive care are vital steps.
Conclusion
The evolution of stroke care, from the ancient despair of “apoplexy” to today’s precision medicine, is a testament to scientific progress. Globally, imaging revolutions and reperfusion therapies have transformed outcomes, but in Nepal, these advancements are tempered by geographic, financial, and systemic barriers. Yet, the nation’s journey is one of resilience. Incremental progress—through guidelines, training, and stroke units—offers hope for a future where life-saving stroke care transcends the Kathmandu Valley and reaches Nepal’s most vulnerable. The path forward lies in Nepali-tailored solutions, leveraging community networks, telemedicine, and policy reforms to ensure equitable access to care.
