I am glad to see that my letter has piqued the interest of
interventional neuroradiologists like Dr. Jagadeesan. I agree with him
that no one should be running a fellowship that does not have the volume
to expose trainees to enough cases so that they may obtain the necessary
experience to practice safely. However, I think he has misunderstood my
point. As I stated about the original piece, "I have no objection to the
lo...
I am glad to see that my letter has piqued the interest of
interventional neuroradiologists like Dr. Jagadeesan. I agree with him
that no one should be running a fellowship that does not have the volume
to expose trainees to enough cases so that they may obtain the necessary
experience to practice safely. However, I think he has misunderstood my
point. As I stated about the original piece, "I have no objection to the
logic and opinions expressed, and actually have no opinion on the issue
for or against these fellowships." My only request was for the authors of
the original article to disclose the fact (as Dr. Jagadeesan has nicely
done in his own letter) that they may have potential conflicts of interest
by way of already completed and reaping the potential rewards of the very
same fellowship training that they now advocate curtailing, so that the
reader may use this information when making up his or her own mind. I have
no interest in standing between interventional neuroradiologists and their
patients (unless one is trying to run over the other, in which case I hope
I could intervene). As far as taxi drivers, I would applaud their
specialty if one disclosed that he gotten his driver's license from the
black market instead of completing the required training and tests -
indeed, that information might affect my decision to ride in his or
another cab.
We read with great interest the article by Turk et al[1] assessing
the safety and efficacy of endovascular stroke intervention based on CT
perfusion (CTP) criteria. The authors are to be congratulated for this
excellent report and for achieving remarkably high rates of favorable
outcomes (42%) in stroke patients with poor neurological sta...
We read with great interest the article by Turk et al[1] assessing
the safety and efficacy of endovascular stroke intervention based on CT
perfusion (CTP) criteria. The authors are to be congratulated for this
excellent report and for achieving remarkably high rates of favorable
outcomes (42%) in stroke patients with poor neurological status (mean
NIHSS, 18.2). They further categorize their patient population based on
time from symptom onset and clearly show that patients treated after 8 h
had no difference in outcomes or mortality than those treated before 8 h.
The fact that time from symptom onset to intervention was as long as 16.4
h in the late group (>8h) lends further credence to their findings
because the extent of salvageable brain tissue and the prospect of
improvement significantly decrease with delayed recanalization.[2-4] This
report adds substantially to the growing body of literature supporting the
use of CTP in stroke patients and reinforces what we have always believed;
specifically, CTP can optimize and guide patient selection for
intraarterial therapy based on an individual's physiological parameters
namely the extent of salvageable ischemic penumbra.
Although we agree with the authors about the merits of CTP and stress
the importance of their results, we would like to bring to their attention
that their conclusion may not be totally supported by the presented data.
The authors have compared functional outcomes in patients treated <8 h
and >8 h after symptom onset. Although all patients were selected for
endovascular stroke intervention based on CTP criteria, they conclude that
"physiologic imaging-guided patient selection rather than time for
endovascular reperfusion in ischemic stroke may be effective and safe". We
believe the only way to reach such a conclusion is to compare two groups
of patients, one selected based on CTP criteria and the other based on
time from symptom onset. Indeed, the authors do not discuss the study by
Hassan et al[5] published in 2010 that retrospectively compared 69
patients undergoing CTP-guided and 127 patients undergoing time-guided
endovascular treatment. The authors of this study found no incremental
benefit with the use of CTP, with similar rates of recanalization,
intracranial hemorrhage, favorable outcomes, and in-hospital mortality in
both groups. It should be noted, however, that only 40% of patients in
their study underwent mechanical thrombectomy and that CTP-guided
treatment at the primary author's institution was compared to time-guided
treatment at a different institution, which could have influenced their
results. Still, this is to our knowledge the only study that has compared
time-guided to CTP-guide patient selection for acute stroke intervention.
Randomized controlled trials comparing the 2 strategies are needed
especially that many prominent centers still have not adopted CTP as a
screening tool in this setting.
We would also like to highlight some of the potential shortcomings
associated with CTP that were not discussed in this study. The inter-
observer variability remains a great concern with CTP.[6] Additionally,
the optimal post-processing algorithm for defining penumbra and core
infarct have yet to be determined, and thresholds for guiding therapy are
still under investigation.[7] The variation in reconstruction of CTP
images and qualitative interpretation of salvageable tissue may lead to
selection of a relatively heterogeneous population, leading to the
inclusion of patients with limited salvageable tissue. False negatives and
non interpretable imaging can occur with CTP due to low cardiac output,
inappropriate slow rate of bolus administration, contrast extravasation in
the subcutaneous tissue, patient movement, and operator inexperience.
Finally, despite the potential caveats of CTP imaging , Turk et al[1]
have clearly demonstrated that CTP allows effective treatment of many
patients who otherwise would be destined for supportive management or end
of life care due to presentation outside of the therapeutic window. We
commend the authors for their rigorous work and await similar
contributions that will help us determine the best approach for patient
selection for acute stroke intervention.
References
1. Turk AS, Magarick JA, Frei D, et al. CT perfusion-guided patient
selection for endovascular recanalization in acute ischemic stroke: a
multicenter study. J Neurointerv Surg 2012 doi: neurintsurg-2012-010491
[pii]
10.1136/neurintsurg-2012-010491[published Online First: Epub Date]|.
