Rocket Science?
It goes to show the lack of understanding neuroradiologists have about the importance of the clinical exam & the need to follow up these patients to see if any CLINICAL IMPACT of their procedures in the long run. This is the reason why they are acting like technicians in the angio suite without knowing if their procedures do any good or not.
Here are some common myths about INR/ESNR/IN (and whatever fancy name you want to call it):
1)Myth that INR is a radiologist's/neurosurgeon's turf: INR has existed since the 1970's (actually the
first direct carotid dye injection angiograms were done in the 1940s-60s by neurologists to look for vessel distortions in patients suspected to have intracranial space occupying lesions, who then lost this field to radiologists because of the location of the angio suite. This is our turf & these are our patients. We are taking it back because we understand the disease pathophysiology & we will eventually succeed in taking it back because our intervention in this field has improved patient outcomes. That this is the neuroradiologist's turf is a myth. They are welcome to participate as collegues & contribute to improving imaging techniques.) having made no headway in stroke intervention till the 1990's when stroke neurologists like Antony Furlan (CCF & CASE) & Larry Weschler (UPMC) used their knowledge of the pathophysiology of large vessel stroke to design a study (PROACT II) & prove for the 1st & only time (so far till the IMS III study comes out- another study designed by Joseph Broderick a stroke neurologist at U Cin) that intraarterial thrombolysis works.
Through my 3 years or residency, I have seen many funny things happen in the angio suite. Here is a true anecdote of a patient with epilepsy taken to the angio suite & get IA TPA when a stroke neurologist was not on call for BAT & then seize with a catheter in his head with TPA running through it. The neuroradiologist running the show (in all fairness to INR, with the neurologist on call {an autonomic specialist with his own theories for neurological clinical signs} for BAT) went against the advise of the senior resident on call (there were no stroke fellows in the program then) that according to, the history given by the patient's wife, the eye movements at the beginning of the patient's presentation was more in conjunction with a seizure followed by Todd's paresis, rather than an MCA stroke (the wife had seen him look to the left before falling to the ground & he had presented with left arm & leg weakness). However, niether the IN radiologist nor the autonomic neurologist listened to the residents. He was wheeled to the angio suite where INR picked up no clot on angio. They did see intracranial atherosclerosis (<50%) in both MCAs
Lt>Rt, which the IN radiologist suggested was a thrombus in propagation in the
LEFT MCA (in the vessel ipsilateral to the side of weakness). In conjunction with the neurologist, he proceeded to give IA-TPA
in the LEFT MCA. Minutes later he said the patient was moving the weak left side quite strongly (remember, this was the side ipsilateral to the MCA getting the TPA). Obviously, being an INR he did not know what a clonic seizure looked like. When the senior resident (your truly) stepped in & pointed out the patients inability to follow commands & the clonus, the autonomic specialist had a fright & asked for the TPA to be stopped, catheter to be withdrawn & ativan & fosphenytoin to be hung. Of course, the INR's hair were standing on their end with him having visions of iatrogenic (a rarely used term in diagnostic codes) intracranial dissection or vessel rupture.
This is the first time I have seen
IA TPA used for primary prevention of stroke as the INR was trying to break a clot in the opposite MCA to the side of the lesion even before the patient got weak on his right side(or was he trying to justify the $23,000 DRG for the procedure). I should have written a case report on this one & sent it to the Am Journal of Neuroradiology. After all it is a world first!!
Just some advice to all those who argue about the importance of history, exam & follow up & against vascular neurologists doing INR procedures:
I hope your family members or God forbid yourself are not treated with by these undertrained cowboys when the need arises.
This happened at a large residency training program which has years of experience with angios, stroke thrombolysis including intraarterial therapy & where there is an advanced epilepsy program. Not a peripheral hospital with poor INR back up & general neurologists runnig the show.
I think the INR guy should go back to med school get extra course credits in neurology before touching another catheter.
The neurologist should be made to repeat 3 years of residency training before stepping into a hospital, his negligence was worse than the INRs as he was the clinician at hand who was subjecting his patient to an unnecessary procedure which sounds hilarious but could have ended in tragedy.
2) There is this myth that most INR programs are interviewing NSx graduates then radiologists followed by neurologists. I have been down the interview road this year through 9 places so far with at least another 2 lined up in the future, I am going to one tomorrow. At many programs I was told that most (>50%) of the applications are from neurologists followed by Neurosurgery (20-30%) & the least (20%) are from Neuroradiologists. These figures have been told to me during the interview at atleast 4 programs all run by Neurosurgeons or IN radiologists.
3) Another myth is that stroke is not a big part of interventional radiology. Whoever said this was not paying attention to his/her public health & preventive medicine courses at med school & is speaking off his head. Stroke is the biggest part of interventional NR today. It is the 3rd largest disease that kills and the largest reason for permanent disabilty (a bigger fiscal drain on medical costs) in the WORLD (I learnt this in my 3rd world med school preventive medicine course & am surprised that top of the line residents/fellows in INR dont know of this in the US) & virtually in every country is no.3 on the list after MI & cancer. Whoever wrote this, is probably not doing acute stroke interventions at their place. Just by statistics alone one can reach this conclusion. If you had to make a guess, even as people involved in neuro care (where we will have Berksonian bias for seeing a high number of neurological disorders) how often per month does one see an aneurysm or an AVM that requires intervention- aneurysm 2wice to 3 rice a month/AVMs less than once a month. Then again, how often does one see a large vessel embolic stroke!!! At big stroke centers-once or twice a day. That too when even at the best places just 18-23% of the acute stroke is caught in time. Whoever didnt see large vessel stroke in their interventional neurorad practice & thinks aneurysm & AVMs are a big part of this practice has not heard of Berksonian/referral bias. This is the growing field as more physicians, hospitals & patients become aware that stroke can be treated acutely. This is the reason stroke neurologists were able to get into INR again & take back what they lost out to technicians.
Besides all big comprehensive stroke centers (with angio facilities) are at places with nationally recognized Vascular Neurology training programs. Why?? Because these are the places where decisions are made by vascular neurologists about TPA treatment based on disease physiology. This is where NIH is funding research, almost 90% of the PIs (barring those in imaging) for these studies are Vascular Neurologists.
It is a forgone conclusion that vascular neurologists will be back into INR in the next 10 years in a big way as it becomes a major part of the way this disease with its huge burden is treated interventionally. The people with no clinical skills will lose out in the long run. Let no one discourage any future neurology resident who is looking to get into INR through the VN pathway, you will be better trained & prepared than the rest.
There are 700,000 strokes/yr in the US, 20% are embolic= 280,000 of which about 4% get treated=11,200. There is still another 269,000 embolic strokes that need intervention. It is estimated that even with the best efforts, 30% will come to the hospital in time in the future to be treated (30% of 280,000 is 84000-11200=72,800). There are 73,000 strokes every year that can be potentially thrombolysed intraarterially. Compare this to the annual incidence of aneurysms presenting as SAH=36,000; 30 to 50% of which die before reaching the hospital (70% of 36,000=25,200). So, 25,200 can get angiography with less than that who can be coiled based on location, size & width of the neck etc. Annual US incidence of intracranial AVMs is estimated at 0.55/100,000 which for a population of 300 million comes to 1,650 AVMs nationally per year. Not all bleed & hence will not need to be treated. The figures speak for themselves.
