New cure for stroke, but prevention is key

* A 32-year-old female patient was suddenly unable to move one side of her body. She was rushed to Upendra Devkota Memorial National Institute of Neurological and Allied Sciences (Neuro Hospital) where doctors used a new non-invasive treatment to remove a clot that was obstructing the artery supplying blood to her brain. The patient’s mobility was immediately restored and she walked out of the hospital.

* A man in his mid-fifties arrived at Neuro hospital five hours after suffering a stroke. He underwent the 15-minute procedure after which he could move all of his limbs freely.

The strokes could have been fatal for both patients if they had not been rushed to hospital, and if the new state-of-the-art mechanical thrombectomy procedure was not available.

The prevalence of strokes in Nepal has increased 40% in the past decade, and more and more younger people are suffering the condition that could paralyse or kill them. 

Strokes are the third leading cause of premature deaths in Nepal, and ranks first for disabilities. A person somewhere in Nepal suffers a stroke every 20 seconds. 

Doctors say a changing lifestyle and dietary habits, including heavier drinking and smoking has led to an increase in hypertension, diabetes, high cholesterol — all precursors to strokes.

Recent studies have also reported that people infected with Covid-19 have an elevated risk of ischemic stroke, adding to the burden of disease. Other risk factors include aging, congenital heart diseases, hormonal changes and pregnancy. Women are comparatively more prone to suffering strokes.

Ischemic strokes account for 85% of all cases, where an artery supplying blood to the brain is blocked damaging it. Haemorrhagic stroke, on the other hand, occurs when blood from a ruptured artery collects in the brain.

“A stroke is a medical emergency, especially ischemic stroke which can lead to permanent disabilities and even death if it is not treated immediately,” says Subash Phuyal, Nepal’s first interventional neuro-radiologist at the Neuro Hospital in Bansbari.

In fact, speed is of the essence to save the life or prevent life-long paralysis of a patient. But patients in Nepal often are not aware of symptoms and get to hospitals too late, where the right treatment may not be available.

Unlike a heart attack, stroke patients do not feel any pain, making it difficult to identify it. Which is why doctors have come up with the acronym BE FAST (Balance, Eyes, Face drooping, Arm weakness, Slurred speech, and Time) to identify signs of stroke in time.

Patients usually experience a sudden problem with their sense of balance, have blurred vision, double vision or loss of sight in one or both eyes. There could be facial drooping, weakness or paralysis on one side of the body, and slurred speech.

If a patient gets to hospital within four hours of a stroke, they are immediately given a medicine to dissolve the blood clot obstructing the artery, restoring blood flow to the brain. This treatment is effective in only 10% of patients. 

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However, with mechanical thrombectomy, 90% of patients who get to hospital in time can be cured. A small incision is made in the thigh and catheters inserted using an imaging machine in the cath lab. 

The catheter travels along the major arteries until it retrieves the clot to allow the blood to flow again.

In the case of haemorrhagic stroke, surgery to clip the blood vessel is now replaced with a method called endovascular coiling in which the catheter inserts platinum coils to block the aneurysm.

This non-invasive mechanical thrombectomy was first devised in 2015, and it was already available at the Neuro Hospital in Kathmandu four years later. Its biplane cath lab has been treating up to 25 patients a month.

The hospital’s founder Upendra Devkota (see box) was determined to introduce the newly-developed endovascular treatment technology in Nepal, but did not live to see it save lives. He died of cancer in 2018. 

His wife Madhu Devkota completed the dream, and set up an interdisciplinary team for stroke patients. Neuro Hospital is also building a rehabilitation centre for recovering patients who often need physiotherapy.

But despite having the most advanced stroke treatment in Nepal, most people are not aware of the danger signs of a stroke. They also do not know that such non-surgical treatment is available in Kathmandu. It is also not widely known that such care is available in the country, and up to half the stroke patients at Neuro Hospital are brought too late for treatment.

Nepal’s topography adds to the problem of getting patients to hospital in time. Madhu Devkota suggests the government could provide an air ambulance facility, as it does for complicated maternity cases.

Says Subhash Phuyal: “People must know that strokes are preventable, and that advanced treatment is available right here in Nepal. But the most important thing is to get the patient to hospital as quickly as possible.” 

Visionary doctor

A young and talented doctor at Bir Hospital, Upendra Devkota, was sent on a scholarship to the Glasgow Neuroscience Institute in 1983 to train in neurosurgery. Under the guidance of the renowned Professor Graham Teasdale, Devkota proved himself among the best neurosurgeons in the world and had a bright career ahead of him in the UK.

But the Gurkha-native left all that behind to return to Nepal in 1989 to set up the country’s first Neurological Trauma Unit at Bir Hospital. He worked day and night, while also training young neurosurgeons with limited resources.

Devkota briefly served as the Health Minister under King Gyanendra in 2005, and a year later started setting up the National Institute of Neurological and Allied Sciences.

“Many tried to dissuade us, but despite challenges we were determined to set up an institution dedicated to preventing paralysis and disabilities in Nepal,” says Madhu Devkota. “My husband had foreseen the need for an advanced neurological centre in Nepal. So we thought, if not us, who would? So, we ran with it.”

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