LAHORE GENERAL HOSPITAL

Department of Interventional Neuroradiology

On 23^rd December 2014, the Neuroradiology Department at Lahore General Hospital successfully treated two patients suffering from Ischemic stroke through mechanical thrombectomy. It was a major breakthrough as this was the first time such a procedure was performed in Pakistan. An Ischemic stroke occurs because of a loss of blood supply to parts of the brain leading to permanent disability and in many cases, death. Even though many countries are successfully performing mechanical thrombectomy, in Pakistan patients are only offered conventional treatment through medication leading to disability or death that in majority cases could have been prevented. International experience demonstrates that through mechanical thrombectomy, effects of an Ischemic stroke may be reversed and paralysis can be avoided.

The Neuroradiology Department at Lahore General Hospital has the required trained personnel and medical equipment to perform mechanical thrombectomyhowever the Department urgently needs the following to develop a Stroke Center:

1.     Disposable medical items
2.     Availability of anesthesia services throughout the week
3.     Availability of post care services
4.     Availability of medical staff for round the clock care

Stroke is the most common cause of disability and a leading cause of mortality worldwide. Even though the incidence of stroke is falling in developed countries, it is projected to increase enormously in Pakistan due to increasing risk factors associated with stroke.The proposed Stroke Center will be the first such center set up in Pakistan and would vastly improve the treatment, well-being and survival rate of stroke patients in the country.
                                            BACKGROUND
Lahore General Hospital (LGH) is renowned for its Neurological services. The first and only dedicated Neuroradiology Department was developed as an integral part of the Neurosurgery in 1970. By 1994, the Nueroradiology Department at LGH was declared as a separate and autonomous specialty. In 2000, through the efforts of the Department�s own personnel, the Neuroradiology Department evolved from a diagnostic facility to a treatment facility offering neuroendovascular treatment and spinal intervention. By 2010, the treatment facilities were expanded to include neuroendovascular treatment for aneurysm (coiling), AVM and Dural AVF (embolization) that in the last four years alone has saved 600 lives.

EXISTING FACILITIES
�        5 trained doctors
�        6para-medical staff
�        Latest and only Bi plane Neuro-Angio Machine in Pakistan
�        MRI, Carotid Doppler and 2 CT Scans  

ACHIEVEMENTS

Today the Neuroradiology Department functions as a diagnostic and treatment center for blood vessel diseases in the brain and spine including head and neck. Since 1990, the Department has diagnosed over three hundred thousand patients. After evolving into a treatment center in 2000, it has treated over fifteen hundred patients through different treatment facilities that have been added over the years.

STROKE CENTER

 Due to the increasing incidence of patients suffering from stroke, a letter dated September 2008 (Annex I& II) was issued to develop a state of the art Stroke Center within the department.However as that did not lead to any tangible results, the personnel of the department made every effort to receive international training and experience in mechanical thrombectomy.On 23^rd December 2014 a team of professionals led by the Head of the Neuroradiology Department, Dr. Umair Rashid and assisted by local and international experts successfully performed the first mechanical thrombectomy on two patients in Pakistan. (Annex III)

 Building on this success, it is proposed that a Stroke Center located in the Neuroradiology Department, LGH be set up to cater to patients suffering from strokes. The Stroke Center will give patients the opportunity to avoid paralysis and disability that are caused as a direct result of strokes.

REQUIREMENTS FOR THE STROKE CENTER

 1.      Disposable medical items

To perform mechanical thrombectomy at the proposed Stroke Center, disposable medical equipment including catheters, micro-wire, stents and other small medical appliances will be required.

 2.      Availability of Anesthesia services throughout the week

Currently the Neuroradiology department at LGH has access to anesthesia services only once a week causing significant delays in the treatment of the patients. Due to the nature of strokes, timely intervention ranging from 8-24 hours will be critical for successful treatment thus making it absolutely essential that anesthesia services be made available throughout the week.

