My first time posting here, and I hope to be an interventional neuroradiologist after graduating RCSI (wish me luck! I’ll need it).
Now, after doing my rotations (I managed to get an elective in diagnostic radiology at NYU), I was struck by something: neuroradiologists perform image-guided biopsies of the spine, maxillofacial structures, skull, etc., but I almost never hear of them doing stereotaxic percutaneous biopsies of brain lesions and abscess drainage.
It seems to me that they should be just as capable as neurosurgeons in performing the burr hole needed to insert the 18-ga Tru-Cut needle in order to get the sample, or the drainage catheter to drain the pus. We already let neurointensivists place EVDs, and they have similar complication rates as neurosurgeons. And some emergency physicians place emergency burr holes for EDH.
Same issue with inserting depth electrodes. Why this requires a full neurosurgeon when it could be done cheaper by an interventional neuroradiologist with some extra training is something I hope you will enlighten me.
Maybe the issue is that most neuroradiologists would rather be reading CTs and MRIs and make $400 every 20 minutes, rather than spending an hour setting up a stereotaxic frame and worrying about post-op infection.
Wouldn’t your valuable time be better spent resecting tumors, removing intervertebral discs, performing all manners of functional surgeries, and managing pre- and post-op patients, then doing biopsies and inserting depth electrodes?
Another interesting issue is the new Visualase laser thermal ablation system used for epilepsy. Radiologists will use it for every other application, like ablating liver and kidney tumors, but, despite how it requires MR-guidance, no interventional neuroradiologist seems to have ventured into using it for brain issues, only the neurosurgeons seem to have the chutzpah.
Maybe neurosurgeons just have more of a cowboy in their hearts than neuroradiologists. Even neurointensivists are willing to drill into someone’s skull to insert a catheter to relieve intracranial hypertension, but neuroradiologists seem to prefer the darkness of their reading rooms and angiosuites.
I find it very cool how PD Purdy at UT Southwestern invented percutaneous intraspinal navigation, which should revolutionize neurosurgery and interventional neuroradiology. Now common neurosurgical procedures like third ventriculostomy and deep DBS placement can be done via a lumbar puncture. Let’s hope it gets off the ground and into clinical trials.
Maybe you could even do a RF cingulotomy via that route. I guess the problem would be designing a flexible electrode that’s thin enough to simply dissect the tissue it’s passing through on the way to the cingulate gyrus from the third ventricle, rather than tearing it, as well as get from the lumbar spinal canal to the third ventricle.
My view is that if it can be done under image-guidance through a burr hole, an interventional neuroradiologist should be able to do it. They certainly have the neuroanatomy knowledge and technical skills. If I was a neurosurgeon, I’d rather spend my days doing GBM resections, spinal fusions, temporal lobectomies, and decompressive craniectomies than threading electrodes through holes.
And besides, the more physicians there are to offer a procedure, patients will be happier because of easier access, and the poor performers will be weeded out by market forces and lawsuits.
Maybe I should try to get into NYU’s triple-board combined residency program in neurology, radiology, and neuroradiology. Or maybe I should do neurology and then either a) try to get into a neurosurgical residency (yeah, right, but it’s possible), or b) get into an interventional neurology fellowship. Then I’ll try to arrange a clinical trial comparing neurosurgeons and interventional neuroradiologists in performing stereotaxic brain biopsies. I can’t be the only one who’s wondered about this.
Hopefully the answer to my question isn’t “because neurosurgeons aren’t willing to train INRs in these procedures,” which smacks of wanting to protect income, though I highly doubt the majority of a neurosurgeon’s income is going to go away if they no longer do stereotaxic brain biopsies, abscess drainages, depth electrode placement, tumor and epilepsy foci ablation, etc. It didn’t happen to interventional radiologists when they lost most of their arterial work to cardiologists and vascular surgeons.
General surgeons welcomed interventional radiologists to deal with their abdominal abscesses, TIPS placement, tumor ablations, etc., because they allowed them to focus on cases that truly required an open or endoscopic approach, rather than cases that could be easily taken care of percutaneously. Ian Ross, a neurosurgeon at Huntington Memorial Hospital, reported a case series of successful EDH management by coiling the middle meningeal artery.
I mean, would you guys rather spend your evening a) draining a brain abscess or performing a biopsy, or b) evacuating a SDH?
I’m pretty sure I sound like an arrogant uninformed medical student, right? I just find it strange that interventional neuroradiologists never seem to venture beyond aneurysms, strokes, and some small spine work. Feel free to call me stupid, as I know that’s how I probably sound.
