Complete Core Curriculum

Henry Ford Hospital Neuroradiology Training Program Core Curriculum is based on ASNR Education Committee Core Curriculum. This Core Curriculum will be followed in Conjunction with ACGME Program Requirements for Fellowship education in Neuroradiology.

Overall scope of practice:

The body of knowledge, training, and practice of Neuroradiology comprises both imaging and interventional procedures related to the brain, spine, and spinal cord, head, neck, and organs of special sense in adults and children. The neuroradiology trainee will function as an expert diagnostic and/or therapeutic consultant and practitioner.  Additionally, the trainee will foster one or more of the following depending upon circumstances: appropriate and effective consultation with clinical colleagues in Neurology, Neurosurgery, Neuro-oncology, Neuropathology, Otolaryngology, and Ophthalmology, Radiation Oncology, Rehabilitation, Pain Management, Emergency Medicine, and Anesthesia, and, if applicable, to provide opportunity, skills and/or support for research.

1. Imaging strategies (modalities)

The neuroradiology trainee will acquire basic knowledge about different imaging modalities [including fluoroscopy, radiographs, computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, angiography, positron emission tomography (PET), imaging strategies, image-guided therapy (interventional angiography, biopsies and spine procedures), radiation and safety issues related to the different modalities and how to properly use these modalities in the evaluation of disease in brain, spine, and head and neck. The neuroradiology trainee will also understand how the practice of Neuroradiology interacts and overlaps with other disciplines of Radiology such as Nuclear Medicine and thoracic imaging wherein complete evaluation of a patient's current imaging or optimal decisions regarding imaging modality choice necessitate incorporation of this information in decision-making.

MRI

Basic concepts and imaging techniques

• Basic knowledge about underlying physics/imaging principles for MRI
• Knowledge about differences between different MRI techniques (spin echo, gradient echo, fast spine echo, echo planar imaging), and different sequences (T1, T2, STIR, FLAIR, fat saturation), and their advantages and limitations in brain, spine, and head and neck. The appearance of common artifacts such as: Gibbs/truncation, chemical shift, fast-spin-echo-induced edge blurring, susceptibility-induced, flow-induced phase shift.
• Knowledge of operator selectable parameters/their modifications, their advantages/disadvantages in clinical MR imaging
• Differences in signal characteristics, artifact, effect of contrast agents due to different field strength
• The role of applying contrast agents and their effect on signal on different sequences, techniques and field-strength (see separate paragraph)
• Knowledge of different radio-frequency coils for Neuroradiological applications, including fundamental concepts of coil design and the advantages and limitations of coils.

Paramagnetic contrast agents in MRI

Knowledge of the effects of such agents on the tissue imaged.

• effect of dose, timing, sequence type and parameter selection
• normal and abnormal contrast enhancement patterns in the brain, spine, and head and neck

MR safety considerations

Knowledge of safety issues related to scanning patients

• Procedures to insure that only instruments and objects known to be safe are introduced into the MR environment
• sedation
• claustrophobia
• contraindications
• contraindications, relative and absolute
  • Renal failure
  • Retained metal
  • Implanted devices
• pregnancy
• sound volume
• general issues regarding the magnetic field, use of contrast agents, radiofrequency, gradient, including specific absorption rate (SAR) and particularly in relation to ultrahigh magnetic fields (3T, 4T and 7T).

Pharmacology and use of pararamagnetic contrast agents in MRI

Knowledge of the effects of such agents on the tissue imaged.

• effect of dose, timing, sequence type and parameter selection
• normal and abnormal contrast enhancement patterns in the brain, spine, and head and neck

MRI of the brain

Knowledge of the additional techniques used in the brain

• DWI
  • underlying physics/imaging principles, b-values
  • the techniques sensitivity/specificity, artifacts, and clinical applications in the brain
• DTI
  • underlying physics/imaging principles, ADC, FA, eigen values and other metrics
  • different techniques to implement DTI, multicolor image/maps techniques
  • capabilities and limitations of fiber tracking
  • clinical application
• MR perfusion
  • underlying physics/imaging principles of contrast enhanced perfusion, techniques T2*, T1 weighted limitations, calculations of CBV, MTT, CBF
  • clinical application
• MR angiography
  • underlying physics/imaging principles of contrast-enhanced, time-of-flight, phase-contrast  MR angiographic imaging techniques
  • knowledge of different reconstruction techniques: the maximum intensity projection (MIP), algorithm, 2DFT, 3DFT, their advantages/disadvantages
  • effects of dynamic and/or steady state contrast administration
  • limitations of the technique, artifacts
  • contrast-enhanced versus time-of-flight techniques
  • clinical applications
• MR spectroscopy
  • underlying physics principles and different techniques: 2D-CSI, 3D-CSI, SVS.
  • the localization and appearance of normal and abnormal brain metabolites on the x-axis (ppm scale)
  • effects on spectra by field-strength, by field homogeneity, water saturation
  • artifacts and limitations in performing MR spectroscopy
  • costs and limitation due reimbursement issues.
• Functional MR imaging
  • knowledge and understanding of underlying BOLD technique, how perform the study, reliability in data collection
  • different functional tests

