Unnecessary Cerebral Angiograms

[CCM-MD]

We have been seeing a pattern of this at my hospital, specifically from one neurointerventionalist. Frequently performed in situations where it is not expected to change the management or outcome of the patient.

Do these reimburse extremely well? Is there ever a push from the hospital to do more? I.e. can’t keep the neuro lab without cases.

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[Postictal Raiden]

Could you provide examples of situations where you deem it unnecessary to obtain a cath angio at your hospital?

At mine, we often do cath angios to help with dx of RCVS although not indicated and findings don’t change management (which is clinical monitoring +/- CCB for headache).

 

[xenotype]

I would suspect low volumes and needs more cases if true but would need examples of what you consider to be unnecessary. If truly unnecessary it'd be as bad as unnecessary surgery and would need to be stopped ASAP as even a routine DSA can have rare but really terrible complications.

 

[CCM-MD]

Could you provide examples of situations where you deem it unnecessary to obtain a cath angio at your hospital?

At mine, we often do cath angios to help with dx of RCVS although not indicated and findings don’t change management (which is clinical monitoring +/- CCB for headache).

Sure. Here’s a case from earlier this week:

80 year old patient with multiple comorbidities ends up with a severe ICH. ICH score 5. Warfarin and hypertension are thought to be the etiology. Neurological exam is very poor. Palliative care is involved early, code status is deescalated and family is contemplating comfort measures. CTA does not show any vascular anomalies. Neurointerventionalist performs a cerebral angiogram to look for AVM. No AVMs found. Even if he did find one, prognosis would unlikely be impacted IMO.

This is not an isolated incident. I am also not the only one who has noticed this. Some of his cases have undergone peer review. He also has a tendency to give severely patient families an overly optimistic prognosis but that’s a whole different issue.

 

[xenotype]

Sure. Here’s a case from earlier this week:

80 year old patient with multiple comorbidities ends up with a severe ICH. ICH score 5. Warfarin and hypertension are thought to be the etiology. Neurological exam is very poor. Palliative care is involved early, code status is deescalated and family is contemplating comfort measures. CTA does not show any vascular anomalies. Neurointerventionalist performs a cerebral angiogram to look for AVM. No AVMs found. Even if he did find one, prognosis would unlikely be impacted IMO.

This is not an isolated incident. I am also not the only one who has noticed this. Some of his cases have undergone peer review. He also has a tendency to give severely patient families an overly optimistic prognosis but that’s a whole different issue.

Very likely unnecessary but not an egregious example particularly if there were subarachnoid blood products present and at the time the procedure was arranged family still wanted full diagnostic work up/aggressive care/no stone unturned. Not a case I would push back strongly against NIR about, but I'd notice and certainly pay attention if there is a pattern like you are saying. Any others? If most bleeds go to angio suite with no discretion then that would be quite bad. As for prognosis after bleeds- ICH5 is inarguable but we've all seen the grade 5 SAH with the prolonged ICU course, palliative talks that walks into clinic two years later and tells about how 'all the doctors wrote them off'- bleeds are much harder to predict than ischemic stroke in long term disability.

 

[CCM-MD]

Very likely unnecessary but not an egregious example particularly if there were subarachnoid blood products present and at the time the procedure was arranged family still wanted full diagnostic work up/aggressive care/no stone unturned. Not a case I would push back strongly against NIR about, but I'd notice and certainly pay attention if there is a pattern like you are saying. Any others? If most bleeds go to angio suite with no discretion then that would be quite bad. As for prognosis after bleeds- ICH5 is inarguable but we've all seen the grade 5 SAH with the prolonged ICU course, palliative talks that walks into clinic two years later and tells about how 'all the doctors wrote them off'- bleeds are much harder to predict than ischemic stroke in long term disability.

Agree we have all seen those patients. This was a severe parenchymal bleed with a very bad exam. The family did not desire aggressive care - but lay people will agree to any procedure that may help if “sold”, which this individual can be quite good at.

 

[robellis]

Agree we have all seen those patients. This was a severe parenchymal bleed with a very bad exam. The family did not desire aggressive care - but lay people will agree to any procedure that may help if “sold”, which this individual can be quite good at.

Give more cases

 

[elanmorin]

Do these reimburse extremely well? Is there ever a push from the hospital to do more? I.e. can’t keep the neuro lab without cases.

From the interventionalist perspective, a 4-vessel diagnostic angiogram bills more than a mechanical thrombectomy. From the example above you gave, I can't necessarily say it was an egregious case. If someone is doing a 4 vessel angio for every thrombectomy case though (as I've seen at some places), then I would be more concerned about their ethics, for example.

 

[Clean7795]

Sure. Here’s a case from earlier this week:

80 year old patient with multiple comorbidities ends up with a severe ICH. ICH score 5. Warfarin and hypertension are thought to be the etiology. Neurological exam is very poor. Palliative care is involved early, code status is deescalated and family is contemplating comfort measures. CTA does not show any vascular anomalies. Neurointerventionalist performs a cerebral angiogram to look for AVM. No AVMs found. Even if he did find one, prognosis would unlikely be impacted IMO.

