1. Definitions and Objectives

Endovascular Neurological Surgery (EVNS) is a subspecialty of Neurological Surgery that uses catheter technology, radiological imaging, and clinical expertise to diagnose and treat diseases of the central nervous system. The unique clinical and invasive nature of this subspecialty requires special training and skills. The training program must include education and experience in the following:

1. Signs and symptoms of disorders amenable to diagnosis and treatment by neuroendovascular surgical techniques.
   
   
2. Neurological examinations to evaluate patients with neurological disorders.
   
   
3. Pathophysiology and natural history of these disorders.
   
   
4. Indications and contraindications to neuroendovascular surgical procedures.
   
   
5. Clinical and technical aspects of neuroendovascular surgical procedures.
   
   
6. Medical and surgical alternatives.
   
   
7. Preoperative and postoperative management of endovascular patients.
   
   
8. Neurointensive care management.
   
   
9. Fundamentals of imaging physics and radiation biology.
   
   
10. Interpretation of radiographic studies pertinent to the practice.
    
    

In this subspecialty, the objective of training is to give residents/fellows an organized, comprehensive, supervised, full-time educational experience in endovascular neurological surgery. This experience includes the management of patients with neurological disease, the performance of neuroendovascular surgical procedures, and the integration of neuroendovascular surgical therapy into the clinical management of patients.

Training in endovascular neurological surgery must be conducted in an environment conducive to investigative studies of a clinical and/or basic science nature. Training programs in endovascular neurological surgery (EVNS) shall be accredited by The Society of Neurological Surgeons (SNS) Committee on Accreditation of Subspecialty Training (CAST) and administered by the sponsoring program. Exceptions to this requirement will be subject to the review and approval, on a case-by-case basis by the SNS.



2. Duration of Training
   
   

The program shall offer 1 year of graduate medical education in endovascular neurologic surgery. For those individuals lacking required preliminary training, this experience may be provided within the EVNS fellowship with the duration of additional training at the discretion of the fellowship program director.

3. Endovascular Neurosurgery Program Director
   
   

The EVNS program director (or neurosurgical co-director) must be certified by either the American Board of Neurological Surgery or possess appropriate educational qualifications as determined by the SNS Committee on Accreditation of Subspecialty Training. The director must have special expertise in endovascular neurological surgery techniques and concentrate at least 50% of his/her practice in endovascular neurological surgery. In addition, the director must devote sufficient time to the program to fulfill all the responsibilities inherent in meeting its educational goals. The director should hold an appointment to the teaching staff in neurological surgery. The director is responsible for establishing and maintaining the curriculum, selecting and supervising the residents/fellows, and selecting faculty members. The director must have adequate support from the institution and sponsoring department to carry out the mission of the program. The director of the endovascular neurological surgery training program must be appointed by and be responsible to the program director and/or chair of the sponsoring neurosurgical training program.



4. Faculty
   
   

The faculty must include at least one full-time member with expertise in endovascular neurological surgery who is (1) certified by the American Board of Neurological Surgery or (2) possesses appropriate educational qualifications as determined by the SNS/CAST. The faculty must provide didactic teaching and direct supervision of residents'/fellows' performance in patient management and in the procedural, interpretive, and consultative aspects of endovascular neurological surgery. The faculty also should stimulate scholarly activities and be able to direct residents/fellows in the conduct of such activities. Faculty members should hold appointments in the neurological surgery department. Evaluation of the faculty should be accomplished at least annually.



5. Faculty-to-Resident Ratio
   
   

The total number of trainees (resident and/or fellows) in the program must be commensurate with the capacity of the program to offer an adequate educational experience in endovascular neurological surgery. To ensure adequate teaching, supervision and evaluation of trainees' academic progress, the faculty-to-resident ratio must be at least one full-time faculty person for every 2 residents/fellows enrolled in the program.

