Prof. Silva Andonova is the director of UMBAL "St.

Marina" - Varna. She is one of the leading medical specialists in her field. Her comment is from a specialized health forum dedicated to strokes.

The issue of high mortality and disability as a result of strokes is not only a complex medical but also a socio-societal problem.

According to Eurostat statistics from 2017, the death rate in Bulgaria as a result of strokes is four times higher than in other European countries.

What has been done in Bulgaria?

Already in 2019, we have a clinical pathway for endovascular treatment.

For us neuroscientists, this is especially important, it is a standard.

As we all know, different methods have been introduced in Bulgaria regarding endovascular treatment.

They are described and can be used.

Specialists have also been trained in the centers where it is applied - some in our country, others abroad.

We also have pilot experience at national and regional forums.

It has already been discussed in the relevant centers. 

What is endovascular treatment? 

This is a treatment when we have an occlusion of a large cerebral vessel.

The frequency varies widely.

In all cases, these large vessels that have thrombosed supply blood to common brain areas, ultimately, if it does not lead to death, it leads to severe disability.

The percentage of thrombolytic treatment that results in recanalization is very small.

If we give these patients intravenous thrombolysis, we have a 10-25 percent good outcome.

With a trained multidisciplinary team, the possibility of improving the patient's condition and correspondingly reducing the motor deficit is between 80 and 90 percent.

Let's not forget that the effect of eunovascular treatment is time-dependent.

The sooner it starts, as well as the thrombolytic, the better the results. 

The problems

The unfavorable trend of recent years continues.

While in 2019-2020 the centers treating stroke with thrombolysis were 49, they are already decreasing and are 44 out of a total of about 130 in number.

On the other hand, there remains a persistent tendency for the centers where endovascular treatment is carried out to be too few.

This is what the two locations look like - in Sofia and Varna, and the others.

There is no good distribution of thrombolytic treatment centers in the country.

In the countries of Eastern Europe, the trend continues for a very low rate of performed thrombolysis, which is also low for endovascular therapy.

Endovascular treatment is performed by a licensed neurointerventionalist, respectively a stroke specialist and a neurointerventionalist in experienced medical centers that meet national and international requirements. 

A few important questions

One of them is what are the most important obstacles in implementing this type of treatment and what is the role of economic aspects.

Regardless of the fact that since 2019 we have two clinical pathways - two for thrombolysis and one for vascular treatment, if they are done in one center, then

NHIF only pays for one pathway per patient.

How, in such a case, will I choose one path and not apply the other one if the first one was not successful for the patient. 

On the other hand, the specifics of individual hospitals are not taken into account by the organizations for their implementation.

What are the minimum educational criteria for specialists, including so-called neurointerventionalists, and which specialties provide neurointerventional treatment.

In one hospital the radiologist is allowed to do this, in another the neurosurgeon, in a third the cardiologist.

We do not yet have national criteria in this regard.

Who tracks and evaluates centers that implement thrombolysis and endovascular treatment.

It is not just numbers that are needed, but to know that these centers actually correspond to modern differentiated treatment methods.

What is necessary

This is staff training, ongoing, not incidental public information.

A team approach is also needed, and in addition to hospital teams, emergency medical centers and general practitioners should also be involved.

There must be an active interrelationship between these units.

Staff must be certified.

It is necessary to build high-tech centers for endovascular treatment of strokes.

In our country, it is necessary to update the principles of primary and secondary prevention, promotion of new methods for increasing health awareness. 




Prof. Silva Andonova