NEURORADIOLOGY DIVISION

Karen Black, MD, Chief, Division of Diagnostic Neuroradiology

Rona Woldenberg, MD, Assistant Chief, Division of Diagnostic Neuroradiology

Salvatore Parrinello, MD, Neuroradiologist

Avi Setton, MD, Chief, Division of Interventional Neuroradiology

The neuroradiology rotation at the North Shore University Hospital exposes the radiology resident to all aspects of state of the art neuroradiology. During the course of their residency, the trainee will be afforded extensive experience in the interpretation of neuroradiology examinations, during specific Neuroradiology rotations, and while on-call. The medical center has a large volume of both adult and pediatric patients with neurosurgical, neurological, ophthalmologic, otolaryngologic and spinal disorders.

North Shore University Hospital has two state of the art General Electric 1.5 Tesla magnetic resonance scanners, 3 GE helical CT scanners, including 2 sixteen multi-detector General Electric Lightspeed scanners,(including one in the emergency department), 1 64 slice CT scanner, 3 digital subtraction angiography suites, 1 digital remote multipurpose room and E film computed radiography.

There is a neuro reading room for the interpretation of neuroimaging studies including MRI, CT and myelograms. Interventional procedures can also be viewed on the E film system. The reading room includes 4 E film workstations, 2 GE independent workstations and a 3D (Vital Images) workstation.

GLOBAL EDUCATIONAL GOALS AND OBJECTIVES

As a result of clinical training and didactic conferences, it is expected that the radiology resident completing his or her neuroradiology training at North Shore University Hospital will:

· have gained a thorough knowledge of normal anatomy and be able to recognize normal variants of the central nervous system, skull, skull base, orbit, temporal bone, facial bones, compartments of the supra-hyoid and infra-hyoid neck and spine

· have exposure to interventional neuroradiology procedures including coiling of aneurysms, AVM embolization, carotid stenting, tumor embolization and treatment of epistaxis

· be proficient in the recognition of central nervous system, spine and head and neck pathology and be able to formulate a differential diagnosis

· learn how to generate a concise diagnostic radiology report

· interact effectively with referring physicians, medical students, housestaff, patients and their family members

· understand the appropriate indications, limitations and contraindications to Neuro MRI and CT and be able to advise referring physicians as to their appropriate use

· be able to protocol neuroradiology CT and MRI examinations

· be able to discuss the indications, relative merits and risks of neuroangiography, myelography and imaging guided procedures

· be proficient as a 1^st assistant in the performance and interpretation of cerebral angiography, fluorscopically guided lumbar punctures, lumbar, thoracic and cervical myelograms, and imaging guided procedures

· have a thorough knowledge of neurovascular anatomy and pathology

EDUCATIONAL PROGRAM

Computed Tomography and Magnetic Resonance Imaging

There are daily CT and MRI readout sessions. The neuroradiology resident may be given the opportunity to review the studies, in order to arrive at his or her own conclusion prior to the readout sessions. It is expected that the previous neuroimaging studies or relevant ultrasound, nuclear medicine studies and plain films will be reviewed. An attending neuroradiologist will review all of the cases with the resident. The neuroradiology resident will dictate diagnostic reports on the Powerscribe voice recognition system. The reports will be closely reviewed by the neuroradiology faculty for content, grammar and style. Constructive criticism will be provided.

During the third and four years of the residency, the trainee will become familiar with the post processing of CT and MR angiograms on the Vital Images workstation in the MRI reading room.

The third and fourth year neuroradiology resident is expected to protocol the next day’s CT and MRI examinations, and to review them with the neuroradiology attending. The trainee should carefully consider whether there is an appropriate indication for the study requested and should be aware of the limitations, if any, of the particular study. If necessary, the trainee should be able to suggest alternative studies to the referring physician.

Invasive Procedures

The neuroradiology rotation at the North Shore University Hospital gives the 3^rd and 4^th year radiology residents the opportunity to assist in diagnostic procedures under the direct supervision of a neuroradiology faculty member.

Invasive procedures include conventional catheter cerebral angiography; imaging guided biopsies; fluoroscopically guided lumbar punctures for cerebrospinal fluid analysis, intrathecal installation of medication, and myelography. The residents are given graduated responsibility in the performance and interpretation of procedures.

