Interventional Neuroradiology?

[amph119]

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I'm a first year medical student right now with a strong but admittedly preliminary interest in neurology, and while I have been looking into it I came across things such as interventional neurology, interventional neuroradiology, and neurointerventional surgery, and some other specialty combos.

I guess I don't really have any specific questions, I was just wondering if anyone had any input on what exactly the differences between all of them are (especially how they differ from straight up neurology), and what residencies / training is required, as well as any personal input, love stories, or what not. I know I can wikipedia all of them, but I was more interested in some experienced-based advice if there is any out there 🙂

Thanks guys!

 

[typhoonegator]

While interventional neurology could be taken to mean a number of things, interventional neuroradiology is a field that specializes in catheter-based techniques for imaging and treatment of the central neuraxis.

INR is reachable from neurology, neurosurgery, or radiology, and there have been many threads dedicated to this on our forum in the past. Some programs are more neurology-friendly than others, but this is in a state of constant flux. For neurologists, you would complete a neurology residency, a vascular neurology fellowship, and then an INR fellowship, which usually consists of a mixture of training in remedial diagnostic neuroradiology techniques, and interventional procedures.

INR is very different from straight-up neurology, because once you are trained in INR, your time is far more remunerative scheduling, performing, and following-up procedures than it would be in the neurology clinic seeing headache follow-ups and new MS diagnoses. This is akin to interventional cardiology -- those guys aren't doing primary care clinics. INR people tend to be on-call a lot, because there aren't that many of them around, and they need to be available for urgent procedures in the middle of the night.

INR docs do catheter angiograms, carotid and vertebral stenting, aneurysm coiling and stent-coiling, stenting of intracranial stenoses, acute IA thrombolysis in acute stroke, acute mechanical thromborrhexis in acute stroke, lysis of venous thrombosis in VST, and many other things. There is very little well-controlled data on many of these interventions, so research in INR is very hot right now, and opportunities abound.

There are several people on this forum with an interest in INR, and hopefully they'll chime in with some other helpful hints for you.

 

[amph119]

Thank you so much for your response! This field has fascinated me for the whopping two weeks that I have known about it (don't worry, I'm fully aware that my residency/specialty choice is apt to change numerous times).

I understand that it is a very new field. Wikipedia tells me it was established in 2000, so I'm sure things are constantly in flux. However, is there a "recommended" path to it, i.e. one residency over the another?

I think one of the appealing sides of INR, and something you mentioned to me in your post, is the idea of being on call for urgent procedures. It may be me being naive as a first-year, but I like the idea of combining my neurology interest with critical care on call type stuff.

 

[typhoonegator]

Then I humbly suggest that you consider neurocritical care, which actually does combine neurology with "critical care type stuff".

 

[bonran]

I would not choose neurocritical care (NCC) to go into INR/ESNR for the following reasons:

- the ACGME guidelines for training in ESNR clearly state that the pathway for neurologists is through Vascular Neurology & do not mention NCC as a route. Although, in the past NCC fellows have done ESNR, this trend is gradually changing. Even the biggest proponent of this kind of training, MCW-Milwaukee is starting to take in more VN graduates.

- The NCC Society is interested in discontinuing this trend as it feels it takes their graduates into a field from where they cannot practice NCC (thus reducing research output/specialists in the field & affecting patient care). This also drains away specialists into INR/ESNR (an ACGME approved specialty) & reduces their numbers thus preventing their ultimate goal (to get ACGME accreditation for NCC as a specialty). At present NCC is not an ACGME accredited specialty due to turf battles & opposition from special interest groups in Medical Critical Care & Neurosurgery. Thus NCC is not interested in losing its graduates to ESNR & may not support a fellow wanting to do ESNR in the future.

- At present, the easiest way (but not necessarily the best) to be sure of getting an ESNR fellowship is through Radiology-Neuroradiology pathway. For radiology graduates, ESNR lifestyle is not a good fit. With increasingly acute patients treated by ESNR at odd hrs, long procedure times, not much increase in renumeration compared to other radiological specialties (MSK/Breast/Body-imaging) & poor post-procedure outcomes due to lack of comprehensive post-procedure care/lack of understanding of pathophysiology of disease processes by radiologists; there is waning interest in radiology graduates to go into this field. Many fellowships go empty each year and are attainable. However, this may change in the future (a la Interventional Cardiology) if the branch slips out of Neuroradiologists hands & moves into NSx/Vascular Neurology realm. This is a very real possibility, specially since you are in the first yr of medical school & at least 7 yrs from fellowship. You need to plan accordingly.

