Training in endovascular surgical neuroradiology.

BACKGROUND: During the past few years, the field of endovascular surgical neuroradiology has been expanding. Neurosurgeons, radiologists, and neurologists are currently being trained. We analyzed data from a national survey of endovascular training programs to assess the current training status and future projections. METHODS: Survey participation requests were sent out to program directors and members of the Society of Endovascular Neurosurgery, the Society of Neurointerventional Surgery, and the Society of Vascular and Interventional Neurology. The format was an on-line survey designed by the authors, and completed through the SurveyMonkey.com website. Forty-three programs were identified and invited to participate. RESULTS: We achieved a response rate of 81% (n = 35). Twenty-seven (79%) of the 35 respondents listed their training program as academic, and 7 (20%) listed it as a mixture of academic with private practice. The training program faculty consisted of 57 radiologists, 39 neurosurgeons, and 10 neurologists. Length of fellowship offered was the same for all specialties in 43%, and differed based on clinical experience/background in 51%. Of the programs, 86% offered a 2-year fellowship, 49% had a mandatory resident rotation, 17% offered an infolded complete fellowship for residents, and 34% offered an infolded partial fellowship. Only 9% reported no resident exposure at all. There were 12% of respondents who reported to have knowledge of vascular surgeons or cardiologists performing intracranial procedures. At the time of the survey, there were 68 fellows in training, and most entered training immediately after residency (38%), whereas 26% entered after a fellowship and another 26% trained while in residency. There will be a 14% increase of graduates within the next 5 years. Comparing the past 5 years (2003-2007) with future 5-year projections (2008-2012), the number of radiologists is declining by 37% (73 vs. 46), whereas the number of neurosurgeons (74 vs. 106) and neurologists (20 vs. 37) is increasing by 42.5% and 112%, respectively. CONCLUSIONS: This survey suggests that there is a strong interest in endovascular surgical neuroradiology. The overall number of graduates is increasing, particularly in neurosurgery and neurology. Although the majority of current faculty is still comprised of neuroradiologists, the number of graduates in radiology will be decreasing during the next 5 years, reflecting a trend toward greater subspecialization within the fields of neurosurgery and neurology. Peer-Review Article.

Pupillary reactivity upon hospital admission predicts long-term outcome in poor grade aneurysmal subarachnoid hemorrhage patients.

BACKGROUND: Historically, the prognosis for poor grade subarachnoid hemorrhage patients has been considered dismal. As a result, many hospitals have chosen conservative management over aggressive therapy. This guarded approach, however, is based on studies that do not take into account newer, more effective, management protocols and more recent long-term evidence that significant neurological recovery occurs in the months to years following discharge. More accurate and predictive methods are needed to decide when aggressive therapy is warranted. METHODS: Two hundred and twenty-six grade aneurysmal subarachnoid hemorrhage (aSAH) patients of grades IV and V were admitted to Columbia University Medical Center and enrolled in our study. Demographics, clinical information (e.g. pupillary reactivity on admission), and treatment course (operative versus non-operative) were recorded. Rankin scores at 14 days, 3 months, and 1 year were also recorded. A favorable Rankin score was defined as 0-3. Unfavorable was defined as 4-6. RESULTS: Among all poor grade patients who received operative therapy, pupillary reactivity at admission was not predictive of a favorable Rankin score at day 14 (odds ratio = 3.3, P = 0.129). Pupillary reactivity, however, was predictive of Rankin score at 3 months (odds ratio = 4.57, P = 0.05) and 12 months (odds ratio = 6.44, P = 0.008). After constructing a Kaplan-Meiers survival curve, pupillary reactivity was a better predictor of survival at 12 months than H&H grade [Hazard ratio 3.342 (1.596-7.000) P = 0.001 versus 1.964 (1.016-3.798) P = 0.045]. CONCLUSIONS: This study demonstrates that significant recovery occurs in the weeks to months after poor grade aSAH. Pupillary reactivity on admission can be used as a predictor of survival and recovery at intermediate and long-term time points, more so than Hunt and Hess grade.