Stroke is not only the third leading cause of death with 10% of all deaths in Nepal but is also associated with a drastic reduction in quality of life. With Nepal lacking a national register of stroke data, estimating the incidence rate is challenging. However, based on stroke incidence in Low and Middle Income Countries (LMIC), it is estimated that there are roughly 117 stroke cases per 100,000 persons annually in Nepal, equating to around 33,000 individuals suffering from stroke each year.
Stroke, an acute disease of the brain, is caused by an interruption of the blood supply in the brain supporting vessels and without an immediate restore of blood support leading to an irreversible damage of brain tissue. Most strokes are ischemic caused by a blood clot in the brain supporting vessels (ischemic stroke), still approximately one third of all strokes in Nepal are caused by a bleeding (hemorrhagic stroke).
While strokes were an incurable disease many years ago, in recent years several therapeutic options for acute treatment and secondary prevention have been developed. Acute therapeutic strategies for ischemic stroke are aiming to restore the blood flow in the brain vessels by dissolving the blood clot (thrombolytic therapy or Intravenous thrombolysis or IVT) or mechanical removal of the blood clot in an angiography (endovascular therapy or endovascular treatment or EVT). While EVT is offered only at a few tertiary care centers, IVT is being administered safely in many secondary health centers worldwide.
A recent systematic review on the status of stroke care in Nepal showed that only 55 studies conducted in Nepal within the last 20 years have analyzed stroke outcomes or aspects of care. This indicates a lack of comprehensive understanding of stroke care in the country. Geographic and demographic differences further pose a difficulty in evaluating the national care status. Studies predominantly focus on densely populated regions in central Nepal with better health infrastructures, potentially overestimating the level of stroke care. One of our goals is to allocate resources for high-quality research and access to publication in international journals to enhance understanding of stroke care in Nepal.
Stroke is a preventable disease as many of the vascular risk factors for stroke can be modified by healthy lifestyle or medication. The most common risk factors in South Asia are high systolic blood pressure, high cholesterol, diet low in fruits and vegetables, household air pollution and smoking. The high prevalence of preventable risk factors among stroke patients indicates the need for more awareness in the population and effective prevention strategies targeting modifiable risk factors.
The backbone of any acute stroke treatment, either ischemic or hemorrhagic, is to treat stroke patients by an expert team for stroke care (so called stroke unit care) which is proven to be superior in reducing stroke associated complications and preventing recurrent stroke. Nowadays, an acute stroke can be treated effectively and safely with systemic thrombolysis in clinical routine within the first 4.5 hours after onset. However, the overall absence of stroke units and low rates of thrombolysis (below 2.5%) highlight the lack of organized stroke care in Nepal, which is crucial for improving outcomes. The Nepal Stroke project is working on establishing dedicated stroke units and improving access to thrombolysis and other acute therapies to enhance patient outcomes.
Additionally, the mean age of stroke onset in Nepal is 62.4 years, which is younger than the global average [63.1 in low middle income country (LMIC) vs. 68.6 in high-income countries (HIC)], which might be attributed to limited stroke care quality and accessibility.
Outcomes often depend on rapid recognition of symptoms, rapid transport to a trained hospital, and rapid diagnosis and therapy there. Even outside this narrow time window, clarification of the cause of the stroke and initiation of targeted secondary prevention is essential. The unavailability of stroke units is all the more detrimental because the long-term outcome of stroke can be significantly improved by preventing complications and recurrent stroke, which usually happens in a stroke unit. Common post-stroke infections, such as pneumonia and urinary tract infections which affect 18.8% and 7% of patients, contribute to extended hospital stays. Stroke recurrence is common, emphasizing the need for preventive measures and long-term care strategies.
Timely access to emergency care is one of the most relevant aspects in acute stroke treatment, as preclinical delays impede the chance of successful recanalization. A major barrier to rapid presentation at a stroke center is the lack of awareness and knowledge of stroke symptoms and of the time window for acute treatment options.
If you want to know more about the situation of stroke care in Nepal, we recommend the following scientific overview: