ESO East Supplement 2023 - 32

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European Stroke Journal 8(1S)
Table 1. Outcomes of acute ischemic stroke revascularization
therapy in Armenia from 2019 to 2021.
AIS characteristics
Agea
Sex (M)b
IVT onlyb
IVT with EVTb
EVT onlyb
Onset-to-admission timea (min)
Door-to-needle timea (min)
Door-to-groin puncture timea (min)
Admission NIHSSa
Discharge NIHSSa
mRS at 3 months (mRS 0-2)a
Symptomatic intracranial hemorrhageb
(n = 1230)
Mortality (n = 1230)b
706 (57.4%)
486 (39.5%)
184 (15%)
546 (44.4%)
95 (60-155)
50 (38-66)
90 (70-113)
12 (7-18)
3 (1-10)
Post-EVT recanalization TICI 2b-3b (n = 730) 635 (87%)
mRS at dischargea
1 (0-4)
1 (0-3)
45 (3.7%)
126 (10.2%)
AIS: acute ischemic stroke; IVT: intravenous thrombolysis; EVT: endovascular
thrombectomy; NIHSS: National Institutes of Health Stroke Scale;
TICI: thrombolysis in cerebral infarction; mRS: modified Rankin scale.
aMedian (IQR).
bn (%).
treatment remains a significant problem for patients in the
provinces. Unpublished data indicated that only 8% of the
patients from distant provinces received treatment for acute
stroke in 2019-2020. Expansion of the NSP is in progress.
In March 2022, the first stroke center outside of Yerevan
was opened in Gyumri, the second largest city in Armenia.
The Gyumri Medical Center will serve a population of
nearly 250,000.19 Plans are underway to link it with a primary
stroke center in another city 1 h away to expand its
catchment area further. Telemedicine is part of acute stroke
treatment programs in many parts of the world.20,21 ASC
recommended the implementation of TeleStroke network to
link peripheral and regional hospitals with the comprehensive
stroke centers. In collaboration with ArMed, the
national eHealth operator, the initial steps have been taken
to set up a TeleStroke service between the Gyumri Medical
Center and the EMC. This link will serve as a model for
expanding the TeleStroke service throughout Armenia.
Discussion
The introduction of state-of-the-art acute stroke treatment
was delayed in Armenia, but the last 8 years have witnessed
rapid advances. The results of the acute stroke revascularization
procedures presented in Table 1 are encouraging and
meet international standards. Contributors to this progress
consist of extensive collaboration between local and international
stroke experts facilitating knowledge transfer and
development of hospital stroke teams, a pre-existing solid
Overall (n =1216)
69 (62-77)
cadre of motivated physicians, the decision of the MOH to
initiate the NSP, and the willingness of the private sector to
make substantial investments, particularly in neuroradiological
equipment, such as magnetic resonance imaging
(MRI) and computerized tomography angiography (CTA),
and stroke ward development. Major hurdles remain.
Although the medical culture of Armenian health care professionals
is changing, it needs more time to evolve. Prehospital
EMS care and hospital-based emergency room
care, and stroke referral network development present
opportunities for improvement. As in many post-Soviet
countries, stroke risk factors remain highly prevalent and
are not optimally mitigated. Furthermore, financial constraints
remain key determinants for individual choices in
seeking treatment. Available medical data are also not consistently
solid. For example, epidemiological data are often
incomplete and probably under-estimate prevalence and
incidence because of incomplete and retrospective recording.
The need for a prospective national stroke database is
recognized, and there are early plans to organize it in the
near future. These challenges are unlikely to change rapidly
and will require long-term planning.
Conclusion and future directions for
stroke care in Armenia
The past 5 years have witnessed substantial advances in
building the medical infrastructure and delivering acute
stroke care in Armenia. Active stroke centers now exist in
the country's two largest cities, and care is provided to the
population irrespective of their ability to pay. These substantial
successes have geographical limitations with a significant
divide between urban and rural populations. The
immediate need is to expand acute stroke care to underserved
parts of the country by adding TeleStroke capability
and additional primary and comprehensive stroke centers.
The program is expected to evolve to meet the population's
needs and to optimize care. The long-term plan is fivefold:
first, public education regarding the management of
stroke risk factors, a collaborative effort between the
MOH, ASC, and the larger medical and nursing community;
second, the monitoring of the quality of care provided
and outcomes at the different stroke centers. This requires
establishing quality of care standards and monitoring the
centers' results at regular intervals. Because it funds the
majority of the acute stroke treatments, the MOH has
access to quality measures, and the ASC provides the
expertise to assess them. Third, the continuous education
and further development of physicians, nurses, and healthcare
professionals in cerebrovascular diseases, particularly
in areas of advanced expertise, such as neuroradiology,
that are not well developed. As indicated in the preceding
paragraphs, courses geared toward nurses and neurologists
have already been organized by the ASC, the EMC, and the
plan is to continue with them. Fourth, is expansion of the
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