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Toward a New Renaissance in the Treatment of Neurovascular Diseases and Stroke

2014; Lippincott Williams & Wilkins; Volume: 74; Issue: Supplement 1 Linguagem: Inglês

10.1227/neu.0000000000000239

1524-4040

Bernard R. Bendok, Elad I. Levy,

Moyamoya disease diagnosis and treatment

“Innovation has nothing to do with how many R&D dollars you have. When Apple came up with the Mac, IBM was spending at least 100 times more on R&D. It's not about money. It's about the people you have, how you're led, and how much you get it.” —Steve Jobs “Insanity: doing the same thing over and over again and expecting different results.” —Albert Einstein “I have not failed. I've just found 10,000 ways that won't work.” —Thomas A. Edison Although research and development efforts are linked to financial resources, innovation requires much more than budgets. Although often serendipitous, innovation requires a culture marked by disciplined risk taking, creativity, thinking outside traditional boxes, and collaboration across specialty lines. But, as innovation has many facilitators, it also has many barriers: silos, acceptance of the status quo, nihilism, and blind dogmatism are some potential barriers that can hinder creativity, novelty, and innovation. Although the treatment of neurovascular diseases and stroke has advanced significantly over the past several decades, these diseases remain dominant causes of mortality and major disability. Early daring pioneers such as Dandy, Serbinenko, Drake, and Leksell would very likely marvel at the facets of modern microsurgery, endovascular surgery, and radiosurgery. They would undoubtedly be struck by the precision of patient diagnosis, operative management, and postoperative care. Moreover, they would likely be overwhelmed by the knowledge that has been amassed on epidemiology, pathophysiology, genetics, and natural history. The past 2 decades have demonstrated that a focus on the clip vs coil debate is not the best catalyst for dynamic innovation. Undoubtedly, microsurgical and radiosurgical endovascular treatments play complementary roles and are here to stay. Centers that excel at all techniques for neurovascular care likely serve patients better than centers that focus exclusively on 1 technique. Although innovation has and should continue to occur for each of our techniques, the integration and interface of these techniques is also a fertile terrain for innovation. The question “which technique is better?” is both inadequate and masks the highly variable nature of neurovascular pathologies. This is remarkably clear when one examines the diversity of arteriovenous malformations and their treatment options. A great need exists for each technique to undergo further refinement. Examining the weaknesses of each tool for solutions and not taking strengths for granted will pave the way for new advances. For a new Renaissance to occur in treating neurovascular diseases, however, innovation must extend beyond techniques. Innovation is needed in the areas of prevention, early diagnosis, rapid patient triage to qualified centers, safety of treatment, durability of outcomes, and enhancement for quality of life. The time has come to go beyond and build on evidence-based medicine and to embrace Precision Medicine. What may be good for the average patient in a population may not be good for the individual. Although it may seem that we have achieved great heights in vascular neurosurgery, areas such as screening, disease prediction, and individualized natural history prediction remain in their infancy. Every “mature phase” of a field can be the dawn of a new phase of innovation. In this supplement, Advances and Innovations in Vascular Neurosurgery, leading authorities in the field were invited to share their views on advances in the field and to lay out a vision for where things can go. This requires a look back and a look forward beyond the horizon. Although specialty “siloism” has focused attention on independent advances in microsurgery, neurointerventional surgery, and radiosurgery, synergies among these tools have often been neglected. Moreover, greater interface is needed between neurovascular experts and thought leaders in the areas of bioinformatics, genetics, vascular biology, imaging, nanotechnology, device development, and neuropharmacology to catapult us into the next era. Health care delivery was not designed for stroke. The unique aspects of stroke care will require quantum leaps in efficiency. It is said that health care delivery is going to the home. Stroke care has been slow to make that “house call.” Future innovations will likely bring the stroke team into the ambulance. The early days of aneurysm and arteriovenous malformation surgery were marked by daring, seemingly superhuman feats. Superhuman efforts are now needed to meet higher expectations of disease prevention, disease prediction, rapid patient triage, greater safety and durability of treatment, and optimization of quality of life. Diversity is said to be a fertilizer for innovation. The diversity of experts converging on stroke and neurovascular disease care has never been greater. Uniting these experts in the common cause of innovation will be the needed catalyst for the next Renaissance in Vascular Neurosurgery. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.