MR of the spine

Knowledge of additional sequences in the spine

• DWI/DT
• Underlying physics/imaging principles
• Possible clinical application in the vertebral body, discs and spinal cord

MR of the head and neck

Knowledge of selective sequences used in the head and neck imaging

• High-resolution imaging of the skull base, cerebellopontine angle and face (e.g., for detection of perineural tumor and evaluation of cisternal cranial nerve segments).

CT

Basic concepts and imaging techniques

• Basic knowledge of the physics of CT techniques; conventional CT with single slice, multi slice technique, CT perfusion, CT angiography, portable versus fixed CT.
• Operative parameters: window and level optimization, use of Houndsfield units, slice thickness, multi-planar reconstructions
• Radiation safety and radiaton biology
• Radiation dosimetry, dose reduction and safety issues
• Pharmacology of CT contrast agents
• Appropriate use of contrast agents; dose, contraindications, adverse reactions and  their treatment
• Appropriate use of CT in diagnosis of brain, spine and head and neck
• Comparative role for CT and MRI for diagnosis and monitoring disease in brain,  spine and head and neck
• Knowledge about advantages/disadvantages of specific imaging protocols and  techniques

CT in the brain

Knowledge of specific sequences for the brain

CT perfusion

• Contrast agents,
• Advantages/disadvantages with different methods to perform CT perfusion and of measurements: rCBV, CBF, TTP and MTT
• Color map display
• Artifacts and limitations

CT angiography

• Contrast agents, dosage and timing for intracranial vessels, and  vessels of the neck
• Application of vascular reconstruction algorithms
• Artifacts and limitations

CT in the spine

• Knowledge of different scanning techniques, slice thickness, helical CT
• Reconstruction methods; 2D and 3D reformatted images

CT myelogram

• Knowledge of appropriate indications and contraindication
• Knowledge of puncture technique and imaging, appropriate contrast agents  and dosage
• Artifacts and limitations
• Post-procedure complications and treatment

CT in the head and neck

• Knowledge of protocols for different areas of the head and neck: paranasal sinuses, temporal bone, skull base, orbits, neck soft tissues.
• Knowledge of specific problem-solving techniques in CT imaging, such as gantry angulation (to avoid dental artifact), phonation techniques
• Understanding of contrast doses and acquisition timing
• Reconstruction methods; 2D and 3D reformatted images

2. Intervention (approaches)

Basic knowledge of physics/imaging principles of different interventional procedures in the brain, spine and head and neck including:Indications, patient selection, contraindications, use of contrast agents, alternative imaging modalities, complications and patient care/management. This body of knowledge encompasses diagnostic and technical skills as well as clinical acumen.

Technical knowledge and skills

• Principles of radiologic physics including x-ray beam collimation/magnification, radiation dosimetry and safety, fluoroscopy, and digital subtraction techniques
• Contrast utilization - principles and safety, including contraindications and treatment of contrast reactions, dosing, and use of mechanical injectors
• Endovascular access techniques
• Percutaneous Biopsy techniques

Diagnostic and clinical skills

Basic knowledge angiographic appearance of the normal vascular anatomy, variants and disorders of the cerebral and spinal vasculature

• Knowledge of different endovascular access techniques, catheter type, contrast agents (type and dosage), appropriate selective angiographic methods, imaging technique
• Knowledge of use of therapeutic agents and their advantages /disadvantages for treatment of vascular processes in the brain, spine and head and neck
• Knowledge of contraindications to cerebral catheter angiography,alternative imaging modalities (CTA, MRA) and alternatives to iodinated contrast agents.
• Pre- and post procedural patient monitoring, recognizing and managing complications
• Recognition of artifacts and the impact on technical factors on the angiograms.

