Tommy Andersson speaks to NeuroNews about how his career developed from physical education teacher to one of the world’s leading interventional neuroradiologists. He also discusses the new technology that he is keeping his eye on and addresses the biggest challenges for interventional neuroradiology in 2016.
What drew you to medicine and neurosurgery/neuroradiology in particular?
I started as a physical education teacher and got interested in work physiology and neurophysiology during those studies. I was, however, also interested in education and teaching so I first continued to study pedagogics and received a Master in educational research. During those studies I also lectured in statistical methods and history of science at the Stockholm Institute of Education. After that I had to do military service, which I did as a Russian interpreter and interrogating officer but after finishing, my research interest in physiology made me start to study medicine.
During my medical studies, I, however, became fascinated by neuropathology and started to do research in parallel with the studies and at the same time earning extra money by doing autopsies and neuropathological investigations of brains. Later, also in parallel with the medical studies, I started to work extra time in general surgery, being on-call in the ER and doing basic surgical procedures. After finishing medical school, I continued to do research and in parallel work in general surgery, and was able to finish my PhD in neuropathology and virology after a few years, using persistent viral infections to study mechanisms of acute neuronal death, like excitatory amino acids and calcium overload. As I then had experience from neuropathology, surgery and basic neuroscience, I thought it might be a good combination for neurosurgery. I approached the Department of Neurosurgery at the Karolinska Institute and was offered a residency. After finishing that and exercising vascular and spinal neurosurgery, I was offered a fellowship in vascular and endovascular neurosurgery in Toronto, Canada, fully paid by Karolinska. This offer was too good to decline so I accepted and spent two years in Toronto.
After coming back, Michael Söderman and I together built the endovascular practice at Karolinska from scratch, but I also had to become board certified in neuroradiology, which meant taking courses, etc. So I am board certified in both neurosurgery and neuroradiology today but I still feel more like a clinician than a radiologist. Recently I got an offer from AZ Groeninge in Kortrijk, Belgium, to help them build a neuroendovascular practice. My family (wife and kids still living at home) and myself spent one year full-time in Belgium and even though we have now returned to Sweden, I still work one in three weeks in Belgium.
Who were your career mentors and what have you learned from them?
Dr Göran Edner who was the head of Vascular Neurosurgery at the Karolinska was a great mentor. From him I learned a very pragmatic and efficient surgical technique and the importance of knowing the anatomy of the brain and the blood vessels. But also how to meticulously take care of your patients and to pay attention to what could seem like minor details.
Prof Karel Terbrugge, head of Neuroradiology in Toronto was another mentor. Karel has a tremendous experience in neurovascular pathology and neuroendovascular therapy, and I benefitted very much from being a fellow in his group and learned from his great knowledge. I also realised that it is so much smarter to collaborate with your colleagues in other specialities than being competitors. Toronto had a very strong neurovascular team-approach, which later has been the raw model for many other institutions.
Which innovations in neuroradiology have shaped your career?
Michael Söderman and I started to do thrombectomies in 2005. This came after I had visited the booth of Concentric Medical at the International Stroke Conference (ISC) and asked them if the Merci device was available in Europe. They said “yes” and agreed that we could start to use it, gradually in more and more patients, always with great support from the neurologists. So the Merci device with all the variants certainly meant a lot. Later we were able to establish a first-class animal angiography lab at the Karolinska in collaboration with Philips Medical Systems, and in that lab we helped Concentric to develop what later became the Trevo and we also took part in the development of the Capture, initially named IRIIS. Since then, I have hosted 35 courses in acute stroke management for more than 300 European physicians taking advantage of the animal lab in collaboration with EV-3/Covidien/Medtronic utilising the Solitaire. Most recently we have developed a collaboration with Neuravi in basic clot studies as well as regarding their Embotrap device and I am also the European principal investigator for the ARISE-II study. So, basically, you may say that innovations for acute endovascular stroke treatment have been and continue to be instrumental for my career and interest.
What has been the biggest disappointment—ie. something you thought would be practice-changing but was not?
Of course many people had great hope when the bioactive coils emerged on the market but you can today say that they were generally a big disappointment. Further, I still think that intrasaccular flow diverters have a lot to prove until I am convinced of their superiority. I thought that was a great concept but have so far not been impressed by their performance.
Can you please describe one of your most memorable cases? What did this experience teach you?