If I was in your place, I would choose to go into Neurosurgery (if you can withstand that lifestyle) followed by Neurology-Vascular Neurology.

 

[amph119]

Thank you very much guys. I really appreciate this input. Lots to figure out over the next 2 years. I guess my next question would be (though you both have somewhat/mostly answered it already) would be...

"An prospective INR is someone who wants to ___?___"

That blank not necessarily being the procedures, but more general... if that makes any sense. Split up of patients vs research, lifestyle, other stuff I'm not aware of, etc.

I guess what I'm trying to get at is that I'm not particularly interested in a outpatient-centered neurology career, but more inpatient/academia oriented one. I'm gathering that NCC is a viable option, but may have its own disadvantages when it comes to accreditation or a trend of changes when it comes to viable post-NCC training. I'm also very serious about the idea of neurosurgery, but I just don't know if I can take a 7 year residency then add fellowships on top of that.

 

[bonran]

It takes 7-8 yrs any which way you do ESNR/INR:

Radiology:
4yr residency+ 1yr NR fellowship+ 2yr INR fellowship

Neurology:
4yr residency+ 1yr VN fellowship+ 2yr ESNR fellowship

Neurosurgery:
7yr residency with ESNR fellowship built into the 2yr research time. No seperate fellowship is required.

 

[typhoonegator]

For the record, I was not proposing NCC as a way into INR, but rather as an end unto itself.

 

[typhoonegator]

Thank you very much guys. I really appreciate this input. Lots to figure out over the next 2 years. I guess my next question would be (though you both have somewhat/mostly answered it already) would be...

"An prospective INR is someone who wants to ___?___"

That blank not necessarily being the procedures, but more general... if that makes any sense. Split up of patients vs research, lifestyle, other stuff I'm not aware of, etc.

A neurointerventionalist is someone who wants to spend most of their clinical time doing procedures, is interested in clinical research, and doesn't mind compromising lifestyle to achieve their career goals. That last point is an important one to consider, as you will not always be a gung-ho MS1. That isn't to dissuade you -- just be honest with yourself.

As Bonran said, many neurosurgery residencies can accommodate INR training within elective time, although if the program requires lots of research time that could be a problem. The length of time from rads or neuro is about the same.

NCC is a separate specialty, a 2 year fellowship after neurology, neurosurgery, or anesthesia. NCC is not a bridge to INR, but is a fully-developed specialty. There is an accreditation process already in place for NCC that is independent of vascular neurology, to which it was once tied.

 

[eddieberetta]

poor post-procedure outcomes due to lack of comprehensive post-procedure care/lack of understanding of pathophysiology of disease processes by radiologists

If I was in your place, I would choose to go into Neurosurgery (if you can withstand that lifestyle) followed by Neurology-Vascular Neurology

Pathetic. If you spent more time honing your own radiologic and clinical skills rather than maligning others who participate in this highly specialized area you would be a much better doctor.

And I am sorry you regret your choice to go into neurology...

 

[RAD345]

Can we just not comment on how one specialty is better than the other, and leave them alone.

In every filed, there are very smart people that they amaze you with they do.

Just my 2 cents.

 

[eddieberetta]

Can we just not comment on how one specialty is better than the other, and leave them alone.

In every filed, there are very smart people that they amaze you with they do.

Just my 2 cents.

I agree that there is no reason why one cannot be an exceptionally good INR from any of the base disciplines.

I thought it was ridiculous that he had to embed that comment about poor patient outcomes as if it was an accepted fact -- of course we would not be doing this job if that were the case. His comment is an affront to radiologists who participate in INR who have undergone years of radiological, procedural , and CLINICAL training, admit and round on their own patients, and run clinics either on their own or in collaboration with vascular neurosurgery or neurology. He is bad-mouthing a large number of people who were basically involved in inventing and developing the specialty and who even to this day train individuals to the best of their ability irrespective of their base discipline.

I suppose he believes ISAT and ISUIA2 (where only a tiny minority of interventional cases if any were performed by neurologists) favored coiling despite the crappy care that we radiologists provide to patients?

To the OP, just to give you some idea of the scope of procedures we perform in INR

Aneurysm coiling
Vessel sacrifice and flow remodelling stent
Stenting of the intra and extracranial head and neck arteries
embolization of vascular malformations and tumors of the head neck and spine using a variety of agents both intra vascular and percutaneous
Embolization for epistaxis and trauma
acute stroke intervention
Percutaneous biopsy and intervention in the extracranial head and neck and spine
Spine pain procedures
A few other miscellaneous things

In INR should be someone who wants to take an active role in treating neurological diseases, who enjoys neuroradiology, neurology and neurosurgery (the order there should determine your base specialty), loves anatomy, loves procedures, has good hand-eye coordination, is good with patients, enjoys research, loves to work hard, likes or at least doesn't mind being on call, and someone who can think creatively on their feet.

