INR through radiology or neurology

[atari13]

I am a final year international student who likes interventional nauroradiology, but I cannot choose between joining it after radiology or neurology residency. I have a few questions that I have searched for answers to but could not find any, and I believe the answers to these questions are going to help me take that decision.

1- I understand that in the present time, NIR fellowship programs accept and train applicants who have completed neurosurgery/radiology residencies more than those who graduated from neurology residency. Is this correct? And if it is correct, do you believe this is going to change in the future?

2- I know that NIR has teams that include specialists from the 3 specialties and other specialties, but I do not clearly understand the role of a Neurointerventional radiologist outside the NIR suite, as well as what their clinical knowledge makes them capable to do. I understand that it is now part of the training to complete 6 months rotating in Vascular Neurology, Neurocritical Care, and Neurosurgery, but I do not know if these would provide me with enough clinical knowledge to help me follow up my own patients and provide care to them after the procedure. Even if I work in a team in which other specialists provide the postoperative care, I would like to have the knowledge of what they are doing and why. Do you think radiologists have enough clinical knowledge to provide postoperative care to their patients and follow them up in the clinic? And do they follow up their patients in the present time?

3- Many medical student and residents try and speculate if one specialty is going to take over the field of NIR in the future. Do you believe that this might happen? And since neurologists are probably the first ones to see the patients and give tPA, could roles be strictly defined and this would be their only role in the future, and radiologists and neurosurgeons would be the only ones performing the procedures?

Thanks!

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[Radology]

Neurosurgery

 

[Cognovi]

Neurosurgery

Very few IMGs match into neurosurgery, compared to the numbers that match into neurology or radiology.

 

[Radology]

Then you’re probably wasting your time. Unless you’re willing to practice in the middle of nowhere, you’re not doing neuro ir

 

[NDcienporciento100]

Then you’re probably wasting your time. Unless you’re willing to practice in the middle of nowhere, you’re not doing neuro ir

Do you consider Cleveland Clinic main campus and Mount Sinai Miami the middle of know where, Because they both young Neuro interventional radiologist doing full time neuro IR. And I could keep going. I hate when people say things that are misinformed and act like what there saying is 100% the way it is. As to the question it really depends on what you like, both neurology and Radiology bring unique skill sets one being superior clinically and the other being superior with regard to imaging, both are essential to the team, both can go on to perform procedures. Choose based on what aspect you like more. I actually think neurology will come to be the more dominant force in this field in years to come because frankly I don’t know many people in rads that want to do it and neurosurgery is 7 years and 2 additional neuro interventional training and I don’t think there will be enough to meet the demand. The salary’s that neuro interventional can bring in are far great then a general neurologist could expect to make in most cases but this is not the case for rads or neurosurgery. Bottom line decide what you like more clinical medicine or imaging and from both you will be able to do neuro interventional. Good luck!

 

[irwarrior]

Some Integrated IR residents are pursuing a combination of peripheral and neurointerventional. They are doing a bunch of neuro ICU and stroke rotations and neurointerventions during the 6 year residency and then do a 2 year dedicated neurointerventional fellowship afterwards. They get very strong imaging and technical skills and get better clinical skills compared to previous pure neurorad /IR trainees. They start to focus on endovascular skills as early as PGY1.

 

[NDcienporciento100]

Some Integrated IR residents are pursuing a combination of peripheral and neurointerventional. They are doing a bunch of neuro ICU and stroke rotations and neurointerventions during the 6 year residency and then do a 2 year dedicated neurointerventional fellowship afterwards. They get very strong imaging and technical skills and get better clinical skills compared to previous pure neurorad /IR trainees. They start to focus on endovascular skills as early as PGY1.

Where?

 

[Shufflin]

Do you consider Cleveland Clinic main campus and Mount Sinai Miami the middle of know where, Because they both young Neuro interventional radiologist doing full time neuro IR. And I could keep going. I hate when people say things that are misinformed and act like what there saying is 100% the way it is. As to the question...

Agreed. Like most of the online and print media, and most of the human race for that matter. It takes a somewhat mildly enlightened person to rise above this.

