Interventional neurology

[ariwax]

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I'm trying to get some answers on interventional neurology. So far as I can tell, there are three kinds of people who can do intravascular work intracranially: interventional neuroradiologists, vascular neurosurgeons, and, now, interventional neurologists. Though it's a fairly new subspecialty, I'm wondering if there's any info out there on just how competitive IN's are for the patient population needing interventions, as opposed to rads or neurosurgery. Can one get a job in this field? Any insights would be appreciated.

-ariwax

 

[ariwax]

Nobody has ANY information at all?

 

[Rite]

I'm trying to get some answers on interventional neurology. So far as I can tell, there are three kinds of people who can do intravascular work intracranially: interventional neuroradiologists, vascular neurosurgeons, and, now, interventional neurologists. Though it's a fairly new subspecialty, I'm wondering if there's any info out there on just how competitive IN's are for the patient population needing interventions, as opposed to rads or neurosurgery. Can one get a job in this field? Any insights would be appreciated.

-ariwax

I think this field is self selective. Not every neurology resident will want to prolong their training by additional 3-5 years. However, one has to be qualified to compete for spots at some programs which take radiology, neurosurgery, or neurology applicants. There are two routes to an interventional fellowship (or Endovascular Surgical Neuroradiology). 1 year ACGME Vascular neurology fellowship (stroke fellowship) or NICU fellowship (1-2 years) than interventional fellowship (2-3 years). Once you finish training, obtaining a job will not be too difficult. However, credentialling at certain hospitals may be difficult. Because, the gate keepers may be radiologist. Then, the question will become, "Who did you train under." If you want to be a Jedi, one has to train under a great Jedi master=).

 

[anxietypeaker]

not that i care personally, but is there a chance that the careers of interventional neurologist will take the same route that interventional cardiology did? I ask this cuz (this is anectdotal now) most neurorads i know just want to read films and get home rather than stress/on call/etc. Also, the neurosurgs seem to already have enough procedures that are keeping them busy as it is (or so the neurosurgs i know have said anyways) and prefer and have to do the regular invasive stuff rather than endovascular ops because of board recertifications. In other words, based off these things, a neuroradiologist (w/o endovascular surg) has said that he can see int. neuro going the same way as interventional cardio. He also added though, that he believes neuroradiologists are the most ideally trained for interventional procedures, but that doesnt matter when it comes to the future of whos going to be normally doing the interventional work. Also, one important challenge to this happening he said was that these fellowships are headed normally by neurosurgs/neurorads. Im assuming what he meant by this statement is that neurologists will have a harder time getting their foot in. Still, the guy said he believes that neurologists will get the intervent. procedures in time. I dont remember exactly but he said people will prolly be able to BEGIN seeing a strong hint of this in ~10 years. any thoughts?

DISCLAIMER: all this info is anectdotal. I got it from like 3 residents, 2 fellows, 1 attending...only 6 people...still sounded interesting to me.

 

[Rite]

not that i care personally, but is there a chance that the careers of interventional neurologist will take the same route that interventional cardiology did? I ask this cuz (this is anectdotal now) most neurorads i know just want to read films and get home rather than stress/on call/etc. Also, the neurosurgs seem to already have enough procedures that are keeping them busy as it is (or so the neurosurgs i know have said anyways) and prefer and have to do the regular invasive stuff rather than endovascular ops because of board recertifications. In other words, based off these things, a neuroradiologist (w/o endovascular surg) has said that he can see int. neuro going the same way as interventional cardio. He also added though, that he believes neuroradiologists are the most ideally trained for interventional procedures, but that doesnt matter when it comes to the future of whos going to be normally doing the interventional work. Also, one important challenge to this happening he said was that these fellowships are headed normally by neurosurgs/neurorads. Im assuming what he meant by this statement is that neurologists will have a harder time getting their foot in. Still, the guy said he believes that neurologists will get the intervent. procedures in time. I dont remember exactly but he said people will prolly be able to BEGIN seeing a strong hint of this in ~10 years. any thoughts?

DISCLAIMER: all this info is anectdotal. I got it from like 3 residents, 2 fellows, 1 attending...only 6 people...still sounded interesting to me.

