NICO.LAB announces new partnership with AI Advance

By | News

NICO.LAB and AI Advance announced a new partnership that will revolutionise stroke care across Australia and New Zealand. AI Advance will be distributing StrokeViewer, an artificial intelligence solution that empowers physicians with the triaging, diagnosis and treatment decision making of patients in the emergency stroke setting.


StrokeViewer is a clinical-decision support tool that combines artificial intelligence (AI) algorithms and a communication platform to help stroke experts make faster well-informed treatment decisions. StrokeViewer allows physicians to diagnose stroke patients remotely, on any mobile or desktop device. The secure cloud-based infrastructure of the solution makes implementation straightforward, requiring no additional hardware. Hospitals across Australia and New Zealand, including those with minimal infrastructure, can implement StrokeViewer and raise their standard of stroke care.

Jeroen Pex, Chief Commercial Officer at NICO.LAB: “AI Advance brings a long experience in the medical field and large network to the table, enabling NICO.LAB to hit the ground running in Australia and New Zealand. Their focus on AI solutions, makes them the right partner for us and for the hospitals and clinics in Australia and New Zealand.”

Peter Rady, Director and Co-Founder of AI Advance (Australia): “I am really excited to bring StrokeViewer to the Australian market. As a country we are leading with mobile stroke treatment which is attracting government investment to reduce the time to treatment of stroke patients. I am proud that StrokeViewer can further support this strategy.”

Stroke is a time-critical disease and third-biggest killer worldwide. During a stroke two million brain cells die every minute until blood flow is restored [1] therefore starting treatment earlier can make the difference between recovery or life-long disability. In Australia, every 19 minutes a patient suffers from a stroke. There are an estimated 450,000 stroke survivors living in the community, needing daily care[2]. Over half of all stroke survivors need some form of care. Besides the devastating effects on people’s lives, the economic burden in Australia in 2020 was over $6.2 billion[2].

The TGA and Medsafe cleared algorithms are embedded in a cloud-based infrastructure. Medical specialists are notified of the AI results on their smartphone within minutes of the patient being scanned. The physicians are then able to inspect the CT images via a certified diagnostic viewer and diagnose a patient remotely or at the hospital.

[1]Saver, 2006 – “Time is brain—quantified.” Stroke 37.1 (2006): 263-266


Merel Boers CEO & Founder

An introduction to our CEO, Dr. Merel Boers

By | News

NICO.LAB’s CEO, Dr. Merel Boers co-founded the company in 2015 following the groundbreaking MR CLEAN trial. The first Randomized Clinical Trial that proved the benefit of Endovascular Treatment which led to a paradigm shift in acute stroke care and triaging.

Merel is an ambitious and inspiring entrepreneur as well as an innovative researcher. At a very young age Merel is driving NICO.LAB to internationalisation and great success.


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Merel gained a huge amount of knowledge through her PhD in stroke imaging that led her to obtaining one of the highest honours, summa cum laude, in her research at the University of Twente. During her PhD working at the Academic Medical Center, Amsterdam, Merel and her research colleague, Renan Sales-Barros (co-founder and Chief Technology Officer of NICO.LAB) identified the opportunity and need to improve care for such a time critical disease.

NICO.LAB at ISC 2021

By | News

Our cloud-based solution enables physicians to provide every stroke patient with the right treatment in time.

With Medicare Reimbursement, ICD-10-PCS code, we can help your hospital to improve patient outcome while reducing hospital costs

StrokeViewer helps to reduce undetected LVOs

  • Artificial intelligence detects occlusions up to distal M2 on CTA
  • User immediately notified of findings via App/email
  • Automated PDF reports

“I think it works brilliantly as a screening tool to alert the team that there is high suspicion of LVO. The communication gets everyone coordinated in a parallel fashion...”

Dr. Albert Yoo, MD

Medical Director at Texas Stroke Institute

Want to schedule a meeting with Merel, our CEO or one of our Country Managers?

