A doctor’s experience with stroke care in Armenia

During my recent visit to Yerevan, my primary objective was to deepen my insights into the country’s healthcare system, specifically focusing on the management of stroke. The journey provided me with a unique opportunity to actively participate in the ongoing efforts and initiatives related to stroke care in Armenia, along with exploring other aspects of endovascular neurosurgery and interventional neuroradiology services. The experience improved my understanding of the tireless efforts within the stroke care community in the nation, further intensifying my dedication to contribute to the progress of healthcare in Armenia.

What is stroke?

Stroke is a debilitating condition that affects millions of people globally each year. It is the second leading cause of death and the third leading cause of disability worldwide. One in every four adults over the age of 25 will have a stroke in their lifetime, 12.2 million will have their first stroke this year and, tragically, 6.5 million will die as a result. Moreover, 143 million years of healthy lives are lost each year due to stroke-related death and disability. 

In Armenia, stroke is the second leading cause of death, trailing only behind ischaemic heart disease, with a mortality rate of 75.5 per 100,000 population. For a country with a population of just under three million and which faces significant financial constraints and disparities in healthcare coverage among its population, stroke poses a major public health challenge. The prevention and effective management of stroke have enormous economic implications as well. Given that a large proportion of strokes occur among people of working age, coupled with the fact that Armenia has a relatively youthful population in contrast to its upper-middle-income counterparts (where a substantial 85-percent of its population is below the age of 60), the impact of stroke on its economy is particularly concerning.

Stroke occurs when there is disruption of blood supply to the brain. This is frequently caused by a blood clot that obstructs a major blood vessel in the brain, resulting in severe and often permanent brain damage. Stroke can significantly alter a person’s quality of life by affecting various functions such as movement of limbs, speech, comprehension and memory and may even result in death. 

What are the risk factors for stroke in Armenia?

Risk factors for stroke include high blood pressure, tobacco usage, physical inactivity, obesity, diabetes, genetic predisposition, stress, depression, excessive alcohol consumption, excess blood cholesterol levels and underlying heart conditions like atrial fibrillation.

In Armenia, unfortunately, these risk factors are prevalent at concerning levels. Lifestyle factors such as tobacco usage, alcohol consumption, high salt intake and insufficient physical activity, along with non-modifiable risk factors like diabetes, high blood pressure and raised cholesterol levels, are highly prevalent.

To illustrate further, 38-percent of Armenian adults aged 18-69 have high blood pressure, while only 64-percent of those diagnosed receive adequate treatment, and a mere 16-percent have their blood pressure controlled despite treatment efforts. Moreover, 48-percent of Armenian adults are overweight, 20-percent are classified as obese, 30-percent are heavy smokers and average daily salt consumption surpasses recommendations set by the World Health Organization (WHO). Adding to this, the recent war and its aftermath have contributed significantly to high levels of depression, stress and anxiety. These psychological burdens, in turn, indirectly contribute to compromised physical health and wellbeing.

During my time in Yerevan, I noticed an unusually high occurrence of atherosclerotic disease in young patients—a condition where fatty deposits accumulate in arteries, causing blockages and increasing the risk of strokes and heart attacks. In the United Kingdom, where I undertook my medical training, encountering such high levels of atherosclerotic disease in the younger cohort is not something I am accustomed to seeing. In Armenia, unfortunately, this is sometimes considered normal, likely attributable to the disproportionately elevated lifestyle and non-modifiable risk factors listed above. As the population ages, I anticipate that this will only worsen, presenting significant challenges for hospitals and healthcare professionals, many of whom already work in demanding and extremely challenging environments with scarce resources. 

How do we treat stroke?

The urgency in treating stroke cannot be overstated. With every passing minute, the brain sustains irreversible damage. On average, a staggering two million brain cells are lost for each minute that a stroke goes untreated. The phrase “time is brain” resonates here, serving as a reminder of the preciousness of time when it comes to preserving brain function and minimizing the long-term impacts of a stroke. 

In recent years, medical and technological advancements have led to the emergence of a highly effective and minimally invasive surgical intervention called endovascular mechanical thrombectomy (or stroke thrombectomy for short). Stroke thrombectomy is an emergency and often lifesaving procedure aimed at restoring blood flow to the brain. The surgery is performed under either general anesthesia (where the patient is fully asleep) or conscious sedation (where the patient is semi-awake). In the operating room, we make a tiny incision either in the groin or the wrist and, utilizing x-ray guidance, gently introduce a system of incredibly fine catheters and wires into the arterial circulation of the body and navigate these instruments toward the blocked vessel within the brain. Once past the blood clot, we deploy a specialized device known as a stent-retriever, which we position to capture the clot, allowing for its careful extraction under continuous suction. If this proves successful, the outcome is immediate restoration of blood flow and oxygen supply to the affected brain tissue—a potentially life-saving intervention when performed within the appropriate time window.

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Development of specialist stroke services in Armenia

I was extremely proud to learn about the way in which Armenia’s healthcare system has embraced stroke thrombectomy, resulting in significantly improved outcomes for patients. The introduction of this procedure has redefined the prognosis for stroke patients in Armenia, offering hope to those who might have faced irreversible brain damage before, and has brought transformative change to our nation’s healthcare system.

Armenia has made commendable progress in the overall treatment of stroke over the past several years. The country has invested in upgrading its stroke facilities and training its healthcare professionals to provide state-of-the-art care. The round-the-clock 24/7 availability of stroke thrombectomy care in Armenia (which is still a rarity in many parts of the world, including some highly developed nations) filled me with immense pride. The fact that Armenia has embraced this crucial aspect of stroke care reflects a progressive mindset that recognizes the potential for improved outcomes for patients.

