Interventional Neurology

Peter8989 said:

I am a medical student who is very interested in interventional neurology. First, I was wonder what all programs offer the combined seven year route. I have heard that NYU offers this route, but are there any others?

Next, how competitive is it to get one of these combined fellowships? It seems as though it would be pretty tough and you would need a very strong resume.

Finally, how competitive is it get into this field through the traditional neurology route.

Thank you for the responses in advance. It is really hard for me to find information about this field becuase I do not even know of anyone who has taken this route!

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I don't know much about this because I'm not really interested in doing interventional, but I know the Interventional Radiology fellowship at UTSouthwestern is very open to taking neurology residents. Two of the faculty interventional radiologists are double-boarded neurologists. I don't think too many IR fellowships are open to non-radiologists.

If you are interested in neurology primarily and would like to do interventional procedures, traditionally done by radiologists, this is a great time to enter the field via neurology. To begin with, you can get background information at the AAN website's Interventional Neurology section:

http://www.aan.com/about/sections/interventional.cfm

It containts most of the curriculum information for the neurology pathway as well as progress in the fieild published in the annual newsletter, all of which can be downloaded from the links to the right on the section page.

If you are interested in the field as a med student or neurology resident, I encourage you to keep up with the newly formed Society of Vascular and Interventional Neurology (SVIN). It was recently formed and aims to promote the field and provide training guidelines for budding neuro-internvetionalists.

Currently, there are three established ways to enter internventional neuroradiology (INR) programs:

1. Radiology (5 years)->Diagnostic Neuroradiology (1 year)->Interventional Neurorads (1-2 years) = 7-8 years

2. Neurology (4 years)->Stroke/Vascular neurology (1 year)->Diagnostic Neuroradiology (6 months-1 year)->Internvetional Neurorads (1-2 years) = 7-8 years

3. Neurosurgery (6 years)->Diagnostic Neuroradiology (1 year)->Interventional Neurorads (1-2 years) = 8-9 years

The neurology route is a widely accepted pathway to Interventional Neuroradiology. It is for this reason, many programs neurology programs have created Vascular neurology fellowships as a segway into interventional neurology. Keep in mind, this same field also goes by Endovascular Surgical Neuroradiology (ESNR) at many fellowship programs around the country, but entails the same type of training and pre-requisites.

For more information on training guidelines, refer to the January 2005 issue of the Neurology, green journal:

http://www.neurology.org/cgi/content/full/64/2/190

The article is a first of its kind joint statement by the various societies that govern the field of INR, such as AAN (neurology) and ASITN (neuroradiology), and others. It outlines the training necessary to acquire the cognitive and technical skills to be certfied in INR through the pathways I outlined above.

From speaking with several internventional neurologists, the field is wide open for trainees coming from neurology residencies. Just about every academic medical center in the country has or is currently training interventional neurologists. So if you are interested, first figure out what your primary interests are, whether they be in neurology, radiology, or even neurosurgery as you can do interventional work in the future through any of those routes.

I have posted the latest newsletter from the AAN internventional neurology section on the NeuroBound website:

http://neurobound.googlepages.com

Click on the interventional neurology link at the right to download it.
I will also post updates on the newly formed SVIN with opportunities for membership soon.

It is great to know that there are three pathways to the field, but I have a question that is bothering me:

If the INR fellowship PD gets 3 applications, one from the Neurology path, another from Radiology path, and the 3rd from the Neurosurgery path....wouldn't the Neurosurgeon's application look more attractive, since his training involved performing an extensive amount of delicate procedures?

Thanks

I love neuro and I'm interested in interventional neurology at the moment. But I'm not committing my self to it yet. Too many cool things to choose from in neurology . I have a few years before I need to apply to fellowships anyway.

I guess if you like neuro & you want to do INR, then the pathway choice is simple. If you love the OR & neurosurgery, go via neurosurg route. If you like Rads... you get my point.

If you think you like INR, but are not sure which pathway is best for you. I suggest you look at your preferrences & characteristics. Neurology, neurosurgery & radiology offer different things to their practitioners; patient contact, problem solving, working with hands, elegent bedside skill & interaction, working hours, independence from hospital... just to mention a few.