2. Wardlaw JM, Murray V, Berge E, et al. Recombinant tissue plasminogen
activator for acute ischaemic stroke: an updated systematic review and
meta-analysis. Lancet 2012;379(9834):2364-72 doi: S0140-6736(12)60738-7
[pii]
10.1016/S0140-6736(12)60738-7[published Online First: Epub Date]|.
3. Hesselmann V, Niederstadt T, Dziewas R, et al. Reperfusion by combined
thrombolysis and mechanical thrombectomy in acute stroke: effect of
collateralization, mismatch, and time to and grade of recanalization on
clinical and tissue outcome. AJNR Am J Neuroradiol 2012;33(2):336-42 doi:
ajnr.A2746 [pii]
10.3174/ajnr.A2746[published Online First: Epub Date]|.
4. Vergouwen MD, Algra A, Pfefferkorn T, et al. Time Is Brain(stem) in
Basilar Artery Occlusion. Stroke 2012 doi: STROKEAHA.112.666867 [pii]
10.1161/STROKEAHA.112.666867[published Online First: Epub Date]|.
5. Hassan AE, Zacharatos H, Rodriguez GJ, et al. A comparison of Computed
Tomography perfusion-guided and time-guided endovascular treatments for
patients with acute ischemic stroke. Stroke 2010;41(8):1673-8 doi:
STROKEAHA.110.586685 [pii]
10.1161/STROKEAHA.110.586685[published Online First: Epub Date]|.
6. Hassan AE, Zacharatos H, Chaudhry SA, et al. Agreement in endovascular
thrombolysis patient selection based on interpretation of presenting CT
and CT-P changes in ischemic stroke patients. Neurocrit Care 2012;16(1):88
-94 doi: 10.1007/s12028-011-9577-9[published Online First: Epub Date]|.
7. Amenta PS, Ali MS, Dumont AS, et al. Computed tomography perfusion-
based selection of patients for endovascular recanalization. Neurosurg
Focus 2011;30(6):E6 doi: 10.3171/2011.4.FOCUS10296[published Online First:
Epub Date]|.
As a participant in the creation of the original ACGME ESNR
fellowship training standards, I read the article concerning fellowship
suspension with great interest (1). The paper is timely and thorough. It
is unfortunate that the Neurointerventional world is dealing with so many
unknowns. We do not seem to know how many we are, where we work, what we
do, or where we were trained. The problem is very well summarized at...
As a participant in the creation of the original ACGME ESNR
fellowship training standards, I read the article concerning fellowship
suspension with great interest (1). The paper is timely and thorough. It
is unfortunate that the Neurointerventional world is dealing with so many
unknowns. We do not seem to know how many we are, where we work, what we
do, or where we were trained. The problem is very well summarized at the
end of the paper. We seem to be spreading our patient population among
too many practitioners, which subsequently restricts the number of
patients available to each practitioner to stay in practice, make a
living, and be proficient.
The first line states: "The purpose of any training program is to
provide a supply of skilled workers to address an unmet demand for their
services." The authors discuss numbers of procedures and extrapolate
implications but do not discuss what the training was that got these
people out into the world. Further, there is no clear statement as to
what these unmet needs are. These workers might perhaps be skilled in
certain areas, but not know anything about other subjects.
Adequacy of numbers is the primary thrust of the article. One
endovascular neurosurgeon can possibly cover 5 different hospitals by
themselves for aneurysms, AVMs etc., and could do 300 aneurysms per year
easily. Most, but not all, neurointerventional fellowships provide an
adequate number of aneurysms for training. But as correctly pointed out,
the numerous auxiliary procedures that are necessary to be proficient in
this profession, such as skull base tumor embolization, epistaxis,
vertebroplasty, nerve root block or ablation, are not routinely performed
at all institutions. AVMs might be completely ignored at many places.
Endovascular spinal procedures are rare.
The gaping hole in fellowship training is acute ischemic stroke.
Consistently complete training for all fellows continues to be a void in
our profession and a gap in the entire premise of this statement. It is
perfectly acceptable to produce specialists in aneurysm intervention as
well as vertebroplasty, but we should not count them all in the same
bucket and presume we have enough people to cover the nation for stroke.
Everyone does not do everything nor do they want to. Many fellowship
programs have inadequate caseload and resultant inadequate or poor
training in acute stroke treatment. We should not just expect this
specialized training to magically appear in fellowships where there is
inadequate case volume to begin with. Therefore, what is the true number
of interventionists that are available, trained, able, and willing to
treat strokes?
The need for trained physicians to treat stroke is not based upon the
number of strokes (as might be the case for aneurysms), but rather on the
number of hospitals that need stroke coverage. The issue with stroke
coverage is that there needs to be a minimal number of practitioners at
each hospital to take call 24/7/365, no matter the number of cases: 1 per
month or 1 per day. Another paper describes the necessity of stroke
coverage as 2-3 interventionists per center for 24/7/365 coverage (2),
contradicting the official SNIS stated position as well as EMTALA
(Emergency Medical Treatment and Active Labor Act) that states that no
requirement can be made for 24/7 coverage with less than 4 persons. If
there is a need for 200 hospitals to have 24/7/365 coverage, then there
needs to be at least 800 interventionists just at those hospitals alone.