You will be surprised how many academic programs have neurosurgery currently doing majority of the neurointerventional procedures. What does this mean? It means that radiology is already losing ground on this turf. Already several programs (UT Memphis, U. Pitt as examples) are looking predominantly for neurology or neurosurgery residents for their programs. I think we have much to learn from the masters of intervention from neuroradiology, but currently less radiology residents are opting to pursue neurointerventional. As more clinical services such as neurosurgery and neurology who are gate keepers of the patient population continue to do the procedures, radiology will naturally lose the opportunity take care of these patients.

 

[anxietypeaker]

so i guess your agreeing with the previous statement i made with an addendum...neurrads will lose turf...neurosurgs/neurol will gain it.

I guess that makes sense. Im not sure though that neurosurg will remain interested in interventional stuff in the future for the same reasons i previously posted.

Lastly, i have a question. What is the minimum requirements for a neurologist to become certified in interventional proced. I heard its 4 years residency, 1 year vascular neuro, then an interventional fellowship. Ive also heard that the NORM though is different. Typically, ive HEARD its 4 years residency, 1 year vascular neuro, AND 1 year intensive care neuro, then an interven. fellowship. But then some people have told me most applicants have done a neurrad program too?!! 😕 Anyone care to tell us what the typical neurologist applicant has (for training) when applying for interven. fellowships?

 

[Bluemirage]

You will be surprised how many academic programs have neurosurgery currently doing majority of the neurointerventional procedures. What does this mean? It means that radiology is already losing ground on this turf. Already several programs (UT Memphis, U. Pitt as examples) are looking predominantly for neurology or neurosurgery residents for their programs. I think we have much to learn from the masters of intervention from neuroradiology, but currently less radiology residents are opting to pursue neurointerventional. As more clinical services such as neurosurgery and neurology who are gate keepers of the patient population continue to do the procedures, radiology will naturally lose the opportunity take care of these patients.

This is a very interesting thread about this upcoming field. Does anyone know if interventional neurologists are strictly hired in academic settings or are there some working in private practice? I wonder what the perceptions of Neurosurgeons and Interventional Radiologists are of the competency of Interventional Neurologists work?

 

[Rite]

This is a very interesting thread about this upcoming field. Does anyone know if interventional neurologists are strictly hired in academic settings or are there some working in private practice? I wonder what the perceptions of Neurosurgeons and Interventional Radiologists are of the competency of Interventional Neurologists work?

I know of neurologists in both settings. Hard to tell what most future interventional neurologists will do in terms of practice settings.

 

[mysophobe]

I didn't think interventional neurologists would be able to support a private practice doing just interventional, much like vascular surgeons in private practice pretty much have to do general as well to keep themselves afloat. Are they doing mostly general neurology and then just doing the interventional stuff themselves rather than referring it out?

 

[ariwax]

Thanks for the replies, people - I appreciate the viewpoints. There is a big interventional neuro center at my hospital in NJ which is headed by a neurosurgeon. I intend to pump him for information when/if I get a chance. Interventional neurology seems like a fascinating field, and if I were to combine a pain practice, say, with the ability to take call on a stroke team at an academic center for a couple of days a week, it sounds like the perfect balance for me. A lot of training, though - still less than a neurosurg residency plus fellowships, and about as long as the radiology route.

 

[mysophobe]

Not so sure about that length thing. Interventional neuro would be a minimum of 7 years (4 yrs neuro + 1 yr vascular neuro + 2 yrs int. neuro), and potentially more. Add the pain fellowship on top of that and you're pushing 10. If you just wanted to do interventional neuro, then it would be about the same as a neurosurg residency or radiology->neuro rads or IR. Correct me if I'm wrong.

 

[ariwax]

Taking the pain fellowship out of the equation, I mean. Taking the time requirement for interventional neuro (IN) as 7-8 years (i.e. 4 yrs residency, 1-2 yrs vascular neurology/stroke, 1 yr "preparatory skills training" [PST, i.e. VIR fellowship], 1 yr IN) ...

