Medicosnext
Currently, in Nepal, a biplane cath lab machine is only available at Upendra Devkota Memorial National Institute of Neurological and Allied Sciences, and Dr. Subash Phuyal, Head of Intervention Neuro-radiology and Diagnostics, is the first post DM in Nepal trained to perform neurointervention procedures.
Photo Courtesy: Upendra Devkota Memorial National Institute of Neurological and Allied Sciences (hospital has taken patient’s permission for the coverage)
Toran Prasad Pandit, a 30-year-old architect diagnosed with an aneurysm in his brain, was given two options for his treatment. One was to have his cranium surgically opened and have a clip placed on his aneurysm. The second was to have a platinum coil sent to his brain through an artery in his thigh, which would then fill in the aneurysm. He chose option two. Four days after his procedure, he walked back home, healthy as ever. His one eye, which was almost completely shut due to his neurological condition, went back to normal.
Three years ago, Toran would either have had to opt for option one and get a brain surgery, or he would have had to travel to India for the neurointervention procedure. However, in 2021, he was able to get the procedure done in Nepal at the Upendra Devkota Memorial National Institute of Neurological and Allied Sciences.
Neurointervention is a subspeciality that uses minimally invasive techniques in order to treat diseases of the brain, including stroke, aneurysm, etc. There are different issues related to blood vessels in the brain, such as stroke, which is a blockage in the blood vessel in the brain; aneurysm, which is a bulging out of the wall of the blood vessel; brain hemorrhage, which occurs when the blood vessels burst; and arteriovenous malformation, which is when the blood vessels form an abnormal tangle in the brain. “Through the use of the endovascular technique, which is a minimally invasive procedure, these conditions can be treated effectively. Instead of opening up the skull and surgically operating on the brain, we take a blood vessel of 2-3 mm in the thigh, send a wire through the blood vessel up to the brain, and clear blocked vessels, fill aneurysms, and stitch torn blood vessels,” says Dr. Subash Phuyal, Head of Intervention Neuro-radiology and Diagnostics at Upendra Devkota Memorial National Institute of Neurological and Allied Sciences.
“The gold standard for this procedure is the biplane cath lab, which makes neurointervention very easy. The machine shows the affected areas from many different angles during the procedure and makes this procedure easy to perform,” he adds. Currently, in Nepal, this machine is only available at Upendra Devkota Memorial National Institute of Neurological and Allied Sciences, and Dr. Phuyal is the only radiologist in Nepal trained to use the biplane cath lab to perform neurointervention procedures.
This procedure has been available in India since 2015, and was introduced in Nepal in 2019. “When I was working in India, people from Nepal used to travel there to get these procedures done. However, it is now available in Nepal itself, so Nepalis no longer have to travel abroad for such medical interventions,” states Dr. Phuyal, who trained in India for over seven years before returning to Nepal. “We’ve been able to help over 600 patients, who would have had to otherwise travel abroad to treat their medical condition.”
As per the international standards, this procedure has less than 5% complication rate. More than 95% of patients have been helped without any complication. “Because it is a minimally invasive procedure, it does not require a large cut or opening. So, the risk of infection is minimized. Patients don’t need to stay in the ICU for long. We can discharge them after five to seven days of recovery. They are able to walk, talk, and function like before.” In case of elderly patients, the minimally invasive technology is especially helpful, as less invasion means they can recover easily and return home without complications occurring.
“Medical science is developing rapidly and introducing new technology and procedures that make medical intervention less complicated for the patients. Previously, they used to open up a patient to remove the gallbladder. Now, it is done through laparoscopy by creating a small hole for the procedure, thereby reducing the risk to the patient. Similarly, neurointervention is a new technology that considers the burden and suffering of the patient and helps cure the neurological conditions through a minimally invasive procedure that requires little risk to the patient and takes comparatively very little recovery time,” he adds.