Responsibility for procedures includes preprocedural patient management. It is expected that prior to the examination the resident will review the patient’s chart. Pre-procedure laboratory values and imaging studies should be reviewed. The resident should obtain informed consent following a discussion with the patient about the risks, benefits and alternatives of the procedure. It is expected that the resident will write a brief pre-procedure note in the patient record.

Following the procedure and prior to discharge, the resident must regularly evaluate all outpatients and document appropriately in the patient record. The resident must also evaluate inpatients that have undergone invasive procedures. If a procedure is performed later in the day, it is the responsibility of the resident to inform the diagnostic radiology resident on-call about the patient. Any minor or major complication identified by the trainee on inpatients or outpatients must be discussed with the designated neuroradiology attending and documented in the patient record.

The trainee is required to maintain a procedure log of the invasive procedures that he or she has performed in a log book. Minor and major complications of procedures must be reported to the radiology department’s performance improvement committee.

EDUCATIONAL CONFERENCES

The neuroradiology resident is required to attend the weekly neuroradiology didactic conference, given by a neuroradiology attending or fellow (Thursday 4:30 – 5:30 p.m.). These conferences are intended to supplement the teaching the neuroradiology resident receives during the readout sessions, interesting case conferences, departmental and interdepartmental conferences.

The following is a list of specific educational conferences that were covered during the past academic year.

Brain

· Neuroanatomy

· Craniocerebral Trauma

· CNS Infections

· Neuroimaging of AIDS

· Demyelinating Disease

· Astrocytomas and other Glial Neoplasms

· Meningiomas and other NonGlial Neoplasms

· Pediatric Brain Tumors

· Nonneoplastic Tumors and Cysts

· Sella and Parasellar Lesions

· MR Spectroscopy

· Stroke

· MRA, CTA and conventional angiography of Extracranial and Intracranial Stenosis

· Nontraumatic Intracranial Hemorrhage

· Cerebrovascular Anatomy

· Intracranial Aneurysms

· Vascular Malformations

· Neurocutaneous Syndromes

· Congenital Malformations

· Hydrocephalus

Spine

· Normal Anatomy and Congenital Anomalies

· Extradural (Non-Degenerative) Lesions

· Intradural Extramedullary Lesions

· Intradural Intramedullary Lesions

· Spine Infection

· Spine Trauma

· Degenerative Disease

Head and Neck

· Spaces of the Neck (Supra-hyoid)

· Spaces of the Neck (Infra-hyoid)

· Cystic Neck Masses

· Temporal Bone Anatomy

· Temporal Bone Pathology

· Sinonasal Lesions

· The Orbit

Divisional, Departmental and Interdepartmental Conferences

In addition to the neuroradiology educational conferences on Thursday afternoons, there are many additional opportunities for the trainee to learn by attending the numerous departmental and interdepartmental conferences.

Interesting Case Conference or ER Conference/

The resident will participate in the interesting case conference (Wednesday and Friday at 12:00 PM to 12:30 PM), at which time the rotating diagnostic radiology resident, neuroradiology fellow and neuroradiology faculty members will review current interesting cases.

Neurology Conferences

The radiology resident on the service may attend the weekly neurology/neuroradiology conference given by a neuroradiology faculty member (Monday 2:00 pm – 3:00 pm) where the week end admissions are reviewed.

The Department of Neurology has weekly Grand Rounds (Friday 8:30 AM. – 9:30 AM) that the neuroradiology faculty and trainee may attend occasionally, when there is a relevant topic.

Neurosurgical Conferences

The radiology resident rotating through the neuroradiology rotation is required to attend the triweekly neurosurgical conference ( 3 Tuesdays of the month 7:30 AM. – 8:30 AM).

Radiation and MRI Physics

The radiology resident rotating through the division of neuroradiology will be given the opportunity to attend the lecture series in radiologic physics, radiobiology and radiation protection given on Tuesdays (4:30 – 5:30, November through June). The course is taught by the department’s physicists and is under the direction of the radiation safety officer William Robeson, PhD.

