Interventional Neuroradiology

Krish Kherajani

3rd Year MBBS, Terna Medical College

What better way could there be to grab your attention to this field than an MCQ! (without choices though)

So here it goes:

A 50-year-old right-handed male presented with a mild right temporal headache for half-a-month and denied any sudden episodes of a severe headache or vomiting. Physical examination did not reveal any neck rigidity or other positive signs. He was ordered an MRI which showed an unruptured aneurysm of the right MCA. Which is the gold standard investigation for Intracranial aneurysms?

This question basically describes what Interventional Neuroradiology is and what it deals with. Let me explain how:

Interventional neuroradiology, Endovascular therapy, also known as neurointerventional surgery (NIS), endovascular neurosurgery, is a medical subspecialty of radiology, neurosurgery, and neurology specializing in minimally invasive image-based technologies and procedures used in diagnosis and treatment of diseases of the head, neck, and spine. (In case you’re still wondering about the answer to the question- it’s Cerebral Angiography)

Wait but why this field? Isn’t this what neurologists or radiologists can also do?

There isn’t much of a difference among them when it comes to treatment of acute stroke, aneurysms, etc; the difference rather is in medical decision making- knowing what to go after and where to stop, understanding and interpretation of imaging and then converting to surgical treatment if needed.

So what exactly do INRs do?

A regular day in the life of an INR involves performing interventions (50-60% of his job) or even diagnostic procedures (the remaining 40-50%)

Interventions can be divided into:

-Acute (cases of stroke- stroke thrombectomies are commonly done now, subarachnoid hemorrhages, etc),

-Subacute (carotid artery stenting for stroke prevention, or an Arteriovenous malformation a few weeks after rupture), and

-Elective (brain aneurysm, newly diagnosed AV malformations)- such patients come to the INR clinic for elective treatment.

Entry criteria/ pathway:

Being an INR is typically difficult in India, especially because the field isn’t much known and accessible here; even in countries where healthcare is extremely advanced, this is a relatively new branch, but it is gaining pace with rapidity.

The entry criteria/pathway is different for India and abroad, so I’ll try covering both:

India:

One can do their super specialization in Interventional radiology by giving the NEET SS exam after your MD/DNB in Radiodiagnosis. Following that a few limited hospitals do offer a one year fellowship in INR.

Total duration after graduation:

MD/DNB Radiodiagnosis: 3 years

DM Interventional Radiology: 3 years

Fellowship in Interventional Neuroradiology: 1 year (offered only by limited hospitals in India)

If you want to practice abroad, for instance in the US, the pathway would look somewhat like this:

Entering INR in the US depends on your primary specialty: Radiology, Neurology, or Neurosurgery

After a neurology residency one may complete one of two possible prerequisite fellowships: Vascular Neurology, or Neurocritical Care. These two pathways provide different expertise and perspectives. Generally, a two-year Neurointerventional training would follow.

Thus the approximate duration of training after graduation involves:

Residency: 4 years

Vascular Neurology: 1 year or Neurocritical Care: 2 years

Preliminary endovascular: 1 year

Neurointerventions: 1 year

Yes, that’s a good 7-8 years after 5.5 years of graduation. Who even wants to study for so long!

What the field demands out of a doctor:

Apart from having to spend almost half of your lifespan getting that degree, the journey after that isn’t easy either.

The diseases seen by an INR are extremely time sensitive and thus require you to be on call 24×7 and keep your phone on all the time. Yes you do have a team, but your partner may be tied up in a procedure and you most probably have to fill in for him/her; so you always have to be accessible for the physicians who are used to calling you as they’ll need immediate answers.

You’ll also have to give a good 7-8 years overall to become a well established INR. This

PS : For the purpose of this article I’ve used the abbreviation INR for Interventional Neuroradiology (not for Indian Rupee if that’s what you were thinking!)