In the very early days of the Merci device, a 30-year-old man came with a vertebral dissection and a basilar occlusion. At the angio table he was completely locked-in, something he could tell us afterwards. We managed to remove the clot with the Merci in 12 minutes after which he recovered completely, basically on the table. Later on that same evening he asked me if he could leave the Neuro-ICU and go home. I saw him several times in the outpatient clinic and he described in detail the feeling of being locked-in which changed his life in many ways. To me this was early proof that thrombectomy may really work fantastically in selected cases and I never needed a randomised study to be convinced about that. Without this treatment, this particular patient most likely would have died instead of being a father and working full-time as a journalist. Another, 35-year-old female patient, mother of two, also with a dissection but with a left M1 occlusion, turned out to be pregnant which we did not know even after having consented the husband. We managed to remove the clot quickly; she recovered completely and chose to keep the baby who was born completely healthy about seven months later. She came back to visit with the baby and it was in the daily papers, “The Stroke-Baby”.
It was of course happy moments when the results from the endovascular stroke trials were presented in 2014/15 but to me also a bit sad. We were already convinced, and so were our neurologists, that this method worked for selected acute stroke patients and therefore we did not participate in any of the studies. When the results were presented, I could not help thinking on all the patients, like the two mentioned above, that could have been saved or at least helped during the previous ten years but were refused treatment due to “lack of evidence”. Evidence is of course always good; the question is how you define the term and the strengths and weaknesses that are inherant in every method that you may use to achieve such evidence. If you study the History of Science and Scientific Methods, this becomes quite clear.
What are your current research interests?
It is basically centred around acute stroke treatment. I am responsible for the Swedish National Quality Registry for endovascular stroke treatment, the EVAS-registry, and we have also implemented an extended version of the registry where I work in Kortrijk, Belgium, covering all strokes and all treatments, pharmacological and mechanical. The goal of such a registry is of course to increase the safety and quality of our treatments, basically on all fronts. I am particularly interested in how we can make our procedures faster and more efficient and have therefore established collaboration with the Laboratory for Thrombosis Research at KULAK (a filial of the Leuven University) in Kortrijk, and with Neuravi, who also have a great interest in “clotology” and the interaction between clots and devices. We are trying to study the composition of various clots and how they behave and interact with our attempts to remove them. We are also interested in what happens in the microcirculation in acute stroke patients, especially after reperfusion, and I am therefore collaborating with companies developing drugs to prohibit microcirculation thrombosis due to reperfusion injury.
You have been involved in many studies into new neuro devices throughout your career. In your opinion, what has been the greatest advancement, and how do you see the field of neuroradiology developing in the future?
Surely when Thomas Liebig and others discovered that the Solitaire stent could be used as a retriever for thrombectomies, it was a great advancement. The procedure became so much safer, more efficient and beyond all, easier to perform compared with earlier devices like the Merci, snares, etc. Then I do think that flow diverters have increased our possibility to treat many difficult aneurysms, not least the giant ones. In the future I think initially that the stroke treatment will continue to evolve and expand but finally, I believe that better drugs will be developed that can both expand the time window and more efficiently dissolve the thrombus. I think there will still be a role for endovascular stroke treatment, perhaps for certain clot types or when there is predominately a haemodynamic problem, but pharmacology will “strike back”. I also think that new pharmacological methods will be introduced for other neuroendovascular problems, for instance drugs that can stabilise aneurysms or even make them regress. There will be a role for endovascular therapy in the future but it will be different from what we experience today.
What new technology are you keeping your eye on?
There are some interesting new retrievers that are being tested right now. Retrievers that work with a different concept, not just like another stent retriever trying to reach the market. I think we also need better adjunctive material, for instance I have been asking for a long time for an intermediate catheter with a balloon. I know that there now are some interesting devices being developed that work with a similar principle, focussing on flow-arrest, even though not always utilising a balloon to achieve this. Further, it will be interesting to see how the initial results for the Medina coils look.
What are the biggest challenges for interventional neuroradiology in 2016?
The biggest challenge is probably to keep up with the demand for thrombectomies. We are facing a huge organisational and educational problem at the moment. There is a lot of pressure on groups and physicians to perform endovascular stroke therapy, pressure from society, hospital administrations but also from eager neurologists. In my experience, it is often the same clinicians that previously refused to send patients for thrombectomy because there was “no evidence” that now refuse to send them because they want the patients to be treated in their own hospital. For our patients’ sake, we need to focus on knowledge, training and experience; it is not the title on your name tag that matters but your training and experience. I think that there is unfortunately too much ego in this and many other medical specialities. We treat patients to prove to others and ourselves how good we are, not always for the best of the patient. And instead of collaborating we become competitors, “mine is bigger than yours…”. There is unfortunately very often a hidden agenda behind certain behaviour, which is not always in the best interest of the patients, even though we pretend that it is.
