JOINT MEETING OF THE PULA CONGRESS WITH CENTRAL AND EAST EUROPEAN STROKE SOCIETY Management of stroke in central and east Europe Vida Demarin, Vlasta Vukovic´ & Drazˇen Azˇman University Department of Neurology, Sestre Milosrdnice University Hospital, Reference Center for Neurovascular Disorders and Reference Center for Headache of the Ministry of Health and Social Welfare of the Republic of Croatia, Vinogradska 29, Zagreb, Croatia Objectives: Stroke has been the third most common cause of death in the majority of the developed countries. Therefore, prevention and treatment of stroke have become recognized health priorities in most European countries. Most epidemiologic data show an eastwest difference in terms of stroke risk factors, diagnostics and treatment. In eastern countries, stroke incidence is higher, stroke is the leading cause of death and 30-day case fatality; hospitalization rates for stroke are lower. Data show that eastern countries are very close to standardized quality indicators established in western countries, except for availability of certain technological possibilities (such as CT scaning) in some eastern countries. Over the past few decades, the burden of stroke in developing countries has grown to epidemic proportions. In low- and middle income countries 2/3 of global stroke occurs. Hospital-based studies suggest that the patterns of stroke types and causes of stroke differ between developing and developed countries, resulting in differing needs for acute and long-term care. Eastern countries have a higher 30-day case fatality (mostly above 20%) compared with western countries (mostly below 20%). This is probably due to the higher prevalence of common risk factors for stroke in eastern countries which may result in more severe strokes and worse outcome. Stroke units have been established as a standard care for stroke and proved their usefulness and cost-benefit; in some European countries a nationwide network of acute stroke units was set in accordance to evidence-based recommendations and prespecified criteria. However, stroke units have not been widely established in developing countries mostly due to limited resources. The Safe Implementation of Thrombolysis in Stroke Monitoring Study (SITS-MOST) demonstrated that intraveneous alteplase is well tolerated when used in routine clinical practice within 3 hours of ischemic stroke onset; the analysis showed that the proportion of symptomatic intracerebral hemorrhage is 8.5% and mortality 15.5%. Older age, high blood glucose, high NIH Stroke Scale score and current infarction on imaging scanes are related to poor outcome. Disability before current stroke, diastolic blood pressure, antiplatelet other than aspirin, congestive heart failure, patients treated in new centers and male sex are related to high mortality at 3 months. Several developing countries introduced thrombolysis for acute stroke treatment, however, the number of such countries is still small. The two main barriers for implementation of thrombolytic therapy in developing countries are high costs and lack of proper infrastructure. Thrombolytic therapy can be applied in a small number of stroke patients; the two main barriers for implementation of thrombolytic therapy in developing countries are high costs and lack of proper infrastructure.

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Aims: We have conducted this study in order to analyze current management of acute stroke in 17 European countries: Austria, Belarus, Bosnia and Hercegovina, Bulgaria, Croatia, Czech Republic, Estonia, Georgia, Hungary, Italy, Kosovo, Lithuania, Montenegro, Romania, Russian Federation, Serbia and Slovenia. Methods: A questionnaire has been sent to collaborating stroke centers. Results: Stroke incidence is within the range of 183–623/100 000 inhabitants. All countries have stroke units, except Georgia, Montenegro and Kosovo. The majority of stroke patients are treated in Stroke units, followed by traditional neurological ward, and a small percentage of stroke patients are treated on other wards than neurological. Availability of diagnostic procedures in stroke management largely depends on urban/rural setting and is as follows: computerized tomography (CT) scan is performed in 93–100% of all stroke cases; however CT is performed in 30–70% within the first 24 hours after stroke admission. Duplex sonography is performed in 25–100% of all stroke patients. Thrombolysis is being performed in most countries, it is still not available in Romania, Georgia, Montenegro and Kosovo. The number of patients treated with thrombolysis is increasing every year. After demission, 20–100% (on average 20–40%) of patients is sent to a rehabilitation center. Conclusions: The results of our study showed that most eastern European countries have a well developed neurological care system for acute stroke and most apply thrombolysis for stroke treatment. However, some countries still have technological and socioeconomical needs. Developing countries should focus on primary and secondary stroke prevention strategies and establish stroke units; such approach would be more cost-effective in long-term. References: 1. Demarin V, Lovrencˇic´-Huzjan A, Trkanjec Z, Vukovic´ V,, Vargek-Solter V, Sˇeric´ V, Lusˇ ic´ I, Kadojic´ D, Bielen I, Tusˇ kanMohar L, Aleksic´-Shihabi A, Dikanovic´ M, Hat J, DeSyo D, Lupret V, Berosˇ V. Recommendations for stroke management 2006 update. Acta Clin Croat 2006;45:219–285. 2. Vukovic´ V, Molin CA, Ribo M, Lovrencˇic´ Huzjan A, Budisˇ ic´ M, Demarin V. Neuroimaging techniques-improving diagnostic and therapeutic options in acute stroke. Acta Clin Croat 2006;45:331–341. 3. Lovrencˇic´ Huzjan A, Vukovic´ V, Demarin V. Neurosonology in stroke. Acta Clin Croat 2006;45:385–401. 4. Wahlgren N, Ahmed N, Eriksson N et al. Multivariable Analysis of Outcome Predictors and Adjustment of Main Outcome Results to Baseline Data Profile in Randomized Controlled Trials. Safe Implementation of Thrombolysis in Stroke-MOnitoring STudy (SITS-MOST). Stroke. 2008 Oct 16 [ahead of print]. 5. Wardlaw JM, Zoppo G, Yamaguchi T, Berge E. Thrombolysis for acute ischaemic stroke. Cochrane Database Syst Rev. 2003;(3):CD000213. 6. Durai Pandian J, Padma V, Vijaya P, Sylaja PN, Murthy JM. Stroke and thrombolysis in developing countries. Int J Stroke. 2007;2(1):17–26.

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7. Brainin M, Teuschl Y, Kalra L. Acute treatment and longterm management of stroke in developing countries. Lancet Neurol 2007;6(6):553–561. 8. Steiner MM, Brainin M. Austrian Stroke Registry for Acute Stroke Units. The quality of acute stroke units on a nationwide level: the Austrian Stroke Registry for acute stroke units. Eur J Neurol. 2003;10(4):353–360.

9. Brainin M, Bornstein N, Boysen G, Demarin V. Acute neurological stroke care in Europe: results of the European Stroke Care Inventory. Eur J Neurol 2008;7:5– 10. 10. Czlonkowska A, Skowron˜ska M, Niewada M. Stroke service in Central and Eastern Europe. Int J Stroke 2007;2(4): 276–278.

 2009 The Authors Journal Compilation  2009 John Wiley & Sons A/S Acta Neuropsychiatrica 2009: 21 (Supplement 2): 1–72 Downloaded from https:/www.cambridge.org/core. Imperial College London Library, on 20 Mar 2017 at 10:40:32, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0924270800032804

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