Five to-the-point questions to a neuro-interventional radiologist
Meet Dr Arthur Winter, neuro-interventional radiologist and Branch Manager at SCP Radiology Cape Gate. He is doing invaluable work to strengthen the practice’s interventional services and we asked him five to-the-point questions to give insight into his work.
Briefly plot the career milestones that led you to neuro-intervention and your current position at SCP.
After I obtained my degrees in Stellenbosch and Pretoria respectively, I worked as a general radiologist at Unitas Hospital. One of the pioneers of neuro-intervention in South Africa, Prof. Pieter Fourie had his own practice there. I was exposed to some of the work he did and I found it quite intriguing.
I started watching what they did more closely and attending their academic meetings. When Pieter Fourie wanted to retire, their need for someone to take over from him created an opportunity for me to get involved.
It was a magnificent opportunity. I spent two years training under an experienced person in my own hospital, working from home so to speak. Of course, I also did a course through the University of Toronto but being a successor to Prof. Fourie was pivotal. When he retired I could take over a well-established, well-equipped neuro-intervention practice with the best staff that you can imagine.
I spent the next 12 years as head of the General Interventional and Neuro-interventional Unit at the hospital and got actively involved with the South African Neuro-Intervention Society.
Then, having built up experience and still enjoying working in that practice, I wanted to change my lifestyle and had an opportunity last year to come and work for SCP. Now we’re steadily building the team I want, because neuro-intervention certainly is a good team effort. I’m working with experienced radiographers, getting to know nursing staff in the theatres, and working together with clinicians. It’s an exciting process.
What are the most notable skills you can contribute to any team today?
I am trained and experienced in mechanical thrombectomy, which we often perform in addition to thrombolysis in acute ischemic stroke. I’m also skilled in endovascular cerebral aneurysm treatment, with which neuro-interventionists can effectively treat the vast majority of aneurysms.
I also do treatment and guidance on arteriovenous malformations (AVM), pre-surgical tumour embolisation, epistaxis embolisation, inferior petrosal sinus sampling, and transverse sinus stenting which is a treatment for benign intracranial hypertension or pulsatile tinnitus.
How is this relevant for a doctor or patient reading this?
First of all, awareness of what we do and what we offer is important. In stroke patients with anterior circulation occlusion, for instance, thrombectomy has been shown to significantly reduce disability after 90 days. I think this is where neuro-interventional specialists’ work has a very dramatic impact.
Along similar lines, 90% of aneurysms can be effectively treated with endovascular interventions.
Of course, not all aneurysms are associated with similar risk and need to be treated necessarily, just as thrombectomy will not be indicated for all stroke patients. And treatment is not without risk. This is where our advisory abilities come into play.
Advice doesn’t cost us anything but it can add tremendous value for patients and for our referring doctors.
The fear of having a stroke – and the hope to limit disability from it – is possibly something that most South Africans can relate to. Yet in practice, your skill to perform mechanical thrombectomy only has meaning when a patient reaches you in time. Would timely intervention always be somewhat serendipitous?
It will always be a challenge getting the right patient to the right place at the right time, in time. Statistically, thrombectomy eligibility is low enough as it is – depending on the selection criteria, between 3% and 22% of patients with acute ischemic stroke.
It’s especially difficult in South Africa where we have a small group of patients with medical aid and access to advanced healthcare. We also don’t have large speciality centres, meaning quality healthcare is fragmented into small hospitals.
The odds become even lower if you consider that you need a lot of dedicated and available staff, availability of theatres, availability of equipment and emergency services who are on board and able to get patients to the right place at the right time.
It’s not a one-man job. We can start with awareness and cooperation across the whole healthcare community to try and enlarge the small pool of patients who find timeous intervention. Plus, rather than focusing on patients who don’t reach us on time, we can focus on the ones we are able to help.
Neuro-interventional radiology is a rare subspeciality. As someone with insight on a national level, do you think the country needs more of it and will we see neuro-interventional radiologists in greater numbers in future?
There are so many factors that come into play. What draws someone to a particular subspeciality? In neuro-intervention you need to be patient and diligent and gain experience bit by bit. It’s high stress, the margin of error is small, and if anything goes wrong it can have a severe effect on the outcome. You need to be able to get through the ups and downs because complications do occur. It’s not for everyone.
Another problem with neuro-intervention is that there’s not enough work to be done to do it full time, especially in private practice. In radiology it’s slightly easier because we can cross-subsidise it with general radiology to make it viable.
You also need to do enough of these procedures to be able to maintain your skill levels. If you do too little, you lose your confidence and your ability to work. So, at the moment, there are few of us but probably just enough.
The real problem is that the people who are in the game at the moment will need to be replaced when they retire. We need to look at successors coming through but at the same time, they need to be busy enough with enough patients. It’s a challenge.
Where I am now, I am up for it. I am surrounded by competent people who can respond to the challenges. I have a passion for this and I want to help people. Everything else will follow.