While thrombectomy is a cost effective intervention for stroke, India is not doing enough of these procedures: study

In India, strokes caused 6,99,000 deaths in 2019, which was 7.4% of the total deaths in the country. Photograph used for representational purposes only
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The first prospective Indian registry on mechanical thrombectomy for stroke, which studied 200 stroke patients in 14 centres across the country, has reaffirmed that the treatment is cost effective, with excellent functional outcomes for patients.

“Since 2015, endovascular thrombectomy has been accepted as the life-saving and most cost effective treatment for acute ischemic stroke, especially in patients with large vessel occlusion. We have seen that mechanical thrombectomy gives excellent outcomes for over 50% of the patients. However, the procedure remains under-utilised in the Indian context because of various challenges,” said P.N. Sylaja, professor of neurology, who is also in charge of the Comprehensive Stroke Programme at Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananathapuram.

Data from the Indian Prospective Registry for Assessment of Acute Ischemic Stroke Patients Treated with Neurothrombectomy Devices in India (PRAAN) registry was presented at the 16th World Stroke Congress last month by Dr. Sylaja and Jeyaraj Pandian, professor and head of Neurology, Christian Medical College (CMC), Ludhiana.

Stroke are the leading cause of death and disability worldwide. As of 2019, strokes affected over 101 million people worldwide and caused over 6.55 million deaths. In India, strokes caused 6,99,000 deaths in 2019, which was 7.4% of the total deaths in the country.

The PRAAN registry was set up mainly to study the functional outcomes associated with thrombectomy treatment in Indian patients with large vessel occlusion acute ischaemic stroke. Between August 2021 and October 2023, 200 patients were enrlled at 14 sites—of which 190 patients with an average age of just under 60 years met the eligibility criteria for the procedure.

The scenario in India

In India, about 30% of patients who end up in hospitals with acute ischemic stroke have blockages in main vessels and usually present with increased severity. Intravenous thrombolysis or administration of alteplase, a recombinant tPA (tissue-type plasminogen activator) to dissolve the clot alone will not help such patients, because the drug can dissolve only clots less than 10 mm in size. Also, the narrow time window after stroke onset within which the drug has to be administered, limits its effectiveness.

Endovascular thrombectomy or mechanical thrombectomy, a minimally invasive procedure, wherein an interventional neuroradiologist uses specialised equipment to remove the clot from the artery, can lead to dramatic improvement in stroke patients with large vessel occlusions. There is an eligibility criteria for patients who can benefit from mechanical thrombectomy, and this procedure may be done in tandem with intravenous tPA, if necessary.

Challenges remain

India has an incidence rate of 120-145 per one lakh population when it comes to strokes.

“Given the current incidence of stroke in India, we should be doing at least 2 lakh thrombectomies a year. But currently, we are not doing more than 2,000-3,000 procedures annually because we do not have an adequate number of neuro cath labs in the country or interventional neuroradiologists,” Dr. Sylaja pointed out.

It does not help that most of the existing neuro cath labs are concentrated in big private hospitals in urban areas and are unaffordable to many. The treatment costs about ₹3 lakh in government hospitals and at least ₹5-₹6 lakh in the private sector.

Data shows good outcomes for recovery

“The registry data showed that at 90 days, 60% of the patients had recovered, with no functional loss or disability, a result which is similar to global data. Even when the treatment is expensive, it is cost effective because it eliminates the huge burden of disability due to stroke. We should be able to offer it to more patients under government health insurance schemes,” Dr. Sylaja said.

The cost effectiveness of endovascular thrombectomy for treating stroke in patients has implications for policymakers because stroke continues to be the leading cause of permanent disability. The cost of stroke rehabilitation is often exorbitant, not to mention the indirect costs of lost wages and productivity and the mental and physical limitations imposed by disability on the individual.