Unseen wounds: a multinational investigation of neurointerventionalists on the psychological toll of complications

Abstract

Background

Complications not only affect patients but also impose a significant psychological burden on physicians. Quantitative data in neurointerventional surgery regarding the ‘second victim’ phenomenon are lacking. This study aimed to assess the prevalence and severity of post-traumatic stress symptoms among neurointerventionalists after major complications.

Methods

A survey was developed by a committee of experienced neurointerventionalists and distributed internationally via multiple platforms. Respondents were anonymous. Demographic information, complication type, and institutional support availability were queried. Psychological distress was measured using the validated Impact of Event Scale-Revised (IES-R), which assesses intrusion, avoidance, and hyperarousal domains. Descriptive statistics and regression analyses were performed to identify factors associated with post-traumatic stress symptoms.

Results

Of 1042 invited physicians, 503 responded (48%), with 413 completing the full survey (40%). The most common pathology was cerebral aneurysm, and the most frequent complication was hemorrhage. Overall, 64% scored above the IES-R threshold for possible post-traumatic stress disorder (PTSD) (≥24), with many reaching levels (≥37) associated with long-term stress and physiological sequelae. Intrusion was the dominant symptom domain, particularly distressing reminders about the complication. Lack of institutional support was significantly associated with possible PTSD (OR 1.63, 95% CI 1.1 to 2.5, P=0.02). No differences were observed by specialty, but geographic variations were present. High stress scores persisted long after the index event.

Conclusion

Complications exert a profound emotional and physiological toll on neurointerventionalists, with high rates of possible PTSD and a strong association with inadequate institutional support. Systematic support programs are urgently needed to safeguard physician well-being and patient safety.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Complications can precipitate acute stress responses in surgeons; however, neurointerventionalists have been understudied, and institutional support for second-victim experiences is inconsistent.

WHAT THIS STUDY ADDS

• In a large, multinational cohort, 63% screened positive for possible post-traumatic stress disorder after a major complication, intrusion symptoms predominated, and the absence of institutional support independently increased the odds of distress.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE, OR POLICY

• Our findings underscore the need for institutions to establish structured mechanisms to support physicians after major complications. Practical approaches may include confidential peer-support programs, structured post-event debriefings, and access to mental health professionals trained in second victim support. Successful models in other specialties have incorporated ‘buddy systems’, wellness hotlines, and crisis response teams, which could be adapted for neurointerventional practice. Normalizing these resources and embedding them into institutional culture would help destigmatize help-seeking, protect physician well-being, and ultimately enhance patient safety.

Introduction

The occurrence of complications in medical procedures can have significant consequences not only for patients but also for the physicians involved.^{1 2} Neurointerventionalists, like other surgical specialists, often face high-risk clinical scenarios where adverse events can be distressing and can lead to a phenomenon known as ‘second victim’ syndrome.^{3 4} This term, first coined by Wu in 2000,⁵ intersects burnout, moral injury, and decision-making bias and describes the emotional and psychological impact on healthcare providers involved in medical errors or adverse events. Studies across various surgical fields have shown that complications may trigger acute traumatic stress, anxiety, guilt, and even symptoms of post-traumatic stress disorder (PTSD)^{1 6} that may affect the clinician’s personal well-being, professional performance, and even their decision-making during future procedures.^{5 7}

Despite these insights, few studies have examined neurointerventional physicians, specifically. These professionals, routinely perform complex, high-stakes—often emergent—procedures and, like traditional open surgeons, may experience substantial psychological strain when complications occur, particularly given the potential for devastating neurologic outcomes. The severity of the psychological impact is shaped by perceived responsibility for the event, institutional culture surrounding adverse events, and individual coping mechanisms.^{8 9} Lack of adequate support structures within institutions exacerbates the burden, potentially leading to burnout, decreased quality of care, and increased risk of errors.^{7 8}

This study examines the impact of complications on neurointerventionalists, using the Impact of Event Scale-Revised (IES-R) scale (online supplemental material)—a validated instrument for measuring PTSD symptoms of intrusion, avoidance, and hyperarousal in the aftermath of traumatic events.¹⁰ Building on prior applications of the IES-R in studies on general and vascular surgeons, we seek to quantify the levels of acute traumatic stress among neurointerventionalists and identify predictive factors. Our aim is to highlight the psychological burden faced by these specialists and propose strategies to strengthen support and mitigate post-event stress.