3. Knowledge base

Section - Brain

Scope

Includes knowledge of brain and skull anatomy and including normal variants of the brain, and associated extracranial tissues (i.e., calvarium, meninges) and vascular structures, basic neurophysiology, and normal development. Understanding of the principles of structural and functional imaging with Neuroimaging, including diagnostic skills, knowledge of current radiation and MR safety guidelines, and recognition of common artifacts. This also includes principles and basic skills of performance of diagnostic and therapeutic angiographic techniques

• Infectious/Inflammatory
  • Encephalitis
  • Meningitis
  • Abscess
  • Subdural/Epidural empyema
  • Ventriculitis
  • Infections in the Immunocompromised Host
  • Congenital/Perinatal
  • Granulomatous infections
  • Prion disease
• White Matter
  • Demyelinating
  • Inherited Metabolic/Degenerative Disorders
  • Small vessel ischemic disease, hypertension, and white matter changes of aging
• Trauma
  • Mechanisms of injury
  • Trauma of the immature brain
    • Perinatal trauma
    • Non-accidental trauma
  • Primary
    • Cortical contusions
    • Diffuse axonal injury shearing
    • Subarachnoid hemorrhage
    • Subdural hemorrhage
    • Epidural hemorrhage
    • Parenchymal hemorrhage with differentials
    • Non-accidental trauma
    • Skull fractures, associated complications
  • Secondary
    • Herniation patterns and syndromes
    • Edema
    • Ischemia/infarction
    • Brain death
    • Vascular injuries
    • Chronic effects including atrophy
• Neoplasm
  • Adult
    • Intra-axial
      • Primary
        • Glial
        • Neuronal
        • Mixed neuronal glial
        • Embryonal
        • Pineal
        • Choroid plexus tumors
        • Primary Central Nervous System Lymphoma
      • Metastatic
        • Anatomic locations
        • Paraneoplastic syndromes
    • Extra-axial
      • Primary
      • Metastatic
      • Cerebellopontine angle
      • Sella/Parasellar
  • Pediatric
    • Intra-axial
      • Intratentorial
      • Supratentorial
    • Extra-axial
• Cerebrovascular
  • Ischemia/Infarction
    • Strategies for imaging
    • Etiology
  • Spontaneous hemorrhage
    • Strategies for imaging
    • Etiology
      • Cerebrovascular malformations
      • Hematologic causes
      • Drugs
      • Cerebral amyloid (Congophilic) angiopathy
      • Hypertension
      • Imaging of hemorrhage over time with CT, MR
    • Complications
• Vasculitis
• Dissection (spontaneous)
• Atherosclerosis
• Venous thrombosis
• Posterior reversible encephalopathy syndrome (PRES)

Congenital/Developmental

• Brain development
• Disorders of organogenesis
  • Disorders of neural tube closure
  • Disorders of diverticulation and separation
  • Midline anomalies
  • Prenatal destruction brain disorders
• Disorders of neuronal migration and sulcation
• Cerebellar malformations
  • Diffuse and focal dysplasias
  • Cerebellar hypoplasia
  • Posterior fossa cystic disorders
• Disorders of histogenesis (Phakomatoses)
• Miscellaneous

Degenerative and dementing disorders
   Seizure disorders
   Dementias (distribution and part played by Neuroimaging)
   Parkinson disease and Parkinson plus syndromes
   Multisystem atrophy
   Amyotrophic lateral sclerosis
   Miscellaneous

Acquired Metabolic/Toxic Disorders

• Characteristics
  • Considerable overlap in these categories
  • Typical distribution
• Toxic
  • Poisoning
  • Liver failure
  • Miscellaneous
• Metabolic
  • Mitochondrial disease
  • Inherited or acquired disorders of metabolism
  • Heavy metals
  • Miscellaneous
• Anoxic/Hypoxic injury
• Hypoglycemic injury

Section - Head and Neck

Scope

Includes knowledge of normal anatomical structures making up the skull base, orbit, paranasal sinuses, face and neck including lymph nodes and the cranial nerves. Understanding of the neck fascial layers and the delineation of ‘spaces' in the suprahyoid and infrahyoid neck. Knowledge of basic embryology and how it pertains to the presence or development of neck pathology. Understanding of the principles of CT and MR imaging protocols for evaluation of specific regions within the head and neck and the indications and limitations of each imaging technique. Recognizing the utility and limitations of FDG-PET in the head and neck and specifically for the management of Squamous Cell Carcinoma (SCCa). Knowledge of the principles and basic skills of percutaneous biopsy in the head and neck.