NEURORADIOLOGY CORE CURRICULUM

I. Intracranial

A. CNS Infections

1. Imaging strategies

2. Pyogenic infections

3. Encephalitis

4. Granulomatous infections

5. Parasitic infections

6. Infections in the immunocompromised host

B. White Matter Disease

1. Multiple sclerosis

2. Acute Disseminated Encephalomyelitis

3. Osmotic myelinolysis (Central pontine myelinolysis)

4. Small vessel ischemic disease, hypertension, vascular disease

5. White matter changes in the elderly

6. Radiation/chemotherapy changes

7. Infection – Viral encephalitis

8. Trauma (axonal injuries)

9. Dysmyelinating Disorders

C. Craniocerebral Trauma

1. Imaging strategies: CT/MR/Skull films

2. Mechanisms

3. Primary vs. Secondary

4. Focal lesions

5. Age of hemorrhage by CT/MR

6. Intraventricular hemorrhage

7. Diffuse cerebral swelling & edema

8. Herniation

9. Skull fractures: types, complications

10.Vascular injuries

11. Non-accidental trauma

12. Superficial and soft tissue injuries

D. Neoplasms and Nonneoplastic Tumors and Cysts

1. Tumor classification by histology

2. Tumor evaluation by location

E. Cerebrovascular Disease

1. Infarction

2. Nontraumatic intracranial hemorrhage

3. Aneurysms

4. Cerebrovascular Malformations

5. Angiography

F. Congenital CNS Lesions

1. Embryology of Brain Development

2. Disorders of organogenesis

3. Disorders of neuronal migration & sulcation

4. Disorders of diverticulation and cleavage

5. Posterior fossa cystic disorders

6. Disorders of histogenesis (Phakomatoses)

II. HEAD AND NECK RADIOLOGY

A. Paranasal Sinuses

1. Anatomy of paranasal sinuses

2. Congenital disease

3. Inflammation/Infection

4. Benign Sinus Tumors

5. Malignant Sinus Tumors

B. Oral Cavity, Oropharynx, Hypopharynx

1. Anatomy

2. Masses

3. Infection

C. Paraphayngeal Space

1. Location, contents, anatomy and importance in relation to other spaces

2. Pharyngeal Mucosal Space (Anatomy, contents)

3. Masticator Space (Anatomy, contents)

4. Parotid Space (Anatomy, contents)

5. Carotid Space (Anatomy, contents)

6. Perineural spread

D. Larynx

1. Squamous cell carcinomas

2. Trauma

E. Thyroid

F. Cystic Neck Masses

1. Branchial cleft cyst

2. Thyroglossal duct cyst

3. Cystic hygroma

4. Laryngocele, internal, external

5. Abscess

6. Ranula

7. Dermoid/Epidermoid

G. Lymphadenopathy

1. Graded by level and/or anatomic space.

2. Size criteria for pathologic nodes

3. Etiology

H. Temporal bones

1. Imaging Techniques (Multi-planar CT/MR)

2. Anatomy/Embryology

3. Trauma

4. Tumors

5. Pulsatile Tinnitus

6. Inflammatory Diseases

7. Congenital anomalies

I. Orbits

1. Imaging Techniques

2. Anatomy

3. Lacrimal Gland Tumors

4. Extra-conal Masses

5. Extra-ocular Muscles (Conal)

6. Intra-conal lesions

7. Intra-ocular

8) Trauma

III. Spinal Imaging

A. Anatomy

B. Imaging Modalities

C. Trauma

1. Mechanism of injury

2. Stable fractures and ligamentous injuries

3. Unstable injuries

4. Traumatic disc herniation

5. Extrinsic cord compression

6. Cord contusion

7. Intra-spinal hemorrhage

8. Post-traumatic abnormalities

D. Degenerative disease

E. Inflammatory and Demyelinating Disease

F. Neoplastic Disease

G. Vascular lesions

H. Congenital Anomalies

First Year Neuroradiology Specific Goals and Objectives

Patient Care:

1. Start to become familiar with the indications, contraindications, risks, benefits, alternatives of neuroimaing procedures.
2. Whenever possible, assist a more senior resident in monitoring a study to ensure that it is being performed adequately.
3. Begin to become familiar with the indications and uses of intravenous iodinated contrast material and gadolinium.
4. Begin to become familiar with the protocol for treating contrast reactions.