Methods

Survey design and the IES-R

The study was exempt from institutional review board review because no human subjects were involved. The study design generally followed the consensus-based Checklist for Reporting of Survey Studies (CROSS).¹¹ A writing committee of five experienced neurointerventional physicians including neuroradiologists, neurosurgeons, and neurologists—each with more than 10 years of clinical experience—was formed to develop a concise questionnaire. Drawing on established criteria for evaluating complications in surgical specialties, the committee selected the IES-R as a validated instrument for assessing the impact of complications (online supplemental material). In this context, a complication was defined as a major adverse event within the previous 3 years that resulted in mortality or significant, permanent morbidity.

The IES-R is a widely used self-report questionnaire developed to assess psychological distress in response to traumatic events, particularly symptoms associated with PTSD. It is an updated version of the original Impact of Event Scale (IES) developed by Horowitz et al in 1979,¹² modified by Weiss and Marmar in 1997¹³ to align with the diagnostic criteria for PTSD in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). The IES-R consists of 22 items that are rated on a five-point Likert scale, ranging from 0 (‘not at all’) to 4 (‘extremely’), and it includes three symptom subscales: intrusion, avoidance, and hyperarousal. Total scores range from 0 to 88, with higher scores indicating greater distress. While the IES-R is not a diagnostic tool, scores above certain thresholds can indicate clinical concern^13–15:

• A score ≥24:

  • Suggests potential PTSD symptoms and warrants further evaluation

• A score ≥33:

  • Shown to provide the best sensitivity and specificity for identifying probable PTSD, according to a widely cited study by Creamer et al¹⁴

• A score ≥37:

  • Research suggests that scores above 37 may be associated with long-term measurable physiological consequences such as immune system suppression and elevated cortisol, although this threshold is more relevant in research contexts than in clinical practice.

Based on these thresholds, the following categories were assigned:

• A score <24: PTSD unlikely

• A score ≥24: PTSD possible

• The ‘PTSD possible’ cohort was further subdivided as:

  • A score between 24–32: PTSD is a clinical concern

  • A score between 33–36: Probable PTSD

  • A score ≥37: PTSD may have physiological effects.

Overall, the IES-R is a reliable and validated tool for screening and research purposes; however, it is not intended to be used as a standalone diagnostic instrument. Formal diagnosis of PTSD is based on a comprehensive clinical evaluation, ideally incorporating structured interviews such as the Clinician-Administered PTSD Scale (CAPS-5) for Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5).

The survey included preliminary questions about the respondent’s neurointerventional background, procedure classifications, and the types of complications encountered. No age or gender data were collected. It then analyzed details and impact of the respondent’s perceived worst complication in the last 3 years. Lastly, the survey included a question regarding the overall stress associated with the complication and its aftermath on a sliding scale from 1 to 10, 10 indicating the most stress.

Survey administration and analysis

The survey was created in Qualtrics platform. The survey was distributed internationally through multiple channels to maximize reach. Invitations were shared via multinational WhatsApp groups of practicing neurointerventionalists, as well as through the publicly available membership directory of the Society of Neurointerventional Surgery (SNIS), which was searched systematically by state. Duplicate entries were excluded to avoid redundancy. The survey, administered through the Qualtrics platform, could be accessed more than once; this feature allowed respondents to review the questionnaire and return later to complete it if desired. To ensure integrity of responses, Qualtrics automatically recorded geolocation codes and IP addresses, enabling identification of duplicate submissions. The survey remained open for 1 month. No personally identifying information was collected, and no invitations to participate were posted on public social media platforms.

All data analyses were conducted using JMP statistical software, version 18 (SAS Institute Inc, Cary, NC). Descriptive statistics were used to summarize the data and include measures of central tendency (such as mean and median) and measures of dispersion (such as SD and IQR) for continuous variables. Frequencies and percentages were calculated for categorical variables. For the analytic component, the significance of bivariate associations was assessed as follows: Fisher’s exact test for categorical variables, Student’s t test for continuous variables, and logistic regression analyses as appropriate. When investigating continuous variables with non-normal distributions, non-parametric tests (such as the Wilcoxon rank-sum test) were considered. All tests were two-tailed, and a significance level of α=0.05 was used.

