Panel Is Bringing Stroke Care in Armenia on Par with the West

Grigoryan is an interventional and vascular neurologist in private practice as well as the medical director of neurointervention at Adventist Health Glendale Comprehensive Stroke Center.

He recalled that in 2015, his next-door neighbor in Armenia, a physician herself, had a stroke in front of him. Since he knew an ambulance would not arrive in a timely manner, he got the neighbor’s daughter to drive him and her stricken mother to the hospital and drop them off, while she went to a pharmacy to purchase the clot-busting medication (Intravenous tissue plasminogen activator (IV-tPA), also known as alteplase or Activase), and bring it to Grigoryan.

All this had to be done within three hours to lessen the chance of permanent brain damage.

“It wasn’t readily available in the hospital and nobody had the money to pay for it,” he said.

Grigoryan said that some of the equipment in Armenia is often ahead of equipment in the US. “The biplane cerebral angiography machine in Erebouni is better than the one I use in Los Angeles, without a doubt.”

“The diagnostic tools are very costly, the medications are very costly and the intraarterial procedures are even more costly,” Babikian noted. “In such a financially challenged country, to undertake such a cost is quite brave.”

Strokes are 80 percent preventable, Yeghiazaryan said, but little is done toward prevention efforts in Armenia, though they cost very little in comparison to stroke care.

“As a poor country, we don’t do anything for prevention. We spend a lot of money on treatment but not on prevention,” she said. Things that can help prevent strokes include smoking cessation, physical activity, diabetes treatment, losing weight and treating hypertension.

Reliable statistics regarding common vascular risk factors for stroke are lacking in Armenia, and available figures seem to be underestimations. According to Yeghiazaryan’s paper, one third of adults aged 18 to 69 suffer from high blood pressure, and of those, only 64 percent seek treatment. In addition, about half the adult male population smokes, while only 2 percent of women do so, though they may be affected by second-hand smoke.

Pioneering Work

Previously, in Armenia, there was no training for strokes in medical schools, said Yeghiazaryan. Those who wanted to learn how to treat strokes had to either go abroad or have doctors from abroad train them, she added.

Yeghiazaryan said there are about 5,000 strokes annually in Armenia. According to a paper she wrote with several other doctors in 2022, stroke is one of the country’s major public health problems and ranks as the sixth leading cause of death, with a mortality of 75.5 per 100,000.

“I don’t think the problem of strokes in Armenia is more or less than other country. Strokes are a major problem in most countries, especially developing countries. It is a fatal disease but mainly it is a disabling disease.”

Dr. Zhora Baghdasaryan, a neurointerventional surgeon, has been tasked with taking the lead of the Gyumri and Vanadzor stroke centers.

“You can have a stroke center, as long as you have the basic materials. Now there is infrastructure and better equipment What is cause for optimism is that now, after this program, all the centers have bought new equipment for treatment of stroke victims,” Baghdasaryan said.

He added, for example, that at Erebouni Hospital in Yerevan, there is world-class equipment, thanks to the efforts of the Armenia Stroke Council. He added that in Gyumri, the hospital just got a CT Scanner, which is vital for its work.

The hospitals in Gyumri and Vanadzor are state hospitals, while Erebouni is private.

Yeghiazaryan stressed that the Ministry of Health has been receptive to the suggestions of the ASC and provided the funding for needed treatment.

One issue is how a patient gets to the hospital. Yeghiazaryan said that the ambulance service in Armenia still has a long way to go.

“The sooner you arrive, the more damage you can prevent,” Grigoryan said.

“We have a lot to do but in this field also we have colleagues from diaspora helping,” she said, crediting Dr. Sharon Chekijian, an associate professor in the Department of Emergency Medicine at the Yale School of Medicine, for making “emergency medicine better in Armenia.”

One of the unusual things in Armenia is that instead of paramedics, the ambulances are operated by doctors. “Usually the ambulance is led by a doctor and there is a nurse also. Both go to the patient rather than paramedics. … Ambulances are not under the supervision of the Ministry of Health, but rather the local authorities. It is very difficult to organize them uniformly.”

Still, she said there have been improvements, especially in Yerevan. “They are taking the stroke patients to the closest stroke centers without any discussion.”