 

[guytakingboards]

Questions 1 and 3 seem irrelevant to me.

Question 2:
-the neurologist can do any number of things outside the NIR suite: practice general neurology, practice stroke neurology, be the medical director of a stroke center, etc...
-the radiologist can do diagnostic neuroradiology (or general radiology) outside the NIR suite. NIR guys are not following their patients in a clinic.
-the neurosurgeon can do elective general neurosurgery (spine, trauma, easy tumors).

 

[NDcienporciento100]

Questions 1 and 3 seem irrelevant to me.

Question 2:
-the neurologist can do any number of things outside the NIR suite: practice general neurology, practice stroke neurology, be the medical director of a stroke center, etc...
-the radiologist can do diagnostic neuroradiology (or general radiology) outside the NIR suite. NIR guys are not following their patients in a clinic.
-the neurosurgeon can do elective general neurosurgery (spine, trauma, easy tumors).

Misinformed, NIR do see patients in the clinic that they did work on or are going to do work on. Example; NIR coils aneurysm discovered on imageing after x symptom/sign, follows with nir to ensure stability of coil position and if signs/symptoms are resolveing. Granted if a pt from out of town has a stroke thrombectomie then yea that pt probably won’t follow up.

 

[NDcienporciento100]

Misinformed, NIR do see patients in the clinic that they did work on or are going to do work on. Example; NIR coils aneurysm discovered on imageing after x symptom/sign, follows with nir to ensure stability of coil position and if signs/symptoms are resolveing. Granted if a pt from out of town has a stroke thrombectomie then yea that pt probably won’t follow up.

This concept is really no different then a general surgeon who takes a gall bladder out and sees the pt in his/her office after.

 

[irwarrior]

The NIRs at our practice have clinic and counsel and follow patients with small aneurysms. Determine candidacy for carotid stenting (symptomatic etc). They also follow their Intracranial stents, aneurysm coilings, carotid stents, venous stents etc longitudinally in the clinic. They are busy with a combination of stroke and elective cases, clinic and inpatient consults and rounding.

There are several programs that are starting to look at neurointerventional stroke training during the integrated IR residency. Several places like Brown, U of Arkansas give a considerable amount of INR exposure during the integrated residency.

 

[NDcienporciento100]

The NIRs at our practice have clinic and counsel and follow patients with small aneurysms. Determine candidacy for carotid stenting (symptomatic etc). They also follow their Intracranial stents, aneurysm coilings, carotid stents, venous stents etc longitudinally in the clinic. They are busy with a combination of stroke and elective cases, clinic and inpatient consults and rounding.

There are several programs that are starting to look at neurointerventional stroke training during the integrated IR residency. Several places like Brown, U of Arkansas give a considerable amount of INR exposure during the integrated residency.

Thanks Ir warrior! I wish I knew which program you where a pd/attending at. You seem well informed at any rate and haveing matched into IR I would love to get stroke training for example. The bottom line is there is not enough docs doing it out there and IR docs are fully capable of meeting this shortage.

 

[irwarrior]

There are plenty of resources through SIR about this and plenty of IR trainees getting a considerable amount of stroke training. Just ask your IR PD if you can do elective time throughout your training in INR and take INR call and you should be well on your way.

 

[guytakingboards]

This concept is really no different then a general surgeon who takes a gall bladder out and sees the pt in his/her office after.

Fair point. Those are true statements. When I said they’re not following up much I was referring to the clinical symptomatology. NIRs definitely do follow-up their work, but in terms of managing symptomatology that’s going to be handled primarily by a neurologist.

 

[Neurointerventionalist]

I am a final year international student who likes interventional nauroradiology, but I cannot choose between joining it after radiology or neurology residency.

With a neurology residency you will learn more about clinical management (namely drugs and physical examination).

With an IR residency you will learn more about imaging/anatomy and interventional techniques (catheters, guidewires, stents, filters etc).

I find IR more interesting and "wide" (you can always shift to interventional oncology or VIR), but if you want to become a good NIR then you must dedicate full time (or at least 80%) to NIR, so both neuro and IR are good choices.