You could choose which makes you a better candidate for INR, but I think selecting a career that suits your personal characteristics, likes & needs will be more fulfilling in the longterm.

Things change during residency too. You might start neurosurg & think wow this epilepsy surgery stuff is pretty cool

Wheezy said:

I love neuro and I'm interested in interventional neurology at the moment. But I'm not committing my self to it yet. Too many cool things to choose from in neurology . I have a few years before I need to apply to fellowships anyway.

I guess if you like neuro & you want to do INR, then the pathway choice is simple. If you love the OR & neurosurgery, go via neurosurg route. If you like Rads... you get my point.

If you think you like INR, but are not sure which pathway is best for you. I suggest you look at your preferrences & characteristics. Neurology, neurosurgery & radiology offer different things to their practitioners; patient contact, problem solving, working with hands, elegent bedside skill & interaction, working hours, independence from hospital... just to mention a few.

You could choose which makes you a better candidate for INR, but I think selecting a career that suits your personal characteristics, likes & needs will be more fulfilling in the longterm.

Things change during residency too. You might start neurosurg & think wow this epilepsy surgery stuff is pretty cool

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Mush-koor O-khoo-y!

At-men-nalik Kul-lel Khare

Fee Aman Ella

Hey!

I am currently doing a month of interventional Neurology at UMDNJ in Newark. I think the question of what makes neurologists attractive candidates for interventional spots, and why neurologists are well suited to be leaders in ESN is twofold.

Primarily the neurologists has the training that allows him/her to manage the patient completely, that is from the er to the angio suite to the neuro icu and finally as an outpatient. It is a diffrent paradigm than that of IR, in which the radiologist is excelent technically but is not involved on a large clinical scale.

Futher neurologists bring with them the most experience in dealing with acute stroke, and its many diffrent treatment options. As for neurosurgeons, while they do have a hand up when it comes to technical skills, endovascular is a totally diffrent beast, that really strattles the fence between medicine and surgery.


I believe that we need all three disciplines in ESN, because fragmentation of the field would be very detremetnal to its growth.

Ok,

so if i wanted to do work invovling new technologies that allowed communication to and from the brain with a computer or similar electronic device, what specialty should i go into???

im thinking neurology because they focus on the actual functioning of the nervous system.

but they dont actually do anything to the body physically do they?? or do they perform any "minimally invasive" procedures??

so with that im thinking maybe neurosurgery??? there would likely be some surgical procedures involved, however these would really be minimal, just to allow an electrical connection to a periphial or central nerve for communications in something.

or is this what interventional neurology would do??

thoughts??

Neurology is beginning to show its interventional flare through neurocritical care, interventional neuroradiology, and brain-machine interface (BMI) neurology (my own term). In terms of BMI, I am also curious regarding the scope of a neurologist's practice. It seems to me that for DBS in PD, the neurologist is involved with everything except the craniotomy and pushing the electrode into the brain. This includes clinical evaluation, deciding where to put the electrode, monitoring the firing of neurons as the electrode is pushed in, and testing the system once it is in place. It also includes programming the device and managing it in the clinic for the long-term. I imagine that the neurologist will take a similar role for other future BMI's such as seizure "defibrillators" and neuroprostheses for quad's, TBI and stroke victims, etc.

If you want to drill and push something into the brain, then you must become a neurosurgeon (the only exception is a neurointensivist putting in EVD's). If you want to do a major procedure completely on your own, you pretty much have to do endovascular procedures. Botox and nerve blocks are another option, but not very fancy procedures in my opinion.

Any other thoughts?

B

Bonobo said:

Neurology is beginning to show its interventional flare through neurocritical care, interventional neuroradiology, and brain-machine interface (BMI) neurology (my own term). In terms of BMI, I am also curious regarding the scope of a neurologist's practice. It seems to me that for DBS in PD, the neurologist is involved with everything except the craniotomy and pushing the electrode into the brain. This includes clinical evaluation, deciding where to put the electrode, monitoring the firing of neurons as the electrode is pushed in, and testing the system once it is in place. It also includes programming the device and managing it in the clinic for the long-term. I imagine that the neurologist will take a similar role for other future BMI's such as seizure "defibrillators" and neuroprostheses for quad's, TBI and stroke victims, etc.