Get in touch!

    StrokeViewer Features

    Mobile miniPACS

    This mobile miniPACS is an extension to the familiar hospital PACS , enabling stroke experts to access analyzed patient scans within minutes, anywhere on their device.

    Seamless image sharing

    Rapid image exchange allows stroke experts to forward patient scans to the nearest intervention center with the click of a button, physicians can then plan for patient arrival.

    Certified Diagnostic Viewer

    The certified diagnostic viewer is a unique feature to StrokeViewer. This allows physicians to diagnose patients from their mobile device.

    3D Treatment Planning

    This feature is included in StrokeViewer LVO. It helps neurologists and radiologists visualize the brain vasculature and blood clot.

    Interventional neuroradiologists in particular have reported their use of the 3D Treatment Planning feature for selecting the micro catheters to use prior to patient arrival.

    “It can be really helpful in detecting distal occlusions, because the 3D Treatment Planning can make an occlusion more obvious especially when a vessel goes into another slice or in a different direction. It prevents you from mistaking an occlusion for a loop in the vessel”

    Dr. Bart Emmer, Ph.D.

    Interventional Neuroradiologist, Amsterdam UMC, Netherlands

    New Paper Quantifying the Health and Cost Effects of Faster EVT

    By | News

    Currently 20% of LVOs are initially undetected1 and 40% of patients are treated too late2.

    At NICO.LAB we are working hard to ensure we help hospitals to reduce this % and streamline the workflow to reduce door to groin puncture time. It is extremely rewarding to read a paper with powerful numbers that actually quantifies the impact it has on a patient when just one minute is saved.

    The main conclusion from the paper is that EVT administered 1 minute faster results in overall healthcare cost savings on average of €309 and 1.3 days of disability free life in the Netherlands. Those numbers for an hour faster treatment translate to €18, 540 euro and 80 days on average.

    Click here to read the full paper from the MR CLEAN Registry titled Quantified health and cost effects of faster endovascular treatment for large vessel ischemic stroke patients in the Netherlands3



    Henk van Voorst,Wolfgang G Kunz,Lucie A van den Berg,Manon Kappelhof,Floor M E Pinckaers,Mayank Goyal,Myriam G M Hunink,Bart Emmer,Maxim Johan Heymen Laurence Mulder,Diederik W J Dippel,J M Coutinho,Henk A Marquering,Hieronymus D Boogaarts,Aad van der Lugt,Wim H van Zwam,Yvo B W E M Roos,Erik Buskens,Marcel G W Dijkgraaf,Charles B L M Majoie



    Journal of NeuroInterventional Surgery



    BMJ Publishing Group Ltd.



    Jan 21, 2021


    1: B. Fasen, R. Kwee et al. AJNR 2020
    2: Kunz, W. G., et al. “Lifetime quality of life and cost consequences of treatment delays in endovascular thrombectomy for stroke.” BMJ 10 (2019)
    3: van Voorst H, Kunz WG, van den Berg LA, et al Quantified health and cost effects of faster endovascular treatment for large vessel ischemic stroke patients in the NetherlandsJournal of NeuroInterventional Surgery Published Online First: 21 January 2021. doi: 10.1136/neurintsurg-2020-017017

    Generating brain CT images using Disentangled Variational Autoencoders

    By | News

    Can we generate CT slices of a brain? Or interpolate between two different brains? Or… if we represent the brain image as a set of numbers, can we change brain size, rotation, anatomy just by tweaking these numbers?

    I asked these questions when I first read the paper about Disentangled Variational Autoencoders (β-VAE).

    According to the paper, you can encode an image into a small numerical vector in a way that each vector’s variable will be responsible for one independent and interpretable visual feature. For faces, it can be skin color, age, gender, or image saturation. What these features will be for brain images? Let’s find out.

    Elena, one of our Machine Learning Engineers, shares a paper based on her recent research looking into whether neural networks can understand brain anatomy, maybe just a tiny bit?! Elena tries to answer this question using Disentangled Variational Autoencoder trained on brain CT slices.

