Neurointerventional surgery

Endovascular surgical neuroradiology (ESN), orig-inally known as interventional neuroradiology or neu-rointerventional radiology, is an Accreditation Councilfor Graduate Medical Education (ACGME) accreditedmedical subspecialty specializing in minimally invasiveimage-based technologies and procedures used in diag-nosis and treatment of diseases of the head, neck, andspine. While ESN programs can be ACGME accredited,fewer than ve programs in the U.S. are accredited. Thenumber of physicians in the United States with an activeinterest and special competency in this eld is estimatedto be around 600.

1 History

The technique that constitutes the basis for angiographicneurointerventions, and thus, interventional neuroradiol-ogy, was rst developed in 1927 by the Portuguese physi-cian Egas Moniz at the University of Lisbon to providecontrasted x-ray angiography in order to diagnose severalkinds of nervous diseases, such as tumors, coronary heartdisease and arteriovenous malformations. He is usuallyrecognized as one of the pioneers in this eld. Moniz per-formed the rst cerebral angiogram in Lisbon in 1927.Traditionally spearheaded by neuroradiologists, the sub-specialty has more recently attracted the attention of neu-rosurgeons and, to a lesser extent, neurologists. Thesechanges in practitioner demographics have been recog-nized by formally changing the name of the specialtyfrom interventional neuroradiology (INR) to endovascu-lar surgical neuroradiology (ESN). In addition, the gov-erning body of this specialty, which used to be knownas the American Society of Interventional & TherapeuticNeuroradiology (ASITN), changed its name to the So-ciety of Neurointerventional Surgery (SNIS). Practition-ers from each specialty are generally regarded to bring adistinct set of skills to the practice of ESN; for instance,in general, interventional neuroradiologists are regardedto bring broad angiographic and endovascular experiencefrom non-neurological domains as well as special exper-tise in image interpretation that underlies image-guidedspecialties such as ESN, whereas in general, neurosur-geons are regarded to bring a special understanding of andability to implement conventional surgical alternatives toendovascular treatments for conditions such as intracra-nial aneurysms and arteriovenous malformations that canbe treated by either (or both) approaches.

2 Training

Neurointerventional fellowships are variable in length,but typically last from one to three years with a focus onthe integration of clinical management and performanceof endovascular and minimally-invasive surgeries of theconditions/diseases listed below. Many fellowships re-quire a second year of training that allows participants tofurther hone their technical skills and assert a greater de-gree of inuence in clinical management of patients withdiseases of interest.Preparatory requirements for a fellowship in INR/ESNvary by choice of residency.The most traditional and well-established route to ESNtraining involves successful completion of a medi-cal/surgical internship (1 year) and radiology residency(4 years), the latter of which involves exposure and train-ing not just to ESN techniques but also related techniquesin interventional radiology performed in other parts ofthe body. Following residency, candidates must com-plete a one- to two-year fellowship in diagnostic neuro-radiology before initiating additional fellowship trainingin ESN lasting one to two years. The total length of thistraining pathway is thus 7-9 years, plus at least four yearsin medical school. Graduates of this pathway are typ-ically referred to as interventional neuroradiologists. Asmall number of radiologists complete training in bothinterventional radiology and interventional neuroradiol-ogy.Candidates from neurosurgery must successfully com-plete a six- or seven-year neurosurgery residency, withmost programs now mandating at least some exposure tointerventional neuroradiology techniques during this timein addition to ongoing procedural experience with tradi-tional surgical techniques. Following residency, neuro-surgeons must complete a one- to two-year fellowship inESN, though some have opted formore limited and some-what controversial 6-month fellowships. The total lengthof this training pathway is thus 7-9 years, plus at leastfour years in medical school. Graduates of this pathwayare typically referred to as endovascular neurosurgeons.Candidates from neurology must successfully completea clinical internship (1 year) and neurology residency (3years). In most programs, procedural experience is lim-ited relative to colleagues in themore traditional pathwaysof radiology or neurosurgery. As such, neurologists mustcomplete additional fellowship training in neurovasculardiseases/vascular neurology, stroke neurology, or neuro-

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2 5 REFERENCES

critical care (1 year) followed by fellowship training inESN lasting one to two years. The total length of thistraining pathway is thus 6-7 years, plus at least four yearsin medical school. Graduates of this pathway are typi-cally referred to as interventional neurologists.

3 Diseases and conditions

Endovascular repair of cerebral aneurysm.

Intra-Cranial Angioplasty and Stent of Basilar Artery Stenosis.

The following is a list of diseases and conditions typicallytreated by neurointerventionalists.

Cerebral aneurysm Brain arteriovenous malformation (AVM) Carotid-cavernous stula (CCF) Dural arteriovenous stula Extracranial (brachiocephalic) atherosclerosis Extracranial (head and neck) and paraspinal vascu-lar malformations

Head and neck tumors

Intracranial atherosclerosis Juvenile nasopharyngeal tumor Meningiomas Nosebleeds Paragangliomas Stroke Spinal vascular malformations Traumatic vascular lesions Vasospasm Vertebral body tumors Vertebral body compression fractures

4 See also Interventional radiology

5 References

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