Neurosurgery vs. Interventional neuroradiology

[HarveyCushing]

I am new to this forum and really like it. I am very interested in these two areas of medicine. Just curious about how they differ. I know radiologists dont do surgery, but they are doing alot of cool techniques. How much do they actually get to do? Also how does the training differ between the two and what do you think the future holds for these two areas? thanks for your help.

---

Members don't see this ad.

 

[NSGYResident]

I am new to this forum and really like it. I am very interested in these two areas of medicine. Just curious about how they differ. I know radiologists dont do surgery, but they are doing alot of cool techniques. How much do they actually get to do? Also how does the training differ between the two and what do you think the future holds for these two areas? thanks for your help.

Currently here is how the training goes.

Med school
5 year Radiology Residency
1 year Neuroradiology Fellowship (diagnostic)
1-2 year Interventional Neuroradiology/Endovascular Neurosurgery fellowship

OR

Med school
6-7 year Neurosurgery residency (most are 7)
1-2 year Interventional Neuroradiology/Endovascular Neurosurgery fellowship

Neurosurgeons doing these procedures have better access to patients, know how to take care of the patients pre and post bleed. Have ICU care training, and can surgical deal with their complications if needed. Also, they have an unbiased mind when deciding should a patient be clipped or coiled with no financial gain either way (relatively).

Radiologists developed the field, have access to patients mostly by referrals from neurosurgeons and occassional direct referrals. They do not generally have admitting privledges and have to have an agreement with a neurosurgeon to deal with their pre and postop care issues. Many radiologists are not desiring to go into this specialty anymore, mostly because it can be somewhat grueling (emergent stroke cases, etc) that can keep you up at night. Radiologists in general do not like to work as hard as neurosurgeons. So it doesn't appeal to them as much. A cerebrovascular neurosurgeon is already working really hard, so for him its not much of a lifestyle change to incorporate endovascular into his practice assuming he gets the proper training.

 

[sacrament]

Currently here is how the training goes.

Med school
5 year Radiology Residency
1 year Neuroradiology Fellowship (diagnostic)
1-2 year Interventional Neuroradiology/Endovascular Neurosurgery fellowship

OR

Med school
6-7 year Neurosurgery residency (most are 7)
1-2 year Interventional Neuroradiology/Endovascular Neurosurgery fellowship

INR fellowships are also open to neurologists, BTW.

 

[HarveyCushing]

Currently here is how the training goes.

Med school
5 year Radiology Residency
1 year Neuroradiology Fellowship (diagnostic)
1-2 year Interventional Neuroradiology/Endovascular Neurosurgery fellowship

OR

Med school
6-7 year Neurosurgery residency (most are 7)
1-2 year Interventional Neuroradiology/Endovascular Neurosurgery fellowship

Neurosurgeons doing these procedures have better access to patients, know how to take care of the patients pre and post bleed. Have ICU care training, and can surgical deal with their complications if needed. Also, they have an unbiased mind when deciding should a patient be clipped or coiled with no financial gain either way (relatively).

Radiologists developed the field, have access to patients mostly by referrals from neurosurgeons and occassional direct referrals. They do not generally have admitting privledges and have to have an agreement with a neurosurgeon to deal with their pre and postop care issues. Many radiologists are not desiring to go into this specialty anymore, mostly because it can be somewhat grueling (emergent stroke cases, etc) that can keep you up at night. Radiologists in general do not like to work as hard as neurosurgeons. So it doesn't appeal to them as much. A cerebrovascular neurosurgeon is already working really hard, so for him its not much of a lifestyle change to incorporate endovascular into his practice assuming he gets the proper training.

thanx for the great post

 

[GMO2003]

Currently here is how the training goes.

Med school
5 year Radiology Residency
1 year Neuroradiology Fellowship (diagnostic)
1-2 year Interventional Neuroradiology/Endovascular Neurosurgery fellowship

OR

Med school
6-7 year Neurosurgery residency (most are 7)
1-2 year Interventional Neuroradiology/Endovascular Neurosurgery fellowship

Neurosurgeons doing these procedures have better access to patients, know how to take care of the patients pre and post bleed. Have ICU care training, and can surgical deal with their complications if needed. Also, they have an unbiased mind when deciding should a patient be clipped or coiled with no financial gain either way (relatively).