Results

The survey link was distributed to 1042 neurointerventional physicians. A total of 503 physicians responded to some or all the questionnaire, yielding an overall response rate of 48%. Of these, 413 completed the full survey, resulting in a completion rate of 40%. Overall, out of 500 physicians who listed their primary specialty, there were 293 (59%) neuroradiologists, 120 (24%) neurosurgeons, and 87 (17%) neurologists. Physicians from North America and Europe constituted most respondents (figure 1A) and most physicians had over 10 years of practice experience (figure 1B). Specialty distribution varied significantly by region, with a more even mix of specialties in North America and, to a lesser degree, Asia; a predominance of neuroradiologists in Europe; and neurosurgeons in South America (figure 1C). The most common pathology associated with the complication event was endovascular treatment of cerebral aneurysms, and the most common complication type was a hemorrhagic event (figure 2). These characterizations were similar across all specialties and all geographic regions.

Figure 1. Distribution of the respondents (N=495) by region (A) and years of experience (B). There was significant difference in the distribution of primary specialty by region (C). Geographic locations of Africa and Australia/New Zealand were excluded from this analysIs due to the small number of respondents.

Figure 2. Distribution of complication rates by procedure showed endovascular aneurysm treatment to be the most common procedure associated with a major complication. The most common complication type was an acute hemorrhagic complication. AVF/AVM, arteriovenous fistula/arteriovenous malformation.

The rates of possible PTSD (IES-R ≥24) were determined for the completed questionnaires (N=413). This showed that most of the respondents (64%) fell into the ‘PTSD possible’ category. Notably, more than half of the ‘PTSD possible’ category and one third of the entire cohort had scored ≥37, a threshold associated with physiological consequences (‘PTSD may have physiological effects’) (figure 3). Rates of possible PTSD did not differ significantly by primary specialty (figure 4) or years of experience, but geographic variation was observed (figure 5). Most institutions lacked formal support mechanisms for physicians following major complications (figure 6). Absence of institutional support was associated with significantly higher odds of possible PTSD (OR 1.63, 95% CI 1.1 to 2.5, P=0.02), a difference driven primarily by higher rates of severe symptoms (scores ≥37) among unsupported physicians. The presence or absence of institutional support was similar across specialties.

Figure 3. Distribution rates of PTSD broadly divided into unlikely versus possible based on the IES-R threshold of ≥24. The second chart shows a distribution of IES-R scores for the entire cohort (<24: PTSD unlikely; ≥24: PTSD possible; 24–32: PTSD is a clinical concern; 33–36: probable PTSD; ≥37: PTSD may have physiological effects). IES-R, Impact of Event Scale-Revised; PTSD, post-traumatic stress disorder.

Figure 4. Distribution of possible PTSD rates by specialty. No significant differences were observed. PTSD, post-traumatic stress disorder.

Figure 5. Distribution of possible PTSD rates by region. PTSD, post-traumatic stress disorder.

Figure 6. Availability of institutional support following major complications is shown in the first chart (N=413). The second chart shows higher likelihood of PTSD symptoms, especially with physiological effects when institutional support is not available. PTSD, post-traumatic stress disorder.

Among the subcategories of intrusion, avoidance, and hyperarousal, respondents with possible PTSD had the highest scores in intrusion (median 14, IQR 9–19), followed by avoidance and hyperarousal. Within the intrusion domain, the symptom causing the greatest distress was the intrusive thought: ‘Any reminder brought back feelings about it’. A breakup of the different intrusive categories is represented in figure 7.

Figure 7. Details regarding the ‘ntrusion’ domain questions and responses. The most common intrusive symptom was ‘Any reminder brought back feelings about it’.

Regarding the ‘overall stress associated with the complication and its aftermath’ on a scale of 1–10, the average was skewed towards high stress levels (7.2±2), and respondents with survey scores indicating ‘possible PTSD’ also scored high on the stress levels versus those with ‘PTSD unlikely’ (8.1±1.5 vs 5.7±2, P<0.0001).

Discussion

Dire emotional toll of complications

This study demonstrates that complications in neurointerventional practice exert a profound psychological toll on physicians. Nearly two thirds of respondents (63%) scored above the IES-R threshold for possible PTSD, with a substantial proportion reaching levels associated with physiological consequences such as immune dysregulation and cortisol imbalance.¹⁵ These findings highlight that adverse outcomes affect not only patients but also physicians, creating enduring psychological and physical sequelae. While the ‘second victim’ phenomenon has been documented across surgical specialties,^{1 2 4 7} our work provides large-scale quantitative data among neurointerventionalists—a previously uninvestigated, heterogeneous group drawn from different training backgrounds uniquely exposed to emergent, high-stakes procedures where error margins are narrow and adverse events can be catastrophic.

Symptom profiles and intrusion

Our findings are consistent with reports in general and vascular surgery, where complications have been shown to elicit intrusive recollections, anxiety, guilt, and impaired sleep.^{3 6 8 9} However, the prevalence of possible PTSD in the neurointerventional cohort appears higher than previously reported in surgical populations. This may reflect the devastating consequences of cerebrovascular complications and the emergent nature of neurointerventional procedures.

