Questions about Neurointerventional Radiology and the future of the field

[daffy duck]

I am applying radiology but I recently had the opportunity to work with a neurointerventionalist (neurology trained) who plucked a clot from the basilar artery. I thought it was a cool procedure and I saw how it helped the patient immediately.

I wanted to get more information about the field. I know it is not a new field ( I have already searched the forums but they seem to be old threads from before 2015) and I wanted to get the advice/opinions of older, more experienced radiologists about where the NIR field is going since it will be more than half a decade before I can even being training for NIR.

From my understanding, the relatively recent DAWN and DIFFUSE studies have opened the window for endovascular stroke treatments which means much more demand for NIR guys at the expense of lifestyle (stroke call). I believe that since NSG, neurology and radiology all have access to NIR, that NSG will be the most desired applicant due to their training in "opening up". However it seems like the complications that come from NIR procedure typically involve vascular solutions and not NSG solutions?

I know the bread and butter of NIR procedure is AVM, coiling, MT and a lot of diagnostic angios. Is there a potential to work on CRAO with intra-arterial TPA or any interventional oncology work with primary brain tumors in the future?

I understand that most of the NIR work is relegated to larger academic centers and that the radiology trained guys work with NSG groups. Is there something I should be looking for specifically for in a radiology program and should I begin tailoring my radiology education to neuroradiology?

Is there a consensus of "best NIR" programs? At this point in time, I am interested in an academic career and I can see myself, if lucky enough, staying in a large academic center.

Anyways, a lot of questions and I hope someone can take the time to answer them!

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[Apophilius]

Funny enough, I’m applying to nsg but I found myself here looking for NIR stuff.

I think the first thing is to keep in mind that you shouldn’t pigeonhole yourself into any particular subspecialization. A lot, I mean a lot of people apparently go into DR with the mindset they’re going to become IR guys, then four years later when fellowship apps come around they realize they hate the field. Compare IR fellowship match data to the residency match data—the competitiveness of IR nowadays is almost certainly skilled advertisement towards med students who don’t really know better. In residency you’re FORCED to do IR rotations, and the firsthand experience is better than whatever exposure you get in med school—obviously, the residents know something the students don’t, which is responsible for the difference in competitiveness for IR match between the two arenas. NIR call is likely worse than IR call, and it’s the all and lifestyle that is very off-putting for future IR guys. That being said, the reimbursement per procedure is much better.

Nsg also is trying to learn from the vascular surgery “accident,” in that they are now trying to recover from land they lost by letting IR take over a lot of endovascular stuff. Similarly, nsg is very careful to not let NIR specialists take away their revenue. They like being the only guys fooling around inside the cranium, and they’re pushing towards it, insofar as nsg is now moving towards what is called “enfolded fellowships.” That is to say, their 7 years of residency actually includes 1-2 years of fellowship specialization. So, I think I’ve seen a bit of this, but when a neurosurgery program offers an “endovascular fellowship,” what they MEAN is it’s an endovascular fellowship enfolded into the existing neurosurgery residency curriculum—not to say it’s off-limits for neuroradiologists to apply, but it’s formalized as an option for their residents to just walk into if they so choose. This kind of “pushes out” neuroradiologists from specializing, and talking around with some faculty it looks like neurosurgery is trying to wrestle control of NIR from the neurologists and neuroradiologists—they don’t like to negotiate.

That being said, like anything else on SDN this is all speculation, and nobody really knows what the future looks like. Colorectal surgeons and general surgeons are the only ones “truly qualified” to handle a bowel perf secondary to a colonoscopy, but gastroenterologist (and occasionally family med docs) scope all the flippin time. As long as there’s a surgeon on call to handle the craniotomy for the endovascular complication, there’s enough reasons to say neuroradiologists can do it on their own, but similarly there isn’t a mandate that says neurosurgery will just “let them do it,” so to speak.

Things to expect: very rough call, improved pay, and relative uncertainty of the future of the subspecialty. Neurosurgeons will always be doing it, but neuroradiologists and neurologists don’t have to be—but all of radiology is “uncertain” it seems. Caveat emptor.