Neurointerventional radiology

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DarkProtonics

DarkProtonics

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What is neurointerventional radiology like? The procedures, lifestyle, compensation, and demand? Do neurointerventional radiologists have to have a neurosurgeon standby in case of complications?

Thanks!
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DarkProtonics said:
What is neurointerventional radiology like? The procedures, lifestyle, compensation, and demand? Do neurointerventional radiologists have to have a neurosurgeon standby in case of complications?

Thanks!
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Your best bet is to shadow one. This cannot all be answered in words.

Procedures: angiography, venography, embolization of aneurysms, vascular malformations, fistulae, tumors, stenting above the clavicles, vertebro/kyphoplasty, paraspinal biopsies.

Lifestyle- variable depending on the number of other taking call, whether you "fill" the call roster or refer out, amound of diagnostic work you do.

Compensation: Same as diagnostic rads, or a bit better (not better enough to factor into decition making)

Demand - variable. You will always be a diagnostic radiologist too. But INR is a small subsubspecialty.

Relationship with NSX - yes you need a neurosurgery service because these patients may need procedures like EVDs to be placed. You may admit under NSx or yourself depending on the situation, but many of the sick patients will need neuroICU. You do not need a neurosurgeon to be "standing by" -- most complications must be handled endovasculalry for any chance of salvage, but for reasons above you need to be part of a neurosurgical center.

Also be aware that both radiologists and neurosurgeons are able to train in INR. Obviously the neurosurgeons would be able to handle the issues above themselves.

(So what do radiologists add?

1.) We are the specialty that developed the technology and brought it to fruition. Radiologist continue to drive much of the innovation in INR (not to downplay the contribution from other specialties)
2.) We are the neuroimaging experts, across all modalities. Having a strong and active radiologist contingent to the INR program ensures that the advanced imaging which supports INR is of the highest calibre.
3.) We are trained as angiographers, then as interventionalists.

and from a selfish point of view, I would much rather read scans in between INR cases than operate!


You need to be aware of the issues, and make your own informed choice.
 
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Amxcvbcv said:
Sorry for the tangent.

Is it possible to do practice strictly diagnostic neuroradiology?
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Sure. Most neuroradiologists are diagnostic. Just a subset of those are neuro-interventionalists.
 
Amxcvbcv said:
Sorry for the tangent.

Is it possible to practice strictly diagnostic neuroradiology?
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You mean only read neuro imaging and not anything else ? In the Academic setting I knowthis is the case but I think in private practice you'll be expected to cross-cover a lot of other imaging modalities for your practice.

On a side note, why is neurorad so popular anyways??
 
OHMAN0125 said:
You mean only read neuro imaging and not anything else ? In the Academic setting I knowthis is the case but I think in private practice you'll be expected to cross-cover a lot of other imaging modalities for your practice.

On a side note, why is neurorad so popular anyways??
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I mean do strictly the diagnostic side of neuroradiology, i.e. not do any of the procedures.

I'm interested in interpreting anything that comes across the PACS, but as of today (maybe not tomorrow) I've got a special interest in neuro imaging.
 
eddieberetta said:
Your best bet is to shadow one. This cannot all be answered in words.

Procedures: angiography, venography, embolization of aneurysms, vascular malformations, fistulae, tumors, stenting above the clavicles, vertebro/kyphoplasty, paraspinal biopsies.

Lifestyle- variable depending on the number of other taking call, whether you "fill" the call roster or refer out, amound of diagnostic work you do.

Compensation: Same as diagnostic rads, or a bit better (not better enough to factor into decition making)

Demand - variable. You will always be a diagnostic radiologist too. But INR is a small subsubspecialty.

Relationship with NSX - yes you need a neurosurgery service because these patients may need procedures like EVDs to be placed. You may admit under NSx or yourself depending on the situation, but many of the sick patients will need neuroICU. You do not need a neurosurgeon to be "standing by" -- most complications must be handled endovasculalry for any chance of salvage, but for reasons above you need to be part of a neurosurgical center.