Then you’re probably wasting your time. Unless you’re willing to practice in the middle of nowhere, you’re not doing neuro ir

Most NIR in the best dept are radiologists: Stanford, UCSF, NYU, Johns Hopkins...

 

[NDcienporciento100]

Fair point. Those are true statements. When I said they’re not following up much I was referring to the clinical symptomatology. NIRs definitely do follow-up their work, but in terms of managing symptomatology that’s going to be handled primarily by a neurologist.

Wrong. The Pt came to see the NIR because he had X symptoms and he will follow with the NIR to see if those symptoms have resolved or there needs to be something else done. To go back to the gall bladder analogy if the surgeon takes the gallbladder out and two weeks later the pt develops signs and symptoms of peritonitis he not going back to the family practice doctor that referred him to surgeon in the first place he’s going back to the surgeon so the surgeon can fix the complication. Same thing goes with NIR managing complications/new associated symptoms.

 

[NDcienporciento100]

Wrong. The Pt came to see the NIR because he had X symptoms and he will follow with the NIR to see if those symptoms have resolved or there needs to be something else done. To go back to the gall bladder analogy if the surgeon takes the gallbladder out and two weeks later the pt develops signs and symptoms of peritonitis he not going back to the family practice doctor that referred him to surgeon in the first place he’s going back to the surgeon so the surgeon can fix the complication. Same thing goes with NIR managing complications/new associated symptoms.

And this model goes for body IR as well.

 

[NDcienporciento100]

I am going to give a very biased opinion and some won’t like it and some won’t agree and I would love opinions from all sides.
Neurologist know more about pathophysiology then radiology I will give it to them they deserve it, but if your performing neurointervention on a pt and you accidentally inject a bubble into the vertebral artery how is all that knowledge going to help you then? But developing catheter skills over the years of training that radiologist and Interventional Radiologist do throughout the body will give you the experience and put you in the best spot to perform a neurointervention with as few complications as possible. Final point radiology knows the anatomy far better then the average neurologist that is necessary to perform these procedures. Radiology have been the pioneers in all aspects of endvascular care but historically have been bad a taking care of pts but that is changing.

 

[NDcienporciento100]

 

[NDcienporciento100]

Great Video, that explains everything you need to know about the NIR different paths.

 

[Zack4186]

Neurosurgery is the answer. I know of a few residents who are IMG's.

However, if you are choosing between the two you mentioned above, I believe the best answer is radiology. The decision to intervene is done based on imaging and if there is salvageable penumbra. I've talked to a few INR about this and they told me the same thing.

 

[Tiger100]

The field is getting split now. In many places IR is doing stroke intervention but not coiling or other complex procedures.

Probably the field will be practiced at two different levels:
1- Elective cases or emergent cases other than stroke (SAH and ruptured aneurysm): This will be done at referral centers. Most likely will be dominated by Neurosurgery with a few faculty from neurology and radiology here and there.

2- Stroke interventions at the level of community: This will be done by radiologists and neurologists and the politics will be local. IR will provide the service on the radiology side. I doubt neurosurgeons will do this in the community. There are not enough of them out there and also they are very busy doing spine in the community.

Most community practices don't have the volume to hire a dedicated NeuroIR. The person that they hire should do a lot of other things. In case of IR, the infrastructure is out there. They can do a combination of body IR (and maybe some DR) and also be on call for stroke interventions (they are already on call for body IR so if all of them are stroke trained the infrastructure is already there). I think it is necessary for IR to integrate stroke interventions into its schedule. For neurology the logistics is more difficult since most of them are not stroke or procedure trained.

 

[allre]

For a new DR res interested in stroke as well as high end neuro IR procedures would it be better to go through ESIR or neurorads then dedicated NIR? It seems as if there’s more activity and political weight coming from the body IR people who want to do stroke in the community. Also seems like it depends on intended practice setting based on the above (community - IR, academics - NIR). Is hospital employed clinical NIR going to still exist?

 

[Tiger100]

For a new DR res interested in stroke as well as high end neuro IR procedures would it be better to go through ESIR or neurorads then dedicated NIR? It seems as if there’s more activity and political weight coming from the body IR people who want to do stroke in the community. Also seems like it depends on intended practice setting based on the above (community - IR, academics - NIR). Is hospital employed clinical NIR going to still exist?

