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I want to get some opinions on NIR and where it is headed? What does the new training pathway look like? Is it better to do NIR from a neurology or IR background?
I asked about this on a fair number of interviews. Seems like the big trend is towards primarily Neurosurgery trained clinicians handling endovascular cases. There were some holdouts that were handled by Radiologists, but this was a minority from what I saw.
So I have read that neurology has begun to make inroads into the market as well, do you get this feeling from your experience?Neuro-IR has an interesting recent history. The 2002 ISAT study that showed coiling is superior to clipping for independent survival at 1 and 7 years, despite a higher risk of re-bleeding with coiling. Neurosurgeons were not happy with this result. They published a Neurosurgery review article in 2008 with the conclusion that no clear consensus could be made on the superiority of coiling to clipping. The neurosurgical "takeover" of neuro-IR started around this time. While some say it was because neuro-IR didn't offer a radiologist lifestyle, you can't discount the financial impact the ISAT study had on vascular neurosurgeons.
There were so many people entering neuro-IR, from both radiology and neurosurgery, that a bubble developed (2010-2014):
http://www.ajnr.org/content/31/7/1162.full
https://www.ncbi.nlm.nih.gov/pubmed/23008409
http://www.medscape.com/viewarticle/770792_3
Finally in 2015, after neurosurgery had taken over much of the field, an 18-year follow-up of the ISAT trial showed that coiled patients still had significantly prolonged survival relative to the clipped patients. To add icing on the cake, the 2015 EXTEND-IA trial showed that endovascular thrombectomy was superior to tPA alone for proximal cerebral artery occlusions.
The neurointerventional job market has recovered as a result of these findings, but the jobs are largely allocated to neurosurgeons.
There is a growing number of peripheral interventionalists providing stroke therapy.
Neuro-IR has an interesting recent history. The 2002 ISAT study that showed coiling is superior to clipping for independent survival at 1 and 7 years, despite a higher risk of re-bleeding with coiling. Neurosurgeons were not happy with this result. They published a Neurosurgery review article in 2008 with the conclusion that no clear consensus could be made on the superiority of coiling to clipping. The neurosurgical "takeover" of neuro-IR started around this time. While some say it was because neuro-IR didn't offer a radiologist lifestyle, you can't discount the financial impact the ISAT study had on vascular neurosurgeons.
There were so many people entering neuro-IR, from both radiology and neurosurgery, that a bubble developed (2010-2014):
http://www.ajnr.org/content/31/7/1162.full
https://www.ncbi.nlm.nih.gov/pubmed/23008409
http://www.medscape.com/viewarticle/770792_3
Finally in 2015, after neurosurgery had taken over much of the field, an 18-year follow-up of the ISAT trial showed that coiled patients still had significantly prolonged survival relative to the clipped patients. To add icing on the cake, the 2015 EXTEND-IA trial showed that endovascular thrombectomy was superior to tPA alone for proximal cerebral artery occlusions.
The neurointerventional job market has recovered as a result of these findings, but the jobs are largely allocated to neurosurgeons.
Truth. Many in peripheral vascular IR will enter the realm of acute stroke therapy. When one can provide the gamut of VIR in addition to acute stroke therapy, this can be a very desirable skill that hospitals will want.
where can I find these job boards?It's a risky choice as a field, for sure. The NIR fellow at our institution (rads) got an awesome job this year, and if you look at the job boards, there are some pretty good jobs available. That being said, the limited scope of cases is tough (with VIR if you lose x turf there is always some new thing available, neuro is more limited so I think it'd be harder to move on).
I think if you love neuro it can work, but it's certainly risky, especially if you don't like neuro diagnostics. I was originally interested in neuro IR but am doing body IR instead for the reasons above.
More and more IR practices are looking for an IR who is dual trained in IR/INR due to the explosion of stroke centers and comprehensive stroke centers. The Body IR physicians are starting to do more and more stroke call. I think it is imperative that you actively seek INR training particularly diagnostic cerebral angiography and stroke thrombectomy cases during your residency training.
More and more IR practices are looking for an IR who is dual trained in IR/INR due to the explosion of stroke centers and comprehensive stroke centers. The Body IR physicians are starting to do more and more stroke call. I think it is imperative that you actively seek INR training particularly diagnostic cerebral angiography and stroke thrombectomy cases during your residency training.
More and more hospitals are looking for stroke certification. There are a considerable number of patients that would be diverted to stroke centers for symptoms that may or may not be attributed to stroke . The hospitals want to have access to these patients and this often requires stroke interventions. Comprehensive stroke center has even more vigorous requirements. Many of the high end private practice IR groups are providing this as part of their armamentarium.
Many IR training programs are unable or unwilling to provide this training . Neuro IR may be under the division of neurosurgery or Neurology. Also, in general the body IR would rather have the residents working in their own division covering their service as opposed to being on someone else's service. In my opinion this training can only make you better. The catheter skills you obtain in Neuro IR can only be of benefit (liquid embolic use). Treatment of complex aneurysms, thrombectomy and stents.
Now if your goal is to do 50/50 and do more minor procedures , I agree mammography or other type of imaging may be better to get further training in.
High end IR is not a lifestyle specialty, it is far more like surgery in its day to day existence with a lot of patient care responsibilities. Stroke call can be pretty busy , but it has high impact factor.