The AANS/CNS Task Force on Neuroendovascular Surgery was established by the Joint Officers to develop recommendations that would address the short and long term initiatives related to the endovascular treatment of cerebrovascular disorders. In recent years, endovascular therapy treatments have increased, but the role of different medical subspecialties has not always been clearly defined, or defined in the favor of neurosurgery. It is essential that neurosurgeons, who have the most significant training in treating these cerebrovascular disorders, maintain a strong presence in neuroendovascular procedures.
The initiatives of the Endovascular Task Force could potentially impact:
- Changes in neurosurgical training programs.
- Fellowship programs for training neurosurgeons in neuroendovascular surgery.
- Programs to address retraining for neurosurgeons in practice.
- Mechanisms to integrate interventional neuroradiologists into Neurosurgical Departments on a local basis and organized neurosurgery on a national basis.
- Strategies to increase the market share of neurosurgeons in cerebrovascular disorders.
The Task Force, which includes myself, Daniel Barrow, MD, Hunt Batjer, MD, Ralph Dacey, MD, Steven Giannotta, MD, Roberto Heros, MD, L.N. Hopkins, MD, and Russell Travis, MD, focused on these initiatives when developing recommendations for organized neurosurgery.
Background
Advent of Endovascular Therapies — Endovascular therapies for cerebrovascular disorders have been developed in recent years, including embolization of AVMs and tumors; detachable balloons and coils for the treatment of aneurysms; angioplasty and stenting of extracranial and intracranial arteries; and administration of interarterial therapies. Although the efficacy of these procedures remains unproven, they have gained increasing acceptance within the medical community because of the perceived non-invasive nature, potential cost savings and relative ease of application. Interventional neuroradiology has emerged as a subspecialty within radiology, and has enjoyed a reasonably close relationship with neurosurgery. Despite the availability of training opportunities, relatively few neurosurgeons have gained skills in neuroendovascular surgery. Other specialties competing for this market include neurology and cardiology. Cardiologists have been especially aggressive in expanding the use of intraluminal angioplasty and stenting for craniocervical circulation.
Changes in Interventional Neuroradiology — There exists an ongoing fragmentation within Radiology Departments because of increasing subspecialization, diminishing reimbursement for simple diagnostic interpretation, and the close association between imaging and interventional procedures in several specialties (neuro, vascular, GI). Simultaneously, more non-radiologists have demanded access to angiography and radiology suites. A close relationship between neurosurgeons and interventional neuroradiologists has developed, with frequent instances of neuroradiologists holding joint appointments in Neurosurgical Departments, or infrequently, neurosurgeons who are fully trained in endovascular techniques. With only a few exceptions, however, reimbursement for neuroendovascular procedures by interventional radiologists has been retained by Radiology Departments. This situation has created competition for patients with certain disorders. To promote an interspecialty relationship between neurosurgeons and neuroradiologists, the Cerebrovascular Section of the AANS/CNS has recruited interventional neuroradiologists as Associate Members including an appointment on its Executive Committee. In addition, the CV Section Annual Meeting is now held jointly with the American Society of Interventional and Therapeutic Radiology (ASITN).
Training Guidelines — A prior Endovascular Task Force, in conjunction with the ASITN, has established specific guidelines for interventional neuroradiology. The guidelines delineate additional training required for neurosurgeons (i.e. radiology) and neuroradiologists (i.e. neuroscience). These guidelines were submitted jointly by neurosurgery and radiology resident review committees to the ACGME for review. The World Federation of Neurological Surgery recently approved analogous training guidelines.
Increased Role for Neuroimaging in Treatment of Neurological Disorders — CT scan, angiography, MRI, MRA, SPECT scanning, CT angiography and PET scanning have become important components of neurosurgical practice. In addition, the advent of both frame-based and frameless stereotactic neurosurgery and functional MRI have further integrated neuroimaging into daily neurosurgical care.
Stereotactic Radiosurgery — Neurosurgeons have successfully developed independent or partnered programs in stereotactic radiosurgery for the treatment of cerebrovascular disorders. These partnerships often involve agreements for distribution of reimbursement. Formal instruction in radiosurgery in neurosurgical training programs is sporadic.
Carotid Endarterectomy — The AANS/CNS Carotid Endarterectomy Task Force was created to develop initiatives to increase neurosurgery’s market share of endarterectomy (currently 5- 6 percent of all endarterectomies performed in the U.S.). The Task Force concluded that increased numbers of endarterectomies by neurosurgeons would more likely come about by strategies to increase neurosurgical access to stroke patients, and a stronger emphasis on endarterectomy training in residency programs.
New Medical Therapies for Stroke — The advent of recombinant tPA as an effective treatment for acute ischemic stroke heightened awareness and increased neurosurgical involvement in cerebrovascular disease. The development of Stroke Teams with neurosurgical leadership in several centers has enabled neurosurgeons access to a spectrum of patients with cerebrovascular disorders and has established neurosurgery as a specialty integral to the care of these patients.
Multi-Disciplinary Programs in Stroke — Neurosurgeons are currently active in several programs, including the Brain Attack Coalition and the American Heart Association Stroke Council. These programs all focus on professional and public stroke treatment education.
Recommendations
The Neuroendovascular Task Force proposed and the Joint Officers approved the following recommendations:
1) Neurosurgery program directors and large practice groups should be encouraged to make the following changes:
- Insure that all individuals performing neuroendovascular procedures have appointments in Neurosurgery, and are willing to train neurosurgeons
- Increase exposure of all residents to neuroradiology, including experience in angiography
- Enable interested residents to pursue periods of 1-2 years in endovascular training
- Negotiate redistribution of income from neuroendovascular procedures
2) Finalize acceptance and implementation of training guidelines in neuroendovascular surgery:
- Apply for ACGME recognition of neuroendovascular surgery fellowships
- Distribute to hospital accreditation committees
3) Promote the term “neuroendovascular surgery.”
4) Develop institution-based mini-fellowships in basic neuroendovascular surgical techniques.
5) Offer Associate Membership in the AANS/CNS to all ASTIN members.
6) Promote a Stroke Center Development package through educational materials, workshops and practical courses; monitor the establishment of Stroke Teams.
7) Develop a SMART marketing program for cerebrovascular disease.
8) Initiate prospective randomized trials and/or national registeries for neuroendovascular procedures.
9) Develop multi-specialty guidelines for treatment of cerebrovascular disorders.
The Neuroendovascular Surgery Task Force will be meeting over the next few months to discuss the implementation of these recommendations. If you have any questions about this Task Force, please call me at (206) 543-3570 or e-mail [email protected]