For high end procedures do dedicated NeuroIR.

 

[NDcienporciento100]

For a new DR res interested in stroke as well as high end neuro IR procedures would it be better to go through ESIR or neurorads then dedicated NIR? It seems as if there’s more activity and political weight coming from the body IR people who want to do stroke in the community. Also seems like it depends on intended practice setting based on the above (community - IR, academics - NIR). Is hospital employed clinical NIR going to still exist?

Don't quite understand your question, ESIR Is something you do as a resident, neurorads is a fellowship, NIR is a fellowship that requires a neurorads fellowship is required if you want to go to a acgme fellowship for NIR. ESIR is early specialization in interventional rads its done during you last year of dr residency to decrease your body IR training by 1 year.

 

[NDcienporciento100]

For a new DR res interested in stroke as well as high end neuro IR procedures would it be better to go through ESIR or neurorads then dedicated NIR? It seems as if there’s more activity and political weight coming from the body IR people who want to do stroke in the community. Also seems like it depends on intended practice setting based on the above (community - IR, academics - NIR). Is hospital employed clinical NIR going to still exist?

You could technically do ESIR, neurorads fellowship, and finish with a neuro IR fellowship. It would not extend you training, and will give you catheter and wire skills that will serve you greatly when starting you NIR fellowship.

 

[Tman507]

I am a final year international student who likes interventional nauroradiology, but I cannot choose between joining it after radiology or neurology residency. I have a few questions that I have searched for answers to but could not find any, and I believe the answers to these questions are going to help me take that decision.

1- I understand that in the present time, NIR fellowship programs accept and train applicants who have completed neurosurgery/radiology residencies more than those who graduated from neurology residency. Is this correct? And if it is correct, do you believe this is going to change in the future?

2- I know that NIR has teams that include specialists from the 3 specialties and other specialties, but I do not clearly understand the role of a Neurointerventional radiologist outside the NIR suite, as well as what their clinical knowledge makes them capable to do. I understand that it is now part of the training to complete 6 months rotating in Vascular Neurology, Neurocritical Care, and Neurosurgery, but I do not know if these would provide me with enough clinical knowledge to help me follow up my own patients and provide care to them after the procedure. Even if I work in a team in which other specialists provide the postoperative care, I would like to have the knowledge of what they are doing and why. Do you think radiologists have enough clinical knowledge to provide postoperative care to their patients and follow them up in the clinic? And do they follow up their patients in the present time?

3- Many medical student and residents try and speculate if one specialty is going to take over the field of NIR in the future. Do you believe that this might happen? And since neurologists are probably the first ones to see the patients and give tPA, could roles be strictly defined and this would be their only role in the future, and radiologists and neurosurgeons would be the only ones performing the procedures?

Thanks!

NIR is more exclusively given to radiologists and neurosurgeons.

According to a neurosurgeon i personally spoke to earlier this year told me that the trend tends more toward radiology than any other specialty.

I have read in places that if they were to make a course exclusively to vascular neurologists in NIR, then it would only be for mechanical thrombectomy.

There are NIR programs out there that take vascular neurologists, you have to just look out for them if that's the route you'd want to take.

Catheter skills and imaging experience is in the hands of radiologists.

As far as what to expect from a NIR, you can easily look online at the course outline of any NIR fellowship which will tell you the basics of their general duties you can expect of them.... I'll just do a quick search and send screenshots below.

As for who'll take over, it'll most likely remain between neurosurgery and radiology.
Since neurosurgery and radiology should be in charge of most programs, they'll most likely take candidates within their specialty.

Regarding the screenshots, seems to be from uOttawa (Note I'm not affiliated with them in any way, just merely a random search selection).
The pictures are not exaclty sent in order but should suffice.

 

[Neurointerventionalist]

NIR is more exclusively given to radiologists and neurosurgeons.

According to a neurosurgeon i personally spoke to earlier this year told me that the trend tends more toward radiology than any other specialty.