    Request the full text below and a downloadable version will be sent via email.

      10 Questions With….. Dr. Michael Hill

      By | Expert Series, News, Uncategorized

      Dr. Michael Hill is the Director of the Stroke Unit for the Calgary Stroke Program, Alberta Health Services. He is also a Professor at The University of Calgary for the departments of Radiology, Clinical Neurosciences, Community Health Sciences and Medicine. Dr. Hill has been involved in several stroke studies in recent years including the reputable ESCAPE and ESCAPE-NA1 trials. During this interview Michael shares with us an understanding the potential impact of the ESCAPE-NA1 results.

      How did you get to where you are in your career today?

      The course of my career I suppose has been relatively opportunistic. I’ve had a chance to follow opportunities that I saw or were put in front of me to go forward. For example I started training in internal medicine and then switched over to neurology, obtaining certification in both. When I was starting out in neurology, the NINDS tPA trial was published, which was the first thrombolytic trial for stroke that clearly had a positive outcome. It outlined a way forward for the treatment of stroke when really there hadn’t been a clear path yet in acute therapy for stroke.  Thus, the combination of internal medicine and neurology, and hence specializing in vascular neurology seemed like a good marriage for me. Then the evolution of endovascular therapy began. We ran the ESCAPE trial from Calgary and I was involved in a series of trials which showed the effectiveness of EVT for the worst kinds of stroke, large vessel occlusions. So our involvement has really taken off since then. 

      Congratulations on the recent breakthrough with the ESCAPE-NA1 trial. How does it feel?

      That’s an interesting one too because that also evolved in a similarly opportunistic way, by following the choices that were available at the time. The collaboration between us at University of Calgary and the group at the Toronto Western Hospital & University of Toronto, where the compound, nerinetide (NA1) was developed, has been a very fruitful and enjoyable one. It is a very exciting time, we have shown there is a way forward for cytoprotection in stroke which is a novel concept in itself. We are going to need more research to really solidify our findings and explore more details such as which patients would be eligible for this sort of treatment and at which stage it should be administered but overall I think there will be essentially another arrow in the quiver for treating stroke.

      Can you give me an understanding of the potential impact of NA-1? 

      Well, excitotoxicity is a term that describes a whole series of biochemical reactions which ultimately lead to cell death. In the ESCAPE-NA1 trial we demonstrated the efficacy of the compound called nerinetide or NA1 in treating a very specific group of stroke patients by manipulating this biochemical process. Excitotoxicity is particularly relevant in the brain and spinal cord and there are many other neurological diseases in which excitotoxicity occurs. If nerinetide (NA1) can be applied to prevent cell death in multiple disorders this would have a huge impact. But in this recent trial we targeted a very small subset of stroke patients so we are not talking all strokes here, but these things have to start somewhere. Even if nerinetide (NA1) is only applicable to this type of stroke this will still be a great breakthrough as it is such a common disease.

      What are the tangible results or impacts that could be felt by a patient treated this way? 

      Well first of all, to be clear, we found an interaction effect between nerinetide and alteplase which meant that nerinetide only seemed to work on those that did not receive alteplase as well. Within this group, that didn’t receive alteplase, we saw quite a large effect size of 9.5% absolute benefit in independent outcome; so it essentially means there is one extra person in ten walking out of a hospital functionally independent instead of being severely disabled or dead. This is quite a large effect size, approximately half the effect of endovascular therapy. To give you some perspective, I’ve been involved in stroke for over 20 years and when I began, only 2 out of 10 patients with an LVO would be functionally independent after their stroke and maybe 3 or 4 out of 10 would die. With endovascular therapy this really increased it to 5 out of 10 being able to go home functionally independent and only 1 would die. Now we are talking about 6 out of 10 being functionally independent with EVT plus nerinetide.

