Abstract
The collaboration between Thomas Jefferson University Hospital, Wills Eye/Neurosurgery Institute and Pennsylvania Hospital officially began July 1, 1994. At that time, no guidelines existed for Wills Eye/Neurosensory Institute in terms of neuroradiological coverage. From a general neuroradiological standpoint it was decided that Thomas Jefferson would provide coverage, on an alternating off-month basis with the Department of Radiology at Pennsylvania Hospital, both of which have free-standing departments as well as fully accredited residency programs in radiology. In addition, Thomas Jefferson University has a fully-accredited neuroradiology fellowship program with a total complement of five full-time neuroradiologists and six neuroradiological fellows.
Background
The neuroangiography suite at Wills Eye/ Neurosensory Institute is a state of the art system with fast filming and simultaneous biplane fluoroscopy, an essential instrument in performance of endovascular procedures. This equipment was entirely under the control of the Department of Neurological Surgery. When I was recruited to join the Department of Neurological Surgery I had been back from New York University Medical Center for one year performing endovascular radiological procedures at my former institution. The Chairman of Radiology at Thomas Jefferson, as well as the Chief of the Division of Neuroradiology, were quite concerned about having a neurosurgeon perform these procedures, perhaps at the exclusion of the Department of Radiology. Quite simply, I met with the Chair of Radiology at Thomas Jefferson, The Chair of the Division of Neuroradiology at Jefferson, as well as the heads of the Department of Pennsylvania Hospital. Their major concern was that these institutions would lose all angiography and interventional cases performed at the Neurosensory Institute. After various discussions and compromises we outlined a plan stating that I would not perform any diagnostic procedures. This, in turn, would allow the attendings in neuroradiology, as well as the fellows, significant experience in diagnostic angiography, and would have a senior neuroradiology fellow rotate on the interventional service. They would alternate with a neurosurgical resident in the endovascular service. We also agreed that diagnostic angiography would be performed at Thomas Jefferson University and Pennsylvania Hospitals, but that all endovascular procedures would be performed at the Neurosensory Institute.
From September 1994 through September 7, 1995 at the Neurosensory Institute we performed 226 total procedures, including 109 endovascular cases, of which 92 percent were cerebral aneurysm or arteriovenous malformation. Throughout this first year, our practice relationship between neurosurgery and neuroradiology strengthened to the point that I had the full support of the Department of Radiology when I was appointed the first Chief of the Division of Interventional Neuroradiology for the three cooperating institutions. Recently, a Division of Cerebrovascular Surgery was instituted and I was appointed Chief of that Division by my chairman.
Within the Division of Cerebrovascular Surgery and Interventional Neuroradiology we have also performed 107 procedures for intracranial aneurysm, 70 endarterectomies, and 57 arteriovenous malformations in a multi-modality fashion with embolization, surgery and radiosurgery.
I think a significant portion of the success of our program is directly related to the outstanding caliber of the Chairs of Radiology, and Chiefs of the Division of Neuroradiology at Thomas Jefferson University Hospital and Pennsylvania Hospital. It is clear that a year and a half into this venture, the project has become a clear team effort and that Radiology, Neuroradiology and Neurosurgery have all been winners. I’ve approached this project from the perspective that we can be a model to demonstrate that radiology and neurosurgery can work together in a positive fashion, and I believe we have been successful in that regard.
Suggestions
If a successful endovascular practice is to be taken in the framework of neurosurgery, I think it is important that the person performing the procedures be properly trained and credentialed. Having done the credentialing process at this institution, it is relatively straightforward. This process has been an emotional one from both the radiological and neurosurgical perspectives. It was important to keep those emotions in check and to approach this joint effort in a positive way so that both sides benefited. We have made it clear at our site that radiology and neuroradiology are essential parts of the endovascular service and have worked hard to try and eliminate the “turf” issue.
Summary
At a time when endovascular therapy is becoming an important tool in the armamentarium of the cerebrovascular surgeon, it is important that we develop relationships with our colleagues in radiology and neuroradiology. It is essential that we try to avoid turf issues and, instead, work to develop systems that are mutually beneficial. The neurosurgical community cannot ignore the importance of the radiological sciences if the future of interventional treatment is to be successful and if neurosurgery desires to be a part of this burgeoning new field.