News

Hungarian Stroke Program: 1988–2006

Zoltan Nagy1�, Andras Javor2, Peter Harcos3, and Michael Bodo4

Approximately 50 000 acute stroke emer-

gencies occur annually in Hungary, about

20 000 are fatal within 30 days, making

stroke the third most common cause of

death in Hungary after heart attack and

cancer (1, 2).

From 1988 to 1994, despite political and

economic changes and limited financial

resources, efforts by a small group of physi-

cians evolved into a modern, comprehen-

sive system for treatment of stroke victims.

From 1990 to 2004, stroke mortality

decreased in Hungary from about 240/

100 000 to about 180/100 000, and cardio-

vascular mortality increased slightly (3).

In 1988, a group of neurologists attend-

ing a meeting in Gyor, Hungary, issued a

mandate to decrease stroke mortality. At

that time, it was highly unusual for a non-

government entity to address a public

health problem in Hungary.

As a result of the meeting, a three-

member leadership/organizational com-

mittee was appointed, they then set up a

foundation, initiated free postgraduate

education in stroke treatment, conducted

a survey to assess stroke treatment in

Hungary, and formed stroke units in

several hospitals.

In 1988–1989, the Cerebrovascular

Section of Hungary’s Neurological and

Psychiatric Society was created to increase

the number of medical doctors involved

in the care of stroke patients. The objec-

tives were to include physicians from a

variety of specialties (neurology, internal

medicine, radiology, angiology) and to pro-

vide free postgraduate education through

scientific meetings, research seminars and

case presentations. The group provided

the first postgraduate education for

stroke neurologists in Hungary. Expert

researchers and clinicians from several

universities (Budapest, Debrecen, Pecs

and Szeged) and the National Institute

of Neurosurgery gave guest lectures at no

cost to participants. Semmelweis Univer-

sity Medical School provided classrooms.

Conferences were held at government

sites, and a satellite symposium of the

International Society of Cerebral Blood

Flow and Metabolism was organized in

Budapest (1989).

Kalman Santha Foundation(KSF)

As a funding mechanism for receipt of

donations and grants, the KSF, named

after a physician revered for humanitar-

ianism, was formed in 1989 (4). The main

supporter of the KSF was the Chemical

Works of G. Richter, the leading pharma-

ceutical company in Central Europe

(5). One of the Richter company chiefs

contributed subsidized printing and the

mailing of a free bulletin that was distrib-

uted to members of the Cerebrovascular

Section of the Neurological and Psychia-

tric Society (6).

Stroke treatment survey

A survey was conducted in 1989 to assess

the adequacy of stroke treatment in Hun-

gary. The survey showed that 37�7% of

patients were treated within six hours of a

stroke, 32�6% within 6–24 h, and 30%

after 24 h. The average CT time for a stroke

patient was 12�5 h, considerably greater

than the NIH/NSA recommendation to

have the first CT and begin thrombolytic

therapy within 3 hours. At that time, there

were only 40 CT devices in Hungary. This

information helped explain the country’s

high rate of stroke mortality.

Hungarian Ministry of Health

In 1993, the Neurological Committee

of the Hungarian Government’s Ministry

of Health announced guidelines for the

treatment of stroke and initiated formal

postgraduate education for stroke neu-

rologists. Initially, 26 stroke centers were

organized for the acute care of stroke

patients. Stroke units were usually created

within hospital departments of neurol-

ogy, requiring cooperation and support

among various nonneurology profes-

sionals involved in stroke treatment.

This is a typical problem in countries

during the initiation of modern stroke

care and in transferring research results

into practice (7, 8). The Ministry of

Health provided its first financial support

for the stroke initiative in 1992–1993, by

funding the purchase of Doppler devices

and obtaining financial support from the

World Bank.

March 11, 1992, the Ministry of Health

announced the establishment of the Hun-

garian National Stroke Program (NSP)

and identified the following objectives:

� to reduce stroke morbidity and mor-

tality in Hungary to the average European

level within a decade

� to stop the trend of stroke occurrence

in increasingly younger age groups in

Hungary, and

� to discover the health, social and

environmental factors whose modifi-

cation could retard degenerative illness

(atherosclerosis) and reduce stroke risk

factors (9).

Correspondence: Zoltan Nagy�, Director

General, National Institute of Psychiatry and

Neurology, 116 Huvosvolgyi St.1021, Budapest,

Hungary. Tel: 1361 391 5301; Fax: 1361 391

5493; email: foig.titkarsag@opni.hu1National Stroke Center, Budapest, Hungary2Semmelweis University Medical School,

Budapest, Hungary3St. Imre Municipal Hospital, Budapest, Hungary4Chemical Works of Gedeon Richter Ltd.,

Budapest, Hungary

& 2006 The Authors.240 Journal compilation & 2006 International Journal of Stroke Vol 1, November 2006, 240–241

Stroke screenings

A computerized cardiovascular/stroke

prevention tool to detect arteriosclerosis

was developed, and complex screenings

were initiated in Csengersima, a rural

village in eastern Hungary, to identify the

high risk population (10, 11). The device

received the only award of the French

Minister of Scientific Research in 1993.

