NeuroIR

[BeTheBallDanny]

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?

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[Derv]

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.

 

[Naijaba]

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.

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.

 

[BeTheBallDanny]

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.

So I have read that neurology has begun to make inroads into the market as well, do you get this feeling from your experience?

 

[irwarrior]

There is a growing number of peripheral interventionalists providing stroke therapy and so one should consider the amount of neuroIR training you are going to get in your ir residency. Multiple RCTs showcase the benefit of IA thrombectomy for stroke. You should try to get a certain number of cerebral angiograms and stroke thrombectomies under your belt. Get comfortable with NIHSS, MRS, ASPECTs etc. Also, pain interventions are a growing market in peripheral and neurointerventional which includes palliative pain procedures and spine interventions and you should look to see how much training you will get in that during residency as well.

 

[badasshairday]

There is a growing number of peripheral interventionalists providing stroke therapy.

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.

 

[RadsFTW123]

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.

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.

 

[blebb]

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.

You'll also be on q2/3 call for the rest of your life...


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[rads22222]

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.

where can I find these job boards?

 

[irwarrior]

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.

 

[Naijaba]

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.

I just responded to another post in the Neurology forum. Turns out you do not need a dedicated neuro-IR fellowship to legally perform acute stroke interventions. The current guidelines as of October 1st, 2016 prefer dedicated training in the form of a fellowship, but do not require it. If you land an IR residency/fellowship and go the extra mile to participate in neuro-IR cases, you can practice neuro-IR without fellowship.

 

[Fab5Hill33]

This is BS. It is not imperative to actively seek INR training.

If it's something you're interested in, by all means go for it. But what you posted is just terrible advice.

Most of us who do body IR don't care to do stroke therapy and most of us will never be asked to do stroke therapy. I can assure everyone on this board that you won't be lacking for a job because you can't or don't want to do stroke interventions. You'd be more marketable AND you'd have a better lifestyle if you said you were willing to do some mammography on the side than if you jumped in the stroke call pool.

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.

 

[irwarrior]

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.

 

[Fab5Hill33]

Nobody is arguing the value of stroke therapy. So let's put aside this straw-man argument.

If we had all the time in the world, we would master every possible procedure. But that is not the case. Adding neuro training during your 12-month IR fellowship means less training in other aspects of body IR. I would argue that 1 year is hardly enough to learn basic body IR, let alone adding in neuro. I think most people in IR agree -- which is why we're moving to a 2 year training curriculum... for body IR alone.

If you're suggesting you can do a few neuro cases a month during fellowship and come out "neuro-trained" then I think you're being disingenuous. Neuro-IR is an entirely different animal and deserves its own training pathway. It's not something to be squeezed into a 1 year fellowship.

But back to my original point: Being unable or unwilling to do neuro will not significantly impact your job prospects. And it's simply horrible advice to tell people that it's "imperative" to look for neuro training in their fellowship.

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.

 

[badasshairday]

Yeah. Doing stroke intervention doesn't mean you are learning the gamut of neuroIR. I think that that one NeuroIR procedure can be definitely learned in addition to all the "body" IR (wtf do you guys mean by body, the fellowship is called IR or VIR).

Also not doing stroke will not impact your job prospects negatively i agree. But doing stroke will most definitely increase your marketability. Stroke is exploding RIGHT NOW. Learn it if you can.

 

[m3db01]

This thread was created before the results of the DAWN trial came out...what a huge win for neuro ir and stroke therapy! Has to have major implications in terms of case volume and neuro ir coverage for hospitals, no?