January 27, 2023

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Romania, far too behind in terms of endovascular treatment in stroke

Endovascular treatment or mechanical thrombectomy consists in the mechanical extraction of the clot clogging an artery that supplies the brain, with the help of specific mechanical devices.

According to the medical guidelines in force, it can only be applied in the first six hours after the onset of symptoms.

Every year, about 3,000 of the Romanians who have an ischemic stroke need thrombectomy, but less than 400 are lucky enough to benefit from it. There are only five centers in the whole country where this intervention is carried out: two in Bucharest, at the Universitary Hospital and Elias, one in Târgu Mureș and another in Timișoara. And according to international specialists, we should have one STROKE center per million inhabitants.

Present at the 15th edition of the “International Conference on Neuroprotective Agents” held in Cluj, Prof. Dr. Marc Fisher, president of the World Stroke Organization (World Stroke Organization – WSO), said: “In Romania, at the moment, only radiologists can receive the competence to perform thrombectomies. This needs to be changed, expanded, as it is in other countries: neurologists and neurosurgeons can train to provide neurointerventional treatment to stroke patients. This is one of the most important things you need to resolve quickly.
For thrombectomy you should have somewhere between 15 and 20. It depends on the positioning, the population density. Cluj should probably have one. I live in an area of ​​Boston, the population is four million, and we have six thrombectomy centers. A very important element is telemedicine, and in the case of a stroke. All over the world, including the United States of America, there are few specialists. Part of the plan you should implement in Romania is telemedicine, for the interpretation of images, for example, CT scans.”

Patients from Cluj, Iasi, Constanța or Oradea cannot quickly benefit from thrombectomy in case of a stroke. They are often out of the six-year therapeutic window by the time they are transferred to a specialist centre. And this means that they are left with serious consequences or die.

Professor Ștefan Ioan Florian, Head of the Neurosurgery Clinic at the Cluj County Hospital: “Until recently, the medical team did not have the possibility to perform endovascular treatment. The first initiative came from the private sector. However, the conditions for the contract with CNAS are not met, but we are doing all we can to help. In parallel, we started the construction of the cerebrovascular pathology and neurosurgery center. Already the building is undergoing renovation and there is a new annex building under construction. We hope the project will be funded. It is a complex effort that we are making to ensure equal treatment for patients from this region of Romania. There are stroke centers in Bucharest, in Târgu Mureș, in Timișoara. So far, Cluj has not had any. We are taking the necessary steps to ensure that patients in this region receive the appropriate treatment in the required time. Time makes the difference between what it means to be severely disabled or terminally ill and a fully rehabilitated person. The time interval to treat a stroke patient is not enough for us to transfer a patient from Cluj to Bucharest.”

Specialists from abroad came to Cluj to talk about how the STROKE network developed in their country.

Professor Natan Bornstein, board member of the World Stroke Organization (WSO): “What we did in Israel, with a population of 9.5 million inhabitants. We have divided the territory into regions and each has centers designed in such a way that the patient can reach the hospital by car in a maximum of 19 minutes. Theoretically, one STROKE center is calculated per million inhabitants, but the population is not evenly distributed throughout the country. It also depends on the ambulance system, which is different in each region.
As for telemedicine, our specialists in Israel, coming from the United States, are still using it for STROKE patients. Technology has advanced a lot and can be used for the benefit of patients. I am training abroad for neurointerventional medicine. I convinced the Government to pay, every year, four scholarships for doctors to go abroad to train. They are not fully paid by the state, but a large part. It is a strategy to increase the number of specialists who can treat stroke patients. 60% of stroke specialists are neurologists.”

Prof. Dr. Cristina Tiu, president of the Romanian Society of Neurology: “Interventional radiology occupies a number of therapeutic areas, each with its degree of complexity. We would say that the neuroradiology part is insufficiently represented. Expanding competence is needed because training is complex and the current demand for treatment of ischemic stroke would require a much larger number of specialists and a larger number of centers capable of treating ischemic stroke with mechanical thrombectomy. Moreover, they could perform various procedures for ruptured aneurysms or arteriovenous malformations, so that we no longer need to send them abroad.”

Prof. Dafin Mureșanu, Director of the Department of Neurosciences at UMF Cluj Napoca: “In 2019 we ended up adding 33 more centers where thrombolysis can be done (no. method of treating a stroke in which a small-caliber artery is blocked), and today we have 43 across the country. Still only four of they could do thrombectomy and hardly one appeared in Suceava. In 2017 we were at a treatment rate of 0.8% of treatment, and in 2021 we reached a rate of 5.4%. In 2018, we thrombolyzed 467 patients, in 2019, after expanding the number of centers, we reached 2,300 patients with stroke treated by thrombolysis. In 2020 we went to 2350. 2650 in 2021. That’s significant progress. Thrombectomies in 2021: Bucharest Emergency University Hospital – 126, Târgu Mureș – 76, Timișoara – 75, Elias – 5, and Suceva which had just entered the program 5. This reality is very modest. We need to do much more. We need to move towards normal targets and normal performance parameters. There are few specialists, and those people are overworked. Development is needed. In Romania, we are currently working on establishing some general rules to provide access to neurologists and neurosurgeons who want to obtain neurointerventional competence. This is part of the strategy to expand the STROKE program.”

The training of a doctor to perform thrombectomies is a minimum of two years.

On the other hand, another emergency for Romania is the development of rehabilitation programs and centers. They are far too few for the large number of patients who need them.

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