 

[bonran]

Eddie,

There is no need to come here pouting your holier-than-thou attitude at my expense. I am sure you know how neuroradiologists view "invasion" of "their turf" by neurosurgery/neurology at auntminnie.com, a site you frequent often. It has even been announced from the highest podiums of Neuroradiology at their meetings by their Society President Dr David Youssem of JHMI. If I am stating a fact on a neurology board, I am presenting my interpretation of how things are developing in the field. And I have every right to do that. Please read these articles:

http://annalsofneurology.wordpress.com/2008/07/22/neuroimaging-turf-battles-flare/

http://www.auntminnie.com/forum/tm.aspx?m=245397

http://www.ajnr.org/cgi/reprint/22/9/1650.pdf

http://radiology.rsna.org/content/234/1/26.full.pdf+html

Putting a stent or a coil in a patient is a technical skill, like being a circus monkey. Selecting the right patient & managing the patient post-op is something that I havent seen a neuroradiologist do. Nor have I seen any NR person doing rounds in the NeuroICU post-procedure making decisions about patient management. Neither have I seen them follow patients in a clinic 3 months later, making decisions about optimum medical therapy, something that is taken for granted by interventional neurologists & interventional neurosurgeons.

Neuroradiologist & neurosurgeons have long kept neurologists out of this field. Now that the real physicians are in, this field has started slipping out of the hands of non-physicians (a la interventional cardiology). I have no shame in stating that here. You can cry yourself hoarse criticizing me but it wont change the facts on the ground. And if you want to read views from fear strickened neuroradiologists asking others shamelessly to "defend their turf", just read them at auntminnie.com

As far as my choice of going into neurology, you dont have to feel sorry for me. I have enough radiological skills to go through the Radiology Fellowship MATCH & get into an ACGME accredited radiology fellowship. Thats how good my neurology training is.

 

[typhoonegator]

OK campers,

Tone down the rhetoric please. Direct calling-out of other SDN users is a violation of the terms of service. For the sake of the thread starter, let's try to stay on topic.

For the TS: People interested in INR are lucky enough to have the opportunity to reach this specialty from several disciplines (rads, nsurg, neuro). That means you get to pick the starting point that is most interesting to you. As a NCC fellow, I've worked with people from all three, and they're all great.

What is happening in this thread is that people are defending their route to INR, because they have pride in their training.

 

[neurochica]

in my neck of the woods, IR and NR people do take part in doing rounds in the NeuroICU and have some say, (not a lot) about post-procedure making decisions about patient management.

I am of the believe that since all 3 specialties form INR/ESNR- we should all get along. Hopefully once ESNR gets its own accreditation, we can defend this specialty as our own turf, regardless of our entry-specialty.

 

[OHMAN0125]

Eddie,

There is no need to come here pouting your holier-than-thou attitude at my expense. I am sure you know how neuroradiologists view "invasion" of "their turf" by neurosurgery/neurology at auntminnie.com, a site you frequent often. It has even been announced from the highest podiums of Neuroradiology at their meetings by their Society President Dr David Youssem of JHMI. If I am stating a fact on a neurology board, I am presenting my interpretation of how things are developing in the field. And I have every right to do that. Please read these articles:

http://annalsofneurology.wordpress.com/2008/07/22/neuroimaging-turf-battles-flare/

http://www.auntminnie.com/forum/tm.aspx?m=245397

http://www.ajnr.org/cgi/reprint/22/9/1650.pdf

http://radiology.rsna.org/content/234/1/26.full.pdf+html

Putting a stent or a coil in a patient is a technical skill, like being a circus monkey. Selecting the right patient & managing the patient post-op is something that I havent seen a neuroradiologist do. Nor have I seen any NR person doing rounds in the NeuroICU post-procedure making decisions about patient management. Neither have I seen them follow patients in a clinic 3 months later, making decisions about optimum medical therapy, something that is taken for granted by interventional neurologists & interventional neurosurgeons.

Neuroradiologist & neurosurgeons have long kept neurologists out of this field. Now that the real physicians are in, this field has started slipping out of the hands of non-physicians (a la interventional cardiology). I have no shame in stating that here. You can cry yourself hoarse criticizing me but it wont change the facts on the ground. And if you want to read views from fear strickened neuroradiologists asking others shamelessly to "defend their turf", just read them at auntminnie.com

As far as my choice of going into neurology, you dont have to feel sorry for me. I have enough radiological skills to go through the Radiology Fellowship MATCH & get into an ACGME accredited radiology fellowship. Thats how good my neurology training is.

