Building regional stroke networks for mechanical thrombectomy. Gunnar Andsberg, MD PhD Neurology, Skånes University Hospital Lund Sweden
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1 Building regional stroke networks for mechanical thrombectomy Gunnar Andsberg, MD PhD Neurology, Skånes University Hospital Lund Sweden
2 Region Skåne Halmstad Ljungby Växjö Karlskrona Karlshamn Ängelholm Helsingborg Hässleholm Kristianstad Lund Malmö Trelleborg Ystad Inh Stroke 8 Acute care hospitals 1 Thrombectomy centre 50 km
3 Stroke Networking for thrombectomy - my view of important factors Evidens Regional Stroke Consultant on call consensus PreHospital Stroke Network speed Stroke Treatment Team for thrombectomy deliver high quality Stroke Registers follow up results and comparances
4 Evidens and health economy evaluation during 2015 Health Technolgical Assessment (HTA) report Thrombectomy with stent retrievers in acute ischemic stroke Evidens evaluation (meta analysis GRADE) Health economical evaluation Skåne perspective based on reallife data from the Swedish Stroke Register In collaboration Katarina Steen Carlsson, Health Economy, Lund Univeristy Expanded health economical evaluation of thrombectomy from a swedish perspective Life time perspective Stroke population of severe stroke (NIHSS 8) Real life data (the Swedish Stroke Register) Published in International Journal of Stroke 2017
5 Differences in costs for thrombectomy vs standard care SEK Published in: Katarina Steen Carlsson; Gunnar Andsberg; Jesper Petersson; Bo Norrving; International Journal of Stroke Ahead of Print DOI: / Copyright 2017 World Stroke Organization
6 mrs distribution; 5 RCT 21% 38%
7 Thrombectomy (n) - Skåne Source: The Swedish Stroke Register. Web adress:
8 Regional Stroke Consultant on call since 2015 Experienced stroke neurologists One telephone number Decision support 24/7 Intravenous thrombolysis 50 km Thrombectomy Craniectomy malignant infarcts Complex stroke cases Decentralized model 2 Kristianstad, 1 Hässleholm, 1 Ängelholm, 1 Trelleborg, 2 Malmö, 8 Lund Advantage: Consensus, Exchange experience, Fast spread of new concepts Part of Regional Stroke Network Guideline doument acute stroke treatments
9 PreHospital Ambulance Stroke Test PreHAST pilot study in Hässlehom 2014 PreHAST - a novel test of typical stroke symptoms adapted for ambulance services with high sensitivity for stroke (>85%) and a grading stroke severity (0-19 p). 100% 80% 60% 40% Increasing specificity with higher scores 20% 0% Stroke/TIA Specificity PH>0 PH>1 PH>2 PH>3 PH>4 PH>5 Dual purpose of stroke screening in general and grading stroke severity Published in: Gunnar Andsberg; Magnus Esbjörnsson; Arne Olofsson; Arne Lindgren; Bo Norrving; and Mia von Euler: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine :37 DOI: /s Copyright The Author(s) 2017
10 PreHAST The standardized neurological examination used by ambulance services in Region Skåne since 2015 when acute stroke is suspected. Takes 2-3 minutes to perform Aim A. Screening for typical stroke symptoms (including speech disturbances, deviation conjugee, hemianopia, paresis of face, arm and leg, hemianesthesia and neglect) B. Evaluate severity of symptoms C. Guiding in Stroke triage for thrombectomy
11 Stroke triage for thrombectomy Skåne model Criteria -Suspected stroke -Vital patient -Severe deficit (PreHAST 6 p) Pre notify Acute Stroke Doctor -Description of deficit -PreHAST score Ambulance hold during radiological evaluation Pre notify Regional Stroke Consultant -Description of deficit -NIHSS score Drip and ship - Central ocklusions
12 Stroke triage for thrombectomy Skåne model Other factors to decrease time to treatment One number to competence principle Ambulance to Acute Stroke Care Doctor one number Acute Stroke Care Doctor to Regional Stroke Consultant Regional Stroke Consultant to Interventionist one number Region shared servers for radiology and medical records mobile radiological evaluation (ipad; Sectra UniView) If necessary more advanced radiological evaluation at thrombectomy centre
13 Why not direct transportation to thrombectomy centre in Skåne? Skåne: many patients 30 to 90 min extra transportation time to thrombectomy centre Saves time to thrombectomy but could lead to loss of time to other treatments PreHospital: Severe deficit in suspected stroke patients Unclear benefit if direct transportation Stroke mimics Intracerebral hemorrhage Ischemic stroke without central ocklusion Ischemic stroke with central ocklusion - IVT-responders
14 Stroke Team for Thrombectomy Neurointerventional team Neurointeventionists (on call 24/7) 3 (4) Stroke neurologist team for advanced stroke treaments Experienced Stroke neurologists (on call 24/7) Regional Stroke Consultants 10 Extended collaboration Neuroanesthesiology Neuro Intensive Care Unit
15 IVT and Thrombectomy, all ages Hospitals Skåne 2016 Hässleholm SUS, Lund Helsingborg SUS, Malmö Trelleborg Kristianstad Ystad Landskrona Ängelholm 0% 15% 30% Stockholms län 2016 Skåne 2012 Västra Götaland 2016 Danderyd Södersjukhuset KI, Solna St Göran KI, Huddinge Norrtälje Södertälje Source: Vården i siffror Web adress: Hässleholm Helsingborg Ystad SUS, Lund SUS, Malmö Trelleborg Kristianstad Ängelholm Landskrona Sahlgrenska Södra Älvsborg Alingsås Skaraborg Kungälv NU-Sjukvården Lidköping Mölndal 0% 15% 0% 30% 15% 30% 15% 30%
16 IVT and Thrombectomy, all ages Regions A. Reperfusion frequency Skåne % 15% 10% 5% 0% SWEDEN SKÅNE Source: Vården i siffror. Web adress: based on data from The Swedish Stroke Register. Web adress:
17 Special thanks to Magnus Esbjörnsson, Hässleholm, collaboration in development of Regional Stroke Network, PreHAST and good luck with Prehospital Telemedicine projects Per Undren, Chief Neurointerventional team, Lund Mia von Euler, associate professor, Stockholm Development PreHAST Arne Olofsson, Consultant Ambulance services, Skåne Collaboration in development of PreHAST and leading the Prehospital Stroke Network Bo Norrving, professor, Lund, Sweden RiksStroke Birgitta Ramgren, Neurointerventionist, Lund Hard work with EndoVascular treatment of Acute Stroke registry Marco Brizzi, Stroke neurologist, Malmö Fast Track development for acute stroke treatments (10min/30min)
18 Dawn in Skåne
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