Medical Knowledge:

1. Intracranial: Become familiar with the appearance of major intracranial structures as visualized on axial CT and MR scans. Be able to identify all major structures and components of the brain, ventricles and subarachnoid space. Learn to interpret CT scans with a particular emphasis on studies performed on individuals with acute or emergent clinical abnormalities (infarction, intracranial hemorrhage, subarachnoid hemorrhage, traumatic brain injury, infection, hydrocephalus and brain herniation).
2. Head and Neck Anatomy: Learn the anatomy of the calvarium, skull base and soft tissues of the neck as displayed on plain radiographs and CT. Learn to identify common acute emergent lesions. Become familiar with the plain film and CT appearance of (a) trauma of the orbit, skull base, face and petrous bones and (b) inflammatory lesions (sinusitis, orbital cellulites, mastoiditis, cervical adenitis and abscess). Learn to identify airway compromise and obstruction.
3. Spine Anatomy: Become familiar with the normal appearance of the spine on plain film radiographs and axial CT scans. Be able to assess spinal alignment and be able to identify all osseous components of the spinal canal. Learn the appearance of traumatic lesions on plain radiographs. Become familiar with the CT and MRI findings of degenerative disease.
4. Vascular Anatomy: Learn to identify the large vessels of the cervical and intracranial regions (carotid, vertebral and basilar arteries, jugular veins and dural venous sinuses) as they appear on routine CT and MR studies of the head and neck. Learn to recognize the angiographic features of extra- and intracranial atherosclerosis utilizing catheter angiography, CTA and MRA.
5. Pediatrics: Learn to recognize the normal appearance of the brain, spine and head & neck encountered in the newborn, infant and child. Be able to identify the features of hydrocephalus on CT and MR.
6. Develop an understanding of the relative strengths and weaknesses of neuroimaging studies for arriving at the correct diagnosis for a particular patient presentation or disease process.
7. Attend all of the departmental and interdepartmental conferences whenever possible.
8. Read the recommended textbook and make use of online learning tools, for example, “The Brain Lesion Locator: Differential Diagnosis by Location” by Dr. James Smniriotopolous, http://rad.usuhs.mil/rad/location/location_frame.html

Recommended Neuroradiology textbook for first year resident

Neuroradiology: The Requisites. Robert I. Grossman and David M. Yousem. 2nd ed. St. Louis, MO: Mosby; 2003. 908 pages, 730 illustrations. $95.00.

Interpersonal and Communication Skills:

1. Learn to completely explain the neuroimaging study to be performed to the patient, providing the opportunity for the patient to ask questions. Be able to answer questions in a complete and clear fashion.
2. Learn to obtain informed consent, including a discussion of the risks, benefits and alternatives of a particular CT or MR imaging study.
3. Learn how to present a coherent description of the patient’s clinical problems and relevant past medical history, prior to image interpretation.
4. Learn how to create a clear and informative radiology report using the voice recognition software Powerscribe. Every dictate report must include a section on clinical information, technique, findings and impression. Reports should be concise but contain all pertinent information. The report must be checked for grammatical and spelling errors before signing it off. Whenever appropriate, a differential diagnosis and recommended follow-up should be included in the report.
5. Become aware of the ACR practice guideline for communication (acr.org). Learn how to provide direct communication to the referring physician when there is an urgent or unexpected finding and document this communication in the radiology report.
6. Learn how to communicate effectively and interact responsibly with other health care professionals, including nurses, physician assistants, radiologic technologists, secretaries and schedulers. Appreciate the different roles these individuals play in patient care.

Professionalism:

1. Have an appropriate work ethic. Always report to the readout sessions and conferences on time.
2. Display proper grooming and dress habits.
3. Maintain an appropriate professional demeanor.
4. Demonstrate professional values and ethical behaviors, including integrity, honesty, compassion and sensitivity to patient concerns. Serve as a role model for medical students and residents in other specialties.

Practice Based Learning:

1. Maintain a log of interesting/unknown cases and follow-up on these cases.
2. Attend all Neuroradiology conferences.

Systems Based Practice:

1. Begin to become familiar with the Neuroradiology ACR Appropriateness Criteria.
2. Begin to understand the relative costs of the various neuroimaging procedures and become familiar with issues such as cost containment.
3. Begin to learn how to practice cost-effective health care that does not compromise the quality of care.

Second Year Neuroradiology Specific Goals and Objectives

Patient Care:

1. Recognize the indications, contraindications, risks, benefits and alternatives of Neuroimaging studies.
2. Make sure that any neuroimaging study requested is appropriate.
3. Whenever possible, directly monitor a neuroimaging study to ensure that it is being performed adequately.
4. Know the indications for and uses of intravenous iodinated contrast material and gadolinium.
5. Be able to properly manage a contrast reaction.