Also be aware that both radiologists and neurosurgeons are able to train in INR. Obviously the neurosurgeons would be able to handle the issues above themselves.

(So what do radiologists add?

1.) We are the specialty that developed the technology and brought it to fruition. Radiologist continue to drive much of the innovation in INR (not to downplay the contribution from other specialties)
2.) We are the neuroimaging experts, across all modalities. Having a strong and active radiologist contingent to the INR program ensures that the advanced imaging which supports INR is of the highest calibre.
3.) We are trained as angiographers, then as interventionalists.

and from a selfish point of view, I would much rather read scans in between INR cases than operate!


You need to be aware of the issues, and make your own informed choice.
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Stupid question: What does "admit under neurosurgery, or admit the patient yourself" mean?
 
DarkProtonics said:
Stupid question: What does "admit under neurosurgery, or admit the patient yourself" mean?
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Whenever a patient is admitted to the hospital, it's under the care of either a specific physician or service (neurology, general surgery, neurosurgery, etc.). The physician or physicians on that service are responsible for seeing the patient every day and documenting findings and formulating the plan for the day. Sometimes patients get admitted by another service or physician as a courtesy to another physician.
 
Amxcvbcv said:
Whenever a patient is admitted to the hospital, it's under the care of either a specific physician or service (neurology, general surgery, neurosurgery, etc.). The physician or physicians on that service are responsible for seeing the patient every day and documenting findings and formulating the plan for the day. Sometimes patients get admitted by another service or physician as a courtesy to another physician.
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I thought that, but I wasn't sure.
 
DarkProtonics said:
What is neurointerventional radiology like? The procedures, lifestyle, compensation, and demand? Do neurointerventional radiologists have to have a neurosurgeon standby in case of complications?

Thanks!
Click to expand...

The Procedures: Cerebral angios, stents, coils for treating stenoses, aneurysms, AVMs, delivering lytics etc.

Lifestyle: Rough. At least at my place. Busy during the day, and busy on call.

Compensation: Very high.

Demand: Very high.

Any place that has Neurointerventional guys is going to be a big enough center that they have a Neurosurgeon in house in case they're needed. It's not like they're standing right over your shoulder while you're working in case something goes wrong. In my institution, they tend to work collaboratively on a lot of patients so it's a positive relationship.
 
PeepshowJohnny said:
The Procedures: Cerebral angios, stents, coils for treating stenoses, aneurysms, AVMs, delivering lytics etc.

Lifestyle: Rough. At least at my place. Busy during the day, and busy on call.

Compensation: Very high.

Demand: Very high.

Any place that has Neurointerventional guys is going to be a big enough center that they have a Neurosurgeon in house in case they're needed. It's not like they're standing right over your shoulder while you're working in case something goes wrong. In my institution, they tend to work collaboratively on a lot of patients so it's a positive relationship.
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So it relates to neurosurgery like interventional cardiology relates to cardiac surgery?

Are there ever turf wars b/w INR and NS, like treating aneurysms?

Do INRs treat ischemic and hemorrhagic strokes by stenting and coiling, respectively? I suppose they then send the pt up to NS to do a craniotomy to remove the blood that's already collected subdurally, or excise the dead brain tissue.
 
At a large and well-known institution where I am doing an away rotation in IR, it's sad to see that interventional neuro stuff has been taken over by NS and interventional neurologists. Residents have told me that the future of neurointerventional radiology is not that good. It's too bad. Radiologists have to defend bitterly their core competency of image interpretation.
 
NIR seems to be a very changing field. With the evolution of minimally invasive NS fellowships and neurologists training in interventions as well -- the dynamic of radiologists performing these procedures has changed.

I rotated through three large hospitals where many, not all, NIR guys told me that the field was getting 'less' desireable and the training was not all it was cracked up to be.

Again, this was only the opinion of people I saw in an academic setting. Their volume and compensation was going down and it seemed that they read more neuro film --- than performed procedures.

I would assume too -- most people would do NIR so the procedural end of things, why not just do NR?

Anyways, like someone said - shadow and you will learn more about a day in the life of a NIR.
 
