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Why Neuroimaging Plays a Critical Role in Shaping the Future Of FEATURE STORY Viewpoints: Why Neuroimaging Plays a Critical Role in Shaping the Future of Neurology An integral part of clinical neurology and neurosciences, neuroimaging training must be better harnessed and incorporated into the educational spectrum of the specialty. By Laszlo Mechtler, MD and Joseph Fritz, PhD ith its disciplined process of relating lesion visual- NEUROIMAGING: HISTORY AND CURRENT USES ization to symptoms, neuroimaging is central to The history of neuroimaging rests on the shoulders of Wneurology and used by most of its subspecialties. giants with a wide range of expertise, including neurology, Many neurologists depend on their own interpretation of neurosurgery, engineering, and physics. In 1895, physicist images rather than a written report to make treatment Wilhelm Roentgen demonstrated the first radiograph and decisions because as clinicians, they assume medico-legal opened a new window to medical diagnosis. His revolu- responsibility for their patients. Neurologists possess tionary discovery set the stage for progressive advances in unique insights into the appropriate use of imaging, and general medical and neurological imaging. Walter Dandy, are well positioned to contribute important advances in a neurosurgeon, first performed ventriculography and neurodiagnostics. For these reasons, an understanding of pneumoencephalography in 1918 and 1919.2,3 Egaz Moniz, neuroimaging makes us better neurologists. a neurologist, accomplished the first cerebral arteriogram Unfortunately, diagnostic neuroimaging training for in 1927.4 Neurologist William Oldendorf patented the CT neurologists is insufficient to keep up with increasing concept in 1961, leading to the clinical scanner develop- need. The American Medical Association (AMA) has ment by electrical engineer Godfrey Hounsfield in 1973.5,6 steadfastly supported “organ-specific imaging” by clinical In the early 1970s, physicist Paul Lauterbur published the subspecialists such as neurologists and cardiologists. AMA first spatially differentiated MRI images, and Raymond policy guidelines assert that: (1) individual character, Damadian, an internist, recognized MRI’s role in tumor training, competence, experience, and judgment should detection.7,8 In the early 1980s, the neurologist Ferdinando be the criteria for granting privileges in hospitals; and (2) Buonanno was the first director of the first clinical MRI physicians representing several specialties can and should unit in the US, at the Massachusetts General Hospital.9 His be permitted to perform the same procedures if they first fellow, Carl L. Kramer, is also a neurologist. meet these criteria.1 In recent years, neurologists have an even heightened As our specialty continues to evolve, neuroimaging will reason to review images themselves. The combination play a critical role in our understanding of neurological of an increasing use of general radiologists and radiology disease and the delivery of care. Ahead, we will explain assistants,10 and regulations that mandate clinical access why a greater emphasis on neuroimaging—including to images through certified Electronic Medical Record sys- improved access to training programs—is needed in order tems are placing increased legal risks on clinicians. There to achieve that. is a growing sensibility among neuroradiologists that if NOVEMBER/DECEMBER 2016 PRACTICAL NEUROLOGY 17 FEATURE STORY general radiology continues interpreting neuro-diagnostic images, it will force neurologists and neurosurgeons into “Advances in the burgeoning field taking appropriate steps to uphold quality of care for of functional neuroimaging requires their patients and protect themselves from medico-legal a greater depth of neuroscience implications. Leading neuroradiologist Scott Atlas MD, has stated: “To continue having non-subspecialty-trained training, and will certainly benefit radiologists interpreting sophisticated, complex imaging from the active involvement of studies on patients with diseases that are virtually always clinical and research neurologists cared for by subspecialist referring doctors is unacceptable patient care.”11 who are also trained Neurologists who make urgent point of care decisions in neuroimaging.” are particularly inclined to interpret directly from images; examples include neurohospitalists, stroke specialists, group practices, and its integration is maximally leveraged critical care neurologists, interventional neurologists, and through a symbiotic relationship between clinical neurol- practitioners who use teleneurology. In a 2002 interna- ogy and imaging science. Neurologists trained in neuroim- tional survey, 79 percent of neurologists stated that they aging offer tremendous value in such organizations. made