      We are making incremental progress which is fantastic and certainly with endovascular therapy, it was such a large leap after the ESCAPE trial and MR CLEAN alike we really were visibly able to see the way things were happening on the stroke inpatient service. Fewer people staying for long periods in hospitals and being paralysed, more people going home on the 3rd day instead of staying for several weeks. It is very gratifying for sure. 

      It must be incredibly gratifying. I was wondering if there have been any pivotal moments in the ESAPE-NA1 trial?

      When you design a trial like this you are definitely standing on the shoulders of giants.  We were definitely beneficiaries of failed experiments in the past. I mean you learn something everytime right?

      I think there were a few key things that were done. Firstly actually doing the experiment on primates initially. Lots of ethical issues come up with this and you have to be very careful but doing this was a really important demonstration that it was possible. Then we worked really hard in the trial to make sure we were duplicating that same model but in humans. And I think we were very successful in doing so just based on the study metrics. Duplicating the preclinical model was probably the most important scientific thing we’ve done. This was how the evolution of highly effective endovascular therapy happened. Being involved with both EVT and ESCAPE-NA1 has been terrific, and they followed one from the other.

      Where would the administration of NA1 work in the structure of the current workflow?So that’s important and an example of another feature of trial design. In any trial, you need to integrate whatever you are testing within the current paradigm of care. We gave nerinetide (NA1) at any time after randomisation up until closure of the groin so it was not a linear paradigm. It went in parallel with the treatment. This means it could have been given at many different stages – just before emergency treatment, in the angio-suite, while the thrombus was being extracted or even just after reperfusion. In hindsight, we now think that the earlier you give it, the better the result, so as we go forward with future studies looking at this compound we are really going to try and give it early. 

      How does nerinetide (NA1) work in terms of protecting or restoring the brain cells?

      It’s a rational drug-design peptide. A little protein made up of 20 amino acids. A short segment of amino acids are taken from Tat protein, which is an envelope protein from HIV virus. Tat protein plays an important role in allowing the entire protein to enter a cell, crossing through the blood brain barrier so it gets into neurons and across a lipid membrane without any problem. We see that pharmacologically once it’s been intravenously administered, it is out of the patient’s circulation within 10 minutes and into the tissue. 

      The remaining amino acids form a peptide that interferes with a protein-protein interaction inside the neuron between the cytosolic surface of the NMDA receptor and a protein cascade which is part of the negative aspects of excitotoxicity which would ultimately normally result in excess production of nitrous oxide, which is fatal to a cell. They target the excitotoxic pathway downstream from where it has been targeted before. It’s always been targeted on the extracellular surface of various aspects of the receptor whereas this was the first time it has been targeted inside the cell. It’s never worked well extracellularly because it’s always interfered with normal functions of the receptor.

      You’ve already touched upon what this could lead to in terms of other neurological areas but what are the next steps of opening the door for new leads in stroke research?

      Excitotoxicity is a pathological mechanism important in trauma, MS, Alzheimer’s disease and many other neurological diseases. Could you improve outcomes of concussion or a car accident if you can receive this drug to protect neurons immediately after the event? We just don’t know yet, and we will need more research to be done.

      Although, I’m not saying this idly, there are some animal model data to say the drug is useful in traumatic injury, for example when looking at rats but it hasn’t been studied in humans. This is all speculative so we will have to research and see what the future holds.

      How exciting, you must be incredibly excited yourself, what has been the most significant breakthrough for you to date?

      Well, what I’ve focused on the most in the past 10 years is therapeutics. Some trials have been successful and some have failed but it’s definitely the most recent two for me that have been the most influential. Especially the ESCAPE trial which has had the most impact.  It is now five years since that was done and of course this was not just my research, there is also the MR CLEAN group, the Australian, British, Swiss, French and Spanish groups that all showed how effective endovascular therapy is. Now we’ve got to get on with it and really implement EVT globally. This has completely changed the face of acute stroke management and how people are triaged including how hospitals are organised. 

