Neurosurgery’s Key Role in the Future of Cerebrovascular Surgery

Sean D. Lavine, MD

The 2016 AANS/CNS Joint Cerebrovascular Section (JCVS) Annual Meeting took place this past February in conjunction with the with the Society of NeuroInterventional Surgery (SNIS). Held at Universal Studios, Los Angeles, the meeting was a tremendous success, with over 500 attendees. This success points to a dedicated reinvigoration of joint programming and participation between the SNIS and the JCVS, which enabled the important interaction of all specialties delivering cerebrovascular care, including neurologists and interventional neuroradiologists.

We were honored to host the Neurosurgical Society of Australasia as our international partner. There was great enthusiasm from their society, with several members traveling to be in attendance. The American Heart Association International Stroke Conference immediately followed our meeting in downtown Los Angeles.

The CV Section continues to play a significant role in several important projects that will impact the delivery of cerebrovascular care for the ensuing years. Following are a few highlights on these endeavors.

CV Section President Dr. Sean Lavine presents an award to Dr. Carolina Sandoval Garcia

QOD

A recent notable project has been the development of a CV Module for QOD in conjunction with NeuroPoint Alliance. The National Neurosurgery Quality and Outcomes Database’s (originally N²QOD, now renamed QOD) primary purpose is to track the quality of neurosurgical care and to provide practice groups and hospitals with an immediate infrastructure for analyzing and reporting specific metrics associated with this care delivery. It is extremely important to track cerebrovascular disease using this tool, which will help facilitate research, allow for the development of benchmarks, and meet organizational requirements for data tracking. We were pleased to announce at the JCVS Annual Meeting that as of February, 2016, over 500 patients have been enrolled in the cerebrovascular module, with roughly 13 centers actively collecting data, and several others completing site enrollment.

Acute Stroke Trials

Recently, several landmark studies have been published that clearly demonstrate the superiority of mechanical thrombectomy over the non-invasive treatment of acute stroke caused by large vessel occlusion. The JCVS has been working on three fronts to promote these results. We have been heavily involved with the American Heart Association and American Stroke Association in the revision of the 2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients with Acute Ischemic Stroke Regarding Endovascular Treatment. After our revisions were accepted, our executive council voted for endorsement. Other members of the Neurovascular Coalition are also endorsing of the revisions.

The CV Section has also written a letter to the major payors in alliance with the AANS/CNS Washington Committee with assistance from Cathy Hill and Katie Orrico. The CV Section, past president of the CNS Dr. Nathan Selden, and current president of the AANS Dr. Hunt Batjer endorsed the letter. We finalized the distribution list using the policy reporter monitoring system, and sent the letter in September 2015 to the carrier medical directors of 31 major payors that had negative coverage policies for mechanical thrombectomy. According to the policy reporter, 23 of the payors that had previously considered mechanical embolectomy investigational have now changed their policy to medically necessary. This is a major step toward promoting the use of this important technique for our stroke patents and to insure the physicians who perform this vital work are compensated for their efforts. Through the AANS/CNS Washington Committee, along with the excellent work of Dr. Henry Woo and others, we are hoping the Centers for Medicare and Medicaid Services will soon follow suit.

Finally, we have been involved in key editorial statements on the importance of the acute stroke trials. We wrote a preliminary letter with principle members of the SNIS in the Journal of NeuroInterventional Surgery (JNIS) to discuss our position on the recently published acute stroke trials. We also plan to partner with the SIR/SNIS/SVIN/ASNR/CIRA (Canadian IR)/CIRSE (European IR)/ESMINT as a writing group to develop the editorial “Quality Improvement Guidelines for Intraarterial Stroke Therapy.”

Stroke Center Accreditation

We continue to work with the AHA, Joint Commission, DNV-GL Healthcare, the Cerebrovascular Coalition (CVC), and the Brain Attack Coalition to use consistent and appropriate guidelines for the certification of primary and comprehensive stroke centers. There has been much discussion about varied standards by different accreditation organizations, and the lack of adoption of our previously negotiated standards. The latest action will be a consensus statement by the Cerebrovascular Coalition in published form after a consensus has been reached. The AHA has a new Hospital Accreditation Scientific Committee and Dr. Brian Hoh, our past chair, will be a member.

CV meeting attendees review the latest technological innovations

Fellowship Training Standards

The CV section has worked very closely with the task force of the Society of Neurological Surgeons, the JVIN, and the SNIS for the development of CAST (Committee on Advanced Subspecialty Training) standards for endovascular neurosurgery and open cerebrovascular fellowships, as well as program certification. The guidelines are now set, and the CAST website is actively accepting applications for CAST accreditation of a fellowship program in cerebrovascular and neuro-endovascular surgery, as well as certification of individuals in neuroendovascular surgery. The first set of individual neuroendovascular surgeon applicants were vetted at the CV Section Annual Meeting in Los Angeles.

We also recently completed a significant role in the development of an international article, “Training Guidelines for Endovascular Stroke Intervention: An International Multi Society Consensus Document.” Article contributors included the American Association of Neurological Surgeons/Congress of Neurological Surgeons (AANS/CNS); the American Society of Neuroradiology (ASNR); the Asian Australasian Federation of Interventional and Therapeutic Neuroradiology (AAFITN); the Australian and New Zealand Society of Neuroradiology—Conjoint Committee for Recognition of Training in Interventional Neuroradiology (CCINR) representing the RANZCR (ANZSNR), ANZAN, and NSA; the Canadian Interventional Neuro Group (CING); the European Society of Neuroradiology (ESNR); the European Society of Minimally Invasive Neurologic Therapy (ESMINT); the Japanese Society for Neuroendovascular Therapy (JSNET); the Sociedad Ibero Latino Americana de Neuroradiologica (SILAN); the Society of NeuroInterventional Surgery (SNIS); the Society of Vascular and Interventional Neurology (SVIN); and the World Federation of Interventional and Therapeutic Neuroradiology (WFITN). The article will be published in Neurosurgery in the near future.

The Joint Cerebrovascular Section has placed an extremely high priority on neurosurgery’s role in the treatment of hemorrhagic and thromboembolic stroke. In light of recent landmark developments in clinical stroke intervention, our role has never been more vital. In close association with our colleagues in neurology and radiology, we will continue our efforts in education, clinical research, quality and outcomes tracking, training standards, and stroke center certification. The tireless efforts of many individuals in the JCVS will ensure that neurosurgery will continue to have a leading role in the delivery of stroke care to our patients, and in the development of policies related to that care.

23 PAYORS THAT HAD PREVIOUSLY CONSIDERED MECHANICAL EMBOLECTOMY INVESTIGATIONAL HAVE NOW CHANGED THEIR POLICY TO MEDICALLY NECESSARY.