ESO East Supplement 2023 - 46

46
European Stroke Journal 8(1S)
Table 1. Criteria for eligibility as stroke ready hospital, able to perform IVT/EVT.
Necessary facilities to perform IVT
Neurology
Departments and clinics
Radiology
Staff available
On-site neurologist 24/7
On-site diagnostic radiologist 24/7
Investigations available
Brain CT scan 24/7
CT priority for stroke patients
Necessary facilities to perform EVT
Neurology
Radiology
Interventional neuroradiology
Neurosurgery
On-site neurologist 24/7
On-site diagnostic radiologist 24/7
On-call interventional neuroradiologist 24/7
On-site neurosurgeon 24/7
Brain CT scan 24/7
CT priority for stroke patients
Cerebral angiography 24/7
7%
24%
69%
1-2 Neurologists/10.000 people
0.5 - 1 Neurologists/10.000 people
< 0.5 Neurologists/10.000 people
Figure 1. County distribution of neurologists/10,000 people
in Romania. Data were obtained from the Romanian College
of Physicians. Almost 70% of the cities/counties have <0.5
neurologists/10,000 population.
areas. Bucharest (1.67) and Cluj-Napoca County (1.46)
have the highest number of neurologists per 10,000 inhabitants,
while counties like Giurgiu, Calarasi or Ialomita have
less than 0.2 neurologists/10,000 people (Figure 1).
Despite these difficulties, there has been a spectacular
change in the landscape of IVT in Romania in the last
3 years. The national rate of IVT increased from 0.8%, in
2017 to 5.4% in 2021 (Figure 3), with significant differences
throughout the country. There are still seven counties,
with a total population of 2.2 million inhabitants, where
IVT is not available, while some centers, like Brasov or
Emergency Hospital Floreasca in Bucharest, have a rate of
IVT over 25%. In Bucharest, seven hospitals can perform
IVT (two hospitals can also perform endovascular treatment).
The rate of symptomatic hemorrhagic transformation
is 6.07% for all IVTs registered in the national registry
of interventional treatment in acute stroke.
The other project developed inside ESO EAST, ANGELS
Initiative, brought an important educational support. The
Romanian Society of Neurology has designated a team that
organized six regional workshops for neurologists, radiologists
and emergency physicians, several educational sessions
dedicated to nurses, at least 10 simulations in different
hospitals along the country and more than 10 educational
sessions with the ambulance personnel. The educational sessions
moved online during the pandemic of Covid 19.
Stroke Action Plan for Europe, 2018-20302 aims for a
rate of IVT of 15%, which has already been achieved by
some of the centers in Romania. In areas where the percentage
is close to 15% we need to increase stroke awareness
and to develop a functional prehospital emergency system.
In areas where the rate of IVT is very low, beside what we
have already mentioned, we need a governmental involvement,
as the main problems are the low number of neurologists
and radiologists and an insufficiently developed
hospital infrastructure (almost one-third of the CT scans
have ⩽ 16 slices).
Door to needle time has improved along the years but
was negatively influenced by the Covid-19 pandemic. The
emergency state was declared in Romania on March 16th
2020, and basically did not influence DTN registered in
RES-Q in March 2020, but the difficulties that all the medical
systems had to face during 30 months of distorted circuits
and exhaustion of the medical personnel (ambulance
and hospitals) were translated in longer DTN time intervals
(Table 2).
In October 2020, the working group for Priority Action
published together with the Ministry of Health (OMS No.
1832/2020, published in the official Monitor Part I, No.
1008/ October 30th 2020) a pilot program for prenotification
of the hospitals in case of a potential eligible patient for
IVT or MT. The program was put on hold during the pandemic,
as the Ambulance system was utterly overwhelmed.
Mechanical thrombectomy
The situation in Romania is significantly worse for mechanical
thrombectomy. In 2017 a total number of 56 thrombectomies
were performed throughout the country. The number
increased five times in 2021, reaching 285 MTs but this
means only 0.5% of all ischemic strokes. There are three main
centers which regularly perform EVT (University Emergency
Hospital Bucharest, Tg. Mures County Hospital and County
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