Improving the stroke pathway in southern Sweden 

Getting ahead in the race against time 

By implementing a series of procedural and technological innovations, Skåne University Hospital in Lund and 13 local hospitals in the area have greatly improved the patient pathway in the stroke network of southern Sweden. Saving valuable time was a prime objective but also the identification of more patients eligible for endovascular thrombectomy. 

Distance is a major challenge in Sweden’s southernmost stroke network that encompasses the regions of Skåne, Blekinge and southern Småland. The Comprehensive Stroke Center (CSC) at the University Hospital in Lund is located in the very south of this large catchment area. This means that it can take up to three hours to get a patient there from some of the Primary Stroke Centers (PSC) at the local hospitals in the region. To address this situation, the network has implemented a number of procedural changes and technological improvements in order to gain time across the entire stroke pathway but also to optimize the identification of patients with ischemic stroke who can profit from endovascular thrombectomy (EVT). 

Image of Skane University Hospital in Lund, Sweden

The Comprehensive Stroke Center (CSC) at Skåne University Hospital in Lund treats about 250 cases per year and receives patients from the entire southern region of Sweden with its 13 Primary Stroke Centers (PSC) in Skåne, Blekinge, and southern Småland. More than half of the cases occur during off hours, i.e., after 4 p.m. and on weekends. 

Getting a head start

Since 2017, the EMS paramedics in southern Sweden accompany stroke patients along the entire emergency pathway. They wait at the primary hospital in case the patient has to be sent to the CSC as a result of the diagnostic imaging and the consultation with the on-call expert. If secondary transportation was indicated in the past, it could take up to 60 minutes to acquire another ambulance to drive to Lund. Staying with the patients for the whole journey not only saves time, it also provides an element of stability for the patient in this emergency situation, and the paramedics can also report directly to the CSC team about any changes in neurology or vital signs.

The first addition was pre-notification of the local hospital by the paramedics of the Emergency Medical Services (EMS) team who first encounter the patients and initiate the prehospital stroke pathway. This allows the PSC to get their CT ready for the stroke patient and saves between 15 and 30 valuable minutes right at the beginning of the race against time that every stroke case represents.
To tighten the stroke chain further, Skåne University Hospital also installed a central 24/7 on-call expert. “All 13 PSCs can call on us to get support for questions about thrombolysis or even help with deciding whether their current case is actually a stroke. But we also select patients eligible for thrombectomy during these calls,” explains Teresa Ullberg, Senior Consultant in neurology at Skåne University Hospital.
Ullberg is one of the neurologists who alternate as on-call experts. During a typical night shift from 4:00 p.m. to 8:00 a.m., she gets between five and ten calls, and she emphasizes how relieved the callers – during off-hours they are typically young emergency doctors – are to get neurologic support and even the additional advice from an interventionalist at the CSC. For Johan Wassélius, Senior Interventional Neuroradiologist at Skåne University Hospital, this telemedical service has proved vital in identifying candidates for EVT: “We get many patients that we’d otherwise not have treated, and we get them sooner.” As a result, the number of patients referred to Lund for thrombectomy have more than doubled.

<p>Teresa Ullberg&nbsp;</p>

Speeding up therapy

Maps and graph that show the six CSCs in Sweden and the significant increase in EVT treatments per region and per EVT center between 2015 and 2019.

The maps and graph show the CSCs in Sweden and the significant increase in EVT treatments per region and per EVT center between 2015 and 2019.

Wassélius J, Arnberg F, von Euler M, Wester P, Ullberg T. “Endovascular thrombectomy for acute ischemic stroke.” J Intern Med. 2022. doi: 10.1111/joim.13425

Once the patients arrive at Lund, they’re taken straight to the angio suite instead of the ER. CT imaging is only done if patients have been sent directly to the CSC (instead of being sent on from a primary hospital), or if their condition has significantly improved or worsened during transport, a question that the accompanying EMS paramedics can often help to decide. Once the team has decided on EVT, the interventionalist can immediately start with the procedure using the CT images from the primary hospital as a roadmap. 