Radiologists developed the field, have access to patients mostly by referrals from neurosurgeons and occassional direct referrals. They do not generally have admitting privledges and have to have an agreement with a neurosurgeon to deal with their pre and postop care issues. Many radiologists are not desiring to go into this specialty anymore, mostly because it can be somewhat grueling (emergent stroke cases, etc) that can keep you up at night. Radiologists in general do not like to work as hard as neurosurgeons. So it doesn't appeal to them as much. A cerebrovascular neurosurgeon is already working really hard, so for him its not much of a lifestyle change to incorporate endovascular into his practice assuming he gets the proper training.

another issue would be whethe or not one could do and be proficient at both while still maintaining skills in the other specialty...

 

[NSGYResident]

INR fellowships are also open to neurologists, BTW.

Yeah but who would want to take a lazy, whinning neurology resident into one of those demanding fellowships?

On a serious note, the problem with neurologists getting one of those spots is their lack of prepartory experience in doing diagnostic cerebral angiograms during their residency, which is only 4 years long and doesn't have a 1-2 year research time built in (like neurosurgery) that can be instead used for gaining that prepatory time. This means the fellowships for neurologists will DEFINETLY be at least 2 years min and sometimes 3 years depending on the place because they have to schedule a year of prepatory training for you.

 

[NSGYResident]

another issue would be whethe or not one could do and be proficient at both while still maintaining skills in the other specialty...

As a neurosurgeon you would probably have to devote at least 50% of your practice to cerebrovascular possibly more in order to stay skilled enough in the endovascular portion. I don't think you have to devote 50% of your practice exclusively to endovascular as the neuroradiologists would tend to want you to believe. They may have to as neuroradiologists because they are not procedure oriented people and in general a neurosurgeon is much busier on a daily basis... so 25% of his practice time might be somewhat close to 50% of a neurorad's practice time.

If you follow me.

 

[GMO2003]

As a neurosurgeon you would probably have to devote at least 50% of your practice to cerebrovascular possibly more in order to stay skilled enough in the endovascular portion. I don't think you have to devote 50% of your practice exclusively to endovascular as the neuroradiologists would tend to want you to believe. They may have to as neuroradiologists because they are not procedure oriented people and in general a neurosurgeon is much busier on a daily basis... so 25% of his practice time might be somewhat close to 50% of a neurorad's practice time.

If you follow me.

Roger that...hoo-ah neurosurgery resident

 

[sacrament]

Yeah but who would want to take a lazy, whinning neurology resident into one of those demanding fellowships?

On a serious note, the problem with neurologists getting one of those spots is their lack of prepartory experience in doing diagnostic cerebral angiograms during their residency, which is only 4 years long and doesn't have a 1-2 year research time built in (like neurosurgery) that can be instead used for gaining that prepatory time. This means the fellowships for neurologists will DEFINETLY be at least 2 years min and sometimes 3 years depending on the place because they have to schedule a year of prepatory training for you.

So instead of using 1-2 years of built-in research time during their residency... they are using 1-2 years of additional fellowship time. It's still 1-2 years. I don't see the issue. At some point the training has to be done.

 

[NSGYResident]

So instead of using 1-2 years of built-in research time during their residency... they are using 1-2 years of additional fellowship time. It's still 1-2 years. I don't see the issue. At some point the training has to be done.

You have it right. The only thing I was pointing out is that if you are sure you want to do interventional neurorads/endovascular neurosurgery as your career then taking the neurology 4 year residency option does not necessarily save you that much time compared to the neurosurgery or radiology+diagnostic neurorad fellowship tracts. In fact there are VERY VERY few neurologists who are trained in interventional techniques and I'm not sure if there is a bias against them in the application process or not. Currently, there is no question that the safer and more established routes to this training are as neuroradiologists and neurosurgeons.

 

[eddieberetta]

I believe that radiology and neurosurgery are both excellent ways to enter INR. If you choose radiology, you should be someone who also loves disgnostic neuroradiology. If you enter through neurosurgery, you should be someone who also love brain and spine surgery. I agree with the sentiment that both radiologists and neurosurgeons who do INR should devote a large percentage of their practice to it, to maintain proficiency and stay abreast of the latest trends.

It is true that the neurosurgeon could technically manage the ICU care of the patient, but in practice this is seldom the case -- the person on INR is not cross-covering NICU, and of course elective cases do not go to the ICU anyway unless something goes wrong! The published literature suggests that endovascular complications are either handled endovascularly or have a disasterous consequence, it is seldom the case that an operative fix is helpful post-INR treatment (except for EVDs of course).

I do feel that the lifestyle of a radiologist trained INR is superior to that of the neurosurgeon as there is the option to do diagnostic radiology rather than spine surgery in order to pay the bills, but it depends on what turns your crank I guess.

