Stroke epidemiology and outcomes of stroke patients in Nepal: a systematic review and meta-analysis.

BACKGROUND: With an increasing burden of stroke, it is essential to minimize the incidence of stroke and improve stroke care by emphasizing areas that bring out the maximum impact. The care situation remains unclear in the absence of a national stroke care registry and a lack of structured hospital-based data monitoring. We conducted this systematic review and meta-analysis to assess the status of stroke care in Nepal and identify areas that need dedicated improvement in stroke care. METHODS: A systematic literature review was conducted to identify all studies on stroke epidemiology or stroke care published between 2000 and 2020 in Nepal. Data analysis was done with Statistical Package for Social Sciences (SPSS) and Comprehensive Meta-analysis (CMA-3). RESULTS: We identified 2533 studies after database searching, and 55 were included in quantitative and narrative synthesis. All analyses were done in tertiary care settings in densely populated central parts of Nepal. Ischemic stroke was more frequent (70.87%) than hemorrhagic (26.79%), and the mean age of stroke patients was 62,9 years. Mortality occurred in 16.9% (13-21.7%), thrombolysis was performed in 2.39% of patients, and no studies described thrombectomy or stroke unit care. CONCLUSION: The provision of stroke care in Nepal needs to catch up to international standards, and our systematic review demonstrated the need to improve access to quality stroke care. Dedicated studies on establishing stroke care units, prevention, rehabilitation, and studies on lower levels of care or remote regions are required.

Prevalence of Stroke and Stroke Risk Factors in a South-Western Community of Nepal.

BACKGROUND: Stroke related studies in Nepal are primarily hospital-based and mainly from the capital city. OBJECTIVES: We aimed to estimate the prevalence of stroke and stroke risk factors in the South-Western community of Nepal. METHODS: A cross-sectional study was conducted from May to August 2018 among 549 randomly selected Nepalese participants from diverse ethnicity, aged ≥15 years, in a region with the availability of neurological support facilities. Data were collected using a stroke questionnaire designed for the purpose. Stroke was identified by enumerators using the Balance-Eyes-Face-Arms-Speech-Time (BEFAST) scale, and a senior neurologist confirmed it. We assessed the presence of major risk factors associated with stroke. RESULTS: The crude and age-standardised prevalence of stroke were 2368 and 2967 per 100,000 respectively. Of all the surveyed participants, 61% (n=335) reported consumption of full-fat dairy products >3 days per week, 87.6% (n=481) reported a high intake of salt (>5 g/day), 83.6% (n=459) with a low intake of fruits and vegetables (<400 g/day), 45.2% (n=248) with perceived stress related to work or home, 51.6% (n=283) with financial stress (283, 51.6%), 86.7% (n=457) with low high-density lipoprotein, 96.2% (n=507) with high blood urea nitrogen, 47.1% (n=356) were either overweight or obese 20.4% (n=112) with hypertension and 6.2% (n=34) with diabetes. CONCLUSIONS: The prevalence of stroke in the community of the South-Western part of Nepal is relatively higher than that estimated in South-Asia and global context. Our findings suggest an urgent community intervention, particularly with healthy lifestyles changes for future stroke prevention in the high-risk group.

Recurrent severe secondary haemorrhage due to facial artery pseudoaneurysm following styloidectomy via tonsillectomy approach: A case report.

A 41-year-old female who underwent right-sided styloidectomy via tonsillectomy approach experienced refractory short-lasting severe secondary haemorrhage on the third, seventh and thirteen postoperative days. On examination under general anaesthesia, no major vessel injury was noticed. Contrast-enhanced computerized tomography scan of the neck was done because no obvious bleeder was seen and refractory nature of bleeding. Contrast-enhanced computerized tomography scan neck showed pseudoaneurysm of facial artery which was managed with endovascular embolization successfully.

Direct carotid cavernous fistula treated with transvenous approach: a case report.