One particular case that Grigoryan worked on was that of a 2-year-old girl, who had suffered from a dangerous brain dissecting pseudoaneurysm that caused several strokes. Because she was at risk for permanent disability, she was transferred to the Erebouni MC where she received endovascular brain surgery by Grigoryan and Dr. David Sahakyan. Now age 7, she is doing very well and is ready to conquer the world.

Providing Services to Rural Armenia

Baghdasaryan has headed up the Neurology and Comprehensive Stroke Center of Gyumri Hospital since March 2022.

“We treat over 500 stroke patients every year. We are getting more patients because they know to come to the hospital and also don’t have to go to the capital. Also people from neighboring provinces now come to the center,” he said.

The second affiliated regional stroke center, in Vanadzor, came on line two months ago. However, it lags behind the Gyumri center for the time being.

Grigoryan said, “I’m very proud of that. Zhora was the first interventional neurologist [in Armenia]. He came from China and did a unique fellowship.” Baghdasaryan did a three-year residency in neurointerventional surgery at the Shanghai Naval Medical University.

The Gyumri Medical Center offers both thrombolytic therapy and thrombectomy — a minimally invasive brain plumbing procedure to clear blockages.

One effort championed by the ASC is TeleStroke treatment. “That is the latest major accomplishment. Through joint efforts we were able to put in place telehealth. We built on the infrastructure we had and it allowed us to have decision making and thrombolysis, without the doctor being there.” He specific said the work is allowing the doctor to save at least one hour in administering life-saving treatment or treatment that will possibly save the patient’s life or make sure they return back to normal.

At the Vanadzor Medical Center, there is still not a sufficient number of stroke specialists, and this TeleStroke program, is allowing non-specialist doctors to administer IV thrombolysis there in collaboration with stroke specialists at the Gyumri Medical Center. The center just handed its sixth patient though Tele Stroke.

Baghdasaryan said he hoped the program would expand to other rural regions in Armenia and that the concept would spread throughout the country.

Baghdasaryan said, “Our initial plans were to establish a primary stroke center in Vanadzor, for which from the technical point of view, they were ready, but since we were not able to have trained doctors there immediately. Therefore, we decided to go a different route. If we had to wait for the center with trained doctors, it might have taken a few years. The TeleStroke project allowed us to change Vanadzor to a thrombolysis-ready hospital.”

Now, the Vanadzor center transports stroke patients after procedures to Gyumri.

“Step by step it is improving. In time, we will have a primary center. This is the price we paid to have a center quickly. In a few months, we are going to analyze all the data of the two centers,” Baghdasaryan said.

He paid tribute to the ACS for keeping a close eye on the centers. “The Stroke Council keeps a close eye on things and makes suggestions. … We think we will have concrete results and now taking care of the problems we encounter will help us have a primary center.”

The key to a stroke center, Baghdasaryan said, is having property trained doctors, and that is very hard in rural areas.

“You can buy CT scans and MRI scans, but having the specialist there is the most important thing,” Baghdasaryan said.

In fact, he himself moved from Yerevan’s Erebouni Hospital to Gyumri to head the center.

They started with four specialists in Gyumri, including himself. Within the first few months, he said, the team got great help from Baghdasaryan’s friends at Erebouni. “They came to Gyumri and for a month, two specialists stayed in Gyumri until we could move things forward,” he said. “Again, like Vanadzor, we found creative solutions.”

“Now we don’t have a need for specialists in Gyumri. We have eight neurologists there, which is a very large number for a provincial hospital,” he said. “We have eight stroke specialists thanks to the Stroke Program.”

Babikian noted, “Like Zhora said, the focus for so long had been Yerevan. We are changing that. Now, we want to focus on Goris and get a center there, but it is an uphill effort. The second is to have stroke clinics all over Armenia, for checking blood pressure or other contributing factors. Finally, there are no neurointensive care units in Armenia. For example, if an Armenian sustains a serious brain injury from a motor vehicle accident, at the present time there is no neurointensive care center to provide appropriate care.”

“It’s a big lack of expertise in Amenia and the stroke counsel’s goal is to work on it,” he said. “I hope within the next two years we will get going on it.”

Fellowships

Baghdasaryan stressed that an important component of the Stroke Council was the creation of fellowships.

