I think endovascular treatments will be of prime importance in treating stroke in the future. The cerebrovascular system is different than the coronary system, but the basic principles of hemodynamics still holds. Clot removal will still make a difference, especially if we can do it more cleanly in the future. Another big important use of endovascular methods will be providing medications specifically to the brain region affected that might be toxic to other regions of the brain. tPA is one example, of course, and the upcoming IMS-2 trial will hopefully show that giving 1/2 of the tPA endovascularly will allow us to extend the time window and improve morbidity and mortality after stroke. Add neuroprotective agents of various sorts, and endovascular methods will possibly become even more important.
As the population ages, and patients are more often put on aspirin, plavix, and possibly blood thinners for below-the-neck problems, the rates of ICH will also expand quickly. I sense that endovascular treatments here will also be useful in controlling the bleeding *internally* and then shooting of agents to trunk arteries to help protect the surrounding brain tissue.
It is really simply a matter of basic physics: what can be done well systemetically, can be done better locally--where it is needed most.
On turf matters, btw, neurologists are rapidly taking up more and more training spots in interventional. I don't think the turf issues are really there among neurologists, radiologists, and neurosurgeons that much. Those neurologists that are as qualified and demonstrate equal eagerness and determination to enter this field--possibly one of the most demanding in all of medicine--will get spots, and good ones too. I know of neurologists trained at MGH, UCLA, Columbia, and the list goes on. Neurosurgeons really don't care that much because to be good at endovascular techniques, one cannot also compete with other neurosurgeons in performing lucrative surgical procedures--so what was the point of spending a combined 4 years of their life studying spinal surgery? Neuroradiologists will mostly realize the good life in the dark room. The real turf war is with cardiologists trying to do all the carotid stents. This is where we really need to fight--for the sake of the field and patients....
B
