Setup of Interventional Stroke Service

[TundraT100]

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Hi, I'm a medical student who attends a school that doesn't have an interventional 'neurology' service (we have interventional neurorads). I wanted to ask people who have interventional neurology team at their institution the following questions:

1) How is your service setup? Is the interventional neurology service mainly a consultant to a stroke team or do stroke patients become the service's primary after intervention?

2) What are the pros and cons of the system you have at your institution?

3) Does your institution also have an internventional neuroradiology service or endovascular neurosurgery team? Is this even possible to have these coexist? If so, does each service manage a separate pathology? For example, endovascular neurosurgery gets ruptured aneurysms requiring urgent coiling, interventional neurorads gets elective aneurysm coiling and AVMs, and interventional neuro gets urgent stroke patients who have past window for tPa

 

[Strokeguy]

Each neurointerventionalist (regardless of background) does all kinds of cases - emergency or elective, aneurysm or stroke, etc.
All stroke cases have 'Stroke' as the primary service and all aneurysms (ruptured or unruptured) have Neurosurgery as the primary service. If there is a Neurocritical care service, then NICU is the primary svc for all cases as long as they are in the ICU (depending on how it is structured).
Remember that a neurointerventionalist also needs to be covered when he is doing the 'non-interventional' part of his job (all clinicians do it). For example when an endovasc nsurgeon is in the OR, the interventional neurologist or neurorad are scheduled in the suite. When the neurologist is taking calls for acute stroke or rounding on the stroke service, the radiologist or nsurg are scheduled in the suite. So in most places that have a multidisciplinary team, there is cross coverage. This is the best and most practical way to run the neuroendovasc 'service'.
Whether you are an interventional neurologist, IN radiologist or endovasc neurosurgeon, usually you would have joint appointments in radiology, neurosurg and neurology.

 

[TundraT100]

So basically it doesn't matter what kind of pt you have, just matters who's on call. Makes sense for urgent cases like ruptured aneurysms or ischemic stroke, but how are elective cases handled? To use cardiology-speak, which service 'controls' the patient? Does an internist just consult 'the interventional service' and whoever is in the angio suite that day will do the procedure or is it more complicated than that?

 

[Strokeguy]

For acute cases, whoever is on call does those. Elective cases are also done on schedule. If the Neurosurgeon has OR schedule on 2 days of the week , then his schedule for endo vasc would be on other days. If the int. neurologist is scheduled to round in the stroke unit and respond to acute stroke calls in the ER or telemedicine, then he/she does not usually schedule endovasc cases on those days. This is usually determined by the interventionalists among themselves. Often you have 2 suites for INR, then they also schedule elective cases intermittently. Also there are diagnostic angios to do. Sometimes an aneurysm case is going on (during regular hours) with the on call interventionalist scrubbed in and an acute stroke needing IA shows up in the ER. In such situations, the other interventionalist steps up for an emergency case (even though he/she is not on call).
Regarding who 'controls' patients, the clinical services - stroke for ischemic stroke and neurosurgery for aneurysms/AVMs and NICU as long as patients are in the ICU.
I cannot comment on cardiac pts.
But understand, the difference in disease patterns in neurointervention vs cardiac. Intracranially - you have aneurysms, AVMS, fistulas, and ischemia/occlusion/stenosis and then congenital lesions,etc. These patients need multidisciplinary care - eg ICP monitoring, EVD , cerebral blood flow monitoring.
In the heart, most lesions are ischemic and you hardly see bleeds from aneurysms/AVMs or fistulas. Such lesions are very uncommon. Unless there is trauma or acutely ruptured aortic aneurysm/dissection, most of such lesions are dealt with by cardiologists.
So we can realistically never compare neurointervention from cardiac intervention. Cardiac patients require close monitoring in the CCU so internists wont manage them in the acute or immediate post-procedural phase unless they are diagnostic cardiac caths.

 

[Strokeguy]

Another thing, cogenital cardiac lesions are also elective and taken care of by cardiologists. Some of them can also be treated endovascularly.
I think multidisciplinary neuro-care is the best and most practical for several reasons.

 

[bonran]

So basically it doesn't matter what kind of pt you have, just matters who's on call. Makes sense for urgent cases like ruptured aneurysms or ischemic stroke......


Well, an aneurysm rupture is a neurosurgical emergency but not necessarily an endovascular one. It needs to be studied before it is coiled. Its not like the aneurysm is bleeding continuously. In most places, the patient goes to the NSU, is stabilized, gets imaging studies & is then coiled or clipped based on the anatomy-usually the next day.

 

[bonran]

For acute cases, whoever is on call does those. Elective cases are also done on schedule. If the Neurosurgeon has OR schedule on 2 days of the week , then his schedule for endo vasc would be on other days. If the int. neurologist is scheduled to round in the stroke unit and respond to acute stroke calls in the ER or telemedicine, then he/she does not usually schedule endovasc cases on those days. This is usually determined by the interventionalists among themselves. Often you have 2 suites for INR, then they also schedule elective cases intermittently. Also there are diagnostic angios to do. Sometimes an aneurysm case is going on (during regular hours) with the on call interventionalist scrubbed in and an acute stroke needing IA shows up in the ER. In such situations, the other interventionalist steps up for an emergency case (even though he/she is not on call).
Regarding who 'controls' patients, the clinical services - stroke for ischemic stroke and neurosurgery for aneurysms/AVMs and NICU as long as patients are in the ICU.
I cannot comment on cardiac pts.
But understand, the difference in disease patterns in neurointervention vs cardiac. Intracranially - you have aneurysms, AVMS, fistulas, and ischemia/occlusion/stenosis and then congenital lesions,etc. These patients need multidisciplinary care - eg ICP monitoring, EVD , cerebral blood flow monitoring.
In the heart, most lesions are ischemic and you hardly see bleeds from aneurysms/AVMs or fistulas. Such lesions are very uncommon. Unless there is trauma or acutely ruptured aortic aneurysm/dissection, most of such lesions are dealt with by cardiologists.
So we can realistically never compare neurointervention from cardiac intervention. Cardiac patients require close monitoring in the CCU so internists wont manage them in the acute or immediate post-procedural phase unless they are diagnostic cardiac caths.

I would also say this about ischemia in the brain: unlike ischemia in the cardiovascular bed, ischemia in the brain is heterogeneous. Different causes/areas of ischemia need to be differently treated based on symptoms & pathophysiology. In cardiac ischemia, the vessel needs to be opened in all cases emergently-either endovascularly or surgically. Then the patient needs long-term management of risk factors just like in ischemic stroke.

 

[Strokeguy]

Agree with above