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Perhaps its from being in the Midwest, but I don't see the future as dire for NIR. Interventional Neurology basically just doesn't exist here.

Neurosurgeons ARE learning more endovascular techniques (in their basic residency, not even in their own fellowship for it), but the sense I've come away with (again, small data set, so YMMV) is the majority of neurosurgeons trainees don't particularly relish this aspect of their field versus stuff like cranis, spine surgeries, etc. Of course, compensation can change that sense.

That said, I see the future somewhat like the basic Vascular IR side. Are you the only act in town? Nope, just like VIR compete with Cardiology and Vascular surgeons, NIR will compete with Neuro Inteventionalist and Neurosurgery. But just because these guys exist doesn't mean you're automatically forced out, especially because there's less a sense of a specialty (Cardiology) controlling the patient base.
 
I see mostly the vascular surgeons vying with our IR procedures people, and not so much the neurology/NS people. The vascular guys (and gals) are doing limited things compared to the IRs who do everything.

That might be our local academic area but so far it has been pretty well defined. Our rads department is huge and really excellent for neurorads.

The beauty of neurointervential is that your training is so deep that you can still really do all the other things under the pyramid tip - N IR being the tip, so to speak. It's not like you are limited to cerebral angios all day.
 
Perhaps its from being in the Midwest, but I don't see the future as dire for NIR. Interventional Neurology basically just doesn't exist here.
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I am sorry to say this, but you must be blind. Medical College of Wisconsin and University of Minnesota (midwest, ain't it?) have neurology-run interventional fellowships (90% of the faculty are neurologists by training) the official name for which is ESN (Endovascular Surgical Neuroradiology) and another midwestern program, University of Iowa, although radiology-run, has been training neurologists exclusively for the past 4-5 years. That's not to say that radiologists are falling out of favor. Many such fellowships, such as UCSF still almost exclusively train radiology applicants. But the field is wide open to applicants from neurology, neurosurgery, and radiology alike and thank God for that, because each of them contribute significantly to the field.
 
So I guess for those interested mostly in INR and that aren't able to make it into radiology residency still have the choice of going into neuro residency and then do INR.
 
neuroir said:
I am sorry to say this, but you must be blind. Medical College of Wisconsin and University of Minnesota (midwest, ain't it?) have neurology-run interventional fellowships (90% of the faculty are neurologists by training) the official name for which is ESN (Endovascular Surgical Neuroradiology) and another midwestern program, University of Iowa, although radiology-run, has been training neurologists exclusively for the past 4-5 years. That's not to say that radiologists are falling out of favor. Many such fellowships, such as UCSF still almost exclusively train radiology applicants. But the field is wide open to applicants from neurology, neurosurgery, and radiology alike and thank God for that, because each of them contribute significantly to the field.
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This isn't true anymore for UCSF either. At least two current fellows (both happened to be MD/PhDs that I know of) were trained as neurologists and now in the NIR program at UCSF.

It seems that NIR is going to be more a neurology specialty in the future--which makes sense, I think...classical (and the fun part of) radiology is just not about treatment.
 
sluox said:
This isn't true anymore for UCSF either. At least two current fellows (both happened to be MD/PhDs that I know of) were trained as neurologists and now in the NIR program at UCSF.

It seems that NIR is going to be more a neurology specialty in the future--which makes sense, I think...classical (and the fun part of) radiology is just not about treatment.
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How does that make sense? Yes most radiologists don't want interventional training. But to me it makes more sense for neurosurg to have NIR rather than neurology.

Realistically, I think in the future it will be between neurosurg and neurology. Interesting to see how things work out.
 
Over the 5 or so years I've been following the field, it has indeed been in constant flux. The only constant seems to be that nobody really relishes doing it. From a rads perspective, you essentially gain the lifestyle of a neurosurgeon for not that much more reimbursement and three extra years of training. From the neurosurgeons' point of view, vascular work is reimbursed less than say spinal work and has one of the worst lifestyles. The neurologists have some motivation to do it as it would substantially raise their salaries, but I don't know about you, but most neuro folks I know aren't exactly the surgical type. Since NIR programs couldn't fill with neurosurgeons and radiologists though, they started accepted neurologists.