Introduction: Carotid cavernous fistulas are uncommon vascular abnormalities marked by anomalous connections between the carotid artery and the cavernous sinus. The authors present a case of a direct carotid cavernous fistula and its successful treatment in a 42-year-old female. Case presentation: A 42-year-old female presented with right eye painful swelling and visual disturbance. She had no known comorbidities or history of injury. Examination showed proptosis, chemosis, and orbital bruit. Carotid angiography confirmed a carotid cavernous fistula, which was managed endovascularly. The patient fully recovered after treatment. Discussion: Carotid cavernous fistula occurs spontaneously or as a result of trauma or other vascular abnormalities. Common clinical manifestations include proptosis, chemosis, and orbital bruit, with vision loss being a feared complication. Diagnosis is typically confirmed through angiography, with digital subtraction angiography being the gold standard. Endovascular treatment is usually effective, although surgical management may be necessary in certain cases. Conclusion: Carotid cavernous fistula is a rare but potentially sight-threatening neurological condition. Treatment with a transvenous approach is effective for the management of direct carotid cavernous fistula.

Endovascular management of residual intracranial aneurysm after neurosurgical clipping: a case report.

Introduction and importance: Endovascular coiling can be used to treat residual intracranial aneurysms with prior neurosurgical clipping in aneurysmal subarachnoid haemorrhage. Aneurysmal subarachnoid haemorrhage is a rare subtype of stroke which can be life-threatening. Case presentation: The authors herein report a case of successful management by endovascular coiling of residual intracranial aneurysm post-surgical clipping in a 60-year-old male who was previously diagnosed as diffuse subarachnoid haemorrhage (SAH) Fisher grade 4. On examination, he had a Glasgow Coma Scale 14/15 with verbal confusion present and was hypertensive. Clinical discussion: Aneurysmal subarachnoid haemorrhage is a rare and serious type of stroke and may result in dependency. Endovascular coiling can be used to treat residual intracranial aneurysms with prior neurosurgical clipping. It further helps in decreasing dependency and mortality. Conclusion: Endovascular coiling is a good treatment option for patients who have undergone neurosurgical clipping as their prior surgical attempt in aneurysmal subarachnoid haemorrhage. An endovascular approach may further lead to a better prognosis.

Sequential mechanical thrombectomies in acute bilateral middle cerebral artery strokes: A case report and review of literature.

Simultaneous occlusion of both middle cerebral arteries (MCAs) is very rare and usually devastating. Few case reports are available in the literature where bilateral thrombectomy was done simultaneously to remove the clot. High NIH stroke scale with a low level of consciousness can be a clue for the diagnosis. Timely intervention is necessary to decrease morbidity and mortality in these patients. We also reviewed the existing literature where mechanical thrombectomies were done for bilateral MCA stroke in PubMed, Google Scholar, Cochrane, and Embase. Herein, we report a case of 47-year-old female having rheumatic heart disease presented with simultaneous bilateral MCAs occlusion, treated with mechanical thrombectomies successfully.

Radiological Features and Management of Intracranial Aneurysms Associated With Moyamoya Disease: A Case Series of Single-Center Experience.

Background Moyamoya disease (MMD) can be a major cause of hemorrhagic stroke. Though extensive angiographic studies have been undertaken, the understanding of the association between aneurysms and MMD remains unanswered. In this study, we explore the association of the aneurysm with MMD and its management. We have also reviewed such associations described in the literature and how the present cases differ from those previously described. Materials and methods The clinical and radiologic data of moyamoya disease cases were accessed from medical and radiological records between January 2010 and July 2017. Two neuroradiologists independently analyzed the data and imaging details. Results Out of 103 patients with MMD, eight patients (7.77%) had associated intracranial aneurysms with eleven aneurysms. Out of the 11 aneurysms, five were the tip of the basilar artery aneurysms and were the most common location for aneurysm (45.5%), followed by lenticulostriate artery, PCA perforator, and distal ACA (DACA) in the P1 PCA, P2 PCA, and P3 PCA artery aneurysms. Out of eight patients, five (62.5%) had a hemorrhage on a non-contrast computed tomography (NCCT) scan of the brain, whereas three (37.5%) had an ischemic presentation. Out of 11 aneurysms, seven aneurysms, including three basilar tip aneurysms (unruptured) and one PCA perforator (ruptured), and three saccular PCA (P1, P2, and P3) (ruptured) were treated by endovascular coiling. Follow-up angiography showed stable aneurysmal occlusion except in one basilar tip, where recurrence was observed. Conclusions MMD-intracranial aneurysm is commonly observed in patients with intracranial hemorrhage and carries a higher risk of rupture. Therefore, identification of the aneurysm is essential for management. Endovascular treatment, either with coil or glue embolization, can be a safe and effective treatment method for such aneurysms with long-term good results.

