Warren R. Selman, MD

Don't Touch My Hat
Conventional Wisdom Seems Compelling,
but May Obscure Clear Vision

"Well you can have my girl, but don't touch my hat."
Lyle Lovett

As suggested in this homespun bit of wisdom by contemporary singer-songwriter Lyle Lovett, that which we value is always relative. It is, however, only natural to keep "them" from getting what is "ours." "Ownership" is a difficult issue with respect to patient management, and one that raises several questions. Can a group of physicians or a specialty truly own a technique? Does a technique belong to the pioneers of its development? Does it belong to those with access to the greatest number of patients? Rather than respond to these questions, the important questions to consider are who should be treated, who should render treatment, and which method is appropriate.

Consider the case of endoscopic surgery. Urologists were using the cystoscope to examine the bladder long before anyone contemplated using it to peer inside the deepest recesses of the brain. In fact, a urologist from Chicago, Victor Darwin Lespinasse, performed the first documented endoscopic neurosurgical procedure in 1910, using a rigid cystoscope to fulgurate the choroid plexus for treatment of hydrocephalus in two infants, one of whom died immediately.¹ Fortunately, Lespinasse abandoned neuroendoscopy for other scientific interests such as testicular transplantation for "rejuvenation," as he believed that "a man is only as old as his glands." That, however, is another story, and I will leave you to ponder how he convinced the donors to give of themselves.

Skills to use an instrument or technique should not be the sole criterion for determining its optimal use in the treatment of diverse disorders.

This brief glimpse into the past clearly demonstrates that possession of the skills to use an instrument or technique should not be the sole criterion for determining its optimal use in the treatment of diverse disorders. The same remains true for catheter expertise and cerebrovascular disease. Although there are those who believe that possession of catheter skills alone is a sufficient circumstance for treatment of any type of vessel disorder in any organ, I would strongly urge that this logic not be applied to the treatment of cerebrovascular disorders. The interests of the patient are best served by having care delivered by individuals who obtain training from those with documented expertise in a recognized neuroscience program and who have an abiding interest in the blood vessels and the brain. In this respect, cerebrovascular neurosurgery, interventional neuroradiology, and neurology all have a natural alliance. We should continue to stand together in support of defining optimal training guidelines for developing expertise in the management of cerebrovascular disorders with endovascular techniques.

In 1999, the AANS, CNS, CV Section, and ASITN worked diligently to obtain the approval of the Accreditation Council for Graduate Medical Education for a new fellowship, Endovascular Surgical Neuroradiology. As noted in the recommendations outlined by Higashida and colleagues in their special report, a resident was to obtain hands-on experience by being involved in "at least 100 catheter-based diagnostic angiograms."² Few would challenge the idea that quality of training and the principles outlined in this document must be preserved. The adoption of these recommendations, which were developed after careful and thoughtful consideration for the purpose of ensuring quality, must not be rushed or circumvented. It is, however, important to note that the current ACGME fellowship guidelines do not include a requirement for the performance of a specific number of diagnostic angiograms prior to entering endovascular surgical neuroradiology training. It is clearly possible to adhere to the quality standards outlined in the special report, yet be more innovative in taking advantage of the advancements that have been made both in catheter-based technology and educational opportunities, in the end providing training for cerebrovascular neurosurgeons that is commensurate with the experience and goals of the trainee.

Cerebrovascular neurosurgeons will carry on a proud tradition of innovation and excellence.

I have had the good fortune to work with extremely gifted interventional neuroradiologists. Through many years of close cooperation we have learned to act as one unit. I firmly believe this is a good model of practice. But I also believe, with resolution just as firm, that the development of the modern day cerebrovascular chimera - the endovascular microneurosurgeon who is equally skilled and facile with both techniques - must be pursued with unwavering determination. It is my hope that the existence of this new breed of cerebrovascular neurosurgeons and our goal of developing additional means of training them is not viewed as a challenge or a threat to either microneurosurgeons or interventional neuroradiologists, but rather that the dichotomy between treatment practitioners will disappear and neurosurgical cerebrovascular specialists will be identified by the disease and the patient treated, not by the training path or technique employed.

I am honored to have had the opportunity to serve as chair of the Cerebrovascular Section. I am indebted to those who have helped me throughout this year, and wish to express my appreciation to my fellow officers and members of the Executive Council whose motivation, dedication, and hard work are responsible for the vibrancy of our section. I am proud to be associated with this organization, whose efforts will ensure that future generations of cerebrovascular neurosurgeons will carry on a proud tradition of innovation and excellence.

References
1. Cohen AR, Perneczky A: Endoscopy and the management of third ventricular lesions, in Surgery of the Third Ventricle, ed. Apuzzo, MLJ: Baltimore: Williams and Wilkins, 1998, 889-936.

2. Higashida RT, Hopkins LN, Berenstein A, Halbach VV, Kerber C. Program requirements for residency/fellowship education in neuroendovascular surgery/interventional neuroradiology: a special report on graduate medical education. AJNR Am J Neuroradiol. 2000 Jun-Jul;21(6):1153-9. PubMed