If you want to do it, most NIR programs are headed by radiologists who prefer to train their own for political reasons (to try to hold onto the field) from my understanding so the field is wide open. My NIR "mentor" is a radiologist, and he advised me strongly against going into it, as neurosurgeons trained in it are typically able to outcompete rads for business as they hold the "we can open if we need to" trump card to hand to referrers.

Give the need for the field though and the paucity of people willing to do it, I think you'd be alright if you chose it. Just one man's uninformed opinion though.
 
There doesn't seem to be much information on the specialty online. Most programs seem to be 2 years in length based on the SNIS website (last updated in 2007). Is there any preceding fellowship required (specifically diagnostic neurorads) before the 2 year fellowship? I was always told that most programs are 3 years.
 
Yes, most require a diagnostic neuroradiology fellowship first before the two-year NIR fellowship. There are some programs that do admit directly to a two year program. From my understanding, these programs generally admit internal candidates who they've groomed for a while with more focused neuroradiology training during their residency.
 
I think at some places (MIR comes to mind) it's only a 1-year fellowship. It's probable preceded by a 1-year neuroradiology one.
 
most neurosurgery and neurology residencies offer neuroIR training. radiology has lost a LOT of turf in the past decade, and it will be all but gone in the next decade, IMO. To limit yourself to a field like that would be a terrible idea, IMO
 
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NeuroIR is far from being the bread and butter procedure of any community hospital.It is limited to big centers.

You have to consider it as an additional skill to diagnostic neuroradiology, that you may or may not do in the future. Neurosurgeons obtain the skill to coil an aneurysm once in a while, but barely make a career out of it. Neurologists may eventually do most of it. Thoug, Since the life style is bad and the case volume is not high, there is not a great interest in neurology community to do it.

As long as you are at the mercy of another single specialty to send you patients, you are doomed to fail the same as what happened to IR for PAD or what happened to CT surgery. Family doctors and ER doctors do not send a patient with aneurysm or even stroke directly to you to do the procedure. it should come from neurosurgery or neurology respectively. Some radiologists will do it in the future, but overall, it is very susceptible to turf loss.

The problem with current IR or NeuroIR environment is the lack of understanding about turf loss. We are focused more and more on technical aspect, the procedure or the clinical aspect of the procedure and post procedure management. It does not matter. The only thing that matters is to change the referral pattern. The best example is CT surgery or even breast cancer.
 
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badasshairday said:
Bump
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If you are really deep into procedures, don't do either IR or NeuroIR. Go and do a surgical subspecialty or even GI.

If you like diagnostic radiology and just want to dabble into light procedures but don't mind not doing them, radiology is a great field with lots of oppotunities.
 
Or if you have plans to stay in academics at a tertiary center than NeuroIR is good too. Unless you are doing it all the time, nobody, neurology/neurosurgery/neuroradiology should be doing these procedures. Turf isn't a concern, it is volume.
 
shark2000 said:
If you like diagnostic radiology and just want to dabble into light procedures but don't mind not doing them, radiology is a great field with lots of oppotunities.
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I like diagnostic radiology and I like procedures a lot. Only minimally invasive, envelope pushing procedures.
 
Taurus said:
Several studies have been published raising serious questions about the future of neuro IR.

http://forums.studentdoctor.net/showthread.php?p=14084050#post14084050

Bottom line, avoid the field completely.
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I wouldn't bet against technology.

Sure acute stroke interventions are dubious at best right now. However, don't forget the huge cost CVA's are on our healthcare system. One CVA will cost the system upwards 150,000$ in the first year alone, given the rehab, home therapies etc that are needed.

If we find a way to intervene on strokes and prevent or complete eliminate subsequent disability, this would be a huge boon for our countries healthcare economics.

Second of all it will be the biggest thing since cardiac angioplasty/stenting. It would be short sited to complete say "avoid the field like a plague".
 