The official SNIS position on stroke coverage is as follows: "Current
staffing levels at Comprehensive Stroke Centers will rarely allow
continuous immediate coverage for IA stroke therapy at all times, 365 days
a year. Instantly available coverage on a continuous basis 24/7/365
should not be expected with fewer than 4 persons. Until adequate staffing
levels are achieved, continuously available catheter-directed intra-
arterial emergency stroke therapy is considered the "ideal", but is not
mandatory in order to be classified as Comprehensive Stroke Center.
Therefore, in agreement with federal regulations, IA stroke therapy might
be available only a portion of the time as determined by local hospital
conditions and staffing levels of qualified and appropriately trained
personnel, and the institution still qualify as a Comprehensive Stroke
Center." (SNIS executive committee, John Barr president, 2005). As we all
know, there are very few hospitals that have 4 neurointerventionists.
There are probably fewer than 20 fellowships in the US that treat by
endovascular techniques more than 50 strokes per year. Maybe 10. Even
with 50 cases, a "fellow" can only "maybe" attain the SNIS mandated 10
cases as "primary operator" in his last few months. Thus, in the
remaining 60-70 fellowships (90%?), the trainees will not get the required
experience. There are numerous examples of fellowships that provide a
certificate of competency for everything "neurointerventional" where the
number of endovascular stroke cases can be counted on one hand... or one
finger. How will these fellows get sufficient training, experience, and
knowledge to have good outcomes when treating strokes when they are in
private practice?
Foremost, I hope that this call for a moratorium in fellowships will
be accompanied by an equally vigorous call for augmented and improved
stroke training for fellows and our members. A recent SNIS webinar
bemoaned the poor operator performance for intracranial stenting during
SAMMPRIS. A recent article has documented "death and destruction" in
endovascular stroke therapy (3). The failure of SAMMPRIS and the stoppage
of IMS 3 only highlights the fact that we are not doing very well at this.
As we all used to believe, IMS 3 should have been a slam-dunk. SNIS/SVIN
should offer specialized intensive training courses that are, in actual
fact, a responsibility of our professional organizations. Our societies
need a plan for improved training and continuing education for our fellows
and members in addition to a moratorium.
References
1) Fiorella D, Hirsch JA, Woo HH, et al. Should neurointerventional
fellowship training be suspended indefinitely? J NeuroIntervent Surg
2012;4:315-318
2) Zaidat OO, Lazzaro M, McGinley E, et al. Demand-supply of
neurointerventionalists for endovascular ischemic stroke therapy.
Neurology 2012;79 (Suppl 1):S35-S41.
3) Cloft HJ. Death and Destruction in the Intra-Arterial Battle with
Acute Ischemic
Stroke. AJNR Am J Neuroradiol 32:1767-70.
Hirsh and Meyers espouse that same party line of the many private non
-governmental agencies (and academics who will personally benefit from
this program) who wish to impose private interest group-unproven corporate
interests upon practicing physicians. They continue to state MOC is
"voluntary" and then describe the many ways these "non-profit"
corporations (who earn handsomely and have over $400 million in assets and
as g...
Hirsh and Meyers espouse that same party line of the many private non
-governmental agencies (and academics who will personally benefit from
this program) who wish to impose private interest group-unproven corporate
interests upon practicing physicians. They continue to state MOC is
"voluntary" and then describe the many ways these "non-profit"
corporations (who earn handsomely and have over $400 million in assets and
as great yearly gross receipts!) will see this product forced on
physicians. HOWEVER, Working physicians do not want or even see any value
in this unproven imposition:
The American Medical Association (AMA) developed the Physician's
Recognition Award (PRA) in the late 1960's as the validation program for
Continuing Medical Education (CME), embraced by most, but not all states,
to validate physician "lifelong learning" as the educational component of
re-licensure. Recently, the Federation of State Medical Boards (FSMB),
Inc., a multimillion dollar, non-profit and non-governmental corporation,
targeted the State of Ohio as the first of 11 pilot states to implement
their corporate brand of MOL (Ohio., Calif., Colo., Del., Iowa, Mass.,
Mississippi, Okla., Ore., Va., Wis.).
On May 19, 2012, the Ohio State Medical Association, as the first Ohio
physician organization, formally resolved at the state meeting to oppose
the FSMB MOL program. (1) OSMA recognized early that FSMB MOL was the
unwarranted regulatory capture of physician licensure: the act of securing
corporate income through legislation. (2) An intense battle over FSMB MOL
ensued within the State Medical Board of Ohio (SMBO), zealously led by two
FSMB board members, who also occupied the SMBO Executive Director and one
senior Board member positions. On October 5, 2012, the OSMA drafted with
10 other state medical associations, representing over 15,000 physicians,
a formal resolution of opposition directed to the SMBO. (3) The defeat of
the FSMB MOL proposal by SMBO vote followed on October 11, 2012.
In the aftermath, the two FSMB board members serving on the SMBO were
formally reviewed. The Executive Director of the SMBO was ousted October
12th and formal investigations regarding violations of conflict of
interests continue regarding the senior SMBO member. (4) Subsequent
communications with legal offices of the SMBO and OSMA concluded that: 1)
FSMB MOL was not advocated by any other corporate, government or consumer
groups, no deficiency of AMA PRA CME programs or physician competency
issues were identified in Ohio and 2) FSMB MOL initiative appeared solely
promulgated by the FSMB as a corporate mandate. It continues to be
actively advocated by FSMB in 9 states and must be either fought or
approved in each state. FSMB MOL serves primarily corporate coffers and
false reassurance through testing vs CME. Effective physician opposition
is primarily possible via grass-roots resolutions at state level. We must
inform and support all state organizations at this time regarding FSMB
MOL, using this "Ohio experience" as evidence and instruction in opposing
this regulatory capture of physicians, solely for corporate profits. (5)
The assertions by the Certification industrial complex including the ABMS
that MOC and MOL are "Done deals" is simple propaganda-nothing more!