Its two new ARTIS icono systems help the University Hospital in Lund take stroke care to the next level. 

To improve the diagnostic and therapeutic options in the angio suite, Skåne University Hospital has recently upgraded their two labs with ARTIS icono systems from Siemens Healthineers. One was installed a year ago, the other just last week. Wassélius is very happy to have two of these high-end systems now: “It’s very helpful, because we no longer have to consider which patient should go where. You have the same advanced features in both rooms, and you can instantly find your way around, no matter which angio suite you’re using. This means that you can focus entirely on the patient and what you want to achieve.”
But even more valuable to him are the numerous technologies that the new systems have brought to the angio suite: “The systems are completely motorized, and that means fast, precise maneuverability,” Wassélius says. “They also enable quick and easy fusion with CT angiography images, which gives us faster access and reduces the contrast dose.* Also, the CBCT imaging is of much higher quality now and we can even perform CBCT angiography.” All this makes a next-level biplane angiography system like the ARTIS icono an important investment in stroke treatment today in Wassélius’ eyes: “It represents a major technological advance, and it’s really taking minimally invasive neurosurgery to a completely different level.” 

<p>Johan Wassélius&nbsp;</p>

A next-generation mobile CT scanner helps eliminate many transports from the ICU to radiology, saving valuable time and staff resources.

After the intervention, seriously ill patients are admitted to Neuro ICU at Lund, where they are routinely checked with CT imaging to detect potential complications. If that should be the case, the race for time suddenly starts all over again, because taking an ICU patient to radiology is a complicated and also risky affair. The team at Lund has solved this problem with their new SOMATOM, a mobile head CT scanner that can be brought right to the patient’s bed. This means that identifying serious complications can now be done in minutes without having to compromise on image quality: “In the past, mobile CT units came with a much lower image quality, but the SOMATOM is almost as good as a stationary CT,” Wassélius says.

A new toolbox

To further improve the stroke workflow in the future, Skåne University Hospital also has another powerful ace up its sleeve with its new NAEOTOM Alpha. This innovative CT scanner has the potential to revolutionize stroke treatment, as Wassélius explains: “Photon-counting is a quantum leap in stroke imaging that we’re only recently starting to grasp.” He is eager to find out what this disruptive CT technology is capable of: “We’ve already seen an increase in quality with the dual energy machines, but the NAEOTOM Alpha has the potential to create an entirely new toolbox for us. The much-improved tissue discrimination could enable us to determine whether the thrombus is mostly fibrin-rich or more of a red clot. Then we could potentially adjust our intervention strategy based on the material composition of the thrombus.”
The process of getting ahead in the race against time is far from finished for Skåne University Hospital and its collaborating regional hospitals. A future improvement that’s being discussed is the installation of a mobile stroke unit that could bring advanced pre-hospital diagnostics to rural areas. “In some cases, we lose time because the ambulance has to drive, say, one hour north to get the patient to the primary hospital and then has to drive all the way back to bring the patient to us,” Ullberg says. “A mobile CT could be waiting at a strategic location where it can easily reach the problematic areas.”

The next level

A promising next step in improving stroke treatment at Lund University Hospital could be the introduction of an “angio-only” approach to shorten door-to-groin time. 

Finally, Wassélius and his colleagues are also thinking about installing a angio-only workflow at Lund that would take patients directly to the angio lab for their initial imaging. This is now possible thanks to the high-quality CBCT images that the ARTIS icono can provide. Because a syngo DynaCT scan in the angio lab takes just a few seconds. Wassélius estimates that this can save at least 30 to 45 minutes in the stroke chain.*
Wassélius is confident that this is the right direction for the stroke workflow to progress: “I think the future of stroke treatment will be focused on the angio suites, similar to the trend for myocardial infarctions. All severe acute stroke cases may initially benefit from the direct-to-angio approach, and later on, perhaps all acute strokes.”