First Hungarian StrokeConference

In 1992, the First Hungarian Stroke

Conference was held, sponsored by the

KSF. There were about 500 registered

participants. The conference included

guest speakers from the United States

and western and central Europe, and

included ten lectures, 56 oral presenta-

tions, 39 posters, a TICLID symposium

and a round table discussion. The round

table discussion, chaired by the Deputy

Minister of the Ministry of Welfare,

stressed the importance of health organi-

zation and program financing in devel-

oping and sustaining a stroke treatment

program as well as increasing medical

knowledge. Abstracts of the conference

were published in Clinical Neuroscience/

Ideggyogyaszati Szemle (46/5-6, 1993).

Since that time, the Hungarian Stroke

Conference has been held biannually.

Hungarian Stroke Society

The name of the Cerebrovascular Section of

Hungary’s Neurological and Psychiatric

Society, a private organization, was changed

to the Hungarian Stroke Society in 1993. In

2006, membership was about 400 (1).

National Stroke Center (NSC)

In 1994, the National Stroke Center was

established by the Ministry of Health. The

NSC took over the publication of the

information bulletin originally published

by the SKF, covering the full spectrum of

vascular neurology (12). The NSC direc-

tor published a textbook of vascular neu-

rology in 2006 (13) and served as

president of the Central Eastern European

Stroke Society.

Clinical and research results of Hun-

garian vascular neurologists and stroke

units have been published in both Hun-

garian and international journals. In

2006, Hungary had 32 stroke centers (1).

Today, postgraduate education of stroke

neurologists has been integrated into the

Hungarian medical postgraduate educa-

tion system. The activities of professional

associations as well as the program’s ad-

ministrative and financial activities are all

operated and coordinated through the

NSC, a government entity (1, 14).

NSP Goals for 2010

� Reduce acute stroke mortality by 15%

� Reduce stroke morbidity by 15%

� Treat a larger ratio of stroke patients in

specialized wards or facilities

� Promote the following in working to-

wards the primary and secondary pre-

vention of vascular disorders: healthy

nutrition, physical activity, smoking

cessation, reduction of alcohol con-

sumption, focus on health promotion

within the educational system

� Improve the effectiveness of screening

for hypertension and treating hyper-

tensive patients

� Create a framework for effective reha-

bilitation

� Design criteria for centrally accrediting

stroke wards and enforcing them sub-

sequently, and

� Reestablish a national database suitable

for epidemiological studies.

Acknowledgements

The authors thank Peter Jozan for supply

of statistical data, Istvan Fejes for finan-

cial data, Emma Bacskai, Berko Zoltanne,

Gabriella Perjes for help in mailing KSF

Bulletin, Richter Ltd for KSF publication

and general support, IBM Budapest Of-

fice for a copy machine, OMFB for finan-

cial support, and Janice Meer for editorial

assistance.

References

1 Hungarian Stroke Society: (www document).

URL: http://www.strokeline.hu/ (Accessed 20

February 2006).

2 Bonita R, Stewart A, Beaglehole R: Interna-

tional trends in stroke mortality: 1970–1985.

Stroke 1990; 21:989–92.

3 Hevesi J. Dominant causes of death: (www

document) URL: http://portal.ksh.hu/pls/ksh/

docs/hun/stadat/load1_01_02.html. (Acce-

ssed 20 February 06).

4 University Medical School. Debrecen, Hun-

gary. Kalman Santha. URL: http://www.

neuropat.dote.hu/ideg/ideg1.htm (Accessed

3 March 2006).

5 Richter Ltd.: (www document) URL: http://

www.richter.hu/RichterWebsite 21 February

2006

6 Bulletin of the Cerebrovascular Section of

Neurological and Psychiatric Society and Kal-

man Santha Foundation, Richter’s documen-

tation number: RGD 32 042.

7 Nagy Z: Vascular neurology: a new subspeci-

alty of neurology. LAM 2005; 15:187–90.

8 Norrving B, Adams RJ: Organized stroke care.

Stroke 2006; 37:326–8.

9 The international statistics leaded by Hun-

gary: Nepjoleti Szemle 1992; 7: 9–13.

10 de Freitas GR, Bogousslavsky J: Pri-

mary stroke prevention. Eur J Neurol 2001;

8:1–15.

11 Bodo M, Thuroczy G, Nagy I et al. A complex

cerebrovascular screening system (Cer-

berus). Med Prog Through Technol 1995;

21:53–66.

12 Agyerbetegsegek (Cerebrovascular disease).

Budapest: Literatura Medica. (www docu-

ment) URL: http://www.lam.hu/ (Accessed

21 February 2006).

13 Nagy Z (ed). Vascularis Neurologia. Buda-

pest, Hungary: B1V Lap- es Konyvkiado Kft,

2006.

14 Foundations: (www document) URL: http://

www.opni.hu/alapitvanyok.htm (Accessed 21

February 2006).

& 2006 The Authors.Journal compilation & 2006 International Journal of Stroke Vol 1, November 2006, 240–241 241

Z. Nagy et al. News