Middle meningeal artery embolization for chronic subdural hematoma refractory to Burr hole surgery: A case report.

Middle meningeal artery embolization is a valuable alternative for chronic subdural hematoma refractory to Burr hole surgery. In a 61-year-old patient, this endovascular intervention effectively resolved the hematoma alleviating associated symptoms.

"Shelf Technique" in braided stent (Leo Baby) in wide-necked intracranial aneurysm.

A 42-year-old female presented with sudden onset severe headache without loss of consciousness 4 days back. Non-contrast computed tomography scan of the brain showed subarachnoid hemorrhage, and angiography showed a wide-necked aneurysm in the right middle cerebral artery (MCA) bifurcation, incorporating the superior division of right M2 MCA and another small aneurysm in the inferior division of right M2 MCA. Because of the wide-necked ruptured aneurysm and another in the inferior division of right M2 MCA, braided stent-assisted coiling (Leo baby) with shelving was done to protect both the aneurysms and to protect the superior branch of M2 MCA. The patient tolerated the procedure well and had an uneventful recovery. In this report, we have also reviewed and discussed the challenges, advantages, and disadvantages of the newly discovered shelving technique with a braided stent for wide-necked bifurcation aneurysms.

Rare case of duplicated middle cerebral artery and acute ischaemic stroke managed successfully with mechanical thrombectomy.

A man in his early 80s presented with acute onset aphasia and right-sided weakness with an NIH Stroke Scale (NIHSS) of 17. He was last seen normal 9 hours before the presentation. MRI of the brain showed acute infarcts in the left caudate, lentiform nucleus and corona radiata. MRI angiogram (MRA) revealed an occluded left main middle cerebral artery (MCA) and an associated ipsilateral patent duplicated middle cerebral artery (DMCA). Mechanical thrombectomy (MT) was performed, and he was discharged with an NIHSS of 8. In this report, we review and discuss the challenges during the intervention of MCA occlusion in the presence of duplicated MCA, a rare anomaly.

Initial Results of a Direct Aspiration First-Pass Technique to Treat Acute Ischemic Stroke Patients in Nepal.

Objective Endovascular therapy has become the mainstay of treatment of acute ischemic stroke (AIS) due to large vessel occlusion. A direct aspiration first-pass technique (ADAPT) using large bore aspiration catheters has been introduced as a rapid, simple method for achieving good revascularization and good clinical outcomes. The aim of this study was to assess the safety and efficacy of ADAPT in the treatment of AIS due to large-vessel occlusion in the Nepali patient population. Materials and Methods Retrospective data were collected for all consecutive patients treated for AIS with ADAPT from March 2019 through January 2021 at two hospitals. Outcomes were successful revascularization (modified thrombolysis in cerebral infarction score of 2b-3), time to revascularization, procedural complications, and good clinical outcome (modified Rankin Scale score of 0 to 2) and mortality at 90 days. Statistical Analysis Retrospective data were collected and descriptive statistics were calculated. Results Sixty-eight patients treated for AIS with ADAPT were included. The median National Institutes of Health Stroke Scale score at presentation was 13 (IQR 10-13.25). The median time from arterial puncture to revascularization was 40 minutes (IQR 30-45). Successful revascularization was achieved in 54 patients (79.4%). No cases of symptomatic intracranial hemorrhage occurred. At 90-day follow-up, good clinical outcome was achieved in 57 patients (83.8%), and 4 patients died (5.9%). Conclusion A direct aspiration first pass technique appears to be a fast, simple, safe, and effective method for the management of AIS in the Nepali patient population.

Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes syndrome: a case report from Nepal.

Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like syndrome (MELAS) is a rare neurodegenerative inherited disorder that is characterized by stroke-like episodes, seizures, endocrine, and multiple system involvement. It is important to consider it as a differential diagnosis in a young patient with stroke-like episodes as it is progressive and has multiple complications. Case presentation: A 28-year-old male presented with slurring of speech and drowsiness for 7 h. He was a diagnosed case of type 2 diabetes mellitus, Wolf-Parkinson-White syndrome, and bilateral hearing loss. Clinical findings and investigations: The patient had expressive aphasia with impaired fluency, repetition, and naming. After being discharged, he represented with loss of consciousness and involuntary movements of the whole body. MRI and MRS showed extension of hyperintense lesions to parieto-occipital regions from temporal regions not limited by vascular territories. MELAS was considered, which was confirmed by molecular genetic analysis. Coenzyme Q10 was used for MELAS. Insulin, Linagliptin, and levetiracetam were used for diabetes and seizures. Regular follow-up was advised to the patient.MELAS is an important syndrome to consider in any young patient presenting with unexplained stroke disorders. A high index of suspicion is needed in an appropriate clinical setting to avoid misdiagnosis.

Post-traumatic Pseudoaneurysm of the Internal Carotid Artery with Intractable Epistaxis: A Case Report.

Epistaxis is a common otorhinolaryngology emergency. There are several treatment modalities for epistaxis, but bleeding from the internal carotid artery necessitates a particular treatment technique. We report a case of a 22-years old man who presented to us recurrent episodes of epistaxis and blurry vision in the right eye for one month. The patient had undergone maxillo-facial surgery following a road traffic accident one year back. Bleeding episodes were occasionally severe with blood loss of up to 800 to 1000ml. These episodes were managed conservatively with posterior nasal packing and frequent blood transfusions. A computed tomography-angiography revealed a pseudoaneurysm arising from the cavernous segment of the right internal carotid artery which was managed successfully by embolization of the aneurysm sac with coils. Despite the rarity of internal carotid artery pseudoaneurysm in individuals with a history of trauma, doctors must be aware of the possibility. Timely identification and treatment of a pseudoaneurysm can save a person's life.

Twin to Twin Transfusion Syndrome: A Case Report.

Twin-twin transfusion syndrome occurs in multiple gestations and involves a chronic flow of blood from one twin to another twin and is a rare entity. We present a case of 32-years-old primigravida with a twin pregnancy who presented with increasing abdominal girth inappropriate with her gestational age at 21 weeks of her pregnancy. Ultrasound findings were suggestive of twin-twin transfusion syndrome. The patient was provided with treatment options but due to polyhydramnios and short cervix, the patient went into spontaneous labour the same day with a poor pregnancy outcome. Twin-twin transfusion syndrome leads to a high rate of perinatal morbidity due to its poorly understood aetiology and difficulty in diagnosing and treatment. Early diagnosis during antenatal ultrasound is important in reducing morbidity and mortality rates. Keywords: case reports; fetoscopy; oligohydramnios; polyhydramnios; twins.

Role of Artificial Intelligence in Unruptured Intracranial Aneurysm: An Overview.

Intracranial aneurysms (IAs) are a significant public health concern. In populations without comorbidity and a mean age of 50 years, their prevalence is up to 3.2%. An efficient method for identifying subjects at high risk of an IA is warranted to provide adequate radiological screening guidelines and effectively allocate medical resources. Artificial intelligence (AI) has received worldwide attention for its impressive performance in image-based tasks. It can serve as an adjunct to physicians in clinical settings, improving diagnostic accuracy while reducing physicians' workload. AI can perform tasks such as pattern recognition, object identification, and problem resolution with human-like intelligence. Based on the data collected for training, AI can assist in decisions in a semi-autonomous manner. Similarly, AI can identify a likely diagnosis and also, select a suitable treatment based on health records or imaging data without any explicit programming (instruction set). Aneurysm rupture prediction is the holy grail of prediction modeling. AI can significantly improve rupture prediction, saving lives and limbs in the process. Nowadays, deep learning (DL) has shown significant potential in accurately detecting lesions on medical imaging and has reached, or perhaps surpassed, an expert-level of diagnosis. This is the first step to accurately diagnose UIAs with increased computational radiomicis. This will not only allow diagnosis but also suggest a treatment course. In the future, we will see an increasing role of AI in both the diagnosis and management of IAs.