1) Interventional neuroradiology (INR) - 1 yr internship, 4 yrs diagnostic rads, 1 yr neurorads, 1 yr PST, 1 yr INR = 8 yrs.

2) Endovascular neurosurgery (ENS) - 7 yr residency (usually), 1-2 yr ENS fellowship = 8-9 yrs.

Of course, these time requirements are basically anecdotal, and the specialty is so new that there aren't many people to ask about it, so I could be off by a year here and there. But it seems to me that the ENS route is dependably longer (and more demanding) than either of the other two. The main benefits of doing it through neurology seem to be the relatively noncompetitive nature of gaining the neuro residency, the relative benignity compared to neurosurg vis-a-vis lifestyle, and the fact that neurologists control the patient load, a la cardiology. Anybody agree with that?

 

[mysophobe]

Ah, okay. I was under the impression you were counting a pain fellowship along with the path to interventional neurology.

 

[anxietypeaker]

DISCLAIMER: im only a lowly PREmed...take what i say with more than a grain of salt...maybe a rock? haha

It seems to me from the boards on SDN and interventional neurologists (profiles ive seen online) that the scheme is the following:

neuro residency + vasc neuro + Critical care neuro + interventional training

From what i can tell from the profiles of neurologists, most have the following type of YEARS of training:
4 years residency + 1 year vasc + 2 years ccn + 2 years interventional = 9 years....is this wrong? that seems an awful lot. Plus the numbers im getting from here are actual numbers on CVs of interventional neuros....is this right????

 

[mysophobe]

Cleveland clinic is 4 years neuro + 1 year vasc + 2-3 years of interventional = 7 or 8 years. I think it varies program to program, but no matter where you go, you're pushing 10 years.

 

[ariwax]

Requirements tend to differ not only from program to program but between applicant types as well. Endovascular neurosurgeons just need a residency; INR types need neurorads and some practical skills, served best by a fellowship in VIR; as far as the ABPN goes, there doesn't seem to be any absolute requirement for neuro critical care, just vascular/stroke and the same 12-month practical requirement expected of radiologists. 10 years is a very pessimistic estimate; it would seem the real requirement would be seven or eight.

 

[mysophobe]

Yes. By "pushing 10 years", I meant closer to 10 than to 5. Sorry for the confusion.

 

[Rite]

DISCLAIMER: im only a lowly PREmed...take what i say with more than a grain of salt...maybe a rock? haha

It seems to me from the boards on SDN and interventional neurologists (profiles ive seen online) that the scheme is the following:

neuro residency + vasc neuro + Critical care neuro + interventional training

From what i can tell from the profiles of neurologists, most have the following type of YEARS of training:
4 years residency + 1 year vasc + 2 years ccn + 2 years interventional = 9 years....is this wrong? that seems an awful lot. Plus the numbers im getting from here are actual numbers on CVs of interventional neuros....is this right????

You can do everything in 7 years minimun via a neurology residency per the ACGME. The reason why there is variability about the years are dependent currently on whether one pursues a 1 year stroke fellowship or 1-2 year neurocritical care fellowship before the endovasucular surgical neuroradiology fellowship (what has been the traditional interventional neuroradiology fellowship-2-3 years). So the minimun is 7 years the long route would be nine.

One example of a private practice model is running the critical care unit with neurosurgery and being the interventional person in the practice.

 

[anxietypeaker]

withdrawn

 

[Bonobo]

I have surveyed about half-a-dozen paths to INR via neurology. I know of 1 that has done it in 7 years (4 neurology, 1 vasc, 2 INR), 3 that have done it in 8 years (4 neurology, 2 NICU, 2 INR), 1 in 9 years (4 neurology, 2 NICU, 1 vasc, 2 INR), and 1 in 10 years (4 neurology, 4 radiology, 2 INR).

Obviously there is a lot of flexibility and the path chosen depends on what you want to do with it. Based on ACGME, you need to do a 1 year vascular fellowship--it isn't clear that NICU fellowships can be used in its place. However, being a qualified interventionalist depends on who you train under and whether they are an ASITN senior member or not (all ACGME-approved fellowships in ESN fullfil this requirement anyway). So if a fellowship program accepts you without a vascular fellowship, then it shouldn't be a problem, and you can probably get grandfathered in later on.

