Interventional Neurology

[Luka75]

Hey, I'm a Neuro intern currently considering interventional Neuro. However, I will only go this route if there's diversity in the cases I can manage. This field is exclusively left to Neurosurg at my institution so I can't really get a decent perspective from a Neuro standpoint there. Forgive the naivete of the question but is there such a thing as limitations to the types of cases providers can see based on their specialty? For example, would I be limited to just thrombectomies if I were to join the field, or would I be trained in/ allowed to treat AVMs, Aneurysms, tumors, bleeds... I've been unable to get a clear answer to this question so far. However, I get the sense that it varies widely from one institution to the next given the speed at which this field is evolving.
Thanks!

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[Clean7795]

You will be able to do whatever you're comfortable/safe doing. Technically you could do it even if you were not comfortable/safe, but aside from killing patients left and right, eventually someone would probably complain.

This comes down to the kind of training you get in fellowship. From most fellowships you should be able to treat everything you described in a broad sense, at least the easy cases. Stroke/aneurysm/AVM/bleeders you will be an expert for sure because otherwise you cannot cover NIR call.

During your off time you will probably help run the neuro ICU or cover stroke/clinic, while the neurosugeon would instead operate and radiologist read scans.

 

[oopsy]

The answer to your question is yes and no. Yes, in that if you graduate from a legitimate training program with appropriate exposure and training, you absolutely are able to treat AVMs, dAVF, etc.

The question is if you will. The market is increasingly saturated, particularly in big cities and referral centers. Many big centers are opening satellite thrombectomy centers, more or less to dump less desirable stroke burden and call there to reserve capacity for hemorrhagic disease at the mothership. A thrombectomy RVU is in the low teens, at all hours of day/night. An MMA embo and aneurysm embo, ~30, done in the morning. No one wants to share as more centers open up because everyone’s individual volumes go down.

Increasingly, many centers see neurologists as thrombectologists to staff those centers while the surgeons stay at the main center. So in a big system, you may be sidelined to a limited role (or maybe not, plenty of folks landing solid jobs). It’s up to you if you’re willing to take that kind of a job. Many are, many are not.

If you start up your own center, you do whatever you want, but are on call a lot more. Lower volume, but always tethered. You can certainly do whatever cases you catch, but there aren’t many dAVF or AVMs walking around. I’m not trying to be sanguine, but it’s an uphill climb as an neurology trained interventionalist. And by the way, life isn’t that much better for the surgeons. How many open cerebrovascular surgeons does one big center need. Two, maybe three tops. Lot of those surgeons hustling to try to find jobs in bigger centers. The bottom line is that there isn’t a huge surplus of hemorrhagic disease, if anything, it’s getting more diluted. But there is a deluge of stroke now, and as the large core trials come likely positive, stroke call is going to be more demanding. If it wasn’t for stroke call, you don’t need that many people at a center. But because of it and the ongoing dilution of cases with new centers, people are being more territorial about who gets to do what.

So yes, you can do all of the cases. It’s unclear if you will though, lots of flux in the job market and dynamics.