Medical Knowledge:

1. Intracranial Anatomy: Develop more detailed knowledge of intracranial anatomy as displayed on multi-planar images. Learn the CT and MR findings of hyperacute infarction (including findings on diffusion weighted MRI). Learn to identify and characterize focal lesions and diffuse processes and be able to provide a short differential diagnosis for the potential causes of these processes.
2. Head and Neck: Become familiar with the complex anatomy of the orbit, petrous bone, skull base and soft tissues of the neck as displayed on CT and MR in multiple planes. Expand your knowledge of the appearance of traumatic lesions on CT. Learn to identify neoplastic masses arising in the orbit, skull base, petrous bone and soft tissues of the neck. Be able to use the standard anatomic classification schemes to accurately describe the location of mass lesions.
3. Spine: Learn to identify normal osseous structures, intervertebral discs, support ligaments and the contents of the thecal sac on CT, MR and myelography. Learn the CT, MRI and myelographic findings of spinal cord compression. Become familiar with findings on all three modalities that allow for accurate spatial localization of spinal lesions (extra-dural, intradural extramedullary and intramedullary). Be able to identify and differentiate discogenic and arthritic degenerative diseases. Learn to identify and characterize traumatic lesions using routine and reformatted CT scans.
4. Vascular: Learn to identify the carotid, vertebral and basilar arteries, jugular veins and dural venous sinuses on catheter, CT and MR angiography. Learn the indications, limitations, risks and benefits for each technique used for visualization of vascular anatomy and pathology. Learn the angiographic appearance of aneurysms, vascular malformations, occlusive disease and neoplasms.
5. Pediatrics: Learn to recognize the congenital lesions and malformations. Be able to detect disorders of the perinatal period on sonography, CT and MR.
6. Be able to provide a differential diagnosis for brain, spine and head and neck pathology
7. Understand the relative strengths and weaknesses of neuroimaging studies (CT, MRI, Angiography, Myelography) for making a diagnosis for a particular patient presentation or disease process.
8. Attend all of the Neuroradiology departmental and interdepartmental conferences
9. Read the recommended textbooks and make use of online learning tools.

Recommended Textbooks for second year radiology residents

Neuroradiology: The Requisites. Robert I. Grossman and David M. Yousem. 2nd ed. St. Louis, MO: Mosby; 2003.

Head and Neck Imaging, 4th ed. Edited by Peter M. Som and Hugh D. Curtin

St Louis, Mo: Mosby–Elsevier Science, 2003

Interpersonal and Communication Skills:

1. Be able to completely explain the neuroimaging study to be performed to the patient, providing the opportunity for the patient to ask questions. Be able to answer questions in a complete and clear fashion.
2. Be able to obtain informed consent, including a discussion of the risks, benefits and alternatives of a particular CT or MR imaging study.
3. Be able to present a coherent description of the patient’s clinical problems and relevant past medical history prior to image interpretation.
4. Create a clear and informative radiology report using Powerscribe. A Neuroradiology report should always include separate sections on clinical information, technique, findings and impression. Reports should be concise but contain all pertinent information. The reports must be checked for grammatical and spelling errors before signing them off. Whenever appropriate, a differential diagnosis and recommended follow-up should be included in the report.
5. Learn the ACR practice guideline for communication (acr.org). Provide direct communication to the referring physician when there is an urgent or unexpected finding and document this communication in the radiology report.
6. Demonstrate the ability to communicate effectively and interact responsibly with other health care professionals, including nurses, physician assistants, radiologic technologists, secretaries and schedulers.

Professionalism:

1. Have an appropriate work ethic. Always report to the Neuroradiology readout sessions and conferences on time.
2. Display proper grooming and dress habits.
3. Maintain an appropriate professional demeanor.
4. Understand the ethical issues pertinent to the practice of Neuroradiology, including patient confidentiality, informed consent and proper documentation.
5. Demonstrate professional values and ethical behaviors, including integrity, honesty, compassion and sensitivity to patient concerns. Serve as a role model for first year radiology residents, medical students and residents in other specialties.

Practice Based Learning:

1. Maintain a log of interesting/unknown cases and follow-up on these cases.
2. Attend and participate in all of the Neuroradiology conferences.
3. Familiarize yourself with medical statistics, which will assist in the critical appraisal of the medical literature.

Systems Based Practice:

1. Become familiar with ACR Appropriateness Criteria

2. Learn the relative costs of the various neuroimaging procedures and become familiar with issues such as cost containment.