The neck

• Imaging Evaluation
• Anatomy
• Embryology and Congenital lesions
• Inflammation/Infection
• Masses

Orbit

• Imaging evaluation
• Anatomy, embryology
• Infectious/inflammatory
• Trauma

Nasal cavity and paranasal sinuses

• Imaging evaluation
• Anatomy
• Inflammation/Infection
• Masses
• Post-operative sinuses
• Miscellaneous

Skull base

• Defects
• Trauma
• Intrinsic bone lesions

Temporal bone

• Imaging evaluation
• Anatomy, embryology
• Sensorineural Hearing Loss
• Conductive Hearing Loss
• Pulsatile Tinnitus
• Trauma
• Inflammatory/Infectious
• Tumors
• Postoperative
• TMJ derangement

Cystic neck masses

• Imaging evaluation
• Developmental
• Infectious
• Neoplastic

Section - Spine

Scope

Includes knowledge of normal anatomical structures of the spine and spinal cord. Knowledge of basic embryology and how it pertains to the presence or development of congenital spine pathology. Understanding of the principles of plain film, CT and MR imaging protocols for evaluation of spine and the indications and limitations of each imaging technique. Understand the utility and limitations of various spine and nerve block procedures. The principles and basic skills of performance of spinal angiography, percutaneous biopsy,vertebroplasty, discography, myelograms, and facet injections/nerve blocks.

Anatomy/Variants and biomechanics

• Vertebral bodies
• Facet joints and transverse processes
• Lamina and spinous processes
• Support ligaments
• Structure of the intervertebral disk
• Specific characteristics of cervical, thoracic, and lumbar segments
• Cranio-vertebral and lumbo-sacral junctions
• Normal stability and motion

Trauma

• Mechanism of injury
• Stable fractures and ligamentous injuries
• Unstable injuries
• Lamina and spinous processes
• Traumatic disc herniation
• Extrinsic cord compression
• Cord contusion
• Intra-spinal hemorrhage
• Post-traumatic abnormalities

Degenerative disease

• Epidemiology
• Nomenclature according to ASNR classification scheme
• Disc degeneration
• End plate degeneration
• Disc herniation
• Spinal stenosis
• Post-operative changes

Inflammatory and demyelinating disease

• Discitis/osteomyelitis
• Facetitis
• Epidural / paraspinal abscesses
• Meningitis
• End plate degeneration
• Spinal cord lesions
• Human Immunodeficiency Virus (HIV)
• Paraneoplastic
• Guillain Barre
• Chronic inflammatory demyelinating polyneuropathy

Neoplastic

• Osseous
• Extradural
• Intradural Extramedullary
• Intramedullary

Cystic Lesions

• Extradural
• Intradural Extramedullary
• Intramedullary

Vascular lesions

• Spinal AVM
• Dural AVM/AVF
• Spinal cord ischemia

Developmental spine lesions

• Embryologic development of spine
• Open Spinal Dysraphism including:
• Closed Spinal Dysraphism
• Complex Dysraphic States including:

Brachial plexus imaging

• Traumatic nerve root avulsions
• Metastatic disease
• Direct extension of tumor
• Nerve sheath tumors
• Radiation changes
• Compressive syndromes

Section - Head and Neck

Scope 
Includes knowledge of normal anatomical structures making up the skull base, orbit, paranasal sinuses, face and neck including lymph nodes and the cranial nerves. Understanding of the neck fascial layers and the delineation of ‘spaces' in the suprahyoid and infrahyoid neck. Knowledge of basic embryology and how it pertains to the presence or development of neck pathology. Understanding of the principles of CT and MR imaging protocols for evaluation of specific regions within the head and neck and the indications and limitations of each imaging technique. Recognizing the utility and limitations of FDG-PET in the head and neck and specifically for the management of Squamous Cell Carcinoma (SCCa). Knowledge of the principles and basic skills of percutaneous biopsy in the head and neck.

