Interventional Neurorad: Where It's Going, Where It's At

[PaddyofNine]

Any thoughts? Quite interested in this field, think minimally invasive neuro procedures will be big in the future, but here (Ireland, EU) and in the US. Anyone any thoughts or comments? Do you think that any new procedures are in the pipeline that will change the field significantly? One attending over here mentioned that he thinks Neurorads have a big part to play in Acute Stroke treatment in the next 10 years - do you guys agree?

I put a similar post in the Radiology forum but am interested to get some surgical perspective!

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[mpp]

Yes, neuroradiology will play a big part in stroke treatment as it is already doing. Clot removal and clot lysis will likely show better outcomes than conservative management. The drugs and the catheter toys will only get better and safer.

 

[iwantneurosurg]

mpp, since you are in residency, this question is for you (and other residents/surgeons)

what will the neurosurgeon's role be in neuroradiology? are you trained in the neuroradiological procedures? will you be able to do what they do?

i'm afraid because cardiothoracics lost a large part of their bypasses because of successful stents and balloon angioplasties, and now cabg's are reserved only for triple occlusions and left main, severely cutting their workload.

will the same happen to neurosurgeons?...i know it's hard to tell, but if it does, will the neurosurgeon be able to do what the neuroradiologist does so he can keep working, or will the neuroradiologists screw cerebrovascular neurosurgeons much like how the cardiologists have severely detracted from the CT surgeons.

...on that note...can CT surgeons do stents and balloon angioplasties? why dont they take that route? or are they already?


we're in the cardiovascular unit now in second year of med school, and it's very clear that the cardiologists are happy about all their work and the vascular surgeons and cardiothoracics are a little resentful, but understanding of the new direction of medicine. i dont want to be in his position fifteen years from now!

 

[mpp]

Many cerebrovascular neurosurgeons now are trained in interventional neuroradiology and institutions usually have both neurosurgery and radiology trained interventionalists.

 

[FutureNeuroStud]

Many cerebrovascular neurosurgeons now are trained in interventional neuroradiology and institutions usually have both neurosurgery and radiology trained interventionalists.

It's my understanding that interventionalists feel that the future of their jobs is threatened by the absorption of their procedures into other specialties. Cardiologists are taking the procedures around the heart and battling with vascular surgeons for the procedures in more peripheral veins. And cerebrovascular neurosurgeons are taking the the procedures from the neck, up. Of course, all of these other specialists need some radiology training in order to perform these procedures.

 

[SoulRFlare]

It's my understanding that interventionalists feel that the future of their jobs is threatened by the absorption of their procedures into other specialties. Cardiologists are taking the procedures around the heart and battling with vascular surgeons for the procedures in more peripheral veins. And cerebrovascular neurosurgeons are taking the the procedures from the neck, up. Of course, all of these other specialists need some radiology training in order to perform these procedures.

...to begin on an anecdotal note--my dad, who is a physician and underwent cardiac angioplasty/stenting, said that he would rather a cardiologist, who understands cardiac physiology and knows the cardio drugs cold, perform the procedure on him than a radiologist...to quote him "Bet me I'd want a radiologist stenting me."
His reasoned that the cardiologists have a better understanding of what can go wrong during the procedure and are better equipped to deal with complications--be it the right drug at the right time or a trip to the OR.
The fact is that physicians who are trained to deal with cardiac issues, who live and breathe the latest medical and surgical cardiac treatments are more equipped to deal with complications than those who are trained in "imaginging, with a special emphasis in heart/brain/lungs/kidney/pancreas"