References:
1) Ohio State Medical Association Statement on MOL. Available at:
http://www.osma.org/files/pdf/facts-maintenance-of-licensure-final-.pdf
Accessed 10/27/12
2)Kempen PM: Maintenance of Certification (MOC), Maintenance of
Licensure (MOL), and Continuing Medical Education (CME):the Regulatory
Capture of Medicine. Journal of American Physicians and Surgeons 2012;
17:72-5. Available at: http://www.jpands.org/vol17no3/kempen.pdf Accessed
10/27/12
3) Kumar D et al: Joint letter from 11 medical societies to the SMBO.
Available at:
http://www.itraumaohio.org/aws/OACEP/asset_manager/get_file/54757/2012.10.5_joint_mol_letter_to_medical_board.pdf
Accessed 10/27/12
4) Alan Johnson In The Columbus Dispatch Thursday October 18, 2012 6:07
AM: State medical board ousts chief Available at:
http://www.dispatch.com/content/stories/local/2012/10/18/state-medical-
board-ousts-chief.html Accessed 10/27/12
5)Kempen PM: What to do about MOC and MOL? Available at:
http://www.youtube.com/watch?v=WRS15Dmsk7E Accessed Nov 1, 2012
I am not a neurosurgeon, neuroradiologist, nor interventionalist. In
fact, I am not a regular reader of your journal. However, the article
entitled "Should Neurointerventional Fellowship Training Be Suspended
Indefinitely?" by David Fiorella, et al., was brought to my attention,
unsolicited, by several different medical web sites. I have no objection
to the logic and opinions expressed, and actually h...
I am not a neurosurgeon, neuroradiologist, nor interventionalist. In
fact, I am not a regular reader of your journal. However, the article
entitled "Should Neurointerventional Fellowship Training Be Suspended
Indefinitely?" by David Fiorella, et al., was brought to my attention,
unsolicited, by several different medical web sites. I have no objection
to the logic and opinions expressed, and actually have no opinion on the
issue for or against these fellowships. But I feel I must register my
shock at what I see as a glaring omission by the journal.
The many authors do indicate their respective affiliations, and
cumulatively list in their disclosure, "Competing interests: None." The
most important disclosure, however, is not listed anywhere as a conflict
of interest. Namely, how many of the authors are practicing, already
fellowship-trained neurointerventionalists? In order to get a sense of any
potential bias, I think the reader would want to know this fact about each
author. Certainly, if most (or all) of the authors currently practice as
neurointerventionalists, regardless of their arguments, some readers might
feel that their position and recommendations simply represent an effort to
restrict competition for their own advantage, and that the journal has
given them a platform to advance this protectionist goal. If General
Motors found themselves with a surplus of unsold cars and made the
argument that there were too many autos already on the road, I might agree
with that statement. But if their proposed solution was to ban further
manufacture of cars so that they would have less competition unloading
their inventories, I might object. Perhaps another company could produce
cars that would be better (more efficient, safer, faster, etc.) and
preventing them from doing so would hurt consumers, who would have fewer
options. Similarly, while the authors may have correctly described the
current problem (too many neurointerventionalists with not enough cases)
their proposed solution (blocking further entries into the field) could be
seen as self-serving. After all, maybe there are potential trainees or
training programs who would introduce better practitioners (more
efficient, safer, faster, etc.) into the market place, pressuring current
(and future) neurointerventionalists to continue to improve the services
they now deliver.
I invite each of the authors of the original article (and of any
subsequent supportive letters) to make that disclosure: who among you are
neurointerventionalists who have already enjoyed the benefits of
fellowship training? Like any disclosure, this should not lessen your
stated arguments; rather it will just allow the reader to know whence your
recommendations are coming from. It only seems fair to be transparent. I'm
just saying.
We thank the authors for their letter entitled, "Caution during use
of DDAVP in IPSS," by Drs. Pecori Giraldi, Federici, and Cavagnini. The
authors suggest that because of the hypercoagulable state that
characterizes Cushing disease, DDAVP may not be safe since it has been
shown to increase the level of von Willebrand factor (vWF) and could
therefore lead to platelet adhesion and cause thromboembolism...
We thank the authors for their letter entitled, "Caution during use
of DDAVP in IPSS," by Drs. Pecori Giraldi, Federici, and Cavagnini. The
authors suggest that because of the hypercoagulable state that
characterizes Cushing disease, DDAVP may not be safe since it has been
shown to increase the level of von Willebrand factor (vWF) and could
therefore lead to platelet adhesion and cause thromboembolism. The authors
point to their own published work suggesting this effect (1). In this
paper, the authors show that not only vWF levels increase, but also t-PA,
likely to achieve a balance by activating fibrinolytic pathways.
Therefore, increased risk of thromboembolic events in Cushing disease
patients in the context of DDAVP administration is a theoretical
consideration.