If you want to drill and push something into the brain, then you must become a neurosurgeon (the only exception is a neurointensivist putting in EVD's). If you want to do a major procedure completely on your own, you pretty much have to do endovascular procedures. Botox and nerve blocks are another option, but not very fancy procedures in my opinion.

Any other thoughts?

B

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Yes: if your motivation is money, keep in mind that at the end of the day the neurosurgeon will take home a lot more $$$ for some one-time "electrode pushing" than the neurologist will for months or years of "clinical evaluation, deciding where to put the electrode, monitoring the firing of neurons as the electrode is pushed in, and testing the system once it is in place, and programming the device and managing it in the clinic for the long-term." Is it fair? Who knows . . . but the powers that be value procedures over maintenance . . .

Neurologists need to consider before getting angry about whether it is fair in these types of circumstances to be paid so much less than a neurosurgeon. Neurosurgeons spend many more hours in grueling training, spend many more working in their careers, and have much greater liability than neurologists do. Overall, I bet the per hour income of a neurosurgeon, corrected for time lost in training and the number of hours they put into training in the first place, plus the costs of liability insurance, are not that much different than that for a neurologist till the age of 50. After that, the neurosurgeon will definitely be reaping greater benefits--but you reap what you sow.

Also, the risk factor must be taken into account. Much like in finance, I bet the Sharpe ratio for neurosurgeons and neurologists is not much different (at least when using per hour income and liability risk).

And probably much worse if you include divorce, depression, estrangement from children, etc as part of the risk.

Putting an electrode and performing a small burr hole carries far greater risk than everything before it include hemorrhage and infection. And while the neurologist will be partly liable, it will be the neurosurgeon who has the potential to lose the most.

B

Leukocyte said:

It is great to know that there are three pathways to the field, but I have a question that is bothering me:

If the INR fellowship PD gets 3 applications, one from the Neurology path, another from Radiology path, and the 3rd from the Neurosurgery path....wouldn't the Neurosurgeon's application look more attractive, since his training involved performing an extensive amount of delicate procedures?

Thanks

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Can someone please answer this question?

shadowfox87 said:

Can someone please answer this question?

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This question has been hammered to the death here, in the Neurosurgery forum, in the Radiology forum, on www.auntminnie.com, and on www.uncleharvey.com. My friendly advice is to start researching this topic alot if it is something that interests you.

The answer is: it depends.

Radiology and neurosurgery department fellowships as a rule love to see radiology applicants and neurosurgery applicants more than neurology applicants. As more neurologists (of increasing quality) apply, this is slowly changing.

There are few (but growing) neurology department fellowships. Check out the SVIN website and the forums mentioned above for more information.

as far as programming DBS, after everything is all said and done and the patient gets to a point where they just need small tweaks, these can be done by a trained RN or MA to the goals set up by the neurologist. And yes, the neurologist is present in the OR for the placement and testing- to me it seemed like a good way to experience the quantified nature of surgical procedures without the "please kill me now" neurosurgery residency. Vagal nerve stimulator placement (for tx resistant epilepsy and bipolar d/o) I'm not as sure about b/c placement on a peripheral nerve seems easier than implanting a probe through cortex. These will also be followed by Neurology eventually.

As far as the $$ factor, yes the neurosurgeon is getting more for the procedure, but the neurologist can see 6 patients or more in follow-up in the time it takes to place one DBS. The neurologist also gets to experience the best fruits of the labor IMO by seeing appreciative patients that have a better quality of life over a period of time.

And as far as what careers can get you into brain-machine interface type things.. Neurology or PM&R (depending on the center) and neurosurgery if you want to be putting the actual thing in but not following up except for your typical surgical followup.

neurosign said:

1. Radiology (5 years)->Diagnostic Neuroradiology (1 year)->Interventional Neurorads (1-2 years) = 7-8 years
2. Neurology (4 years)->Stroke/Vascular neurology (1 year)->Diagnostic Neuroradiology (6 months-1 year)->Internvetional Neurorads (1-2 years) = 7-8 years
3. Neurosurgery (6 years)->Diagnostic Neuroradiology (1 year)->Interventional Neurorads (1-2 years) = 8-9 years

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Wheezy said:

I guess if you like neuro & you want to do INR, then the pathway choice is simple. If you love the OR & neurosurgery, go via neurosurg route. If you like Rads... you get my point.