To take the example one step further, I submit that those trained in surgery are better equipped than non-surgeons to undertake invasive procedures.
let's examine surgical versus non-surgical training. Surgeons are trained to understand physiology and pathophysiology, as are non-surgeons. But the surgeon spends 5-10+ years honing instincts which are more akin to musical atistry--that artistry that a concert pianist taps into when he or she nuances a certain phrase "just right", sweeping the audience off their feet. Ideally, the surgeon has a "feel" for nuances of the body, knowing what touch, be it forte, pianissimo, staccato, or lagatto, is needed. Granted, the "touch" is not scientifically grounded, but is, I believe, what separates the physician from the surgeon, as well as the "good" surgeon from the "gifted" surgeon.
A radiologist is trained to assess pathology based upon imaging studies. The radiologist trains for 4-5 years in diagnostic radiology, supplementing their core training with interventional fellowships. Meanwhile, surgeons are trained for a minimum of 5 years in procedural experience.
Which brings me back to my original point: Neurosurgeons are practiced in both the medical as well as surgical management of patients with neurological diseases. Why, then, did the field of Neurosurgery drop the ball on such important issues as carotid endarterectomies and cerebral aneurysms? Why are vascular surgeons and radiologists, not Neurosurgeons addressing these issues, which are so important to cerebrovascular health? After all, the cardiologists (perhaps the cardiovascular surgeons dropped the ball here), not the vascular surgeons or radiologists, are addressing cardiovascular health.
Vascular surgeons may know vessels inside and out, and radiologists may have the technology to image the same...but is this the case of a violinist telling the pianist what to play and how to play it, or of a music theorist, with minimal instrumental experience him or herself, directing the orchestra?

 

[eddieberetta]

Vascular surgeons may know vessels inside and out, and radiologists may have the technology to image the same...but is this the case of a violinist telling the pianist what to play and how to play it, or of a music theorist, with minimal instrumental experience him or herself, directing the orchestra?

It is not that simple. IR requires a completely different skill set from that provided in a surgical or medical residency. Most IR and NIR complications must be recognized on the basis of imaging (i.e. angiography) and usually dealt with using interventional methods. So whoever does it needs a strong fundamental training in diagnostic imaging, at least in the limited scope of the procedures they perform. Of course that can be learned by non-radiologists (a few years ago we were all "undifferentiated" med students).

Just because you can handle the rare complication that would necessitate surgery does not make you the ideal operator to perform the interventional procedure. Rather, it is extensive training in the IR procedure, experience with recognizing anatomic variants, potential pitfalls, procedural complications, and experience with the interventional management of thiose complications that makes you a solid interventionalist. You also need good clinical judgement, rapport with patients, etc etc.

Radiologists have a solid foundation to be interventionalists, particularly in terms of the imaging aspect. Clinicians also have a good grounding particularly from the judgement side but have a major deficit in the imaging sphere. The worst interventionalists are those that "pick up" a low volume of IR work without proper training.

In my opinion, the ideal interventionalists have had a fellowship that makes up for the inherent "weakness" than comes from entering from their particular specialty. In the future, a more efficient combined stream for training interventionalists would reduce the unreasonable length of current training pathways.

 

[SoulRFlare]

Many cerebrovascular neurosurgeons now are trained in interventional neuroradiology and institutions usually have both neurosurgery and radiology trained interventionalists.

when I did my neurology rotation, I asked the clerkship director what he thought of the 7 year interventional neurology programs. He said "good luck finding privileges." Apparently, the radiologists have a lock on the operative suites, and don't look kindly on non-radiologists horning in or their territory. This is not to say there aren't places where an interventional neurologist or a neurosurgeon can practice...
Here's the way he put it..."the radiologists were aggressive early on and gained a lot of sway in hospitals. They got control of MRI for instance, which doesn't involve radiation whatsoever, but involves electricity. Do you think the radiologists should have control over the light switches throughout the hospital as well?"
Though I may come across to the contrary, I don't hate radiology. However, I do believe that the field of Neurosurgery is in the best position, both in terms of knowledge as well as "hands on experience" to deal with the diseases of the nervous system. People who, from day one to year seven, are trained in the appreciation for, and operative technique of the nervous system are in a better position to treat nervous system pathology than those trained in imaging...imaging...imaging...more imaging and then maybe a year or two of intervention.

 

[SoulRFlare]

It is not that simple. IR requires a completely different skill set from that provided in a surgical or medical residency. Most IR and NIR complications must be recognized on the basis of imaging (i.e. angiography) and usually dealt with using interventional methods. So whoever does it needs a strong fundamental training in diagnostic imaging, at least in the limited scope of the procedures they perform. Of course that can be learned by non-radiologists (a few years ago we were all "undifferentiated" med students).