      I do think we’ve got a really interesting result with ESCAPE-NA1 so if that also evolved to become a big success in stroke and expands beyond then that may be even bigger, i don’t know.

      Can you recall a time in your career to date when you’ve felt most challenged?

      I can think of a couple of different occasions. There are many challenges in research because it is a highly entrepreneurial process. You have to come up with an idea, write a grant, be successful (which only occurs 15-20% of the time), receive the money, hire and organise a team, execute the project and produce results and then there is no guarantee the results are going to be what you hope to see! If you’re successful the first time you then have a much greater chance of doing it again because success allows you to follow on from the things you’ve done before so it’s very much like running a business in terms of getting stuff done. 

      The biggest challenge I find is making sure you can continue to support all your team. If you are the one in charge, receiving all the money coming in, you must make sure you’ve got funds to conduct the research and support the people involved especially when they are risking their time, effort and employment. It is all that kind of stuff that has stopped me from sleeping at night. 

      Congratulations to you and your team as I can imagine it’s been years of extremely hard work!


      NICO.LAB improves clinical practice with innovative and trusted AI. Our product StrokeViewer, is an AI-powered clinical decision support system, offering a complete assessment of relevant imaging biomarkers within 3 minutes.

      NICO.LAB’s 2020 Highlights

      By | News

      2020 has been an exciting year of growth and success at NICO.LAB. As the year draws to a close we want to reflect on some highlights and milestones we have reached during an unusual and challenging year.


      StrokeViewer LVO received FDA Clearance

      In late November, after many months of hard work from the NICO.LAB team, we received FDA approval. We look forward to our next  phase of growth as we enter and expand through the US market, improving the lives of more stroke patients.

      A New Visual Identity

      Our new visual identity was introduced alongside FDA clearance in November. The refreshed look will help us to convey our mission, to empower physicians to provide patients with the right treatment, in time. 

      Proven Effectiveness of StrokeViewer

      Recent studies have proven a reduction in time-to-treatment and improved patient outcome with the use of StrokeViewer. It is very gratifying to see how our work at NICO.LAB aligns with our mission and translates into a proven positive impact for society.

      First Live Stream from NICO.LAB

      In early December, our Live Stream between Interventional Neuroradiologist Dr. Bart Emmer and our Chief Technology Officer Renan Sales Barros focused on ‘How Cloud-based AI Solutions in Stroke Care’. It marked the beginning of an exciting online series. Keep your eyes peeled in the new year as we plan to dive deeper into the different biomarkers used to diagnose stroke which will include the latest advancements in research and hearing more from the experts.

      Being a Part of the ICOVAI Consortium

      The consortium formed in response to the urgent need to quickly diagnose and prioritise patients in the early months of the pandemic in March. ICOVAI aimed to triage COVID-19 patients and speed up diagnosis with powerful AI. During difficult times it was great to see the collaboration of science, research and technology experts to come together and expertise to tackle the pandemic.

      International expansion

      We are proud to be on the ground in Australia, UK, Germany, US and the Netherlands. It is our ambition to provide the best stroke treatment to as many as we can reach. With our cloud-based solution we can scale at a fast rate, and implement in hospitals across the world

      A Growing Team!

      The NICO.LAB team continues to grow and diversify. We now finish 2020 with double the number of Full Time Employees than last year. With employees of 13 different nationalities, we are a passionate and international team! We have unified and kept spirits high in line with NICO.LAB’s values. An achievement in itself considering the difficult circumstances of remote working and little face-to-face contact. 

      Techleap Rise Program

      Back in May we were selected as one of the highest potentials in the Netherlands, to join several other inspiring scale ups on the program. It is designed to help scale ups grow faster internationally. Through workshops and training days we connected with many talented entrepreneurs which helped us all learn and grow together.

      All of us at NICO.LAB would like to thank our colleagues in the healthcare sector and all that have worked so incredibly hard battling the COVID-19 crisis. We hope 2021 will be a better year for all.


      Merry Christmas and a Happy New Year!