Thromboembolism is a rare complication of BIPSS and when reported,
has been linked to lack of prophylaxis with IV heparin (2, 3). In our
practice, we routinely heparinize patients undergoing BIPSS, whether they
receive CRH or DDAVP to stimulate the pituitary (4). The case series
previously reported where DDAVP was used rather than CRH do not indicate
an increased risk of thromboembolic events (5-8). As the increased risk of
thromboembolism is only a theoretical consideration, we can only use this
available clinical data. Because the sensitivity of BIPSS is significantly
increased by the use of CRH or DDAVP, the benefits of using DDAVP appear
at this point to outweigh the theoretical risks. One possible positive
outcome of the CRH shortage is that more data will be accumulated to
determine whether there are unexpected negative effects of using DDAVP.
1. Pecori Giraldi F, Ambrogio AG, Fatti LM, Rubini V, Cozzi G,
Scacchi M et al. Von Willebrand factor and fibrinolytic parameters during
the desmopressin test in patients with Cushing's disease. Br.J.Pharmacol.
2011;71:132-6.
2. Blevins LS Jr, Clark RV, Owens DS. Thromboembolic complications
after inferior petrosal sinus sampling in patients with Cushing's
syndrome. Endocr Pract 1998; 4:365-367.
3. Obuobie K, Davies JS, Ogunko A, Scanlon MF. Venous thrombo-
embolism following inferior petrosal sinus sampling in Cushing's disease.
J Endocrinol Invest 2000; 23:542-544.
4. Deipolyi...Oklu et al. The role of bilateral inferior petrosal
sinus sampling in the diagnostic evaluation of Cushing syndrome. Diagn
Interv Radiol 2012; 18:132-138
5. Castinetti F, Morange I, Dufour H, et al. Desmopressin test during
petrosal sinus sampling: a valuable tool to discriminate pituitary or
ectopic ACTH-dependent Cushing's syndrome. Eur J Endocrinol 2007;157:271-
7.
6. Machado MC, de Sa SV, Domenice S, et al. The role of desmopressin
in bilateral and simultaneous inferior petrosal sinus sampling for
differential diagnosis of ACTH-dependent Cushing's syndrome. Clin
Endocrinol (Oxf) 2007;66:136-42.
7. Malerbi DA, Mendonca BB, Liberman B, et al. The desmopressin
stimulation test in the differential diagnosis of Cushing's syndrome. Clin
Endocrinol (Oxf) 1993;38:463-72.
8. Salgado LR, Mendon??a BB, Pereira MAA, et al. Use of Desmopressin
in Bilateral and Simultaneous Inferior Petrosal Sinus Sampling for
Differential Diagnosis of ACTH-Dependent Cushing's Syndrome. The
Endocrinologist 1997;7:135-40.
Dear Sir,
we have read with great interest the paper by Deipolyi and co-workers on
the use of desmopressin during inferior petrosal sinus sampling (IPSS) in
alternative to corticotropin-releasing hormone (CRH) for the diagnostic
work-up of Cushing's disease (1). As the Authors report, evidence
collected in small series suggests that desmopressin achieves an
equivalent diagnostic accuracy to CRH, thus appears a tempting...
Dear Sir,
we have read with great interest the paper by Deipolyi and co-workers on
the use of desmopressin during inferior petrosal sinus sampling (IPSS) in
alternative to corticotropin-releasing hormone (CRH) for the diagnostic
work-up of Cushing's disease (1). As the Authors report, evidence
collected in small series suggests that desmopressin achieves an
equivalent diagnostic accuracy to CRH, thus appears a tempting and less
expensive alternative. It is worth recalling, however, that desmopressin
is also a potent haemostatic agent and that patients with Cushing's
syndrome are at increased risk for thromboembolic events (2), some even
occuring during IPSS performed at expert centers (3). In this context, we
have recently observed that endothelial factors are released upon
administration of desmopressin to patients with Cushing's disease (4),
although the dose used for diagnostic purposes is roughly half the
haemostatic dosage. The magnitude of the increase in von Willebrand
factor, a promoter of platelet adhesion to the subendothelium in the early
phases of haemostasis, was comparable to the one observed in healthy
subjects and possibly counterbalanced by increased fibrinolytic factors
but to what extent these changes might affect general haemostatic
processes remains to be ascertained. As a consequence, as long as no
further evidence is available on the safety of this haemostatic agent
during endovascular damages, procedures which are per se at risk for
vascular events, extreme caution should be exercised when using
desmopressin instead of CRH during IPSS.
References
1. Deipolyi AR, Hirsch JA, Oklu R. Bilateral inferior petrosal sinus
sampling with desmopressin. J.Neurointervent.Surg.
2012;doi10.1136/neurointsurg-2012-010437.
2. Stuijver DJF, van Zaane B, Feelders RA, Debeij J, Cannegieter SC,
Hermus AR et al. Incidence of venous thromboembolism in patients with
Cushing's syndrome: a multicenter cohort study. J.Clin.Endocrinol.Metab.
2011;96:3525-32.
3. Doppman JL. There is no simple answer to a rare complicaton of inferior
petrosal sinus sampling. Am.J.Neuroradiology 1999;20:191-2.
4. Pecori Giraldi F, Ambrogio AG, Fatti LM, Rubini V, Cozzi G, Scacchi M
et al. Von Willebrand factor and fibrinolytic parameters during the
desmopressin test in patients with Cushing's disease. Br.J.Pharmacol.
2011;71:132-6.
The reply from Perez et al to my letter of March 2012 is misleading
and wrong in two important regards.1 First, they state that their report
of the use of the solitaire stent for thrombectomy was just a case report,
"nothing else". 2 This is not true. In fact, they explicitly use this
report, both in the abstract and conclusion to lay claim for developing
the stentreiever concept for thrombectomy: "This was the first...