 3.      Availability of Post Care Services

The current treatments being offered by the Neuroradiology Department do not require aggressive post-care services however for patients with strokes, it will be essential to develop intensive post-care services. It is being proposed that at least 5 facilities for post-care services be set up next to the Angio Suite

 4.      New Staff comprising 3 Doctors, 5 nurses and 2 Angio technicians

The Stroke Center will require 3 doctors (related to Neuroradiology), 5 nurses with ICU and Angio experience and 3 Angio technicians to ensure that round the clock services are offered to the patients.

ADVANTAGES OF THE PROPOSED STROKE CENTER

• Patient care will vastly improve by significantly reducing the chances of continued paralysis, disability and death

• It will serve as the first and only Stroke Center in Pakistan 

• It will offer an internationally recognized form of treatment previously unavailable to patients in Pakistan 

• Through Post Graduate training facilities, it will train other medical professionals in neurointervention 

• It may be affiliated with international societies and centers in the field of Neuroradiology  

• No significant financial investmentin machines and/or training is required.
  
  
                      6th Neurointervention and Therapeutic Workshop

  17 - 22 December 2014

  In Collaboration with

  Alexandria University School of Medicine, Egypt, Lahore General Hospital, Post Graduate Medical Institute, Lahore-Pakistan, Neuroradiology Section PPRC, Radiological Society of Pakistan

   In a major medical breakthrough for Pakistan, the first catheter-based treatment of ischemic stroke was performed last night at Lahore General Hospital, Lahore.

  A multinational team of specialized neurointerventional physicians was assemble by Dr. Umair Rashid Chaudhry, a Lahore based neurointerventionalist. Dr. Umair�s local team included Dr. ShahzadBhatti, Major Dr. JahanzebLiaqat, Neuropsychician, Military Hospital Rawalpindi and assisted by Dr. Hamid, Dr. Saima and Dr. Atif. International Neurointerventional experts included Dr. OssamaYassin Mansour from Alexandria, Egypt and Dr. HasnainHaider Shah, from Dubai UAE. The team was also assisted by Residents, House Officers and Medical Officers at Lahore General Hospital, Lahore.

  The team was assembled for five days in order to wait for an emergency case of Stroke paralysis that would present in time for emergency mechanical thrombectomy. This is similar to a heart attack where an artery gets blocked, the brain arteries can also become blocked and need to be treated within 6 hours from the start of the �Brain Attack�.

  Last night a 60 years retired army professional was brought to CMH Lahore and his left side of his body was nearly completely paralyzed.  The team quickly moved into action and in less than 4 hours from presentation patient was brought from emergency room to neuroangiography room, Lahore General Hospital.

  In less than 1 hour the team was able to successful placed a very specialized stent retriever (Covidien solitaire FR), which is a clot capture device. If one is able to remove the clot from the main artery the flow in the brain is restored and neurological function will improve i.e. paralysis can improve.

  The clot was partially removed from the patient and flow in the artery was reestablished and the patient started to move the left side of his body more and he regained his strength.

  On the 4^th day of the workshop 2^nd patient FaqeerHussain 55 years old was brought in a critical state to emergency department Lahore General Hospital. He was found to have a Glasgow Coma Score of 4/15 which is a considered to be very severe. He was completely paralysed of all four limbs with breathing difficulty. After initial stabilization at emergency, he was rushed to neurosurgical department of LGH and was found to have complete obstruction of basilar artery with thrombus extending to both post cerebral arteries. He underwent thrombectomy with Penumbra ACE Clot Extraction Device and clot was removed with successful recanalization and establishment of flow.

  The patient is currently admitted to intensive care unit of LGH and recovering from this dreadful attack of paralyzing stroke.

  This emergency clot removal for paralyzing stroke is performed very frequently is USA & Western Europe for over 10 years. In more recent year the treatment has become available in Middle East and India.

  Dr. Umair Rashid Chaudhry when asked about the implication of this treatment. He said �with the right government and private support patients and their families now will no longer to face life long paralysis after stroke, because treatment options are now available in Pakistan�.  Dr. Chaudhry stressed, �now the country needs to establish multiple stroke centres in major cities of Pakistan, since stroke is 2^nd highest cause of mortality in Pakistan and number one cause of life long disability�.
  
   

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