Clinico-Radiological Profile of Patients With Lateral Medullary Syndrome: A Five Years Observation From a Single-Centered Tertiary Hospital in Nepal.

OBJECTIVE: We aim to correlate the prevalence of symptoms of the lateral medullary syndrome (LMS) based on radiological classification. METHODS: A five-year record of 41 patients diagnosed with LMS and admitted to a tertiary care center in Nepal was reviewed. We used chi-square tests to compare symptoms between rostral and caudal groups and different horizontal subtypes. RESULTS: The subtype prevalence in the horizontal classification of LMS was large (31.7%), lateral (22%), dorsal (19.5%), typical (14.6%), and ventral (12.2%). The most common symptoms in the typical subtype of the horizontal classification were: pain/temperature loss in the contralateral body (7.3%) and dysphagia (7.3%); in the ventral subtype, swaying on the Romberg test (12.2%), dysarthria (9.8%) and dizziness (9.8%); in the dorsal subtype, headache (12.2%) and vomiting (12.2%). Whereas headache (22.2%) and lateropulsion on standing (14.6%), swaying on the Romberg test (14.6%), nausea/vomiting (14.6%) were common in the large subtype, and nausea/vomiting (19.5%) and headache (17.1%) in the lateral subtypes. Whereas, in rostrocaudal classification, the rostral subtype (61%) was more common than the caudal subtype (31%). There was no significant variation in symptoms based on the rostrocaudal classification of LMS. CONCLUSION: The common clinical manifestations are different for different radiological subtypes of LMS. Further comprehensive studies are essential to understand the prevalence of symptoms in different radiological subtypes and the clinical-radiologic correlation in LMS.

The association of transradial access and transfemoral access with procedural outcomes in acute ischemic stroke patients receiving endovascular thrombectomy: A meta-analysis.

OBJECTIVE: There is an ongoing debate regarding the benefits of using transradial access (TRA) over transfemoral access (TFA) in endovascular therapies including endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) patients. This study sought to investigate the association of TRA and TFA with procedural success, access-site complications, first-pass reperfusion (FPR), puncture-to-recanalisation (PTR) time and hemorrhagic transformation (HT) by performing a meta-analysis. MATERIALS AND METHODS: PubMed, EMBASE and Scopus were searched. Studies with patients aged ≥ 18 years and head-to-head TRA vs TFA comparisons were included. Random-effects modeling was performed to obtain summary effects and forest plots were plotted to study the association of TFA with access site complications, FPR, HT, PTR time and procedural success. RESULTS: Six studies encompassing 945 patients (347 TRA and 598 TFA) were included in the meta-analysis. Meta-analysis revealed that in AIS patients receiving EVT, TRA was significantly associated with a decreased risk of access-site complications (RR 0.17, 95% CI 0.05 0.54; p = 0.003, z = -2.957) and HT (RR 0.07, 95% CI 0.02 0.27; p < 0.0001, z = -3.8841). However, TRA was not significantly associated with procedural success (RR 0.96, 95% CI 0.90 1.01; p = 0.141, z = -1.473), FPR (RR 0.91, 95% CI 0.79 1.05; p = 0.194, z = -1.299) and PTR time (SMD -0.14, 95% CI -0.42 -0.14; p = 0.323, z = -0.989). CONCLUSION: Our meta-analysis demonstrated that TRA is a safe alternative to TFA, in AIS patients receiving EVT, with significantly decreased access-site complications and HT with TRA, albeit with comparable procedural success, FPR and PTR time to TFA. DATA AVAILABILITY STATEMENT: The original contributions presented in the study are included in the article/Supplementary information, further inquiries can be directed to the corresponding author.