The reply from Perez et al to my letter of March 2012 is misleading
and wrong in two important regards.1 First, they state that their report
of the use of the solitaire stent for thrombectomy was just a case report,
"nothing else". 2 This is not true. In fact, they explicitly use this
report, both in the abstract and conclusion to lay claim for developing
the stentreiever concept for thrombectomy: "This was the first .. use of
the Solitaire stent for this purpose and the ignition spark for the
development of a whole new generation of devices". In addition, this
report was titled a "Historical Vignette". This report was written to
take credit for the development of stentreivers for acute stroke. To
state, as they do in their response to my letter, that their paper makes
no claims is clearly disingenuous.
Second, they dismiss the idea that the prior publication by Kelly et
al -- reporting the use of an Enterprise stent (Codman Neurovascular,
Rayhnam, MA) as a temporary endovascular bypass to achieve successful
revascularization in a patient with an acute ischemic stroke and large
vessel occlusion -- had any influence on their work. This claim is
disingenuous as well. In their response, they state that " ... temporary
bypass might have been a local and ephemeral phenomenon; however it did
not cause to much commotion, at least in Europe." However, the technique
of stent-retrieval, or any kind of temporary stenting for acute stroke is,
in fact, part and parcel of "temporary endovascular bypass". The best
evidence of this is that the authors presented their own original
experience with the Solitaire at the 2010 International Stroke Conference
in an abstract entitled "Temporary Endovascular Bypass for the treatment
of ischemic stroke: Experience After 50 Patients". Clearly their work
with the Solitaire stent in acute stroke was influenced by this prior
report.
In summary, despite their claims, the concept of temporary stenting
for acute stroke treatment preceded the authors' 2008 case. In their
Historical Vignette and subsequent response to my prior letter, the
authors are attempting to rewrite history. They do deserve credit for
taking this concept and rapidly moving it forward in clinical practice,
however.
References:
1. Re: Perez et al 'Intracranial thrombectomy using the Solitaire stent: a
historical vignette'. Derdeyn CP. J Neurointerv Surg. 2012 Mar;4(2):153-4;
Author Response 154
2. Intracranial thrombectomy using the Solitaire stent: a historical
vignette. P?rez MA, Miloslavski E, Fischer S, B?zner H, Henkes H. J
Neurointerv Surg. 2011 Dec 14.
3. Kelly ME, Furlan AJ, Fiorella D. Recanalization of an acute middle
cerebral artery occlusion using a self-expanding, reconstrainable,
intracranial microstent as a temporary endovascular bypass. Stroke
2008;39:1770-3.
4. Liebig T, Lockau H, Stehle S, Dorn F, Prothmann S, Henkes HH. Temporary
Endovascular Bypass in Acute Stroke: Experience After 50 Patients. Stroke
2010 Vol 41,1:e259-260.
We would like to add our strong support to the recent editorial by
Fiorella, et al. Dr. Fiorella and his colleagues should be congratulated
for pointing out the giant elephant in the room. The government, insurers
and patients are increasingly demanding more quality, safety and value
from the healthcare dollar and, like it or not, we can no longer ignore
their pleas. Dr. Fiorella has eloquently shown us with widely ava...
We would like to add our strong support to the recent editorial by
Fiorella, et al. Dr. Fiorella and his colleagues should be congratulated
for pointing out the giant elephant in the room. The government, insurers
and patients are increasingly demanding more quality, safety and value
from the healthcare dollar and, like it or not, we can no longer ignore
their pleas. Dr. Fiorella has eloquently shown us with widely available
data that our profession now has more than enough manpower to handle the
labor demands extending into the foreseeable future. The current trend of
overproducing neurointerventional fellows has already led to decreased
quality and safety and is a profound misallocation of scarce medical
resources. These issues are further compounded by the current lack of a
standardized training curriculum and certifying examination.
One other factor that was not mentioned in the editorial is the
inevitable replacement of the fee for service payment model with bundled
payments or some similar type of payment distribution. It is not a
question of if this change will occur, but rather when it will occur.
Because the procedures we perform are very expensive, our specialty will
be under tremendous scrutiny by the accountable care organizations or
other entities that are tasked with managing and allocating the funds for
these bundled payments. Simply put, this paradigm shift in healthcare
financing will demand that neurointerventionalists intervene only in those
situations that are proven effective and provide value. In a world of
bundled payments, the focus will absolutely be on conservative medical
management rather than complex and expensive interventions. As painful as
it may seem to those of us who perform these procedures, it is inevitable.
We believe this will contribute to declining neurointerventional volumes
in the near future and is why we should halt all neurointerventional
fellowship training until there is adequate volume to maintain expertise
among current practitioners.
Unfortunately, we might be too late to stop this runaway train.
Given the number of fellows currently being trained and the relatively low
rate of retirement from our specialty at this time, we will experience a
glut of neurointerventionalists in the next few years. Because there is
no consistent scrutiny of quality in the neurointerventional fellowships,
there are "puppy mill" fellowships popping up all over the country. These
fellowships do not provide adequate procedure complexity, volume or
oversight to produce even a marginally competent neurointerventionalist.