This is not an isolated incident. I am also not the only one who has noticed this. Some of his cases have undergone peer review. He also has a tendency to give severely patient families an overly optimistic prognosis but that’s a whole different issue.

Sounds unnecessary and probably harmful to the patient's family.

If this is a pattern of behaviour as you make it sound, it is possible he is doing it to generate business.

 

[Alcmaeon of Croton]

Sure. Here’s a case from earlier this week:

80 year old patient with multiple comorbidities ends up with a severe ICH. ICH score 5. Warfarin and hypertension are thought to be the etiology. Neurological exam is very poor. Palliative care is involved early, code status is deescalated and family is contemplating comfort measures. CTA does not show any vascular anomalies. Neurointerventionalist performs a cerebral angiogram to look for AVM. No AVMs found. Even if he did find one, prognosis would unlikely be impacted IMO.

This is not an isolated incident. I am also not the only one who has noticed this. Some of his cases have undergone peer review. He also has a tendency to give severely patient families an overly optimistic prognosis but that’s a whole different issue.

Is he a neurosurgeon? If not, why is he consulted on such case in the first place, who consulted him? Because these are neurology/stroke neurology and NSGY cases.

 

[CCM-MD]

Is he a neurosurgeon? If not, why is he consulted on such case in the first place, who consulted him? Because these are neurology/stroke neurology and NSGY cases.

He is a neurology trained interventionalist. He has training to do angios and endovascularly manage AVMs. Not all neurosurgeons perform endovascular procedures.

 

[Alcmaeon of Croton]

He is a neurology trained interventionalist. He has training to do angios and endovascularly manage AVMs. Not all neurosurgeons perform endovascular procedures.

I understand. I was just wondering how he becomes involved in the first place. Based on your answer, it seems that he sees the patients as part of neuro/stroke service then he does what he does.

 

[Telamir]

I hadn't seen this until recently at a locums assignment.

Hospital was trying to build a stroke program which was NSGY driven. They had asked ERPs to call stroke codes on EVERYTHING. I'm talking symptoms since 2 months ago but slightly worse over the weekend, anything that could even remotely be considered neurological. Then I saw that same NSGY team take people for DSAs cause they had a "perfusion deficit" on CTP with a negative CTA for LVO. It was bizarre and honestly unsafe. Also had them admit a normotensive stroke code with a LKW ~3 days prior to presentation to the ICU because they had "intracranial MCA stenosis and didn't want anyone to restart meds and cause the BP to drop and cause more stroke". Her BP at presentation was 113.

I think this was likely a hospital trying to get more volume since they recently had become CSC but still; it was weird.

 

[elanmorin]

I hadn't seen this until recently at a locums assignment.

Hospital was trying to build a stroke program which was NSGY driven. They had asked ERPs to call stroke codes on EVERYTHING. I'm talking symptoms since 2 months ago but slightly worse over the weekend, anything that could even remotely be considered neurological. Then I saw that same NSGY team take people for DSAs cause they had a "perfusion deficit" on CTP with a negative CTA for LVO. It was bizarre and honestly unsafe. Also had them admit a normotensive stroke code with a LKW ~3 days prior to presentation to the ICU because they had "intracranial MCA stenosis and didn't want anyone to restart meds and cause the BP to drop and cause more stroke". Her BP at presentation was 113.

I think this was likely a hospital trying to get more volume since they recently had become CSC but still; it was weird.

This just highlights that NGSY often has no idea what they are doing when it comes to hyperacute management of AIS. Honestly, more neurologists should become trained in NeuroIR, or just strokeIR, as they're the best suited for selecting which patients will or won't benefit from intervention.

 

[Telamir]

This just highlights that NGSY often has no idea what they are doing when it comes to hyperacute management of AIS. Honestly, more neurologists should become trained in NeuroIR, or just strokeIR, as they're the best suited for selecting which patients will or won't benefit from intervention.

I mean also to be fair I recently had a neuro trained IR guy try to convince me that a 65 year old with transient right sided arm weakness + Headache who had an ulcerated carotid plaque causing 60-70% stenosis AND a partially occlusive MCA thrombus discharged on DAPT + DOAC (?) and returning with the same symptoms 2 weeks later with resolution of intracranial thrombus but redemonstration of carotid plaque was actually having complex migraines and his symptoms weren't vascular in nature so...I think proceduralists should stick to procedures for the most part. That being said your mileage may vary.

 

[elanmorin]

I think stroke neurologists doing thrombectomies should be a thing, same way cardiologists are the ones that do PCI/angioplasty. Don't defer to the "proceduralists" to decide who is a good candidate or not for intervention. Requires revamping the whole vascular fellowship though.

 

[Aldertonghen]

I think stroke neurologists doing thrombectomies should be a thing, same way cardiologists are the ones that do PCI/angioplasty. Don't defer to the "proceduralists" to decide who is a good candidate or not for intervention. Requires revamping the whole vascular fellowship though.

Isn’t vascular fellowship a requirement prior to NIR for neurologists, and hence they’re stroke neurologists? I agree with your opinion btw

 

[elanmorin]

Vascular or ICU. But neurologists are the minority players in NIR, it's mostly neurosurgery and radiology trained interventionalists, and they don't have required vascular neuro (clinical) training.