This technology has been a long time coming. Prof. Dr. Madhu Dixit Devkota, Executive Chairperson at the Upendra Devkota Memorial National Institute, mentions that her husband, the late Dr. Upendra Devkota, had been planning to bring this technology to Nepal before his unfortunate death in 2018. Dr. Upendra Devkota, the founder of this institute was the first neurosurgeon for Nepal, trained in the most prestigious institutes in the UK. He set this institution to provide comprehensive care for neurological and allied conditions under one roof with a focus on timely advancement of its armamentarium for ensuring quality of care. He did all the homework necessary to bring in this technology for Nepal before his untimely death.“I was doing my homework and exploring what machine to bring, when I found out the blueprint of the biplane cath lab on his desk. He had done the entire homework, and had even decided which machine to buy, and from which company to buy it from. After that, the decision-making was easy. The biplane cath lab was brought in and became operational in March of 2019,” she says.
“This machine—this technology—is the first in the country. Even in other developed countries, this technology is not readily available. It is very, very, advanced. My daughter is studying in the UK, and the hospital she is studying in does not have this technology yet. But, we do, here in Nepal,” she adds.
This technology can be used in many different neurological conditions, including stroke, brain hemorrhage, aneurysm, etc. Timely intervention in these conditions is essential to prevent death or permanent life-long impacts. Through the use of neurointervention, using the biplane cath lab, patients can be operated on with minimal risks and become healthy again.
One important thing Dr. Phuyal insists on is the need for immediate intervention in case of stroke. “When people get a heart attack, they feel pain, so they seek immediate medical attention. But, patients do not feel pain when they get a stroke. Instead, they become paralyzed on one side. They become unable to walk, talk, and have problems with vision. In such cases, the patient does not go to the hospital immediately. They take their time, which is not good. In case of a stroke, the time window for intervention is very small. If the blockage in the blood vessels in the brain is removed within six hours, or in some cases 24 hours, we can reverse the paralysis and other symptoms.”
In order to know if someone has had a stroke, an international acronym has been created—BE FAST. It stands for Balance, Eyes, Facial deviation, Arms and legs, Speech, and Time. If someone is having issues with balance, their vision becomes blurry, there is a noticeable facial deviation, their arms or legs feel weak, and their speech becomes slurred, it is a clear sign of stroke. In any of these cases, time is of the essence. Immediate neurointervention is necessary.
To treat a stroke through neurointervention, a wire is sent to the brain through an artery in the thigh, and the blockage is removed to resume normal blood flow to the brain. This immediate intervention can help the patient get back to normal and prevent long-term effects like paralysis, vision loss, etc. In the case of stroke patients, Dr. Phuyal uses the phrase, “Time is brain”, to highlight the need for immediate neurointervention for stroke patients.
To add to his case, Dr. Madhu mentions a case of a 34-year-old man who was brought to her hospital. “He was a healthy, fit young man who was cycling on his mountain bike in Tokha. All of a sudden, his uncle gets a phone call. He tells his uncle that he fainted and is lying somewhere on the ground. He doesn’t know where he is or how he got there. His uncle had the presence of mind to tell him to scream for help. He did so, and some passersby rescued him and took him to a hospital. Eventually, he ended up here at our hospital at six in the evening. He had an occluded artery in his brain. A part of his brain was not getting any blood and was starting to die. The doctor removed the clot in his brain, and the young man walked home on day three.”
Neurointervention has been life-changing for many patients of Dr. Phuyal. He mentions a patient who had been paralyzed and unable to speak or walk. After the procedure, he was able to walk again, talk again, and even went back to his previous job at a 5-star hotel in Kathmandu. “He understood the burden of his disease. His paralysis would have made him not only unable to work and function normally, he would have required a full-time caregiver to take care of him. After having the procedure, patients tend to understand how not having that disease burden positively impacts their life.” The patient still keeps in touch with Dr. Phuyal.
This new technology and neurointervention procedure done with the cath lab also seems unbelievable to many of his patients and their loved ones. “I’ve had amazing responses from the patients. Because we don’t open up the brain for these procedures, patients have reported that when they returned to their villages, their relatives and neighbors refused to believe that they had their brain operated on, because there is no head wound to show a brain operation,” he says. “How can you have brain surgery without opening up your skull? It’s like magic!” was a regular response that his patients got from their loved ones.
The doctor highlights the need for awareness among the general public, and among the medical community, about the availability of these procedures in Nepal. “Many, even among the medical community, are unaware that this technology has been introduced here. So, as a result, many patients still go abroad for these procedures,” he says. “If we can provide high quality medical intervention here, it can help many Nepalis and prevent them from having to spend a lot of money to travel abroad for these procedures.”