If you think you like INR, but are not sure which pathway is best for you. I suggest you look at your preferrences & characteristics. Neurology, neurosurgery & radiology offer different things to their practitioners; patient contact, problem solving, working with hands, elegent bedside skill & interaction, working hours, independence from hospital... just to mention a few.

You could choose which makes you a better candidate for INR, but I think selecting a career that suits your personal characteristics, likes & needs will be more fulfilling in the longterm.

Things change during residency too. You might start neurosurg & think wow this epilepsy surgery stuff is pretty cool

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What I'm asking here is if all these 3 pathways truly do lead to the same subspecialty, INR? That is, would the person who is an INR from #2 pathway earn the same salary as a person who is an INR from #1 pathway, etc.? If it is not the same and you like INR, then the choice is far from simple.

Honestly, I would be wary of going into something that takes 7-8 years to complete at this point, especially if the potential of much higher pay is of high priority to you. Given the financially unsustainable situation the US is in, you'll have to ask yourself if you would be content if you made only moderately more money by doing 3-4 more years of training. It's more or less a given at this point that overall health care spending will have to be cut with a machete, and I don't foresee a good future for much of the expensive care that we are accustomed to now.
I mean, if you truly enjoy INR, and would be perfectly happy doing it for any amount of money, then there's really no downside. But, if that hefty salary is a big part of what you're chasing, then think twice about it.

I'm in rads, going into body IR, not INR, but can tell you that regardless of spending cuts blah blah, there will always be a need for INR regardless of your pathway, though you will likely have to practice your base specialty as well whether that's neurorads, neuro, or NS. And while each pathway has it's benefits, each also has it's drawbacks

1)Rads, you have to learn the clinical part of it, which in the good programs you get by doing NSICU, stroke, etc.

2)Neuro and NS both have to learn the diagnostic component and procedural component, more of an issue for neuro since it's not as much of a procedure base specialty (but you can always do an extra year, or have other attendings in a practice precept you until you are ready)

3)for NS it's mostly about patience, they are used to open procedures and sort of instant gratification, coiling and intra-arterial tpa can get tedious.

salary is dependent on what your base specialties salary is, so regardless of what kind of training you have, when you do a cerebral angiogram, you bill for a cerebral angiogram.

If you take a rads trained, NS trained and neuro trained INR and they do 100% INR (unlikely now, but considering a ridiculously low percent of eligible patients are getting the appropriate treatment it may be likely in the future) they will all make the same amount of money.

If each does 50% INR, and the rest is in stroke, neuroimaging, or neurosurgery, than likely the salary will be NS>Neurorads>neuro, simply because procedures pay more;

There are right now something like 250-300 people trained to do INR in this country, and giving the paucity of training programs will likely remain low, the aging boomer population will guarantee that at least intrarterial tPA will have a nice long half-life, so if you like it go for it, we have neuro, NS, and neurorads all doing it together and they all love it, but their call is just brutal.

bronx43 said:

Honestly, I would be wary of going into something that takes 7-8 years to complete at this point, especially if the potential of much higher pay is of high priority to you. Given the financially unsustainable situation the US is in, you'll have to ask yourself if you would be content if you made only moderately more money by doing 3-4 more years of training. It's more or less a given at this point that overall health care spending will have to be cut with a machete, and I don't foresee a good future for much of the expensive care that we are accustomed to now.
I mean, if you truly enjoy INR, and would be perfectly happy doing it for any amount of money, then there's really no downside. But, if that hefty salary is a big part of what you're chasing, then think twice about it.

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No, that's not it. I enjoy INR because it combines the procedural stuff along with neurology. It's not about being content with the money. I just want to know after working 7-8 years compared to someone else working for the same amount of time, would earn the same.

@davidjones: thanks, that's what I wanted to know.

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