Just because you can handle the rare complication that would necessitate surgery does not make you the ideal operator to perform the interventional procedure. Rather, it is extensive training in the IR procedure, experience with recognizing anatomic variants, potential pitfalls, procedural complications, and experience with the interventional management of thiose complications that makes you a solid interventionalist. You also need good clinical judgement, rapport with patients, etc etc.

Radiologists have a solid foundation to be interventionalists, particularly in terms of the imaging aspect. Clinicians also have a good grounding particularly from the judgement side but have a major deficit in the imaging sphere. The worst interventionalists are those that "pick up" a low volume of IR work without proper training.

In my opinion, the ideal interventionalists have had a fellowship that makes up for the inherent "weakness" than comes from entering from their particular specialty. In the future, a more efficient combined stream for training interventionalists would reduce the unreasonable length of current training pathways.

My point is that the surgeon trains from day one to correlate theoretical/visual/tactile data with theoretical/visual/tactile action. Coming from a musical background, I think of it as the difference between studying music theory for 7 + years and then touching a musical instrument for the first time, with learning the instrument and the theory concurrently. In the best of all worlds, aspiring surgeons would begin learning the practical aspects of the art in medical school--something akin to dental school training.

 

[iwantneurosurg]

while we think about training, the average patient doesn't know any of this.

if i were an average joe and thought, blood problems, i'm going to cardiology even though a vascular surgeon may be better qualified. the name "cardiology" has "cardio" heart, makes more sense to an uneducated individual.

as for neurosurgeons dropping the ball because other people are picking up the cases...the way i see it, 150 new neurosurgeons in an entire year vs. how many cardiologists, interventional radiologists, and vascular surgeons a year? and the neurosurgeons I know do plenty of other stuff too, there's no way their meek numbers can dominate the entire vascular field; you'd have people dying waiting for a neusorugeon to come along and operate.

but we just had the cardiology section (I'm a MS-2) and the CT surgeons all admitted that their field is properly nearing obsoletion, with congenital and anatomical defects reigning their primary source of work. hence they are so few and basically all know each other.

could this happen to neurosurgery? i see neurosurgeons as doing a lot of spine and PNS, which only ortho does, and that's more reconstructive. i guess theyd compete with oncologists and rad-onc for tumor resections. intradural work i guess is there's alone. cerebrovascular there's competition with interventional, cardios, etc. brain tumors - rad-onc again? i guess anything intracranial we control strongly, but cerebrovascular again, we dont dominate.

thirty years from now, are we going to end up like CT surgeons? it seems to me the only protected field is ortho - no one else can go in with lasers and reset a bone; no one else is qualified to replace a hip.

but personally, i'd feel a lot more accomplished being a neurosurgeon than an orthopod; I'm only an MS-II and am already bored with the knee replacements and hip replacements i've seen. then again, i dont want to become a frustrated CT talking to med students twenty years from now either.

i used to be very money oriented (i was hell-bent on spine surgery). i know derm mohs surgery pays more, but the thought of going through all this just do become a zit-popper (i know i'm simplifying) doesn't really do it for me; it's more a lifestyle job than an accomplishment job, and my focus now is on acocmplishment. this has caused me to lean more neurosurgery because i really do feel its a final frontier. infectious disease had their run, WWII did it for gen surgeons, and the current period is for cardio with all these new ldl drugs and whatnot. i think the near future will be geared towards cancer research, leaving brains as the final frontier. that seems pretty damn cool to me.

your thoughts?

 

[cdql]

MOHS surgery, while admittedly not brain surgery, isn't about pimple popping. It's used for skin cancers.

 

[iwantneurosurg]

i know; but for some reason i can't imagine dermatologists doing mohs all day; maybe its just watching too much scrubs.

but it begs the question; do they? and do rads do mohs too, or does derm have that cornered, because by my understanding, it involves beams and whatnot, which seems in the field of rads?

i guess i'll post on the derm forum.