3. Practice cost-effective health care that does not compromise the quality of care.

Third Year Neuroradiology Rotation Specific Goals and Objectives

Patient Care:

1. Confirm that the neuroimaging study requested is appropriate. Carefully consider whether there is an appropriate indication for the study requested. If necessary, suggest alternative studies to the referring physician.
2. Familiarize yourself with the proper technique for performing myelography and cerebral angiography.
3. Responsiblities for all neuroradiology procedures include preprocedural patient management. It is expected that prior to the procedure, the resident will review the patient’s history. Pre-procedure laboratory values and imaging studies should be reviewed. The resident should obtain informed consent following a discussion with the patient about the risks, benefits and alternatives of the procedure. It is expected that the resident will write a brief pre-procedure note in the patient record.
4. Following the procedure and prior to discharge, the resident must regularly evaluate all outpatients and document appropriately in the patient record. The resident must also evaluate inpatients that have undergone invasive procedures. If a procedure is performed later in the day, it is the responsibility of the resident to inform the diagnostic radiology resident on-call about the patient.
5. Any major or minor complication identified by the trainee must be discussed with the Neuroradiology attending and documented in the patient record.

6. Whenever possible, directly monitor CT or MRI studies to ensure that it was performed adequately.
7. Be able to appropriately manage a contrast reaction.

Medical Knowledge:

1. Intracranial Anatomy: Continue to expand more detailed knowledge of intracranial anatomy as displayed on multi-planar images. Learn the CT and MR findings of hyperacute infarction (including findings on diffusion weighted MRI). Learn to identify and characterize focal lesions and diffuse processes and be able to provide a short differential diagnosis for the potential causes of these processes.
2. Head and Neck: Expand upon the complex anatomy of the orbit, petrous bone, skull base and soft tissues of the neck as displayed on CT and MR in multiple planes. Expand knowledge of the appearance of traumatic lesions on CT. Learn to identify neoplastic masses arising in the orbit, skull base, petrous bone and soft tissues of the neck. Be able to use the standard anatomic classification schemes to accurately describe the location of mass lesions.
3. Spine: Expand your knowledge of the normal osseous structures, intervertebral discs, support ligaments and the contents of the thecal sac on CT, MR and myelography. Learn the CT, MRI and myelographic findings of spinal cord compression. Become familiar with findings on all three modalities that allow for accurate spatial localization of spinal lesions (extra-dural, intradural extramedullary and intramedullary). Be able to identify and differentiate discogenic and arthritic degenerative diseases. Learn to identify and characterize traumatic lesions using routine and reformatted CT scans.
4. Vascular: Expand your knowledge of the appearance of carotid, vertebral and basilar arteries, jugular veins and dural venous sinuses on catheter, CT angiography and MR angiography. Learn the indications, limitations, risks and benefits for each technique used for visualization of vascular anatomy and pathology. Learn the angiographic appearance of aneurysms, vascular malformations, occlusive disease and neoplasms.
5. Pediatrics: Master congenital lesions and malformations. Be able to detect disorders of the perinatal period on sonography, CT and MR.
6. Be able to provide a differential diagnosis for brain, spine and head and neck pathology
7. Understanding the relative strengths and weaknesses of neuroimaging studies (CT, MRI, Angiography, Myelography) for making a diagnosis for a particular patient presentation or disease process.
8. Attend all of the Neuroradiology departmental and interdepartmental conferences Read the recommended textbooks and make use of online learning tools.
9. Be able to protocol Neuroradiology CT and MRI examinations
10. Begin to learn the post processing of CT and MR angiograms on the Vital Images workstation.

Recommended Textbooks for third year residents rotating in Neuroradiology

Neuroradiology: The Requisites. Robert I. Grossman and David M. Yousem. 2nd ed. St. Louis, MO: Mosby; 2003.

Diagnostic Imaging:Brain. Anne Osborn, Susan Blaser and Karen Salzman. Saunders, 2004.

Diagnostic Cerebral Angiography. Anne G. Osborn. 2^nd Ed. Lippincott Williams & Wilkins; 1999

Head and Neck Imaging. Peter M. Som and Hugh D. Curtin. 4^th Ed. Mosby-Elsevier Science; 2003.