A lot will evolve in 10 years. For now, the field is probably best in the hands of a neurosurgeon or a neurointensivist who has training in dealing with aneurysms (the bulk of INR's current work). I believe that half of all AVM's will eventually be cured via endovascular methods very soon also, making a stronger claim for the neurosurgeon or neurointensivist to be leading the field. However, intracranial stenting for atherosclerotic disease may prove to be successful bringing the expertise of vascular neurologists into focus.

Radiologists, while having the best training for the procedures themselves, will likely play a smaller and smaller role as time goes on. This is natural. Many radiologists I know enter the field planning to do INR, then drop out half-way through realizing that radiology is a far better lifestyle.

If you want to have substantial respect from non-neurologists as an interventionlist, I think you really have just 2 options: either do fellowships in both vasc and NICU or do an additional radiology residency. In either case, it will take roughly 9 years. This seems bad, but it really isn't since most neurosurgery residencies are 7-8 years without INR training, and most interventional cardiology programs are now requiring at least 8 years of training after medical school also.

B

 

[RB333]

Nice thread.

What are the big centres that train interventional neurologists? The Cleveland clinic is one, how about others?

 

[ariwax]

I think NYU's program is very exciting; it's a combined 7-year program in radiology, neurology and neurorads.

(Link: http://www.med.nyu.edu/radiology_edu/residency/combinedneuroint.html )

ariwax

 

[doctorlarry]

Nice thread.

What are the big centres that train interventional neurologists? The Cleveland clinic is one, how about others?

There are several...but I haven't seen any formal websites. I just know by searching the net for fellowship opportunities, word of mouth throughout the interview trail, etc.

UPitt
UMDNJ
NYU
MGH
UCSD
UCLA
UMiami
Cleveland Clinic

And I'm sure there are others that accept applications from neurologists. For example, Albany, UAB, Duke, etc. I found out about some of these on the ASN (American Society of Neuroimaging) website under fellowships (PDF):

http://www.asnweb.org/clientuploads/pdfs/CurrentFellowshipInformation2806.pdf

Most of these are places where I know neurologists have completed interventional training. If anyone else could shed light on other programs, that would be great! Definitely an exciting time to be a neurologist. 🙂

 

[doctorlarry]

Apparently, a neurologist may be considered for interventional training that is ACGME accredited, according to the ACGME website. Check out the following:

VI. Educational Program
A. Curriculum
The training program must offer didactic and clinical experiences that encompass the full clinical spectrum of endovascular surgical neuroradiology therapy.

1. Preparatory requirements

a. Common requirements: All endovascular surgical neuroradiology residents must have completed at least 12 months, preferably consecutive, in neuroradiology. In addition, all endovascular surgical neuroradiology residents must have skills and knowledge in catheter techniques.

b. Trainees accepted into an ACGME - accredited program in endovascular surgical neuroradiology who do not come from a radiology training program shall have access to a 1 - year period of training in neuroradiology in the institution sponsoring the endovascular surgical neuroradiology program.

c. Residents entering from a neurosurgery background must have fulfilled the following preparatory requirements, in addition to the common requirements:
1) Completed an ACGME accredited residency in neurological surgery.
2) Completed a course in basic radiology skills acceptable to the program director where the neuroradiology training will occur. The basic radiology skills and neuroradiology training may be acquired during elective time in the neurological surgery residency.

d. Residents entering from a neurology background must have fulfilled the following preparatory requirements, in addition to the common requirements:
1) Completed an ACGME-accredited residency in neurology;
2) Completed an ACGME-accredited 1- year vascular neurology program;
3) Completed a 3- month course in basic radiology skills acceptable to the program director where the neuroradiology training will occur. The basic radiology skills and neuroradiology training may be acquired during elective time in the neurology residency.
4) Completed 3 months of clinical experience in an ACGME accredited neurological surgery program, which may be acquired during elective time in neurology and/or vascular neurology training.

The entire link: http://www.acgme.org/acWebsite/downloads/RRC_progReq/422pr403.pdf

 

[doctorlarry]

MGH has a program accepting applications from qualified neurologists. During an interview, I was told that a neurology resident from UMiami matched into this program for interventional.