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Also, currently NeuroIR is mostly coiling of aneurysm, av-malformation embos, diagnostic cerebral angio. All of these are relative low in volume. Acute CVA is a common/frequent cause of death/severe disability in patients presenting to hospitals. Again this will also be a boon to practitioners of the field, whether neurology, neurosurgery, or neuroradiology.
 
badasshairday said:
I wouldn't bet against technology.

Sure acute stroke interventions are dubious at best right now. However, don't forget the huge cost CVA's are on our healthcare system. One CVA will cost the system upwards 150,000$ in the first year alone, given the rehab, home therapies etc that are needed.

If we find a way to intervene on strokes and prevent or complete eliminate subsequent disability, this would be a huge boon for our countries healthcare economics.

Second of all it will be the biggest thing since cardiac angioplasty/stenting. It would be short sited to complete say "avoid the field like a plague".
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That's all fine and dandy but you need the research data to back up the field. Until that data is indisputable, I would avoid the field.
 
Bump. What does everyone think of NIR future in context of the MR CLEAN study findings?
 
I see a lot of people saying that the lifestyle is bad--can anyone comment on that?
 
ESCAPE trial is positive, as well. The lifestyle is bad because every procedure is essential extremely time-sensitive. Meaning, strokes, bleeds, vasospasm, etc. can occur at any given point in time. The number of practitioners (despite market saturation) remains pretty low, meaning that there are usually 1-2 NIRs per practice, and so call is every other day or every other week.
 
Is NIR a competitive fellowship to obtain? I see that neurorads goes unfilled every year. Is the same true for NIR?
 
It probably depends on where you want to train. I don't see very many radiology residents jumping towards it though. Probably doesn't help that neurosurgery dominates the field now.
 
hal9000 said:
Sucks worse than regular IR? Or about the same?
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Way worse. Some of the ones I worked with were on call just about every day, and covered multiple hospitals. They can't do any coiling/pipelines without a neurosurgeon around, so that's why they usually work in neurosurgeon groups. That is also why neurosurgeons are taking over the specialty. It's a long road to get to NIR, and the lifestyle after is not that fun. This is why most don't do it...even though it's the coolest field in medicine
 
RadsonRads said:
Way worse. Some of the ones I worked with were on call just about every day, and covered multiple hospitals. They can't do any coiling/pipelines without a neurosurgeon around, so that's why they usually work in neurosurgeon groups. That is also why neurosurgeons are taking over the specialty. It's a long road to get to NIR, and the lifestyle after is not that fun. This is why most don't do it...even though it's the coolest field in medicine
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Isn't it 5+1+1 years to NIR?
 
hal9000 said:
Sucks worse than regular IR? Or about the same?
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Definitely worse than IR. IR lifestyle varies depending on the type of procedures you do. If you do cold legs and vascular atherosclerosis, then the lifestyle is bad. If you do oncology and bread and butter IR, then the life style is better.
 
Could you talk a little bit more about general IR lifestyle? I know it varies but when people say IR has a better job market, I am guessing that the lifestyle for most of those available jobs isn't great but I don't know. Also, which specialties tend to be more procedurally based but are still generally DR? It sounds like you do quite a few as MSK. I like procedures but I don't think I would prefer them enough lean the way of IR.
 
NIR lifestyle is among the worst of all specialties in medicine, and probably on the road to becoming even worse, now that acute stroke treatment has shown statistically significant benefit. Most NIR physicians are on call nearly everyday or every other week for 1 week at a time. Strokes, bleeds, and vasospasms happen at any given time of day or night. Maybe in the academic setting you have fellows or NPs that can do the initial evaluations, but at the end of the day, you're still coming in.

IR can be pretty rigorous, as well, but you generally have more IRs in an academic practice than you do NIRs, so the workload may be distributed over a greater number of physicians. IR also has emergencies, but the scope of practice really varies from place to place, so it's hard to tell, exactly.
 
I can understand that the call can be busy, but am I mistaken in thinking that the majority of the work is elective aneurysm work, AVMs, etc.?
 
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