Intrusion was the dominant symptom domain, with distressing reminders identified as particularly disruptive. These findings are concerning, given that intrusive symptoms are strongly associated with impaired concentration, decision-making, and sleep.^{6 7} In a discipline where precision and judgment are critical, such impairments could perpetuate a cycle of adverse events and further psychological distress. Persistent high stress scores among respondents suggest that natural recovery without structured support is limited.^{2 3 6}

Institutional support and resilience

Institutional support emerged as a key determinant: respondents without access to supportive mechanisms were significantly more likely to experience possible PTSD (OR 1.63, 95% CI 1.1 to 2.5, P=0.02). This aligns with prior work emphasizing the protective role of structured support systems, peer debriefings, and organizational transparency in mitigating second victim syndrome. Unfortunately, our data reveal that such resources remain absent in most institutions, representing a critical gap in physician well-being infrastructure. Without support, physicians may internalize blame, disengage professionally, or develop maladaptive coping strategies, increasing the risk of burnout and attrition.⁷ Addressing this gap is essential to safeguard physician health and preserve patient safety and institutional resilience.

Geographic variation in the prevalence of possible PTSD was noted across regions. However, the relatively small number of respondents from certain areas, particularly Asia and South America, limits the ability to draw firm associations or conclusions from these differences. In punitive systems, fear of judgment and medicolegal repercussions may exacerbate distress, whereas proactive support cultures may foster resilience. These observations highlight the importance of both institution-level initiatives and broader cultural change to normalize acknowledgment of second victim experiences and to encourage help-seeking behaviors.

Downstream consequences for care

The consequences of complications may extend beyond the affected physician to future patients. PTSD from complications is closely linked to burnout.^{16 17} Burnout, defined as long-term stress characterized by emotional exhaustion, depersonalization, and lack of personal accomplishment, has been reported in 50–60% of neurointerventionalists.¹⁸ Burnout itself is associated with increased medical errors and malpractice lawsuits.^{19 20} Thus, the high incidence of distressing complications in this cohort could have significant downstream repercussions for the quality and safety of patient care. Moreover, anecdotal evidence suggests that complications may transiently shift operator behavior, leading to risk aversion, second-guessing of indications, or avoidance of technically similar cases—adaptations that may compromise optimal care delivery.

Training for complications

As complication rates decline with technological advancement and growing procedural experience, trainees may encounter fewer major complications during fellowship. The assumption that lived experience alone will prepare the next generation for the emotional and cognitive stress of a complication is increasingly flawed. Simulation platforms could be expanded beyond technical rehearsal to include complication management and emotional resilience training. The adoption of formal adverse-event management training could equip trainees with tools to recognize cognitive overload, manage team communication during crisis, and regulate stress in real time.

Future directions and post-traumatic growth

Although the psychological burden is substantial, distress does not invariably culminate in dysfunction. Many physicians experience post-traumatic growth, with painful events ultimately fostering empathy, refined judgment, and strengthened resolve. Facilitating such growth requires institutional cultures that destigmatize emotional responses and provide structured debriefings and mentorship. Senior physicians play a critical role in modeling adaptive responses—normalizing vulnerability while demonstrating that recovery and renewed purpose are both possible and common.

Limitations

Several limitations merit consideration. The reliance on self-report instruments introduces potential recall bias and does not replace formal psychiatric evaluation.^{10 12–14} The survey did not collect demographic variables such as age or gender, which may influence coping strategies and psychological outcomes; future studies should incorporate these factors to better characterize subgroup differences. The cross-sectional design precludes assessment of symptom trajectories, and the 48% response rate, even though high, raises the possibility of selection bias, as physicians most affected by complications may have been more likely to respond. Nonetheless, the large sample size, international representation, and use of a validated tool strengthen the generalizability of these findings.

Conclusion

Complications impose a substantial psychological burden on neurointerventionalists, with high rates of possible PTSD and a strong association with inadequate institutional support. These results call for systemic change in how adverse events are managed—emphasizing not only patient outcomes but also physician well-being. By implementing structured support programs, normalizing help-seeking behaviors, and openly acknowledging the second victim phenomenon, institutions can protect physicians, reduce burnout, and enhance patient safety. Future research can focus on longitudinal outcomes and the effectiveness of targeted interventions to mitigate the lasting burden of complications in neurointerventions.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.