Changing Times
Reflections on the Past
"In the early morning, we read skull, spine and facial radiographs. Later,
we assisted the fellows or staff in performing cerebral angiograms,
myelograms, and the occasional pneumoencephalogram. The highlight of my day
was to help interpret the CAT scans of the head in the late afternoons. The
CAT scans during those days were long examinations (45-60 minutes to complete
a non-contrast scan of the whole head). Our EMI 1010 scanner physically
rotated around the patient's head and took 5 minutes per 360 degree rotation
and produced two contiguous slices (10 mm slice per section)." These were
the reflections of Dr. Edgardo Angtuaco, chief of the division of
neuroradiology at UAMS, who finished his radiology residency in 1979 at the
Boston City Hospital. Times have changed, and today the busy schedule of the
neuroradiology division reflects the tremendous growth that the field has
undergone since those early years.
Neuroradiology at UAMS
Neuroradiology as a subspecialty in radiology was introduced to the
University of Arkansas in 1977 by Dr. Ernest Ferris, then the newly appointed
chairman of the department, who taught neuroembolization techniques with
silicone beads. He then recruited Dr. Eugene Binet in 1978 to be the section
chief of the newly created section of neuroradiology. In 1986, following Dr.
Binet’s appointment as chairman of radiology at Medical College of Georgia,
Dr. Edgardo Angtuaco became the section chief and has been since that time.
In 2000, Dr. Ferris transformed the section of neuroradiology into the
division of neuroradiology.
The subspecialty training of residents and fellows in neuroradiology
continues to be the major goal of the division under the leadership of Dr.
Angtuaco. Reflecting on the years since he came to Arkansas, Dr. Angtuaco
recalls the numerous neuroradiology fellows and residents he has trained.
Today, the division continues this task of teaching with the daily grind of
readout sessions and weekly conferences with the radiology residents.
The division continues to attract young academic staff to the field, as is
reflected by the increase in number of fully-trained active-staff
neuroradiologists. Today, the division is represented as a subspecialty at
the University Hospital (UH), the John L. McClellan VA Hospital (VAH), and
the Arkansas Children’s Hospital (ACH). Six neuroradiologists practice at
the UH and VAH, plus two at the ACH. Average daily workload consists of
about 150-200 diagnostic studies and a variety of interventional procedures.
Growth and change is the motto of the division as it continually strives to
update itself. The division also includes two full time neuroradiology
nurses, a secretary, a PhD physicist, and an MR engineer.
Intra- and Inter-departmental Collaboration
Collaboration with other academic radiologists in the department is an
important activity within the division which allows academic and personal
growth in other aspects of neuroradiology. Active collaboration with the
musculoskeletal and body imaging radiologists, sonologists, interventionalists,
and nuclear medicine physicians are part of the daily schedule of the
neuroradiologists. These close ties allow the division to expand its
knowledge base and lead to an understanding of the applications of these other
specialties to the ever-changing field of neuroradiology. The
newly-introduced, highly technical fields of doppler and 3D ultrasound,
vascular stenting, PET, and the newer techniques in multihelical CT and high
field MR bring additional strengths to the practice of the field.
The strong and congenial relationships with the departments of neurosurgery,
neurology, otolaryngology, ophthalmology, and bone marrow transplantation
enable the neuroradiologists to integrate their activities with these
specialties. The strength of these various departments continues to provide
the backbone to academic research and resident teaching. Formal weekly and
daily clinical conferences are held with these departments. This successful
collaboration has led to combined clinical research and projects, academic
papers, and presentations at national meetings.
Neurointerventional Service
The neurointerventional service is a major effort of the division. This
effort is led by our neurointerventionalists, Dr. Rudy vanHemert and Dr.
Eren Erdem. This specialty has an active and busy practice with total
capabilities in vascular and spine interventions. Initially started in 1990
by Dr. Angtuaco, this service is now recognized as a distinct subspecialty
with growth in the number and complexity of procedures. Today, the service
offers the whole gamut of endovascular neurointerventional procedures with
capabilities in intracerebral and extracerebral interventions. Procedures
that are offered include: glue embolization of AVM, stenting and coiling of
intracerebral aneurysms, stenting of intracerebral and extracerebral carotid
or vertebral stenoses, treatment of dural AVM, and embolizations of vascular
tumors of the head, neck and spine. Spine interventions, particularly
vertebroplasty, are an important part of the service. The special interest
of Dr. Erdem in vertebroplasty of spinal fractures in multiple myeloma has
led to the introduction of novel techniques of vertebroplasty which has
resulted in significant improvement in pain and daily living outcomes in the
successfully-treated patient. Dr. vanHemert continues to develop and improve
the techniques of directed bone marrow biopsies in multiple myeloma patients
and in the deep tissue biopsies of the neck. This service would not be
possible without the strong efforts and dedication of our neuroradiology
nurses, Mrs. Leta Peterson and Mrs. Margaret Justus, who attend to the
medical needs of the patients.
Consultation Service
The neuroradiology division is a source of consultation for the whole
university and state with an active referral center for interpretation of
complex cases referred to the university physicians from outside doctors,
hospitals, and imaging centers. This would not be possible without the
modern picture archival systems (PACS) and 3D workstations available in the
department for physician consultation. Radiographs are a rarity in the
department.
The service provides 24-hour coverage in both diagnostic and interventional
service. The on-call neuroradiologist has a computer at home capable of
communicating with the PACS system in the hospital, which allows for
real-time consultation of emergent cases. As an example, a ruptured cerebral
aneurysm with its initial workup of a computed tomographic scan of the head
can be seen by the on-call neuroradiologist at home, and plans can be made
for the cerebral angiogram or angiography by computed tomography (CTA). In
addition, depending upon the clinical circumstances and wishes of the
referring physician, plans for endovascular coiling of the aneurysm can be
made, avoiding delay in treatment. This is similarly true with the multiple
myeloma patient, where the active neuroradiology service is available for
consultation in difficult cases and can perform semi-emergent procedures of
spine biopsies or vertebroplasties.
Growth and Expansion
The division is also involved in cutting edge technology with advanced CT and
MR equipment available at the University Hospital. Studies such as
multislice helical CT scan as in CTA, perfusion studies for strokes and MR
examinations such as diffusion scans, MRA, spectroscopy, perfusion studies,
and functional MR studies are available for the care of a select group of
patients. The service is also busy with teaching residents. At the UH and
VAH, the studies are available with the PACS format where advanced teaching
methods are available especially with the capacity of actively showing
teaching file cases.
The neuroradiology division continues to grow and its members continue to
expand their knowledge base. The complexity of the specialty allows its
specially-trained physicians to grow and appreciate the demands of their
training. The division is looking forward to the new helical 16-slice CT
scanner in addition to the current two 4-slice CT scanners at the University
Hospital. This coming year, the division will be involved in the new 3.0
Tesla magnet and the biplane neuroangiography suite at the University
Hospital. At the VA Hospital, there are planned acquisitions of a 1.5 Tesla
magnet and a biplane neuroangiography suite.
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