Neurologists can also enter INR fellowship, but it has not taken off, and of those few that do enter, many just want to do stroke thrombolysis. I also feel that they have the biggest educational gap as they have limited experience with anatomic and vascular lesions, and no angio experience.

 

[Bonobo]

INeurologists can also enter INR fellowship, but it has not taken off, and of those few that do enter, many just want to do stroke thrombolysis. I also feel that they have the biggest educational gap as they have limited experience with anatomic and vascular lesions, and no angio experience.

As noted above, the angio and anatomic experience is easily corrected by one year of training in diagnostic neuroradiology. This is standard where neurologists are doing INR fellowships. Also note that neurologists can only enter INR following a vascular neurology fellowship, and most INR neurology fellows have done a NICU fellowship (2 years). Thus, the typical neurologist going into INR can expect about 8-9 years of training (4 years neurology, 2 years NICU/Vascular, 1 year diagnostic neuroradiology, 1-2 years INR). But, in the end, these interventional neurologists are probably most suited for the field since they have 2-3 years of pre- and post-procedure management in the NICU and don't have to split their time between endovascular procedures and neurosurgery procedures (required for neurosurgeons to stay boarded).

You are right that there are currently only a handful of practicing interventional neurologists, but a survey last year suggested that by the summer of 2006, there will be about 25 interventional trained neurologists. Also, after talking to a fellowship director, it appears that at least half of that many neurologists are now attempting to find spots every year suggesting that this field *is* in fact taking off.

B

 

[IMGforNeuro]

As noted above, the angio and anatomic experience is easily corrected by one year of training in diagnostic neuroradiology. This is standard where neurologists are doing INR fellowships. Also note that neurologists can only enter INR following a vascular neurology fellowship, and most INR neurology fellows have done a NICU fellowship (2 years). Thus, the typical neurologist going into INR can expect about 8-9 years of training (4 years neurology, 2 years NICU/Vascular, 1 year diagnostic neuroradiology, 1-2 years INR). But, in the end, these interventional neurologists are probably most suited for the field since they have 2-3 years of pre- and post-procedure management in the NICU and don't have to split their time between endovascular procedures and neurosurgery procedures (required for neurosurgeons to stay boarded).

You are right that there are currently only a handful of practicing interventional neurologists, but a survey last year suggested that by the summer of 2006, there will be about 25 interventional trained neurologists. Also, after talking to a fellowship director, it appears that at least half of that many neurologists are now attempting to find spots every year suggesting that this field *is* in fact taking off.

B

ABSOLUTELY
Now we have dedicated neuro residents who want to pursue this subspeciality. Life style oriented neuro residents go for epilepsy, movement disorders or MS. But neuro residents with inclination towards cerebrovasc dis increasingly want to pursue neuro ICU and INR, so the training duration is equal.

 

[NSGYResident]

As noted above, the angio and anatomic experience is easily corrected by one year of training in diagnostic neuroradiology. This is standard where neurologists are doing INR fellowships. Also note that neurologists can only enter INR following a vascular neurology fellowship, and most INR neurology fellows have done a NICU fellowship (2 years). Thus, the typical neurologist going into INR can expect about 8-9 years of training (4 years neurology, 2 years NICU/Vascular, 1 year diagnostic neuroradiology, 1-2 years INR). But, in the end, these interventional neurologists are probably most suited for the field since they have 2-3 years of pre- and post-procedure management in the NICU and don't have to split their time between endovascular procedures and neurosurgery procedures (required for neurosurgeons to stay boarded).

You are right that there are currently only a handful of practicing interventional neurologists, but a survey last year suggested that by the summer of 2006, there will be about 25 interventional trained neurologists. Also, after talking to a fellowship director, it appears that at least half of that many neurologists are now attempting to find spots every year suggesting that this field *is* in fact taking off.

B

Clearly you are a neurologist, or neurologist-in-training, or medical student hoping to be a neurologist. As far as I know, there is only one neurology trained neuroendovascular specialist with a fellowship program. The rest of the fellowship programs are run by neurosurgeons (increasingly) and neuroradiologists. When you have neurosurgeons (increasingly) applying for these spots who are used to working like dogs, and have superior understanding of the anatomy and ICU care issues (I get 4-5 years of neuroICU experience throughout my residency, not just in a 2 year fellowship) it will be difficult for them to compete for the spots (in my opinion). Maybe I am wrong. I think it is difficult for neurosurgeons to compete for some of the radiology run spots, and I know its difficult for some of the radiologists to compete for the neurosurgeon run spots (that often times expect concurrent evaluation and treatment of opencerebrovascular problems and neurosurgical attending level call).