clinical decisions on stroke care based solely on their independent review of neuroimaging studies.12 Imagine a THE NEED FOR TRAINING neuro-oncologist or multiple sclerosis specialist making Given the historical and clinical case for neurology as clinically pertinent decisions based solely on a general radi- an important participant in the imaging community, it is ologist’s interpretation. astounding that neurologist training in diagnostic neuro- Moreover, there is increasing reliance on functional imaging is sorely lacking, thereby limiting clinical, research imaging techniques that depend more on an understand- and business opportunities for the very subspecialty that ing of neurophysiology than neuroanatomy. Examples most understands the neuroscience behind the technology, include the use of white matter tractography, spectrosco- as well as downgrading the quality of patient care. Many py, perfusion, blood oxygenation functional imaging, and neurology residency training programs offer inadequate connectomics. In our organization, almost one-third of the and inconsistent formal education in diagnostic imaging, MRIs ordered by experienced neurologists are reported and often rely on rotations through radiology departments after visual reading as either normal or having only inci- that are not fully integrated into a neuroscience curriculum. dental findings, even though the patient displayed suspi- There are educational opportunities beyond residency, such cious symptoms. The underlying “functional” neurologic as rotations and preceptorships at appropriate imaging cen- disorder may be better assessed by newer imaging meth- ters; didactics and professional conferences; and formal fel- odologies. Advances in the burgeoning field of functional lowship programs. Fellowship programs of at least one year neuroimaging requires a greater depth of neuroscience should be required for any neurologist interested in pursu- training, and will certainly benefit from the active involve- ing neuroimaging as a subspecialty. ment of clinical and research neurologists who are also To achieve any success in neuroimaging training efforts, trained in neuroimaging. a healthy respect for the complexity of imaging technology Independent practice of neurology can also be improved is needed. That encompasses recognizing how artifacts can by integrating imaging and neuroimaging experts into mimic pathology, understanding how certain techniques can the team.13 Private practices tend to offer more acces- mask or highlight pathology, and learning the process for sible, cost-effective care that strives to avoid hospitaliza- unbiased interpretation of images while concisely addressing tion. Ironically, an unintended consequence of healthcare the clinical question. Such training requires a combination of reform has been a fracturing of this very sector. Survival technical didactics and high volume of experiential learning. of the outpatient practice rests on its ability to afford- The United Council on Neurologic Subspecialties (UCNS) is ably manage the complexities of healthcare affordably. responsible for accreditation of Neurology fellowship pro- Comprehensive outpatient services can offer economy of grams, including diagnostic neuroimaging. It is encouraging scale, improved coordination of care, better patient access, that UCNS approved sites have doubled in number in the last better quality control, and financial bundling opportuni- year, but more are still needed. ties. This contrasts with the very expensive bureaucratic Interest level for imaging education is high among neurol- hospital systems that are typically less able to focus on the ogists. The neuroimaging section of the American Academy needs of the patient and of the neurologist. Neuroimaging of Neurology (AAN), established in 1977 as one of its five is a logical component of multispecialty neuroscience original clinical sections, currently has about 800 members. 18 PRACTICAL NEUROLOGY NOVEMBER/DECEMBER 2016 FEATURE STORY Attendance at AAN and American Society of Neuroimaging awareness by medical students and residents that neurolo- (ASN) imaging education sessions continues to rise, most gists can and do receive training and develop careers in recently evidenced by standing room only crowds at the neuroimaging. Disappointingly, we regularly hear from resi- 2016 AAN Annual Meeting presentations. Anecdotal com- dents who are actively discouraged from such a career path munications such as blog posts and personal letters of inqui- by their attending radiologists or, even more sadly, some ry provide further examples of enthusiasm for more imaging neurologists. Neurology leadership has always recognized education. This is especially true of next generation tech the value of imaging training for neurologists,
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