Not completely true.

Some of the best neurointerventionalists are actually neurologists (Nogueira, Jovin).

For small centers IR/NIR will probably dominate because of the lack of angio suites and endovascular skills for nsg and neurologists.

 

[NDcienporciento100]

Not completely true.

Some of the best neurointerventionalists are actually neurologists (Nogueira, Jovin).

For small centers IR/NIR will probably dominate because of the lack of angio suites and endovascular skills for nsg and neurologists.

Are there any programs that will accept a Radiology applicant without a neurorads fellowship?

 

[Tman507]

Not completely true.

Some of the best neurointerventionalists are actually neurologists (Nogueira, Jovin).

For small centers IR/NIR will probably dominate because of the lack of angio suites and endovascular skills for nsg and neurologists.

Thanks for the insight, just my opinion from what I've been hearing around...also, can a NIR practice IR as well or do they require further training?

 

[SeisK]

Are there any programs that will accept a Radiology applicant without a neurorads fellowship?

Almost certainly not. You really need to know your cerebrovascular anatomy pretty exquisitely, that’s why programs really prefer neurorads. Why you also don’t see many dual-qualified IR/NIRs out there. If any.

 

[NDcienporciento100]

Almost certainly not. You really need to know your cerebrovascular anatomy pretty exquisitely, that’s why programs really prefer neurorads. Why you also don’t see many dual-qualified IR/NIRs out there. If any.

I’m in a body IR program and I would love to do an extra year of neuro IR but I guess its going to be tough.

 

[Neurointerventionalist]

Thanks for the insight, just my opinion from what I've been hearing around...also, can a NIR practice IR as well or do they require further training?

AFAIK if you train now you need the IR training; if you go DR -> NRad -> NIR (fast track to NIR for radiologists) you are not allowed to practise IR.
(I have never seen a pure NRad/NIR shifting to IR, though)

In my opinion the current regulation is a mess (I work in Europe now, so maybe I'm not up-to-date): it's crazy that pure DR finish NIR faster than IR, who maybe is already skilled in carotid stenting!!!

Integrated IR should be allowed to go straight to NIR fellowship, after an enfolded 6months clinical neuroscience, without neurorad fellowship (you really need fMRI or advanced MS imaging to perform thrombectomy or aneurysm embo?!?).

In Europe many radiologists practise NIR during 5y years of residency, and they have a great expertise both in technical skills and in neuroscience.

 

[NDcienporciento100]

AFAIK if you train now you need the IR training; if you go DR -> NRad -> NIR (fast track to NIR for radiologists) you are not allowed to practise IR.
(I have never seen a pure NRad/NIR shifting to IR, though)

In my opinion the current regulation is a mess (I work in Europe now, so maybe I'm not up-to-date): it's crazy that pure DR finish NIR faster than IR, who maybe is already skilled in carotid stenting!!!

Integrated IR should be allowed to go straight to NIR fellowship, after an enfolded 6months clinical neuroscience, without neurorad fellowship (you really need fMRI or advanced MS imaging to perform thrombectomy or aneurysm embo?!?).

In Europe many radiologists practise NIR during 5y years of residency, and they have a great expertise both in technical skills and in neuroscience.

Are you American that decided to go to EU or are you European that trained in US and decided to go back?

 

[Tman507]

AFAIK if you train now you need the IR training; if you go DR -> NRad -> NIR (fast track to NIR for radiologists) you are not allowed to practise IR.
(I have never seen a pure NRad/NIR shifting to IR, though)

In my opinion the current regulation is a mess (I work in Europe now, so maybe I'm not up-to-date): it's crazy that pure DR finish NIR faster than IR, who maybe is already skilled in carotid stenting!!!

Integrated IR should be allowed to go straight to NIR fellowship, after an enfolded 6months clinical neuroscience, without neurorad fellowship (you really need fMRI or advanced MS imaging to perform thrombectomy or aneurysm embo?!?).

In Europe many radiologists practise NIR during 5y years of residency, and they have a great expertise both in technical skills and in neuroscience.