Grigoryan noted, “The fellowship is undoubtedly one of the biggest accomplishments of the Stroke Council. Neurologists now have an opportunity to have a formal exam curriculum developed by many of us. We already have graduates of the program. Before this, subspecialty training in neurology did not exist.”

Currently, the stroke fellowship lasts six months. Grigoryan said that plans are underway to extend the length, through efforts with Armenia’s National Institute of Health, to one year.

Yeghiazaryan added that in Armenia, there are no fellowships. “We decided to do a six-month fellowship training for doctors that were already working in other hospitals. There are two months of intensive training in major stroke centers in Yerevan, and then classes, concluded by a final exam.”

Many of the lectures were given by the doctors interviewed for this piece. While the lectures were recorded, they cannot be used even six months from now, because of the high rate of change in the science.

“We cannot recycle the same lectures over and over again because scene in stroke is evolving so fast. Every six months if not every year, it is changing,” Babikian said. “The advance is amazing.”

About five doctors have been trained so far. Another six had taken part in the fellowships, Yeghiazaryan said, but had not passed the exams.

A new initiative is to host an international endovascular conference in Yerevan at the end of September.

Added Grigoryan, “The biggest help we need is the Ministry of Health expanding the coverage of the stroke program because this is what truly revolutionized the program, to have free acute treatment. There is definitely a role in having the diaspora help with some of the projects within because the stroke program is so multifaceted.”

Armenia as Regional Medical Center

Grigoryan noted that because of the group’s efforts, “Armenia is a regional leader in stroke care. We go and train physicians from neighboring countries because Armenian is sort of politically neutral so it is easier for us and for others to come to Armenia to learn.”

The ASC has 19 members from Armenia, the US, France, Canada and Russia. In addition to Yeghiazaryan, Baghdasaryan, Babikian and Grigoryan, they are Dr. Armine Aghajanyan representing the Ministry of Health, Dr. Manvel Aghasaryan, Dr. Sevak Badalyan, Dr. Sharon Chekijian, Dr. Ruben Fanarjyan, Dr. Arthur Grigoryan, Dr. Gurgen Hovhannisyan, Dr. Yekaterina Hovhannisyan, Dr. Samson Khachatryan, Dr. David Sahakyan, Dr. Nerses Sanossian, Dr. Armine Soghoyan, Dr. Marine Tanashyan and Dr. Lina Zubalova.

Baghdasaryan noted, “Armenians all over the world, can come together and work. We have many plans between the diaspora and Armenia, which don’t go beyond pretty words. That is fine, since there is some interaction but nothing concrete gets done. This, on the other hand, is very concrete. It’s an example of when specialists from Armenia and the diaspora come together and they do some excellent work. I want to stress again that Armenia, the US, Canada, France, those are the countries where the specialists are located. Second, for me, it is most important for me, we have advanced our country unevenly. Our provinces have much fewer opportunities for advances. Our stroke efforts in the provinces go against that trend. It is at an international standard for our provincial residents. I can say that that is the focus of my efforts.”

Grigoryan added, “The biggest accomplishment, in my opinion, of this group, is to make Armenia believe that it can make a self-sufficient program with the help of the government and private owners of the hospital. We made them believe this program could become self-sufficient without reliance on funding. … We always think Armenia is so poor and rely on outside investors. We brought them to the point that they could believe this program could be moving forward and the equipment that Zhora had mentioned was purchased by the owners of the hospitals. Nobody had to twist their arms. They believed in the hospital because they had physicians like Nune, of the caliber that they believe this program has a future.”

And the knowledge accumulating there is shared by neighboring countries; Grigoryan said that a team from Kazakhstan was trained recently.

“With the help of device companies, we have a result training course that is held several times a year, which gives me an opportunity go to Armenia several times a year,” Grigoryan said. “We are a regional leader in stroke care.” Doctors from Russia, Kazakhstan, Baltic republics and Georgia for one-week training sessions. “It’s been very successful. This is the third year we are running that program,” he said. Different doctors take turns with lectures and practical instruction.

Those training sessions are for a fee, and therefore they bring in money for the hospitals.

Added Grigoryan, “Patriotism is loving your motherland with actions. Our main message is that if you want to come across as a true patriot of Armenia, you have to help with actions. This is how things get done.”