 

[Onco]

when I did my neurology rotation, I asked the clerkship director what he thought of the 7 year interventional neurology programs. He said "good luck finding privileges." Apparently, the radiologists have a lock on the operative suites, and don't look kindly on non-radiologists horning in or their territory. This is not to say there aren't places where an interventional neurologist or a neurosurgeon can practice...
Here's the way he put it..."the radiologists were aggressive early on and gained a lot of sway in hospitals. They got control of MRI for instance, which doesn't involve radiation whatsoever, but involves electricity. Do you think the radiologists should have control over the light switches throughout the hospital as well?"
Though I may come across to the contrary, I don't hate radiology. However, I do believe that the field of Neurosurgery is in the best position, both in terms of knowledge as well as "hands on experience" to deal with the diseases of the nervous system. People who, from day one to year seven, are trained in the appreciation for, and operative technique of the nervous system are in a better position to treat nervous system pathology than those trained in imaging...imaging...imaging...more imaging and then maybe a year or two of intervention.

Spot on..

Right now, Radiologists are controlling IVN. Thats a fact. However, I know of 2 neurosurgery residents who completed IVN fellowships but then they were at IVY-league hospitals.

Again, if you are really interested in IVN, best bet to get in would be to do Radiology residency. I personally think NEUROSURGERY beats Radiology in every aspect. Its a dream job for anyone interested in hands on invasive work on the nervous system.

 

[toxic-megacolon]

As Vascular Surgery becomes its own residency (seperate from gen surg) many peripheral vascular radiological procedures will be done by them. Currently Radiologists need referal from another MD for their procedures. (What radiologist has clinic?) As vascular surgeons learn to do these procedures, they are goign to stop refering these out.

 

[mpp]

Mohs doesn't involve any beams. It's all cut and freeze, cut and freeze...

 

[123456789]

It is not that simple. IR requires a completely different skill set from that provided in a surgical or medical residency. Most IR and NIR complications must be recognized on the basis of imaging (i.e. angiography) and usually dealt with using interventional methods. So whoever does it needs a strong fundamental training in diagnostic imaging, at least in the limited scope of the procedures they perform. Of course that can be learned by non-radiologists (a few years ago we were all "undifferentiated" med students).

Just because you can handle the rare complication that would necessitate surgery does not make you the ideal operator to perform the interventional procedure. Rather, it is extensive training in the IR procedure, experience with recognizing anatomic variants, potential pitfalls, procedural complications, and experience with the interventional management of thiose complications that makes you a solid interventionalist. You also need good clinical judgement, rapport with patients, etc etc.

Radiologists have a solid foundation to be interventionalists, particularly in terms of the imaging aspect. Clinicians also have a good grounding particularly from the judgement side but have a major deficit in the imaging sphere. The worst interventionalists are those that "pick up" a low volume of IR work without proper training.

In my opinion, the ideal interventionalists have had a fellowship that makes up for the inherent "weakness" than comes from entering from their particular specialty. In the future, a more efficient combined stream for training interventionalists would reduce the unreasonable length of current training pathways.

I agree with you more. Interventional radiologists must have clinical training. I have seen disasters from radiologists and surgeons and cardiologists. I will almost certainly never let a cardiologist near me with a catheter. I have seen their messes and don't want any part of it. Not to mention their use of contrast is unchecked. Also, their understanding of radiation, etc., really is not there.

Many radiologists do not want to undergo up to 3 additional years to do neurointervention. I agree that a clinically oriented fellowship is essential.

 

[Gunny]

What kinda procedures do interventional neurorads do at present? Are there many more exciting ones in the pipeline?

 

[mpp]

What kinda procedures do interventional neurorads do at present? Are there many more exciting ones in the pipeline?

Interventional neuroradiologistis do diagnostic angiograms, coiling of aneurysms, thrombolysis and clot retrieval in acute stroke, angioplasty and stent placement for stenosis, closing off of feeding arteries in arteriovenous malformations (also in tumors like menigiomas and closing of fistulae). They do vertebroplasty for vertebral fractures. Selective infusion of novel thereapeutics like gene therapy, stem cells, and oncolyctic virus may be in their future.