Thanks, was actually implying that a NIR practice both IR and NIR like a jack of all trades (not a shift from NIR to IR).....about the whole clinical neuroscience part in NIR, like some people mentioned that you have to know and be competent in the neurological examination, so does that mean a NIR would have to perform the examination on patients or only interpret findings from neurologists?

 

[Tman507]

Almost certainly not. You really need to know your cerebrovascular anatomy pretty exquisitely, that’s why programs really prefer neurorads. Why you also don’t see many dual-qualified IR/NIRs out there. If any.

I heard of one that practices both NIR and IR, the guy collects watches buys exotic cars as a hobby

 

[Tman507]

I feel that a NIR and MSK dual fellowship will be pretty sweet too.... Total PNS and CNS coverage

 

[irwarrior]

Outside of the academic centers. There are many VIR groups that have hired neuro IR physicians and then cross train the neuroIR in peripheral IR and the peripheral VIR physicians end up helping with stroke call. There is a great deal of skill overlap in the vascular space. The neuro exam is critical not only for neuro IR but also peripheral IR. The peripheral IR who do pulmonary avms, thoracic aneurysm repairs, bronchial embolization, radial arterial access should do a thorough pre and post neuro exam. It is also getting more and more important to understand peripheral nerve neuro exam as VIR are increasingly doing more tumoral ablations, spinal and nerve blocks as well as rhizotomies.

 

[Neurointerventionalist]

Are you American that decided to go to EU or are you European that trained in US and decided to go back?

European, trained in both.

Outside of the academic centers. There are many VIR groups that have hired neuro IR physicians and then cross train the neuroIR in peripheral IR and the peripheral VIR physicians end up helping with stroke call. There is a great deal of skill overlap in the vascular space.

That's exactly the reason for interventional cardiologists training in stroke thrombectomy.

Not completely crazy IMHO: with a reasonable training (1y dedicated?) they can quickly learn to manage stroke thrombectomy, at least for as long as NeuroIR doctor are not enough.
They are already helping us a lot in developing and spreading the use of radial access for NeuroIR.

 

[Neurointerventionalist]

And two days ago SIR published new guidelines for IR training in stroke treatment (it's like more than half of all NeuroIR activity) and...

... no fellowship needed after IR residency if neuroscience and technical requirements are obtained (debatable IMHO).

https://www.jvir.org/article/S1051-0443(19)30706-7/fulltext

 

[Tman507]

And two days ago SIR published new guidelines for IR training in stroke treatment (it's like more than half of all NeuroIR activity) and...

... no fellowship needed after IR residency if neuroscience and technical requirements are obtained (debatable IMHO).

https://www.jvir.org/article/S1051-0443(19)30706-7/fulltext

Would you recommend someone that is interested in NIR to rather do IR and then specialize in NIR? ...because it seems to me that IR with stroke interventional training will take up spots for a specialist NIR and according to the training they'd have experience in the more advanced neuro diagnostics as well?

 

[irwarrior]

I think that it would be reasonable to get integrated peripheral IR training and then do advanced training if you want to suspecialize in Neuro IR to do intracranial aneurysms and AVMs etc.

 

[Neurointerventionalist]

Would you recommend someone that is interested in NIR to rather do IR and then specialize in NIR? ...because it seems to me that IR with stroke interventional training will take up spots for a specialist NIR and according to the training they'd have experience in the more advanced neuro diagnostics as well?

In large university hospital (CSC - comprehensive stroke centers) hybrid IR/NIR are not so common; even if your background is IR, you will dedicate to NIR almost exclusively. Most IR/NIR spot are in smaller hospitals (TSC - thrombectomy capable stroke center).

But yes, if you have access to stroke (with DSA and CAS, can be as much as 80% of NIR activity) as IR resident without fellowship, with eventual dedicated training for aneurysms/AVM/DAVF, then IR-NIR is way better than DR-NRad-NIR (or NSG-NIR or NLG-VascNLG-NIR), as you get to the NIR fellowship already capable of stroke treatment and with a lot of cool IR skills, very useful both for your NIR activity and for the job market...

 

[BeaHero]

Any changes in the amount of ACGME accredited NIR fellowships recently with these changes?