6. Educational Program
   
   
1. Curriculum
   
   
1. Preparatory Requirements
   
   
1. Completed or currently enrolled in an ACGME accredited residency in neurological surgery.
   
   
2. All endovascular neurological surgery residents/fellows must have completed at least 6 months in neuroradiology which may be obtained in the neurosurgical residency or enfolded into the fellowship training in endovascular neurosurgery. All endovascular neurological surgery residents/fellows must have skills and knowledge in catheter techniques.
   
   
3. Completed a course in basic radiology skills acceptable to the program director where the endovascular training will occur. The basic radiology skills and neuroradiology training may be acquired during elective time in the neurological surgery residency.
   
   
4. Preparatory training must provide residents skills and knowledge in the following areas:
   
   
1. The use of needles, catheters, guidewires, and angiographic devices and materials.
   
   
2. The basic radiological sciences, including radiation physics, radiation protection, and the pharmacology of radiographic contrast materials.
   
   
3. Angiography and image interpretation.
   
   
4. The proper use and interpretation of laboratory tests and methods that are adjunctive to neuroendovascular surgical procedures, such as physiological monitoring, noninvasive neurovascular testing, and noninvasive neurovascular imaging
   
   
5. The evaluation of patients with neurological disease.
   
   
6. The basic and clinical neurosciences, including neuroanatomy, neurobiology, and the pathophysiology and natural history of neurological disorders, especially cranial/spinal/peripheral neurovascular diseases and neoplastic conditions.
   
   
7. The clinical aspects of patient assessment, treatment planning, and patient management related to Neuroendovascular surgical conditions and procedures, including the fundamentals of invasive monitoring and neurointensive care management.
   
   
8. The clinical indications, risks, and limitations of neuroendovascular surgical procedures.
   
   
9. The use and administration of analgesics, antibiotics, anticoagulation agents, neuroanesthetic agents, and other drugs commonly used in neuroendovascular surgical procedures.
   
   

The director of the Endovascular Neurological Surgery Program is responsible for documenting that the applicant has completed the appropriate preparatory training.



2. Endovascular Neurological Surgery Training
   
   

A period of 12 months must be spent in clinical neuroendovascular surgical training, during which the resident/fellow has the opportunity to carry out all of the following under close supervision:



Perform clinical preprocedure evaluations of patients, interpret preliminary diagnostic studies, consult with clinicians on other services, perform diagnostic and therapeutic neuroendovascular surgical procedures, generate procedural reports, and participate in short-term and long-term postprocedure follow-up care, including neurointensive care. The continuity of care must be of sufficient duration to ensure that the residents/fellows are familiar with the outcome of all neuroendovascular surgical procedures. Residents/fellows should serve as consultants under the supervision of staff neuroendovascular surgical practitioners. Direct interactions of residents/fellows with patients must be closely observed to ensure that appropriate standards of care and concern for patient welfare are strictly maintained. Communication, consultation, and coordination of care with the referring clinical staff and clinical services must be maintained and documented with appropriate notes in the medical record. The program must provide adequate opportunity for residents to participate in and personally perform and analyze a broad spectrum of endovascular procedures in adults, children, and neonates. Specific training should be provided in the following areas:



1. Anatomical and physiologic basic knowledge:
   
   
1. Basic knowledge in arterial and venous angiographic anatomy of the brain, spine, spinal cord, and head and neck.
   
   
2. Venous angiographic anatomy of the brain, spine, spinal cord, and head and neck.
   
   
3. Collateral circulation
   
   
4. Dangerous anastomoses
   
   
5. Cerebral blood flow
   
   
6. Autoregulation
   
   
7. Pharmacology of CNS vasculature
   
   
2. Technical aspects of endovascular neurological surgery including:
   
   
1. Catheter and delivery systems
   
   
2. Embolic agents in cerebral, spinal, and head and neck embolization
   
   
3. Flow-controlled embolization
   
   
4. Complications of cerebral embolization
   
   
5. Flow control between the extracranial and intracranial circulation
   
   
6. Electrophysiology
   
   
7. Provocative testing (pre-therapeutic evaluation)
   
   
8. Complications of brain, spine, spinal cord, and head and neck embolization.
   
   
9. Imaging of the vascular system
   
   
3. Pharmacology
   
   
1. Contrast materials
   
   
2. Provocative testing with anesthetics and sedatives
   
   
3. Anticoagulants
   
   
4. Thrombolytics
   
   
4. Coagulation cascade
   
   
5. Brain/spine arteriovenous malformations, arteriovenous fistulas of the brain, spine, spinal cord, head and neck vascular malformations, ischemic stroke, and cerebral aneurysms (all types of ischemic and hemorrhagic diseases of central and peripheral neuraxes)
   
   
1. Classification
   
   
2. Clinical presentations
   
   
3. Natural history
   
   
4. Epidemiology
   
   
5. Hemodynamic basis
   
   
6. Indications for treatment
   
   
7. Contraindications for treatment
   
   
8. Therapeutic modalities
   
   
9. Combined therapies
   
   
6. Tumors of the head, neck, spine, and central nervous system
   
   
7. Revascularization for occlusive vascular diseases
   
   
1. Arteriopathies
   
   
2. Atherosclerotic lesions
   
   
3. Techniques of revascularization: balloon angioplasty, thrombolytics, and stenting. All forms of pharmacologic and mechanical revasculariztion.
   
   
8. Embolization for epistaxis or other causes of hemorrhage
   
   
9. Invasive functional testing
   
   
10. Balloon test occlusions
    
    
3. Conferences and Didactic Training
   
   

Residents/fellows must make daily rounds with the attending faculty during which patient management decisions are discussed and made. Conferences should be organized by the faculty and held to allow discussion of topics selected to broaden knowledge in the field of endovascular neurological surgery. Specifically, teaching conferences should embrace the scope of endovascular neurological surgery as outlined in Section I (Definitions and Objectives) of these Program Requirements. Conferences should include journal clubs, pathology meetings, and neuroanatomy dissection courses related to endovascular neurological surgery. There must be didactic and interactive conference time, including interdepartmental meetings with neurosurgeons and other specialties that may be relevant to patient care. Regular review of all mortality and morbidity related to the performance of neuroendovascular surgical procedures must be documented. Residents/fellows must participate actively in these reviews, which should be held at least monthly. Residents/fellows should be encouraged to attend and participate in local extramural conferences and should attend at least one national meeting or postgraduate course in endovascular neurological surgery while in training.



7. Patient Population
   
   

The institution's patient population must have a diversity of illnesses from which broad experience in neuroendovascular surgical therapy can be obtained. The case material should encompass a range of neurological diseases, including neurovascular. An adequate variety and number of neuroendovascular surgical procedures must be available for each resident/fellow. Each program must perform at least 100 therapeutic neuroendovascular surgical procedures per year. These procedures include treatment of aneurysms, brain arteriovenous malformations, arteriovenous fistulas of the brain, tumors of the central nervous system, occlusive vascular diseases, revascularization, traumatic injury, maxillofacial vascular malformation, and tumors. In addition, the program must provide adequate training and experience in invasive functional testing. Each resident/fellow must maintain a personal case log, which the program director must certify at the completion of training. The EVNS program director must submit the entire clinical experience of the endovascular neurological surgery program and its trainees in the format prescribed by The Society of Neurological Surgeons/CAST. The list of procedures and the logs must be made available to the SNS/CAST at the time of its review of the core program and the endovascular neurological surgery training program.

The subspecialty program in endovascular neurological surgery must not have an adverse impact on the educational experience of resident training in neurological surgery,

8. Equipment and Facilities
   
   

Modern imaging/procedure rooms and equipment must be available and must permit the performance of all neuroendovascular surgical procedures. Rooms in which neuroendovascular surgical procedures are performed should be equipped with physiological monitoring and resuscitative equipment. The following state-of-the-art equipment must be available: MRI scanner, CT scanner, digital subtraction angiography equipment, ultrasound, and a radiographic- fluoroscopic room(s) with a tilt table. Facilities for storing catheters, guidewires, contrast materials, embolic agents, and other supplies must be next to or within procedure rooms. There must be adequate space and facilities for image display and interpretation and for consultation with other clinicians. The institutions where endovascular neurological surgery training is conducted must include appropriate inpatient, outpatient, emergency, and intensive care facilities for direct resident involvement in providing comprehensive neuroendovascular surgical care.