Here is some info:
The Interventional Neuroradiology/ Endovascular Neurosurgery fellowship consists of 2 years of training in Interventional Neuroradiology with case supervision in a graduated progression, as well as call responsibilities. Radiologists must be ABR certified with completion of a Radiology residency. They must also have completed a year of Diagnostic Neuroradiology fellowship. We consider qualified candidates who have completed a Neurosurgery residency or Neurology Stroke/ICU fellowship. These candidates will have to complete a 6-12 month neuro-imaging core as well as radiation biology and safety training.

Our section performs over 750 diagnostic and therapeutic procedures each year. The fellowship focuses on clinical evaluation of patients and diagnostic imaging to develop therapeutic decision making. In some cases interdisciplinary methods may be considered. Post procedure care and follow up are equally important in patient management. Research is a strong component of the section, and fellows will be expected to participate in these activities. These studies include basic science, clinical and translational projects.

CONTACT:
James D. Rabinov, MD
Fellowship Director,
Interventional Neuroradiology and Endovascular Surgery Fellowship

The link: http://www.mgh-interventional-neurorad.org/fellowship.html

 

[PKPK]

According to this website, a neurologist can apply straight to this 2 year fellowship, without having done the 1 year vascular fellowship? Or am I missing something? Are there other programs like this out there?

http://www.med.nyu.edu/radiology_edu/fellowship/noncaq/neurointerfellow.html

I just finished my first year of med school, and am trying to figure out the details of subspecialties within neuro. These threads have helped out a lot, I really appreciate all of the input! Any advice would be greatly appreciated!

 

[Bonobo]

Given that there are now separately approved fellowships in vascular neurology (via ACGME, 1 year) and neurocritical care (via UCNS, 2 years), I wonder if one can really do either before doing interventional. It would seem that both would be important and useful--wouldn't it be nice if the UCNS allowed one to do both in 2 years! But for some reason, I understand that the UCNS does NOT allow this creating a situation where one has to choose. By ACGME guidelines for interventional training, one has to do a vascular fellowship. But in truth, very few interventional fellowships are ACGME accredited, and my sense is that it will stay this way given that what hospitals really care about when hiring an interventionalist is who they trained under and whether they are an ASITN member. If that is true, then a neurocritical care fellowship should be sufficient without the vascular fellowship.

Any thoughts on how this might play out? Who decides this stuff anyway?

Maybe I'll just do both... (my wife doesn't read this forum )

B

 

[RB333]

Hello again,

Thanks for all the input, especially doclarry. Beginning clerkship next month, and exploring all my options. This emerging subspecilaty is particularily intriguing.

Doclarry, or anyone else, once a neurologist completes an interventional fellowship, are they typically involved in patient care? I know in cardiology, you're pretty much in the cath lab doing procedures most of the time. I personally would like the combine both.

 

[Happy613]

Hello again,

Thanks for all the input, especially doclarry. Beginning clerkship next month, and exploring all my options. This emerging subspecilaty is particularily intriguing.

Doclarry, or anyone else, once a neurologist completes an interventional fellowship, are they typically involved in patient care? I know in cardiology, you're pretty much in the cath lab doing procedures most of the time. I personally would like the combine both.

Hi,

I am pretty sure that they are involved in patient care. At UMDNJ, the stroke team rounds on the patients that underwent angio while they are in the hospital. And I am pretty sure all will have to follow up in the office at some time after discharge.

Also as interventional neuro grows, more and more procedures are being developed that can be preformed on an elective basis: (carotid stenting, avm ablation, intra-atrial chemo...etc) which would neccesitate seeing patients in an office setting first.



-David

 

[cooldreams]

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??

 

[MossPoh]

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??

I don't have an exact answer but I think something like that would go with just a good base knowledge of the brain/nervous system. There is a lot of disciplines that can get involved with that from the computer science side, to the psych side, to the medicine side......I think there is still a lot more in the human cognition side....although I can ask my current professor if you want. He works a lot with people in that field(or related) and could probably tell you...