Safety and efficacy of endovascular thrombectomy in patients with severe cerebral venous thrombosis: A meta-analysis.

Background: Cerebral venous thrombosis (CVT) is a rare thrombotic condition which is traditionally treated with anti-coagulation therapy. Subsets of patients with severe CVT have been treated with endovascular thrombectomy (EVT). Despite the high estimated mortality associated with severe CVT, there has been only one randomized control trial done regarding safety and efficacy of EVT in severe CVT compared to standard medical management. Evidence in this area is lacking. Objective: The aim of this systematic review is to analyze all existing literature and generate robust information regarding the role of EVT in the management of patients with severe CVT. Methods: This systematic review and meta-analysis followed PRISMA guideline. PubMed, Embase, Google Scholar, and CNKI were searched for eligible studies from 2007 to 2021. Safety and efficacy of EVT were evaluated by meta-analyzing recanalization status, the good functional outcome at follow-up, recurrent CVT, new hematoma. A pooled proportion with a 95% confidence interval was derived from a meta-analysis of various outcomes (CI). Results: A total of 33 studies comprising 610 patients treated with EVT were included for analysis which comprised one randomized control trial, one prospective study and 31 retrospective studies. Based on pooled data, 85% of patients had good functional outcome, 62% had complete recanalization, 5% had all-cause mortality, and 3% had catheter related complications. The efficacy outcomes in this analysis had a significant heterogeneity and a subgroup analysis was also done to explain these findings. The minimum time of follow up was 3 months and varied EVT techniques were used across the studies. Conclusion: This meta-analysis suggests EVT may be safe and efficacious in treating patients with severe CVT. Registration: Our protocol was registered with PROSPERO: International prospective register of systematic reviews with the registration number CRD42021254760.

Relationship of size of corpus callosum with white matter changes in elderly population; A retrospective analytical cross-sectional study.

Purpose: To study the relationship of size of corpus callosum with white matter changes in the elderly population. Materials and methods: This was a retrospective analytical cross-sectional study. The relationship between the corpus callosum and white matter changes was studied using the magnetic resonance imaging technique, where white matter changes were graded based on Fazekas grading. The Spearman rank order correlation was used to assess the relationship between the size of corpus callosum and white matter changes. Results: The whole corpus callosum (ρ = 0.165, p = 0.044) and rostrum (ρ = -0.232, p = 0.004) was significantly correlated with white matter changes based on Fazekas severity grading. Similarly, in bivariate regression analysis, white matter changes were strongly correlated with rostrum (standardized ß-coefficient = -0.186, p = 0.023). While taking gender in sub-group analysis, white matter changes were significantly correlated with rostrum (ρ = -0.252, p = 0.021) and splenium (ρ = -0.229, p = 0.036) in male and with rostrum (ρ = -0.245, p = 0.048) only in female groups. Conclusions: Corpus callosum size is associated with white matter changes in the elderly population. This association can give insight into the neuropathology of diseases involving the central nervous system.

Middle cerebral artery occlusion due to cardiac tissue following catheter ablation in Wolff-Parkinson-White syndrome.

Catheter ablation is a commonly performed procedure in patients with Wolff-Parkinson-White syndrome. A 56-year-old man developed an acute ischemic stroke immediately after undergoing radiofrequency catheter ablation of the left-sided accessory pathway. Neuroimaging revealed complete occlusion of the proximal middle cerebral artery. Mechanical thrombectomy (MT) was performed with successful retrieval of the thrombo-embolus. Histopathological examination of the thrombo-embolus confirmed organic cardiac tissue. The patient was later discharged from the hospital with no neurologic deficit. There is no report of successful MT in patients with large-vessel occlusion because of the embolization of cardiac tissue after catheter ablation. This report highlights the need to remain vigilant for signs of stroke after any cardiac intervention.