Stroke remains one of the leading causes of mortality and disability in Bulgaria, and the battle against time often proves decisive for the lives of patients. Against this background, the first fully completed stroke center in our country was opened in the capital's UMBAL "St. Anna" hospital, which works according to all modern world standards for the diagnosis and treatment of cerebrovascular diseases. How are we coping... Assoc. Prof. Rosen Kalpachki, head of the Neurology Clinic and the Stroke Center at the hospital, spoke to FACTS.
- Assoc. Prof. Kalpachki, the first fully completed stroke center was recently opened in "St. Anna" hospital in Sofia. This is a high-tech unit for interventional diagnostics and endovascular treatment of cerebrovascular diseases. What is this and what does this center bring to patients?
- First of all, this is a complete structure according to all world standards. There is no cerebrovascular or stroke center in the world that has different equipment. We really have everything - right from the entrance to the center we have an emergency department with the maximum third level of competence. I remind you that this is the first such department in Bulgaria. Then we have all the imaging diagnostic units - from a standard scanner, perfusion to magnetic resonance. Next is an angiography room, where the most delicate diagnostics are performed.
Then we have the already proven Clinic for Nervous Diseases, which is the “heart” of the Stroke Center and takes on all cases - from the mildest strokes to the most severe, with each patient receiving the appropriate treatment.
In our hospital, almost a third of patients receive thrombolysis, with an average level in Europe of 16%. I am talking about statistics from last year.
In the most severe and special cases, we apply mechanical thrombectomy. We work 24/7 in a laboratory where this endovascular treatment is performed. Under X-ray control, the cerebral arteries are entered, the exact location of the thrombus in the brain is determined and it is reached. With various manipulations, the thrombus is removed in order to unblock the clogged artery, which is the most common cause of acute strokes.
This is the core of the Center, but there is more. We have a specialized Rehabilitation Clinic, because for all patients, regardless of the severity of the stroke, rehabilitation begins immediately. We have a speech therapy rehabilitation unit to restore speech faster.
And the newest, and in my opinion something that even many stroke centers around the world do not have, is the special unit for psychological consultation and psychological support. We are talking about psychologists, and not just one. Psychological support is provided both for patients and, in many cases, for the medical team, because it is often necessary to resolve difficult situations - relationships with loved ones, conversations with patients, searching for the most adequate solutions. All this is united in one of the most multidisciplinary hospitals in Bulgaria - – “St. Anna“. We have the support of all other units. Again, we are talking about a 24/7 regime - internal medicine clinics, orthopedics, intensive care, neurosurgery, maxillofacial surgery and all others very often help us, because each patient is unique in itself.
- Why is this center so important?
- Look, at “St. Anna“ we performed 99% of all activities for stroke patients even before the establishment of this center. But it is precisely this crucial one percent, as well as its institutional recognition by the Ministry of Health, that are extremely important. Because now the “path has been paved“ for us to intervene in cases where colleagues from all over the country need help in more complex situations.
Where thrombolysis or mechanical thrombectomy cannot be performed in places, the patient is diagnosed and, when he is still in the therapeutic window, depending on the possibilities – by land or air – is transported to us. And here we are already working 24/7 according to all world standards.
- What part of the country is currently covered in such a way as to provide fast and adequate thrombolytic treatment?
- When we talk about thrombolytic treatment, I think that with few exceptions, thrombolysis is now performed in almost every region of Bulgaria. I can't say that this is happening in sufficient quantities, but as a practice it is now almost everywhere in the country. Colleagues are gaining courage, although not as quickly and smoothly as I would like.
In many places this is a matter of logistics, staffing and support from other specialists, because behind every stroke center there must be a working hospital. A stroke center without a working hospital simply cannot exist. This is not the work of neurologists alone, but of a multidisciplinary team.
Thanks to public support, thrombolysis is no longer considered an unknown treatment. But thrombectomy - the technique I mentioned earlier, which often supplements treatment - is still more of a wishful thinking. I hope that in the coming months the six stroke centers that need to be built in the country will become a reality. For now, the only fully operational center is the one at the “St. Anne” hospital.
- Is the lack of confidence among your colleagues the reason why more thrombolysis is not being performed?
- There are many factors. The main “justifying” reasons are the lack of staff and logistics. Stroke is not a disease of normal working hours. It is not enough to have coverage during the day from Monday to Friday. You need 24/7 coverage. A patient suitable for thrombolysis may arrive at 3 am or on a national holiday. If you don't have a prepared team that can respond and perform thrombolysis, then you don't have a real working stroke center.
Logistics and staffing problems are one reason.
The other is that some of the colleagues in our guild - neurologists, still can't dare to take this step. It so happened that the so-called "agenda-setting" colleagues in our specialty in recent years have not actively treated strokes in their practice. In fact, until very recently, stroke was not in the focus of the entire neurological guild. The good thing is that especially after the establishment of the Bulgarian Stroke Society, this is changing, albeit slowly.
People who deal with modern thrombolysis treatment are still a minority. They are surrounded by a majority of cautious and even skeptical colleagues who say that there are difficulties and risks. Yes, there is undoubtedly one. We are talking about high-tech and super-emergency medicine. There is no way such medicine can be elementary. Imagine a neurological resuscitation that works continuously, around the clock - it is difficult. From this point of view, I think this is some kind of justification, but with time and the accumulation of good experience that we have been building for more than 10 years, things are gradually changing.
However, if I make a comparison - about ten years ago, approximately a hundred thrombolysis procedures were performed throughout the country per year. Today, we are already talking about 2,000 per year nationwide. This is still progress. It is not the kind I would like, but it is progress.
- Do patients manage to arrive on time when they have had a stroke, in the so-called “golden hour“?
- For me, everything is interconnected. More and more patients are arriving on time and there will be even more of them when there is somewhere to go. Every colleague in the Emergency Department seeks the best for their patient. When they know that there is a stroke center nearby, suitable for thrombolysis, where the patient can be admitted immediately, they go. But many times a free bed cannot be found, especially for severe cases. This happens in Sofia every night, not to mention what happens on Friday nights. Every colleague in the Emergency Department can confirm this. When patients and their relatives know that there are places where they will be treated, they start coming more confidently and on time. People have learned. Also thanks to what the media and society have started to comment on the topic of stroke.
People call, they are interested in what is being done. I will say again that stroke is an everyday occurrence, not a working-time illness. Every 10 minutes someone in Bulgaria has a stroke. These are the statistics. Under the influence of patients and their relatives, who already know that such treatment exists, many colleagues are starting to organize. Doctors generally always start with the idea of helping, they start to provide assistance to “muscles“, as they say. This is what I think explains why the system is starting to change in many places. People are coming in more timely and better informed.
This will help all of us break certain psychological barriers and imaginary shackles in the guild in order to change things.
I am absolutely sure that this is an avalanche that cannot be stopped, including due to the reluctance of many people to face the truth. I want to specifically draw attention to the fact that such conversations – thanks to your media and other colleagues of yours – really change things. I can talk and comment on the topic of stroke a lot, but for a number of reasons, it is society and the media that change the situation. Because people who die or have strokes are someone's mothers, fathers, loved ones and relatives who need urgent, adequate and professional help.