Your stubborn egotistical personality is out of control. I dare you to do what u speak then. What I sense from you is that you want to take the field totally into neurology and forget about the surgeons and radiologists. You're doing the exact thing that you criticized those fields of in the past.

 

[bonran]

Dare me to do what??
As far as taking it away from radiologists/surgeons, as you sow so shall you reap.
As far as being an egoist, are you sure you mean me (a mere neurologist) or the neurosurgeons/neuroradiologists?

Cheers

 

[OHMAN0125]

Dare me to do what??
As far as taking it away from radiologists/surgeons, as you sow so shall you reap.
As far as being an egoist, are you sure you mean me (a mere neurologist) or the neurosurgeons/neuroradiologists?

Cheers

Dare u to apply in the match for a radiology fellowship. That's what I bolded in ur cocky rant. U have much to learn about being humble. I hope u don't carry that attitude around in real life.

 

[bonran]

Whats so big about the radiology-Fellowship MATCH?

Briefly, I did go through it in 2009. And I did interview at several programs for neuroradiology & interventional radiology both of which are coordinated through the National Residency Matching Program (NRMP). I did match at an ACGME-approved University radiology-fellowship program. I am in it right now.

(extended answer PMed to you as it may hurt the sensitivities of our dear moderators)

Its not too tough to get into fellowships that the primary specialty grads are too lazy or too clinically inexperienced to go into. Thats the reason why radiologists dont make good proceduralists. Thats why there are surgeons & clinically trained interventionalists. Its also the reason why radiologists lose the procedures they develop & why VIR is coming up with a DIRECT 7yr residency cum fellowship program with 2-yrs of clinical training which has been approved by the ACR since 2009. Its almost like the parent specialty has vindicated what I am stating here. Radiologists need more clinical training if they want to treat patients.

Sitting in a dark room looking at pictures is not a substitute for clinical training. Also, just because a specialty develops a procedure doesnt mean another cannot use it, an arguement often used by radiologists when they defend "our" turf & "our" procedures. Otherwise the real proceduralists would be the venture capitalists & biomechanical engineers who develop the devices that we use as they are the ones developing them (almost like engineers who build the shuttle arguing that they should be going into space as the device is theirs)!!! Such arguements are rubbish & not science. The real arguement is who uses these devices/procedures scientifically with the best outcomes, the best result for the patients & produces scientifically backed evidence of clinical (and not radiological-TIMI 3 flow estabilished) improvement of the patients.

Cheers.

 

[OHMAN0125]

Whats so big about the radiology-Fellowship MATCH?

Briefly, I did go through it in 2009. And I did interview at several programs for neuroradiology & interventional radiology. I did match at an ACGME-approved University radiology-fellowship program. I am in it right now.

(extended answer PMed to you as it may hurt the sensitivities of our dear moderators)

Its not too tough to get into fellowships that the primary specialty grads are too lazy or too clinically inexperienced to go into. Thats the reason why radiologists dont make good proceduralists. Thats why there are surgeons & clinically trained interventionalists. Its also the reason why radiologists lose the procedures they develop & why VIR is coming up with a DIRECT 7yr residency cum fellowship program with 2-yrs of clinical training which has been approved by the ACR since 2009. Its almost like the parent specialty has vindicated what I am stating here. Radiologists need more clinical training if they want to treat patients.

Sitting in a dark room looking at pictures is not a substitute for clinical training. Also, just because a specialty develops a procedure doesnt mean another cannot use it, an arguement often used by radiologists when they defend "our" turf & "our" procedures. Otherwise the real proceduralists would be the venture capitalists & biomechanical engineers who develop the devices that we use as they are the ones developing them (almost like engineers who build the shuttle arguing that they should be going into space as the device is theirs)!!! Such arguements are rubbish & not science. The real arguement is who uses these devices/procedures scientifically with the best outcomes, the best result for the patients & produces scientifically backed evidence of clinical (and not radiological-TIMI 3 flow estabilished) improvement of the patients.

Cheers.

Wow man...wow. Ur absolutely FULL of urself. U never saw the point of my posts. Ur too blinded by trying to defend why ur the best at what u do. Step back and see if ur being an @ss or not please. But I already know u won't be able to see and come back with some reply about how great u are again. I'm done here...good luck.

 

[bonran]

It seems something is making you uneasy here. You seem to have dug a hole for your self by daring me to get what I already have. And now you are without an answer/arguement. Seems like a case of sour grapes.