What are the most important trial results that you are awaiting in 2016?
I think it will be interesting to see if the time window for endovascular stroke treatment can be extended. There are studies for that but 2016 is probably too early to see the results. I think there is a basic problem with such an extension namely that it seems like a thrombus becomes more difficult to remove, regardless of technique, the longer it remains in place. So, it will be interesting to see if this shows up in these studies. For the more distant future I think it will be interesting to see the results from studies focussing on the microcirculation and reperfusion injury problems that we may experience after thrombectomies without even realising it. We can certainly optimise our technique, but also everything around the procedures.
You have mentored and trained a number of physicians throughout your career. What advice do you hope they will always follow?
Always put the patient´s interest in front of your own ego. We are treating physicians, not performing artists in a circus. Always make a plan and stick to it, avoid making difficult decisions on-site, and, have a plan B ready in case the first one fails. If something goes wrong, and it will, always keep your cool, take a deep breath and try to make a rational decision, if possible after consulting some experienced colleagues. A good operator is not the one that never has any problems but the one that can handle them rationally. If you still have a complication, be perfectly honest with yourself and your colleagues but perhaps even more important with the family. Relatives will always accept a mistake but never a lie.
What three questions in neuroradiology are still in need of an answer?
There are many, of course. To me an important question is how we should best organise the acute stroke care in the future but also if and how we should select our patients for thrombectomy. On the same theme, how we should refine our technique to be faster and avoid secondary injuries. Outside the stroke field, I think it is important to further investigate whether the results from the ARUBA trial really means that absolutely no unruptured AVMs should be treated, not even the very low-grade ones.
What are your interests outside of medicine?
It is basically my family of course, wife and four children, but then mainly sports, especially football (or “soccer”). I used to play myself and was a trainer at the national level. Now my two sons play and especially the youngest has performed at a high level. My background as a gym teacher makes it almost impossible for me not to terrorise my children with training schedules and the like. I also have a brown belt in ju-jutsu, but a knee injury has forced me to stop (at least temporarily). You could say that I basically only do two things, either work or support sport activities for my children. Beside that, both my wife and I have an interest in trying to live healthy regarding food products and so on, but also trying to be environmentally friendly. For instance, I try to bike to work as much as I can and if that is impossible, I will take the bus or subway instead of always driving. It actually works very well!
- Professor of Neurointervention, AZ Groeninge, Kortrijk, Belgium
- Senior Consultant in Neurointervention, Department of Neuroradiology, and director for Education in Neurovascular Treatment, Karolinska University Hospital, Stockholm, Sweden
- Shared director for the Section of Neurointervention and Angiography at KERIC (Karolinska Experimental Research and Imaging Centre)
- Chairman of the Swedish national quality registry EVAS (EndoVascular therapy for Acute ischemic Stroke)
- Chairman of the Examination Committee and member of the Executive Board in ESMINT
1994 Doctor of Medical Science (PhD), Karolinska Institute, Stockholm, Sweden
1994 License to practise medicine, the Swedish National Board of Health and Welfare, Stockholm, Sweden
2000 Qualification as a Specialist of Neurological Surgery (board certified), the Swedish National Board of Health and Welfare, Stockholm, Sweden
2000-2002 Fellowship in Vascular Neurosurgery and Interventional Neuroradiology, Departments of Neurosurgery and Medical Imaging, Toronto Western Hospital, Toronto, Canada
2004 Qualification as a Specialist of Neuroradiology (board certified), The Swedish National Board of Health and Welfare, Stockholm, Sweden
2004 International Master Degree in neurovascular Diseases, Paris Sud University, France, and Mahidol University, Thailand
Invited lecturer at >200 international congresses since 2004
Resident’s best lecturer award Beitostölen, Norway, March 2007 and April 2011 (Scandinavian course in vascular neurosurgery)
Visiting Professor, Manila, Philippines, April, 2008 and February 2012
Author of >50 original peer-reviewed articles, 10 book chapters and numerous abstracts