      Merel Boers, CEO and co-founder of NICO.LAB

      I am very proud of the team at NICO.LAB who have worked hard and achieved a huge amount under difficult circumstances. I want to thank all those that have supported NICO.LAB along the way. It is very exciting to think about where we could be this time next year!

      Merel BoersCEO and co-founder of NICO.LAB

      How Cloud-based AI Solutions are Transforming Stroke Care

      By | News

      Renan Sales Barros

      Chief Technology Officer at NICO.LAB

      Dr. Bart Emmer

      Interventional Neuroradiologist at AMC

      On Monday 7 December we Live Streamed an expert discussion between Interventional Neuroradiologist Dr. Bart Emmer and NICO.LAB’s Chief Technology Officer Renan Sales Barros on ‘How Cloud-based AI Solutions are Transforming Stroke Care’. If you didn’t manage to join us on the day there is the opportunity to watch some highlights below.

      Over the one hour they covered a wide range of topics including the different bottlenecks in the current stroke workflow, how AI helps to minimise delays and improve diagnosis, and finally why cloud-based solutions are the way to go.

      Catch up below and we hope to see you at one of our webinars next year!

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      Dr. Emmer and Renan discuss the different challenges and bottlenecks in the current stroke workflow, without the help of artificial intelligence.

      AI solutions can be very effective to save time and improve diagnosis. Radiologists use the various algorithms to go through the different stages of the workflow. Find out more in the video.

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      The AI Solution also helps the interventional team to plan the endovascular thrombectomy, prior to patient arrival.

      FDA approved

      NICO.LAB ready to revolutionize U.S. stroke care following FDA clearance

      By | News, Press Release

      The U.S. Food and Drug Administration (FDA) has cleared StrokeViewer LVO, NICO.LAB’s artificial intelligence powered solution in stroke care. StrokeViewer enables physicians to provide every stroke patient with the right treatment, as fast as possible. Two million brain cells die every minute until blood flow is restored (Saver, 2006), starting treatment earlier can make the difference between recovery or life-long disability.

      StrokeViewer LVOThis week the FDA approved a 510k application (FDA K200873) for StrokeViewer LVO, an artificial intelligence algorithm for fast triaging of stroke patients. StrokeViewer LVO detects image characteristics associated with a Large Vessel Occlusion (LVO) and alerts physicians. The FDA application was supported by a multi center clinical study where the performance of the algorithm was retrospectively evaluated in 384 patients from multiple US stroke centers. An expert panel assessed the data to identify LVOs (ICA, M1 and M2) and comparison with the algorithm showed results that exceeded the performance goal.

      StrokeViewer was developed by the Dutch medtech company NICO.LAB. The cloud-based solution uses artificial intelligence to support physicians in the emergency stroke setting. The FDA-cleared LVO algorithm is embedded in a cloud-based system that sends a notification to the medical specialists involved just minutes after a stroke patient arrives in the hospital. The physicians are able to use their smartphones, in the hospital but also at home, to inspect the CT images in a web viewer and diagnose a stroke.

      Merel Boers CEO & Founder“Medical specialists are under enormous pressure to make fast decisions day and night, but it’s not easy. Complicated assessment and interhospital communication sadly make life difficult for physicians motivated to treat stroke victims effectively” – said Merel Boers, CEO and co-founder of NICO.LAB. “With our first FDA clearance we are now able to show U.S. physicians how impactful the combination of human and artificial intelligence is. And yes, more will follow as we are fully committed to unlocking the full healthcare potential for every patient.”

      StrokeViewer is currently in use in Australia and Europe where it has proven to reduce the time from hospital arrival to start treatment for patients with acute stroke, leading to reduced patient disability in the short-term and more clot removal treatments performed.