 

[cooldreams]

I don't have an exact answer but I think something like that would go with just a good base knowledge of the brain/nervous system. There is a lot of disciplines that can get involved with that from the computer science side, to the psych side, to the medicine side......I think there is still a lot more in the human cognition side....although I can ask my current professor if you want. He works a lot with people in that field(or related) and could probably tell you...

wow that would be really awesome! id really appreciate it.

i have a graduate electrical engineering background and want to work with allowing the human nervous system to control things via signals from the nervous system to a computer or communications circuit in some fashion.

i know there is a lot of work being done on this right now, but it is also at a real infancy stage... i just wanna be ready to do some of this work to help people control things like that when its ready, and i also want to contribute to the research in this....

thanks again....

 

[H_Caulfield]

wow that would be really awesome! id really appreciate it.

i have a graduate electrical engineering background and want to work with allowing the human nervous system to control things via signals from the nervous system to a computer or communications circuit in some fashion.

i know there is a lot of work being done on this right now, but it is also at a real infancy stage... i just wanna be ready to do some of this work to help people control things like that when its ready, and i also want to contribute to the research in this....

thanks again....

Dude....you are DEFINITELY looking at a Ph.D.-type thing; medical school is a waste of time for you, if this is what you're set on. I suppose you could do MD-PhD, but even then you'd probably only find that you could research this but not practice it. Trust me...neurosurgeons and interventional neuroradiologists do not have time to see their (all critically ill) patients AND do extensive ground-breaking innovative research. In Harvey Cushing's time, sure....but things are a bit more divided up now. These practitioners have a hard time just getting home for 8 hours each day, when all they're doing is seeing patients.

 

[cooldreams]

Dude....you are DEFINITELY looking at a Ph.D.-type thing; medical school is a waste of time for you, if this is what you're set on. I suppose you could do MD-PhD, but even then you'd probably only find that you could research this but not practice it. Trust me...neurosurgeons and interventional neuroradiologists do not have time to see their (all critically ill) patients AND do extensive ground-breaking innovative research. In Harvey Cushing's time, sure....but things are a bit more divided up now. These practitioners have a hard time just getting home for 8 hours each day, when all they're doing is seeing patients.

well, then, question.

who are doing these operations:

http://archives.cnn.com/2000/TECH/computing/12/07/robot.man/

http://www.cabalamat.org/weblog/art_518.html

http://dsc.discovery.com/news/briefs/20041018/brain.html

http://scicom.ucsc.edu/SciNotes/0201/lo/mind/index.html

and many others that are just now taking shape. i guess many were done by scientists themselves? but surely in the future as more complex things take shape, and as some even reach mainstream science, it will be a physician that "installs" these things and not some random scientist. right?

HAS ANYONE EVER THOUGHT TO INTRODUCE A SMALL PUFF OF NITRIC OXIDE ONTO THE THALMUS TO WAKE UP PATIENTS IN A LONG STATE OF A COMA???

 

[H_Caulfield]

well, then, question.

who are doing these operations:

http://archives.cnn.com/2000/TECH/computing/12/07/robot.man/

http://www.cabalamat.org/weblog/art_518.html

http://dsc.discovery.com/news/briefs/20041018/brain.html

http://scicom.ucsc.edu/SciNotes/0201/lo/mind/index.html

and many others that are just now taking shape. i guess many were done by scientists themselves? but surely in the future as more complex things take shape, and as some even reach mainstream science, it will be a physician that "installs" these things and not some random scientist. right?

HAS ANYONE EVER THOUGHT TO INTRODUCE A SMALL PUFF OF NITRIC OXIDE ONTO THE THALMUS TO WAKE UP PATIENTS IN A LONG STATE OF A COMA???

Right...it will be an MD-Ph.D-holding, 60 yr. old full professor at johns hopkins med. who has a strictly academic practice.

 

[cooldreams]

Right...it will be an MD-Ph.D-holding, 60 yr. old full professor at johns hopkins med. who has a strictly academic practice.

eh....

im going for a phd in electrical engineering. i am working on a more detailed and accurate modeling of nerves with electric circuits... this is the future of medicine... i know it..........