Interpersonal and Communication Skills:

1. Be able to completely explain the neuroimaging study to be performed to the patient, providing the opportunity for the patient to ask questions. Be able to answer questions in a complete and clear fashion.
2. Obtain informed consent, including a discussion of the risks, benefits and alternatives of a particular imaging study and invasive procedures.
3. Be able to organize cases and present a coherent description of the patient’s clinical problems and relevant past medical history prior to image interpretation.
4. Create a clear and informative radiology report using Powerscribe. A Neuroradiology report must always include separate sections on clinical information, technique, findings and impression. Reports should be concise but contain all pertinent information. The reports must be checked for grammatical and spelling errors before signing them off. Whenever appropriate, a differential diagnosis and recommended follow-up should be included in the report.
5. Know the ACR practice guideline for communication (acr.org). Provide direct communication to the referring physician when there is an urgent or unexpected finding and document this communication in the radiology report.
6. Demonstrate the ability to communicate effectively and interact responsibly with other health care professionals, including nurses, physician assistants, radiologic technologists, secretaries and schedulers.

Professionalism:

1. Have an appropriate work ethic. Report to the Neuroradiology readout sessions and conferences on time.
2. Display proper grooming and dress habits.
3. Maintain an appropriate professional demeanor.
4. Understand the ethical issues pertinent to the practice of Neuroradiology, including patient confidentiality, informed consent and proper documentation.
5. Demonstrate professional values and ethical behaviors, including integrity, honesty, compassion and sensitivity to patient concerns. Serve as a role model for 1^st and 2^nd year radiology residents, medical students and residents in other specialties.

Practice Based Learning:

1. Maintain a procedure log of the invasive procedures that you have performed in a computerized database (Hi-IQ). Minor and major complications of procedures must be logged into the database, in addition to being directly reported to the radiology department’s performance improvement committee.
2. Maintain a log of interesting/unknown cases and follow-up on these cases.
3. Attend and participate in all of the Neuroradiology conferences (as outlined above)
4. Participate in the education of medical students rotating through the department

Systems Based Practice:

1. Be cognizant of the ACR Appropriateness Criteria ( http://www.acr.org)

2. Be familiar with the relative costs of the various neuroimaging procedures and become familiar with issues such as cost containment.

3. Practice cost-effective health care that does not compromise the quality of care.

Fourth Year Neuroradiology Rotation Specific Goals and Objectives

Patient Care:

1. Confirm that the neuroimaging study requested is appropriate. The trainee should carefully consider whether there is an appropriate indication for the study requested. If necessary, the resident should be able to suggest alternative studies to the referring physician.
2. Know the proper technique in performing myelography and angiography.
3. Responsibilities for procedures include preprocedural patient management. It is expected that prior to any procedure, the resident will review the patient’s history. Pre-procedure laboratory values and imaging studies should be evaluated. The resident should be capable of obtaining informed consent following a discussion with the patient about the risks, benefits and alternatives of the procedure. It is expected that the resident will write a brief pre-procedure note in the patient record.
4. Following the procedure and prior to discharge, the resident must regularly evaluate all outpatients and document appropriately in the patient record. The resident must also evaluate inpatients that have undergone invasive procedures. If a procedure is performed later in the day, it is the responsibility of the resident to inform the diagnostic radiology resident on-call about the patient.
5. Any major or minor complication identified by the trainee must be discussed with the Neuroradiology attending and documented in the patient record.
6. Whenever appropriate, directly monitor a neuroimaging study to ensure that it is being performed adequately.
7. Recognize the indications and uses of intravenous iodinated contrast material and gadolinium.
8. Be able to appropriately manage a contrast reaction.

Medical Knowledge:

1. Intracranial: Be able to identify subdivisions and fine anatomic details of the brain, ventricles, subarachnoid space, vascular structures, sella turcica and cranial nerves. Develop the ability to use imaging findings to differentiate different types of focal intracranial lesions (neoplastic, inflammatory, vascular) based on anatomic location, contour, intensity and enhancement pattern. Learn to identify and differentiate diffuse intracranial abnormalities (eg. Hydrocephalus and atrophy). Learn to recognize treatment related findings (e.g. post surgical and post radiation). Become familiar with the utility of Diffusion/Perfusion, functional MR and MR spectroscopy.
2. Head and Neck: Be able to identify all key structures and have knowledge of established classification system for each area. Learn the differential diagnosis of mass lesions. Understand and be able to identify patterns of disease spread within and between areas of the head and neck (e.g. perineural and nodal spread). Learn to recognize treatment related findings (e.g. post-surgical and post radiation). Learn to identify pathologic processes on multi-planar MR studies.
3. Spine: Be able to identify all normal structures on multi-planar images. Learn the imaging findings that allow for the differentiation of inflammatory and neoplastic lesions. Learn to recognized post surgical and other treatment related findings.
4. Vascular: Be able to identify all important extra- and intra-cranial arteries (secondary and tertiary branches of the Carotid and Basilar arteries) and veins (cortical and deep cerebral veins) on all imaging modalities. Learn the indications, risks and benefits for neurointerventional procedures including thrombolysis, embolization, angioplasty and stenting.
5. Pediatrics: Be able to identifiy and differentiate acquired lesions (traumatic, ischemic, inflammatory and neoplastic) of the newborn, infant, child and adolescent.
6. Be able to provide an image based differential diagnosis for brain, spine and head and neck pathology.
7. Understanding the relative strengths and weaknesses of neuroimaging studies (CT, MRI, Angiography, Myelography) for achieving a diagnosis for a particular patient presentation or disease process and be able to advise referring physicians as to their appropriate use
8. Be able to protocol Neuroradiology CT and MRI examinations
9. Be familiar with the post processing of CT and MR angiograms on the Vital Images workstation.
10. Attend all of the Neuroradiology departmental and interdepartmental conferences.
11. Read the recommended textbooks and make use of online learning tools.

Recommended Textbooks for fourth year residents rotating in Neuroradiology

Neuroradiology: The Requisites. Robert I. Grossman and David M. Yousem. 2nd ed. St. Louis, MO: Mosby; 2003.

Diagnostic Imaging:Brain. Anne Osborn, Susan Blaser and Karen Salzman. Saunders, 2004.

Diagnostic Cerebral Angiography. Anne G. Osborn. 2^nd Ed. Lippincott Williams & Wilkins; 1999

Head and Neck Imaging. Peter M. Som and Hugh D. Curtin. 4^th Ed. Mosby-Elsevier Science; 2003.

Interpersonal and Communication Skills:

1. Be able to completely explain the neuroimaging study to be performed to the patient, providing the opportunity for the patient to ask questions. Be able to answer questions in a complete and clear fashion.
2. Obtain informed consent, including a discussion of the risks, benefits and alternatives of a particular neuroimaging study and invasive procedures.
3. Organize cases in order to present a coherent description of the patient’s clinical problem(s) and relevant past medical history prior to image interpretation.
4. Create a clear and informative radiology report using Powerscribe. A report should include separate sections on clinical information, technique, findings and impression. Reports should be concise but contain all pertinent information. The reports must be checked for grammatical and spelling errors before signing them off. Whenever appropriate, a differential diagnosis and recommended follow-up should be included in the report.
5. Provide direct communication to the referring physician when there is an urgent or unexpected finding and document this communication in the radiology report.
6. Demonstrate the ability to communicate effectively and interact responsibly with other health care professionals, including nurses, physician assistants, radiologic technologists, secretaries and schedulers.

Professionalism:

1. Have an appropriate work ethic. Report to the Neuroradiology readout sessions and conferences on time.
2. Display proper grooming and dress habits.
3. Maintain an appropriate professional demeanor.
4. Understand the ethical issues pertinent to the practice of Neuroradiology, including patient confidentiality, informed consent and proper documentation.
5. Demonstrate professional values and ethical behaviors, including integrity, honesty, compassion and sensitivity to patient concerns. Serve as a role model for 1^st, 2^nd and 3^rd year radiology residents, medical students and residents in other specialties.

Practice Based Learning:

1. Maintain a procedure log of the invasive procedures that you have performed in a computerized database (Hi-IQ). Minor and major complications of procedures must be logged into the database, in addition to being directly reported to the radiology department’s performance improvement committee.
2. Maintain a log of interesting/unknown cases and follow-up on these cases.
3. Attend and participate in all Neuroradiology conferences.
4. Participate in the education of medical students rotating through the department

Systems Based Practice:

1. Be conversant with the ACR Neuroradiology Appropriateness Criteria.

2. Know the relative costs of the various neuroimaging procedures and become familiar with issues such as cost containment.

3. Practice cost-effective health care that does not compromise the quality of care.

4. Understand billing and coding practices.

5. Develop a basic understanding of licensure, accreditation, continuing medical education, physician impairment and malpractice