      Stroke is a leading cause for serious long-term disability in the United States. The economic burden of stroke exceeds an astonishing $100 billion per annum (Girotra, Lekoubou et al., 2020). Stroke incidence and associated costs are rising drastically due to an ageing population and increasing unhealthy lifestyle. NICO.LAB is dedicated to playing a crucial role in reducing these stroke related costs and improving quality of life of patients by combining human and artificial intelligence to revolutionize emergency stroke care.

      FDA approvalStrokeViewer consists of a comprehensive set of tools to support the entire stroke workflow. StrokeViewer LVO is the first with FDA approval. Local availability of StrokeViewer functionality is subject to applicable CE marking, TGA and FDA approval (actual status on

      Saver, 2006 – “Time is brain—quantified.” Stroke 37.1 (2006): 263-266
      FDA K200873 – StrokeViewer LVO is approved as HALO under FDA submission number K200873
      Girotra, Lekoubou et al. 2020 – “A contemporary and comprehensive analysis of the costs of stroke in the United States” Journal of Neurological Sciences, volume 410, 116643

      10 Questions With….. Ludo Beenen

      By | Expert Series, News

      Ludo works at the Academic Medical Centre in Amsterdam in the Emergency Department as a Trauma and Emergency Radiologist. We interviewed Ludo during the COVID-19 lockdown when he was working from home a lot more. Ludo told us he feels the stroke workflow will be very different following COVID-19 compared to how things were done prior. He informed us stroke care and all emergency care has been more complicated due to the worry of contamination and spread of infection.

      So firstly Ludo, how did you come to be an emergency radiologist?

      A little bit of chance and a bit of luck. I am a broad oriented physician meaning I’m interested in a variety of things. Radiology concerns a lot of physiological systems in the body which appeals to me. When my predecessor left the emergency department I jumped at the opportunity to become an emergency radiologist! What I love about my job is that you always know there is room for improvement and things are always evolving. If you look at stroke for example, CT perfusion was discovered, then the success of endovascular therapy followed. We then had to work out how to efficiently transfer patients to intervention centers with all the important information, and this is where Nico.lab has come in. I have been very impressed with the performance of StrokeViewer and I really believe it is doing better than the others because it encompasses all aspects of emergency stroke care, from start to finish.

      That is great to hear, what’s it like being at the heart of an emergency department?

      Our Prime Minister recently said during the covid outbreak “you should accept that you will make 100% of your decision based on only 50% information that you have and you should be able to cope with that problem”. I think this is a great way to look at it, even in the emergency department. It can be difficult to accept this and people often want to take their time to make a clear diagnosis, avoiding mistakes. But my state of mind is that it’s important to not see it as a problem but a challenge, and do your utmost best to make the best decision from the 50% of information you start with. Everyone knows if you only have 50% of information, sometimes you’re wrong and coping with that in the emergency department is often the main issue for emergency radiologists. You have to put the different bits of information together like a puzzle and come to a conclusion as best you can. I enjoy that challenge the most, in a timely fashion. It will be interesting to see how artificial intelligence performs. Diagnosing a stroke patient is difficult. I am an expert so most of the time I can see where the problem is but certainly for juniors they can’t identify the problem as quickly so in that aspect artificial intelligence is very important and has the potential to take the pressure off.

      When have you felt most challenged at work?

      Well what is happening now is people have recognized more and more how useful the CT scanner is. When I first joined the ED we only had one sliding gantry CT scanner at the emergency department. But now we have two scanners covering three shock rooms. This means we can have three acute patients arriving simultaneously to the ED when a lot of hospitals would only have capacity for one. Basically triple the pressure which can be the biggest challenge when you have to make treatment decisions and give a fast and accurate diagnosis. But this is also what I enjoy the most about my job! 

      From your professional perspective, can you explain some of the challenges and gaps in the emergency department?

      The challenge is of course from an operational point of view. Everyone has to be very strict and everyone involved wants to do things their own way which can result in delay. People generally think when they are busy, they are doing valuable work but that is not always true given the circumstances! It is a skill of knowing what is necessary for the patient before things have even happened, and ensuring you stick to it and do nothing unnecessary. 

