Hey neusu, I'm curious what your outlook on ESN is? I know it can be achieved via neurosurg, rads, or neurology. Do you think it will eventually become a field dominated by neurology since they are essentially the first line, like cards ended up dominating interventional work instead of CT? Or do you think it will continue to be mainly rads and neurosurg. I'm curious because it's a field I'm highly interested in, but I can't really imagine myself going through a neurosurgery or radiology residency, both sound unappealing, whereas a neurology residency does spark my interest.
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I will assume you mean neurointerventional surgery. Neurosurgeons watched what happened to cardiac surgery and could see the writing on the wall for open vascular neurosurgery. As such, the specialty as a whole has postured to maintain involvement, and even drive the direction of, neurointerventional surgery. As such, it is a part of neurosurgery training for all residency programs. You are correct, however, there are three pathways to learning how to do it neurosurgery, radiology, and neurology. As such, the Society of Neurointerventional Surgery was created
http://www.snisonline.org/ and admits members from all three fields.
I will admit, being a neurosurgeon, I have a bias towards neurosurgery. Of the three, we are most equipped to handle the whole spectrum of disease for acute stroke. Politics aside, the new data on clot retrieval for large vessel occlusion indicates there will be increased need for interventionalists.
With respect to first line, the ER doc, or even triage radio operator, is the one making the call. Thereafter, it really depends on the specific arrangement for the hospital. For acute stroke symptoms, many stroke centers notify the interventionalist as soon as they get the call that there is an incoming patient. The ER does the initial assessment en route to the CT scanner. If there are signs of a retrievable clot, and it is not contraindicated, they are in the angio suite immediately thereafter. Following treatment, the patient ends up in the ICU admitted to the ICU attending (neurointensivist, general intensivist, neurosurgeon). The stroke neurologist may only really get involved days later when the patient is stable and sent to the floor.
The difference I see between neurology and cardiology, with respect to interventional, are many. Acute MI is not uncommon and something traditionally handled by cardiologists. Prior to interventional cardiology, CABG was really the only treatment available for stenosis or occlusion. Cardiologists really were involved from the beginning with cardiac angiography, angioplasty, and stenting. With respect to the brain, historically it has been neuroradiologists and neurosurgeons performing diagnostic angiography and pushing the envelope for interventional techniques. Further, neurologists have a more diverse array of sub-specialties they can pursue (stroke, critical care, electrophysiology, MG, GB and so forth).
Finally, what about neurosurgery or radiology sounds unappealing?