The Neck

• Imaging Evaluation
• Anatomy
• Suprahyoid and Infrahyoid spaces
• Embryology and Congenital lesions
• Inflammation/Infection
• Masses
• Benign and Malignant
• Staging of Squamous Cell Carcinoma
• Nodal Disease
• Node level system (anatomy)
• Imaging criteria for malignancy
• Different size criteria
• Necrosis, extranodal spread, calcifications
• Thyroid gland
• Masses, neoplasms & recurrent tumors
• Imaging evaluation
• Incidental thyroid nodules 
• Parathyroid glands
• Masses
• Imaging evaluation

Orbit

• Imaging evaluation
• Anatomy, embryology
• Infectious/inflammatory
• Trauma
• Globe lesions
• Pediatric ocular
• Adult ocular
• Intraconal lesions
• Optic nerve pathology
• Extraocular muscle lesions
• Lacrimal apparatus

Nasal Cavity and Paranasal sinuses

• Imaging evaluation
• Anatomy
• Inflammation/Infection
  • Acute & Chronic 
  • Complications
• Masses
  • Benign and Malignant
    • Nasal cavity masses
    • Paranasal sinus masses
    • Fibro-osseous lesions
• Post-operative sinuses
  • Expected findings & complications
• Miscellaneous

Skull Base

• Defects
  • Congenital & Acquired
  • CSF leak
• Trauma
• Intrinsic bone lesions
  • Clival lesions
  • Benign & Malignant tumors
  • Bone Dysplasias

Temporal bone 

• Imaging evaluation
• Anatomy, embryology
• Sensorineural Hearing Loss
  • Congenital
  • Acquired
• Conductive Hearing Loss
  • Congenital
  • Acquired
• Pulsatile Tinnitus
• Trauma
• Inflammatory/Infectious
  • Complications
• Tumors
• Postoperative
• TMJ derangement

Cystic Neck Masses 

• Imaging evaluation
• Developmental
• Infectious
• Neoplastic

Section - Spine

Scope
Includes knowledge of normal anatomical structures of the spine and spinal cord. Knowledge of basic embryology and how it pertains to the presence or development of congenital spine pathology. Understanding of the principles of plain film, CT and MR imaging protocols for evaluation of spine and the indications and limitations of each imaging technique. Understand the utility and limitations of various spine and nerve block procedures. The principles and basic skills of performance of spinal angiography, percutaneous biopsy,vertebroplasty, discography, myelograms, and facet injections/nerve blocks.

Anatomy/Variants and Biomechanics

• Vertebral bodies
• Facet joints and transverse processes
• Lamina and spinous processes
• Support ligaments 
• Structure of the intervertebral disk
• Specific characteristics of cervical, thoracic, and lumbar segments
• Cranio-vertebral and lumbo-sacral junctions
• Normal stability and motion

Trauma

• Mechanism of injury
• Stable fractures and ligamentous injuries
• Unstable injuries
• Lamina and spinous processes
• Traumatic disc herniation
• Extrinsic cord compression
• Cord contusion
• Intra-spinal hemorrhage
• Post-traumatic abnormalities

Degenerative Disease

• Epidemiology
• Nomenclature according to ASNR classification scheme
• Disc degeneration
• End plate degeneration
• Disc herniation
• Spinal stenosis
• Post-operative changes

Inflammatory and Demyelinating Disease

• Discitis/osteomyelitis
• Facetitis
• Epidural / paraspinal abscesses
• Meningitis
• End plate degeneration
• Spinal cord lesions
  • Idiopathic acute transverse myelitis
  • Demyelinating diseases
  • Infectious diseases
  • Vasculitides
• Human Immunodeficiency Virus (HIV)
• Paraneoplastic
• Guillain Barre
• Chronic inflammatory demyelinating polyneuropathy

Neoplastic

• Osseous
  • Primary tumors, benign
  • Primary tumors, malignant
  • Metastases
• Extradural
• Intradural Extramedullary
• Intramedullary

Cystic Lesions

• Extradural
• Intradural Extramedullary
• Intramedullary

Vascular Lesions

• Spinal AVM
• Dural AVM/AVF
• Spinal cord ischemia

Developmental Spine Lesions

• Embryologic development of spine
• Open Spinal Dysraphism including:
  • (hemi)Myelomeningocele
  • (hemi)Myelocele
• Closed Spinal Dysraphism
  • Simple Dysraphic States including:
    • Posterior spina bifida
    • Lipoma (intradural, intramedullary, filum terminale)
    • Tight filum terminale
    • Persistent terminal ventricle
• Complex Dysraphic States including:
  • Dorsal enteric fistula
  • Neurenteric cyst
  • Split cord
  • Dermal sinus
  • Caudal regression 
  • Segmental spinal dysgenesis

Brachial Plexus Imaging

• Traumatic nerve root avulsions
• Metastatic disease
• Direct extension of tumor
• Nerve sheath tumors
• Radiation changes
• Compressive syndromes