Mandate Time in Angiography Suites During Neuro Training

The modern neurology training curriculum is due for a big change given the new demands in acute stroke triage and the scarcity of endovascular therapy specialists, one group said.

Neurology residents should be required to undergo neuroangiography rotations, and all vascular neurology fellows should be spending time in the angiography suite, argued Ashutosh Jadhav, MD, PhD, of Barrow Neurological Institute at St. Joseph’s Hospital and Medical Center in Phoenix, and colleagues.

“In light of the paradigm shift in recent years of stroke workflow as well as the growing body of evidence highlighting the gap in neurointervention exposure and the demand for it, the authors believe there is an urgent need to restructure the neurology training curriculum. The exposure should include a minimum of 4 weeks of dedicated neurointervention exposure as part of the core curriculum,” Jadhav and team wrote in Stroke.

The rotation would include a structure involving ambulatory and inpatient clinical responsibilities, as well as journal club activities.

Those 4 weeks, the authors said, would expose trainees to neuroanatomy, angiography, and the challenge of decision making in clinical cases in which there may be limited evidence. Additionally, neurology trainees may deepen their appreciation of their radiology and neurosurgical colleagues on multidisciplinary teams.

Giving all trainees greater exposure to neuroangiography would reflect challenges in the stroke field that cannot be met by neurointerventionalists alone: even if neurology residents and fellows do not end up in a neurointervention fellowship, they may consider a career in stroke and vascular neurology after their rotation, Jadhav and colleagues suggested.

“Stroke physicians are now expected to master the acute interpretation of advanced imaging and rapidly incorporate these findings into clinical assessment. In parallel, nonvascular fellowship-trained neurologists are increasingly involved in the triage of patients with acute stroke in the community and are directing these patients to stroke centers,” they wrote.

“Ultimately, this augmentation of the current neurology trainee experience will ensure higher quality care for patients with cerebrovascular diseases,” the authors concluded.

Yet such a change to the curriculum would be a tough sell for most medical schools. Among the barriers to mandatory neurointervention rotations are limitations in time for rotations, access to endovascular suites, and local mentorship.

Survey data suggest that actual trainee support for such a rotation is also questionable — many neurology residents have said that they would prefer having 4-8 weeks of elective time instead, Jadhav’s team acknowledged.

“Our philosophy for residency education is to ensure a comprehensive [neurology] education while helping residents fulfill their professional goals,” commented Nirali Vora, MD, neurology residency director at Stanford University School of Medicine in California.

She noted that Stanford neurology residents already undergo required stroke rotations, which expose them to thrombectomy decision making, and receive vascular neuroanatomy teaching by neurointerventionalists. For those interested, a dedicated neurointerventional radiology rotation is also available as an elective.

“All programs should have a pathway to explore the technical aspects of this subspecialty if a resident desires, but not [require it] given the breadth of neurology education and opportunities for scholarship and professional development that programs need to deliver,” Vora wrote in an email to MedPage Today.

In any case, Jadhav and colleagues complained that vascular neurology — without a required rotation to address competency in endovascular surgical neuroradiology — still lags behind radiology and neurosurgery in integrating cerebral angiography in the educational curriculum.

Several neurology residency and fellowship directors declined to comment for this article.