Sadly, we have seen the recent intrusion of this type of subpar training
program into our medical community with as many as six fellows being
trained simultaneously in community, suburban, nonacademic hospital
facilities. Those of us who practice in the larger, academic, tertiary
referral hospitals are now seeing the unfortunate consequences imposed
upon the patients. The disasters range from procedures that clearly
should have never been attempted, even by experienced operators, to
procedures that are declined due to being "technically difficult" despite
really being rather straightforward and clinically warranted.
Obviously, we are just as passionate about this crisis as Dr.
Fiorella and his long list of distinguished coauthors. While it might be
too late to avert our current crisis, the impact could be dampened if all
future fellows that have not yet started their programs and those that are
considering our profession were to strongly consider these circumstances
and perhaps choose a different subspecialty.
We would like to thank Dr Hirsch and colleagues from Massachusetts
General Hospital for their insightful comment on our paper.1 The authors
advocate a more cautious conclusion regarding the efficacy of endovascular
stroke intervention in the elderly since a control group of younger
patients is lacking in our study. Although comparison to a younger group
of patients is interesting, such data can hardly be used for drawing...
We would like to thank Dr Hirsch and colleagues from Massachusetts
General Hospital for their insightful comment on our paper.1 The authors
advocate a more cautious conclusion regarding the efficacy of endovascular
stroke intervention in the elderly since a control group of younger
patients is lacking in our study. Although comparison to a younger group
of patients is interesting, such data can hardly be used for drawing
definitive conclusions regarding the efficacy of endovascular therapy. A
clinical comparison between young and older patients is unfortunately not
possible due to tremendous differences between the two study populations,
such as pre-existing medical comorbidities and dementia. Randomized
controlled studies comparing patient outcomes with intra-arterial therapy
versus intravenous thrombolysis or best medical management will be needed
to provide definitive information on the best therapeutic approach in this
patient population.
In patients with NIHSS of 8 or above who have failed or were not
eligible for intravenous thrombolysis, such as in our study population,
medical therapy is unfortunately limited to supportive management. Most of
these patients are destined to end of life care or are neurologically
devastated from their stroke. In an era of FDA-approved intra-arterial
thrombolysis, there is an ethical dilemma in randomizing patients that
meet criteria to such life-saving interventions to medical therapies,
regardless of their age group. It is therefore extremely challenging to
obtain level-one evidence data in the elderly or any other age population
comparing medical and endovascular stroke therapies.
Timely recanalization in acute ischemic stroke improves patient
outcomes.2-4 Arterial recanalization can be achieved by intravenous or
intraarterial means. Evidence suggests that treatment benefit with
intravenous tissue plasminogen activator (IV-tPA) extends to patients
older than 80 years.5 It is therefore plausible that intra-arterial
thrombolysis could confer a similar benefit in elderly patients. In our
study, almost a third of elderly patients achieved favorable outcomes with
intraarterial thrombolysis, and similar rates were also reported by other
investigators.6-7 In our opinion, such rates can be regarded as
satisfactory considering the compromised collateral circulation, the
reduced neuronal reserve, as well as the high frequency of pre-stroke
comorbid conditions in this age group. However, we agree with Dr Hirsch
and colleagues that this would require further confirmation by prospective
controlled data.
In a recently published study by Chandra and colleagues8 from
Massachusetts General Hospital, 49 elderly and 130 nonelderly patients
treated between 2005 and 2010 were rigorously compared with respect to
angiographic reperfusion, rate of parenchymal hematoma, and 90-day
clinical outcome. The authors report comparable rates of reperfusion and
hemorrhage between the two groups but favorable outcomes in only 2% of
elderly patients and conclude that recanalization in this group "may be
futile". In our view, these results warrant a more cautious conclusion
than the one advocated in their report not only because comparison to a
control group treated with medical therapy is lacking but also for the
following reasons. 1) Nearly 33% of elderly patients in their study were
disabled at baseline (mRS score 2 or greater), which makes the prospect of
a favorable outcome nearly impossible in as many as one-third of their
cohort. 2) Medical care was withdrawn in 55% of elderly patients, which
obviously complicates any assessment of outcome. 3) CT perfusion data was
not used to select patients for acute stroke intervention, which could
possibly suggest that some patients with little or no salvageable brain
tissue may have undergone endovascular treatment. In fact, CT perfusion
can optimize patient selection for endovascular recanalization based on an
individual's physiological parameters rather than an arbitrary time frame
and may be of greater value in this specific population by helping
identify "the subset of elderly patients who may benefit" from treatment.9
-11
Finally, we agree with Dr Hirsch and colleagues that endovascular
stroke intervention in elderly patients is safe. Although the question of
its efficacy requires more investigation, we believe that elderly patients
should not be excluded from consideration for treatment especially if
perfusion studies indicate adequate penumbra. The significance of proper
patient selection for endovascular recanalization cannot be overstressed.
References
1.Ghobrial GM, Chalouhi N, Rivers L, et al. Multimodal endovascular
management of acute ischemic stroke in patients over 75 years old is safe
and effective. J Neurointerv Surg. Jul 11 2012.
2.Meyers PM, Schumacher HC, Connolly ES, Jr., Heyer EJ, Gray WA,
Higashida RT. Current status of endovascular stroke treatment.
Circulation. Jun 7 2011;123(22):2591-2601.
3.Tissue plasminogen activator for acute ischemic stroke. The
National Institute of Neurological Disorders and Stroke rt-PA Stroke Study
Group. N Engl J Med. Dec 14 1995;333(24):1581-1587.
4.Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3
to 4.5 hours after acute ischemic stroke. N Engl J Med. Sep 25
2008;359(13):1317-1329.