My only point is it is not as rosey as you would make it sound for the neurologists.

Although of course I am biased the other direction.

 

[Bonobo]

Clearly you are a neurologist, or neurologist-in-training, or medical student hoping to be a neurologist. As far as I know, there is only one neurology trained neuroendovascular specialist with a fellowship program. The rest of the fellowship programs are run by neurosurgeons (increasingly) and neuroradiologists. When you have neurosurgeons (increasingly) applying for these spots who are used to working like dogs, and have superior understanding of the anatomy and ICU care issues (I get 4-5 years of neuroICU experience throughout my residency, not just in a 2 year fellowship) it will be difficult for them to compete for the spots (in my opinion). Maybe I am wrong. I think it is difficult for neurosurgeons to compete for some of the radiology run spots, and I know its difficult for some of the radiologists to compete for the neurosurgeon run spots (that often times expect concurrent evaluation and treatment of opencerebrovascular problems and neurosurgical attending level call).

My only point is it is not as rosey as you would make it sound for the neurologists.

Although of course I am biased the other direction.

I think you are absolutely right. From a few people that I have talked to, it is difficult for non-neurosurgeons to get into the neurosurgery run programs. Thus, neurologists are forced to either enter one of the 3 (soon 4) neurology run programs or attempt to find a spot at a radiology-run program. Radiologists are however beginning to accept a few neurologists (all NICU trained), usually because they cannot find a neurosurgeon or radiologists of equal calliber. But when you add all this up, there are about 8-10 spots filled every year by neurologists. This is significant and hopefully sufficient to allow neurologists to take on a role in stroke intervention. In fact, one stroke director at a prominent institution told me that they were planning on somehow reconstructing the stroke fellowships nationally to require training in diagnostic cerebral angiograms with additional optional training for stenting and thrombolysis with an extra year of training. This type of training would of course mirror cardiology.

My guess is continued political uncertainty for at least another decade if not more. Radiologists will probably be the first to leave the field unless they lose the current imaging turf war. Kind of stinks for those of us interested in INR. Which way should we go?

B

 

[sacrament]

For further reading:

http://www.neurology.org/cgi/content/full/64/2/190

 

[INR]

In fact, one stroke director at a prominent institution told me that they were planning on somehow reconstructing the stroke fellowships nationally to require training in diagnostic cerebral angiograms with additional optional training for stenting and thrombolysis with an extra year of training. This type of training would of course mirror cardiology.

B

That would really dilute the INR field, and create a sub-standard tier of interventional neuro fellows who are not trained to do anything more than stroke thrombolysis and some stents. But, once somebody gets privileges to get a catheter into the brain, there is nothing that stops them from treating aneurysms and AVMs which require more complex skills and this can hurt patients. There are rumors that such things are happening already in some 'prominent' institutions.

 

[INR]

From a few people that I have talked to, it is difficult for non-neurosurgeons to get into the neurosurgery run programs. Thus, neurologists are forced to either enter one of the 3 (soon 4) neurology run programs or attempt to find a spot at a radiology-run program.
B

It doesn't matter who runs the program, experience and willingness to train are more important. As mentioned in other posts, well-prepared neurologists have a very good chance of getting trained in some outstanding INR programs - UCLA, NYU, MGH, St-Luke's Roosevelt (Dr Berenstein), Columbia, Cornell, Pittsburgh, Iowa, Duke, Cleveland Clinic have trained/are training neurologists

 

[Eugenie98]

Yeah but who would want to take a lazy, whinning neurology resident into one of those demanding fellowships?

On a serious note, the problem with neurologists getting one of those spots is their lack of prepartory experience in doing diagnostic cerebral angiograms during their residency, which is only 4 years long and doesn't have a 1-2 year research time built in (like neurosurgery) that can be instead used for gaining that prepatory time. This means the fellowships for neurologists will DEFINETLY be at least 2 years min and sometimes 3 years depending on the place because they have to schedule a year of prepatory training for you.

As sacrament pointed out in his link, ACGME ruled that only if a neurologist has at least an additional year of training via a vascular neurology program could he or she go into an interventional neuroradiology program.

See:
http://www.clevelandclinic.org/neuroscience/professionals/training/neurology/residency.htm

and

http://www.jvir.org/cgi/content/full/15/12/1347