9. Scholarly Activity
   
   

Graduate medical education must take place in an environment of inquiry and scholarship in which residents participate in the development of new knowledge, learn to evaluate research findings, and develop habits of inquiry as a continuing professional responsibility. The responsibility for establishing and maintaining an environment of inquiry and scholarship rests with the teaching staff. While not all members of a teaching staff must be investigators, the staff as a whole must demonstrate broad involvement in scholarly activity. This activity should include:

1. active participation of the teaching staff in clinical discussions, rounds, and conferences in a manner that promotes a spirit of inquiry and scholarship. Scholarship implies an in-depth understanding of basic mechanisms of normal and abnormal states and the application of current knowledge to practice.
   
   
2. participation in journal clubs and research conferences.
   
   
3. active participation in regional or national professional and scientific societies, particularly through presentations at the organizations' meetings and publications in their journals.
   
   
4. participation in research, particularly in projects that are funded following peer review and/or result in publications or presentations at regional and national scientific meetings.
   
   
5. offering of guidance and technical support (e.g., research design, statistical analysis) for residents/fellows involved in research.
   
   
6. provision of support for resident/fellow participation in scholarly activities
   
   
10. Research
    
    

A subspecialty program should have an investigational component such that the residents/fellows may become familiar with the design, implementation, and interpretation of clinical and basic research studies. Facilities should be made available for research activity.

11. Research Facilities
    
    

The institution should provide laboratory facilities to support research projects pertinent to endovascular therapies.

12. Interchange With Residents/fellows in Other Specialties and Students
    
    

Residents/fellows should be encouraged to participate in research activities with residents and staff in other related specialties. They also should be encouraged to attend and participate in clinical conferences. It is desirable that they participate in the clinical teaching of neurological surgery and radiology residents/fellows and medical students.

13. Duty Hours and Conditions of Work
    
    

(See Program Requirements for Residency Education in Neurological Surgery.)

14. Evaluation
    
    
1. Residents/fellows
   
   

Subspecialty program directors must establish clearly defined procedures for regular evaluation of residents'/fellows knowledge, skills, and overall performance, including the development of professional attitudes consistent with being a physician. The assessment must include cognitive, motor, and interpersonal skills as well as judgment. The program director, with participation of members of the teaching staff, shall:

1. At least semiannually evaluate the knowledge, skills, and professional growth of the residents/fellows, using appropriate criteria and procedures.
   
   
2. Communicate each evaluation to the resident in a timely manner.
   
   
3. Advance residents/fellows to positions of higher responsibility only on the basis of evidence of their satisfactory progressive scholarship and professional growth.
   
   
4. Maintain a permanent record of evaluation for each resident/fellow and have it accessible to the resident/fellow and other authorized personnel.
   
   
5. Provide a written final evaluation for each resident/fellow who completes the program. The evaluation must include a review of the resident's/fellow's performance during the final period of training and should verify that the resident/fellow has demonstrated sufficient professional ability to practice competently and independently. This final evaluation should be part of the resident/fellows' permanent record maintained by the institution.
   
   
2. Faculty
   
   

Faculty must be evaluated at least annually to review teaching abilities, commitment to the educational program, clinical knowledge, and scholarly

3. Program
   
   

The educational effectiveness of a program must be evaluated in a systematic manner. In particular, the quality of the curriculum and the extent to which the educational goals have been met by residents/fellows must be assessed by the subspecialty program director. Written evaluations by residents/fellows should be utilized in this process.

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Updated 11/16/2006