Question Regarding a Letter to the Editor

[Neuro321]

Hello All,
Just this am, I read a Letter to the Editor in JNIS (below).
PostSrcipt
Are there too many fellowships or not enough training?
Buddy Connors
J Neurointervent Surg published 7 January 2013, 10.1136/neurintsurg-2012-010627
http://jnis.bmj.com/content/early/2013/01/07/neurintsurg-2012-010627.full?papetoc

It continues a discussion regarding a moratorium on NeuroIntervnetional fellowships. Anyway, the issue I am interested is specific to the management of Acute stroke, and the (suggested) large demand for Endovascular coverage at Stroke Centers 24/7/365. I am a medical student, interested in Vascular Neurology and was curious if the inclusion of endovascular procedures limited to the management of Acute Stroke (ie IA TPA, Use of devices like Penumbra etc.) has ever been considered to be included in the Neurology Vascular Fellowship. It seems to my medical student mind, that this may be one method to address this need for 24/7/365 coverage and allow Vascular trained Neurologists the ability to manage strokes w/o relying on Rads/NS for endovascular coverage.
Just Curious.
Thanks!

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[typhoonegator]

There is no way you could become technically proficient enough in the use of these devices in a one year stroke fellowship. No way. I know people who are fully trained neurointensivists who went on to a full neuroIR fellowship, and now practice both. But if you aren't doing IR procedures a large amount of your time, then you shouldn't be doing them at all.

Hell, even with tons of experience these procedures are technically difficult a significant proportion of the time.

 

[neglect]

Are there too many fellowships or not enough training?

Not a mutually exclusive conjunction.

IMSIII failed. I don't see too much more use for endovascular therapies outside the first 1-2 hours. The IMSIII data is still pending, which I think is telling. This editorial was honest in that he said that he (and his entire peer group) thought IMSIII was going to be +. Reminds me of die hard GOP, predicting a Romney win (but everyone I know voted Romney!). Now they're flogging the data for the sliver of people who seemed to respond.

The truth is that they will probably find such cases, but acute stroke patients showing up with the proper characteristics (say within 1 hour with NIHSS >10) will be much more rare. As such, there are too many fellowships and there will be little acute stroke training.

I am a medical student, interested in Vascular Neurology and was curious if the inclusion of endovascular procedures limited to the management of Acute Stroke (ie IA TPA, Use of devices like Penumbra etc.) has ever been considered to be included in the Neurology Vascular Fellowship. It seems to my medical student mind, that this may be one method to address this need for 24/7/365 coverage and allow Vascular trained Neurologists the ability to manage strokes w/o relying on Rads/NS for endovascular coverage.

It'll never happen. You have to be OK with actually getting the catheter up to the vessel and that's what the two year fellowship lets you do apparently. And if not endo-neurovascular, then all the other endovasc people have dibs above a single year stroke fellow. So now most vascular neurologists no longer want to just do medical stroke. They want to do vascular and neuro-interventional. The field (neurology ->stroke -> endovascular) is attracting surgical minds who, for whatever reason, didn't actually like surgery 4 years previously or didn't cut it as surgeons or want to make bank. None of these reasons are particularly good for the field.

Hell, even with tons of experience these procedures are technically difficult a significant proportion of the time.

I have been told that acute stroke is the least technically demanding thing they do. Can't pass the [insert latest greatest device that is better than the others times 1,000,000,000] device, then do IA tPA.

I think it is a great question. Perhaps the way to cut down on door to cath to angiographic success time (which IMSIII does seem willing to come out and say: was associated with best outcomes, which also seems like saying that coming out of the rain will be associated with drying) is to do direct ICA sticks and injections.

 

[Neuro321]

Thank you all for the interesting comments.

I never meant to imply that endovascular training should be included in the 1 year of fellowship training and still be considered sufficient to be "technically proficient". Instead I was simply implying the possibility or consideration for the ALREADY Fellowship trained Vascular Neurologist or those during Fellowship the ability to extend (by x amount of time) to gain additional training in procedures specific to stroke, has ever been considered possible. I would then consider that some of these (possibly more complex) procedures relating to aneurysm/spine/tumor embolism etc. would not be required and possibly proficiency in medical and interventional stroke treatment would be increased b/c of the focused nature.

Thanks all for the comments.

 

[Mattchiavelli]

This is just to point out something that comes up on the regular

If you want to do something related to the nervous system that tis procedural, your best bet is to be a neurosurgeon. Following that, go to it through IR, however the general rads residency might be boring. There isn't a secret shorter less competitive backdoor through vascular neurology because anyone smart enough to do that already thought of that.

IR and endovascular procedures are interesting because they blur the medical/surgical line, which used to be much more clearly demarcated if you think of the history of the fields. It is really cool and I can see the appeal but the problem is really a numbers game- in the US at least we still have a ways to go as far as getting people to recognize stroke symptoms and realize there is a timeframe for optimal medical care- at that point you'll see a lot more volume as the number of people showing up 10 hours, 4 days, etc after symptom onset decreases and number of people that would even be considered for an endovascular procedure increases

I'd also mention this is not specifically directed at the OP as they have been pretty accepting

 

[Strokeguy]

I will add to the question - 'Are there too many fellowships or not enough training?' - 'Not enough patients'.
After IMS-3, the number of pts who 'potentially benefit' from intervention will be thoroughly investigated since taking every pt to the angiosuite has been futile. This by itself significantly cuts down on procedural cases. In IMS-3, patients treated with IA, were treated very early. Having enrolled pts in this study, I know that pts in the IA groups received 2/3 the standard IV TPA dose so they could receive upto 14 mg by IA. Centers that have enrolled in IMS-3, have always started the standard of care TPA infusion early. The consent, enrollment and randomization was all accomplished within 40 minutes of the bolus in order to stop TPA infusion by 2/3rd dose for pts randomized to the IA arm. All of these were rushed to the angiosuite. So we will see that despite all these pts treated very early by IA, it was still futile.
Med students and residents should also be aware that evolving non-endovascular therapies (which are well into phase 3 trials) will compete with IA therapies. In my opinion if all vasc neurologists were to even do IA cases, they would not be able to bill enough to even justify their medical malpractice.
One fact is that endovasc procedures became so widespread due to FDA device approval needing just 'safety' as opposed to medical therapies requiring safety as well as efficacy for FDA approval; and insurance companies willing to reimburse. But I think in the next few years when a lot of medical therapies making through phase 3 trials, we would have more protocol for acute stroke care that are evidence based. In any case the IA case volume is never going to increase and there already are interventionalists fighting for cases.