5.Mishra NK, Diener HC, Lyden PD, Bluhmki E, Lees KR. Influence of
age on outcome from thrombolysis in acute stroke: a controlled comparison
in patients from the Virtual International Stroke Trials Archive (VISTA).
Stroke. Dec 2010;41(12):2840-2848.
6.Loh Y, Kim D, Shi ZS, et al. Higher rates of mortality but not
morbidity follow intracranial mechanical thrombectomy in the elderly. AJNR
Am J Neuroradiol. Aug 2010;31(7):1181-1185.
7.Kim D, Ford GA, Kidwell CS, et al. Intra-arterial thrombolysis for
acute stroke in patients 80 and older: a comparison of results in patients
younger than 80 years. AJNR Am J Neuroradiol. Jan 2007;28(1):159-163.
8.Chandra RV, Leslie-Mazwi TM, Oh DC, et al. Elderly Patients Are at
Higher Risk for Poor Outcomes After Intra-Arterial Therapy. Stroke. Jun 28
2012.
9.Abou-Chebl A. Endovascular treatment of acute ischemic stroke may
be safely performed with no time window limit in appropriately selected
patients. Stroke. Sep 2010;41(9):1996-2000.
10.Jovin TG, Liebeskind DS, Gupta R, et al. Imaging-based
endovascular therapy for acute ischemic stroke due to proximal
intracranial anterior circulation occlusion treated beyond 8 hours from
time last seen well: retrospective multicenter analysis of 237 consecutive
patients. Stroke. Aug 2011;42(8):2206-2211.
11.Natarajan SK, Snyder KV, Siddiqui AH, Ionita CC, Hopkins LN, Levy
EI. Safety and effectiveness of endovascular therapy after 8 hours of
acute ischemic stroke onset and wake-up strokes. Stroke. Oct
2009;40(10):3269-3274.
I am glad to see that my letter has piqued the interest of interventional neuroradiologists like Dr. Jagadeesan. I agree with him that no one should be running a fellowship that does not have the volume to expose trainees to enough cases so that they may obtain the necessary experience to practice safely. However, I think he has misunderstood my point. As I stated about the original piece, "I have no objection to the lo...
Nohra Chalouhi M.D., Stavropoula Tjoumakaris M.D.,and Pascal Jabbour M.D.
We read with great interest the article by Turk et al[1] assessing the safety and efficacy of endovascular stroke intervention based on CT perfusion (CTP) criteria. The authors are to be congratulated for this excellent report and for achieving remarkably high rates of favorable outcomes (42%) in stroke patients with poor neurological sta...
As a participant in the creation of the original ACGME ESNR fellowship training standards, I read the article concerning fellowship suspension with great interest (1). The paper is timely and thorough. It is unfortunate that the Neurointerventional world is dealing with so many unknowns. We do not seem to know how many we are, where we work, what we do, or where we were trained. The problem is very well summarized at...
Hirsh and Meyers espouse that same party line of the many private non -governmental agencies (and academics who will personally benefit from this program) who wish to impose private interest group-unproven corporate interests upon practicing physicians. They continue to state MOC is "voluntary" and then describe the many ways these "non-profit" corporations (who earn handsomely and have over $400 million in assets and as g...
Dear Sir:
I am not a neurosurgeon, neuroradiologist, nor interventionalist. In fact, I am not a regular reader of your journal. However, the article entitled "Should Neurointerventional Fellowship Training Be Suspended Indefinitely?" by David Fiorella, et al., was brought to my attention, unsolicited, by several different medical web sites. I have no objection to the logic and opinions expressed, and actually h...
Dear Sir,
We thank the authors for their letter entitled, "Caution during use of DDAVP in IPSS," by Drs. Pecori Giraldi, Federici, and Cavagnini. The authors suggest that because of the hypercoagulable state that characterizes Cushing disease, DDAVP may not be safe since it has been shown to increase the level of von Willebrand factor (vWF) and could therefore lead to platelet adhesion and cause thromboembolism...
Dear Sir, we have read with great interest the paper by Deipolyi and co-workers on the use of desmopressin during inferior petrosal sinus sampling (IPSS) in alternative to corticotropin-releasing hormone (CRH) for the diagnostic work-up of Cushing's disease (1). As the Authors report, evidence collected in small series suggests that desmopressin achieves an equivalent diagnostic accuracy to CRH, thus appears a tempting...
The reply from Perez et al to my letter of March 2012 is misleading and wrong in two important regards.1 First, they state that their report of the use of the solitaire stent for thrombectomy was just a case report, "nothing else". 2 This is not true. In fact, they explicitly use this report, both in the abstract and conclusion to lay claim for developing the stentreiever concept for thrombectomy: "This was the first...
We would like to add our strong support to the recent editorial by Fiorella, et al. Dr. Fiorella and his colleagues should be congratulated for pointing out the giant elephant in the room. The government, insurers and patients are increasingly demanding more quality, safety and value from the healthcare dollar and, like it or not, we can no longer ignore their pleas. Dr. Fiorella has eloquently shown us with widely ava...
We would like to thank Dr Hirsch and colleagues from Massachusetts General Hospital for their insightful comment on our paper.1 The authors advocate a more cautious conclusion regarding the efficacy of endovascular stroke intervention in the elderly since a control group of younger patients is lacking in our study. Although comparison to a younger group of patients is interesting, such data can hardly be used for drawing...
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