I dont need you to make me see any point. You are a resident & not experienced enough. I am in my second fellowship, in my third university program. I have also trained in 3 countries in 3 different continents. Whether you think I am full of it or really know what I am talking about is not something you can really judge from your limited exposure to medicine. I have my own experiences & can very well make judgements for myself.

As you can see, I am the one who has cross-trained, not you. If anything, I dare you to go to a neurology/neurosurgery fellowship to get some clinical experience to learn how to assess, counsel & treat patients.

Goodbye & good luck in your training.

 

[dusselas]

So, if someone wanted to do ESNR starting with neurology residency, is it preferable to choose neurology programs that also offer vascular and ESNR fellowships?

 

[typhoonegator]

So, if someone wanted to do ESNR starting with neurology residency, is it preferable to choose neurology programs that also offer vascular and ESNR fellowships?

Not necessarily. You could always do residency and then change programs for fellowship. While many programs favor internal candidates for vascular fellowships, it certainly isn't impossible to fellowship match outside of your home program. Pick the program that feels best to you. You never know what is going to happen in the intervening four years. You might fall in love with something else.

That being said, it might be helpful to focus on residencies affiliated with strong INR divisions, so you at least have good exposure to the sub-specialty. It would help to affirm your interest, and provide you with potential letter-writers at your home institution.

 

[Jacknut]

Whats so big about the radiology-Fellowship MATCH?

Briefly, I did go through it in 2009. And I did interview at several programs for neuroradiology & interventional radiology both of which are coordinated through the National Residency Matching Program (NRMP). I did match at an ACGME-approved University radiology-fellowship program. I am in it right now.

(extended answer PMed to you as it may hurt the sensitivities of our dear moderators)

Its not too tough to get into fellowships that the primary specialty grads are too lazy or too clinically inexperienced to go into. Thats the reason why radiologists dont make good proceduralists. Thats why there are surgeons & clinically trained interventionalists. Its also the reason why radiologists lose the procedures they develop & why VIR is coming up with a DIRECT 7yr residency cum fellowship program with 2-yrs of clinical training which has been approved by the ACR since 2009. Its almost like the parent specialty has vindicated what I am stating here. Radiologists need more clinical training if they want to treat patients.

Sitting in a dark room looking at pictures is not a substitute for clinical training. Also, just because a specialty develops a procedure doesnt mean another cannot use it, an arguement often used by radiologists when they defend "our" turf & "our" procedures. Otherwise the real proceduralists would be the venture capitalists & biomechanical engineers who develop the devices that we use as they are the ones developing them (almost like engineers who build the shuttle arguing that they should be going into space as the device is theirs)!!! Such arguements are rubbish & not science. The real arguement is who uses these devices/procedures scientifically with the best outcomes, the best result for the patients & produces scientifically backed evidence of clinical (and not radiological-TIMI 3 flow estabilished) improvement of the patients.

Cheers.

I'm not sure if this guy is just a Troll or an @sshole...either way gtfo.

thanks in advance👍

 

[bonran]

I'm not sure if this guy is just a Troll or an @sshole...either way gtfo.

thanks in advance👍

And where were you bred?? From the language it seems you just crawled out of the gutter!!👍

 

[typhoonegator]

Given the deterioration of this thread, and dearth of any useful information of late, I'm very tempted to close it. This forum is not meant as a medium for interpersonal squabbles. I realize the emotional nature of the topic, but please feel free to use the private message feature for interpersonal communication, rather than derailing the thread.

 

[medsRus]

Given the deterioration of this thread, and dearth of any useful information of late, I'm very tempted to close it. This forum is not meant as a medium for interpersonal squabbles. I realize the emotional nature of the topic, but please feel free to use the private message feature for interpersonal communication, rather than derailing the thread.

Please do.

 

[bonran]

You're right typhoonegator. This link has served its purpose.

As it is, the moderators here dont like it when neurologists give it back to the neuroradiologists. I hope you have read how neurologists are potrayed as undeserving impotent bumblers on auntminnie.com & other radiology sites. Go ahead & close the discussion here. And at the same time, why dont you just ban me too for standing up for neurologists. 🙂

 

[RAD345]

Cool down B.

I am surprised that that TG has not closed the thread yet. There is no reason to BAN anyone,
'cause everybody knows
how hot this topic is and
how crazy IR fans are!

😱😱😱

I hope by now "amph119" knows what the IR is and what are the pathways for going to IR. 🙄

 

[typhoonegator]

Alright. With that measure of consensus, this thread is closed.