      The second part is the infrastructure. If there is a lot of data that has to be calculated from the scanner this can take time. We now accept this and have to wait a minute or so but we know how valuable time is. A faster calculation of data would be really helpful. Maybe that is also where artificial intelligence solutions would work and a part of that is you calculate them and then it has to be transferred to the PACS system. That is something that is not working as fast compared to what I want. I know the moment it is scanned and calculated but i can’t see it. I still have to wait some minutes. People are not always aware of how much damage is done every second in the emergency department. When you are 15 minutes slower there can be huge consequences and that is something we should share. So I would say the main challenges are time and sharing the information.

      In the current stroke workflow when a stroke patient comes into the ED how do you go about making your decisions?

      This is really a team effort, and we regularly discuss optimization of the workflow with all the stakeholders. When a stroke patient comes in, I try to be as clear as possible, and want other members of the team to also work as efficiently as possible, without wasting time. Non-contributing tests should be avoided. It’s a matter of making a sequence of binary decisions in a strict manner, with always the possibility to adapt the workflow to the circumstances.

      Is it a stroke: yes – what do I need to know? Is it hemorrhagic or not? Is another diagnosis possible? What about brain perfusion? And are there filling defects visible on the CT Angiography? Are the radiological findings and clinical findings comparable? What type of therapy should be started, intravenous or endovascular? This should be performed in a timely fashion: Time = Brain!

      In your opinion where do you think AI could be most useful for you and how could it be implemented into the radiology department? 

      Although it wouldn’t be typically thought of as AI, I think the calculation of penumbra and core is very useful, but still needs some further studies. It’s great that support from AI calculations is now accepted. In my opinion, if you want to implement a new AI powered tool into a healthcare system it needs to require very little effort from the hospital’s end. It needs to be something that is easy to implement, easy to use and easy to interpret. The moment it is presented to physicians with very little effort then they can accept that they have to know what it is all about!

      Can you see how AI can have a helpful role in the stroke workflow?

      Yes, there are certainly a few ways in which I think AI benefits the workflow. The most obvious role is the recognition of clots which for me is not the most difficult challenge when I can correlate it with the perfusion calculation. But some of my colleagues can have some difficulties in finding the clot so there is definitely an advantage in that. 

      On a broad scale we have quite a few parameters which is great when trying to diagnose patients. The question we really want to know the answer to is what will the patient outcome be for a particular treatment. I know this means taking into account many parameters. Some interventionists are reluctant to treat older patients for example over 80 years old. But I believe for every individual it is different. Some 85 year olds may have at least another 15 years of valuable life. So this can be a moral problem. Hopefully in time when enough data is available we will be able to predict the probability of a beneficial outcome for a particular treatment.

      What is your experience of AI in the stroke workflow and do you see it adding value in your opinion?

      One of the most important things StrokeViewer does for me is the transfer of information of patients between hospitals and radiologists which can save so much time. When a patient is on its way to you, knowing all the information the primary center has found means there is no risk of wasting time repeating procedures. This has been of great value for us when trying to diagnose and deliver the best care. The system we had in place before meant that for half of the cases we were unsure whether CTA had been performed or we were unable to see the images so time would be wasted. Whereas now we always have the information beforehand and can make a quicker decision whether it is worthwhile the patient going directly to the endovascular suite. In that respect AI is great support for clot detection.

      Are you excited about the potential impact of AI and the future?

      Yes I think there are interesting ways in which AI can support several processes and have a positive impact, which is exciting to see. I also do have my reservations but it’s not a fear. Personally I think it is illogical to think AI will take over and humans will just be the support to AI. The human brain is very different compared to AI even though AI is the product of humans. I think the human brain functions very differently therefore AI will help support and strengthen us. 


      Nico.lab improves clinical practice with innovative and trusted AI. Our product StrokeViewer, is an AI-powered clinical decision support system, offering a complete assessment of relevant imaging biomarkers within 3 minutes.

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