Although stroke thrombectomy has been available in Yerevan since 2016, it was initially only available to those who could afford to pay for it privately. In February 2019, following productive and dynamic collaborations between an international faculty of experts and the Armenian government, an acute stroke care service was established with the launch of the National Stroke Program (NSP), funded by the Ministry of Health and regulated by experts of the Armenian Stroke Council (ASC). Within the first 36 months of its implementation, over 1,200 patients received stroke treatment. A significant proportion of these patients, and more than 5,000 to date, have hugely benefited from these treatments. This has important implications, as studies have demonstrated that stroke patients who receive proper care in a dedicated stroke unit are more likely to be alive and independent and live without disability a year after having a stroke. 

Thanks to dedicated efforts of enthusiastic experts, international collaborative efforts, innovation and advocacy to drive positive change, Armenia currently offers universal state-sponsored access to specialist stroke centers with a total of four centers available, three of which are in Yerevan, and one in Gyumri. This is fantastic news for our nation but implies that a huge disparity in access to stroke care remains between the capital city and rural areas. Greater efforts are required to ensure that the benefits of stroke treatment are accessible to all, regardless of proximity to Yerevan.

During my trip, I also learned that the quality of training and education for healthcare professionals in Armenia has drastically improved since the introduction of modern stroke protocols. I was fortunate enough to be based at Erebuni Medical Center, which is the largest and most advanced specialized stroke center in the country, performing the highest number of cases in the country. The center is equipped with the most sophisticated and up-to-date operating room and treats many other neurological and neurosurgical conditions, including brain aneurysms and complex vascular abnormalities of the brain and spine.

In addition, residents and medical students in Armenia now gain greater exposure to the management of stroke, and the Department of Neurology and Neurosurgery at the Armenian National Institute of Health even offers a Stroke Fellowship Program.

Furthermore, the availability of stroke thrombectomy in Armenia has raised awareness about stroke. Timely recognition of stroke symptoms and prompt medical attention are critical for optimal outcomes, and increased public awareness has contributed to reducing treatment delays. Despite ongoing efforts in the country to raise awareness about stroke symptoms on TV and social media, there is a greater need for comprehensive public health efforts to reduce the incidence of stroke in Armenia, improve outcomes for stroke survivors and lessen the burden of stroke on individuals, families and society.

Challenges

While my experiences were largely positive, I also encountered some of the challenges that reflect the realities of stroke management and healthcare in general in Armenia. Though access to emergency ambulance services and primary care is available to the whole population, there is still a huge proportion of undiagnosed and therefore untreated cases. Post-hospital care also remains underdeveloped for stroke survivors. There needs to be expansion and greater access to neurorehabilitation centers and comprehensive facilities to support patients following discharge from the hospital after immediate treatment in the acute setting. Another issue facing physicians is the lack of additional funding for specific medical equipment and certain newer state-of-the-art devices, which are often imperative when treating more complex cases.

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Any action can have a significant impact

Anyone can make a significant contribution to the healthcare needs in Armenia. As healthcare professionals, however, we are in a unique position to raise awareness about health issues, offer consultations, perform surgeries, provide second opinions on cases, participate in healthcare initiatives, source and donate medical equipment and so on.

During my time in Yerevan, I had the privilege to make meaningful contributions by performing procedures, interpreting radiology scans, providing second opinions and donating specialized medical equipment from my own facilities. These resources, which can be extremely expensive and challenging to obtain, were greatly valued by my colleagues in Armenia. The experience also gave me the opportunity to enhance my own professional growth by acquiring diverse techniques and skills from seasoned and exceptionally experienced physicians. I therefore plead all healthcare professionals to consider dedicating time and effort to the Armenian healthcare system by actively participating in healthcare initiatives. This not only holds immense advantages for the nation but also promises substantial personal gains for the individuals involved.

Conclusion

By embracing cutting-edge medical interventions, such as stroke thrombectomy, Armenia continues to take significant steps towards improving healthcare infrastructure and patient outcomes. As the nation continues to evolve its healthcare system, the integration of advanced treatments and diagnostic services will undoubtedly contribute to a brighter and healthier future for the people. Significant challenges remain, but the country’s commitment to continuous learning ensures a promising future. By prioritizing prevention, early intervention and comprehensive support, Armenia can also work towards reducing the economic impact of diseases such as stroke while improving the wellbeing of its people.

My experience has been incredibly rewarding, humbling and eye opening, and I have gained a slightly better understanding of the challenges and triumphs of healthcare in Armenia. Through these opportunities, I have witnessed the dedication of local healthcare professionals working tirelessly to provide outstanding care to their patients within the limited resources available to them. This has given me a deep appreciation for the hard work and compassion that define the medical community in Armenia.

Acknowledgements

Thank you Dr. Mikayel Grigoryan, Dr. David Sahakyan, Kevork Nalbandian, Gregory Boyrazian and the exceptional Erebuni Medical Center staff for making this endeavor a reality.

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Dr. Vartan Balian

Dr. Vartan Jacques Balian is a neuroradiologist in the U.K. Dr. Balian qualified from the University of Liverpool Medical School in 2014 and completed specialty and fellowship training in radiology and neuroradiology in England, obtaining the European Diploma in Neuroradiology in 2023. He has published in peer-reviewed journals, presented at multiple international and national conferences and has held multiple leadership roles, including currently the inter-society lead for The World Federation of Neuroradiological Societies.

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• A doctor’s experience with stroke care in Armenia - November 29, 2023