Pedatric Neuroradiology Rotation

CS Mott Children's Hospital
University of Michigan Medical Center
Ann Arbor, Michigan

The Neuroradiology Fellowship Training Program Director (Currently Dr. Ellen Hoeffner), Department of Radiology, University of Michigan Center in Ann Arbor, Michigan, will be in charge of both educational and supervisory responsibilities of rotating neuroradiology fellows at CS Mott Children's Hospital.  The program director and neuroradiology faculty will have the responsibility for teaching, supervision, and formal evaluation of fellows.  The fellowship program director at University of Michigan will be responsibility for educational rationale, following stated goals and objectives, policies, and procedures that will govern Henry ford Hospital neuroradiology fellow's education during the four weeks of rotation at CS Mott Children's Hospital.  The Henry Ford Hospital neuroradiology fellow will report to the Program Director at the University of Michigan at the beginning and end of the rotation.

Core curriculum, goals, and objectives:

1. Imaging strategies:

MRI

Understand MR safety protocols, learn to institute the protocol, and apply it consistently.

Understand how different pulse sequences are utilized for imaging of the pediatric patient  and how these sequences can be altered for specific application in different disease processes.

Implement special imaging sequences (CSF flow studies, spectroscopy, etc.) for the  evaluation of pediatric disease processes.

Understand the use of contrast in the pediatric patient and obtain informed consent for its  usage.

Understand the risks and benefits of fetal MRI and obtain informed consent for its  performance.

CT

Become familiar with the principle of ALARA for pediatric CT protocol design.

Understand and implement contrast dosing for the pediatric patient.

Understand the role of special CT examinations (Perfusion, CTA) for pediatric exams.

Interventional

Become familiar with the common neurointerventional procedures performed on pediatric  patients from indications, patient evaluation, procedure performance, to post-procedure  care and followup.

Become efficient in the use of fluoroscopic equipment used for these procedures.

Understand and implement fluoroscopic techniques used to reduce patient radiation and  contrast dose.

Ultrasound

Gain experience in the performance and interpretation of fetal, neonatal, and pediatric &ultrasound of the CNS and head and neck.

2. Knowledge base:

Brain

Normal development

• Fetal imaging and the grading of brain maturation in preterm infants
• Postnatal brain development and myelination milestones
• Terminal zones of myelination
• MR spectroscopic alterations during normal brain development

Congenital abnormalities

• Anomalies of the corpus callosum
• Malformations of cerebral cortical development
• Chiari malformations
• Cerebellar malformations
• Anomalies of the brainstem
• Anomalies of the hypothalamic-pituitary axis
• Phakomatoses
• Prenatal ultrasound diagnosis of these disorders

Infectious/Inflammatory

• Congenital and perinatal infections
• Septic and aseptic meningitis
• Ventriculitis
• Subdural/epidural empyema
• Encephalitis/Abscess
• Autoimmune disorders (ADEM, MS)
• Collagen vascular diseases (SLE)
• EG

Toxic/Metabolic

• Storage disorders involving WM, GM, and both
• White matter injury from radiation and chemotherapy
• Mitochondrial disorders
• Toxic exposure (lead, solvents)
• Neurodegenerative disorders (Huntington's, PKAN, etc.)

Trauma

• Non-accidental trauma patterns and recognition
• Intracranial hemorrhage in newborn (birth trauma); appearance on CT, MR, and US
• Contusions/DAI

Neoplastic

• Intra-axial masses
• Extra-axial masses
• Sellar and suprasellar masses
• Pineal region masses

Vascular

• Hypoxic/ischemic brain injury (localized and diffuse)
• Perinatal brain injury (porencephaly, hydranencephaly)
• Veno-occlusive disease
• Parenchymal hemorrhage (term and pre-term); germinal matrix hemorrhage grading on US
• Vasculopathy (Moya-moya, sickle cell)

Vascular malformations

• AVM, AVF (VOG); prenatal (US,MR) and postnatal diagnosis
• Cryptic malformations (cavernomas, etc.)
• Aneurysms

Hydrocephalus

• Congenital versus acquired
• Communicating versus non-communicating
• Benign enlargement of the subarachnoid spaces
• Shunting complications

Head and Neck

Normal development

• Normal development of the skull and paranasal sinuses

Congenital

• Cephaloceles and other calvarial/skull base defects
• Anomalies of the eye
• Syndromic and non-syndromic craniosynostosis
• Phakomatoses
• Cystic masses of the neck

Trauma

• Non-accidental trauma patterns and recognition
• Extracranial birth trauma (cephalohematoma, etc.)
• Skull fractures

Neoplastic

• Ocular tumors (retinoblastoma, etc.)
• Vascular orbital masses
• Soft tissue masses of the orbit (sarcoma, leukemia, etc.)
• Tumors of the neck soft tissues and airway (hemangioma, angiofibroma, etc.)
• Bony tumors of the skull base

Vascular

• Vascular malformations of the neck soft tissues

Spine

Normal development

• Normal ossification centers and progression of fusion

Congenital

• Abnormalities of neurulation
• Anomalies of the caudal cell mass
• Anomalies of notochord development
• Syringohydromyelia
• Phakomatoses
• Congenital tumors of the spine (teratoma, dermoid, etc.)

Trauma

• Non-accidental trauma patterns and recognition
• Birth trauma
• Spinal trauma (accidental), emphasis on ligamentous injury
• Spinal hemorrhage

Neoplastic

• Intramedullary tumors
• Extramedullary tumors

Infectious/Inflammatory

• Spinal meningitis
• Transverse myelitis
• Diskitis/osteomyelitis
• Spinal empyema
• Sarcoid
• EG

Vascular

• Cord infarction
• Vascular malformations (intramedullary AVM, dural AVF, etc.)

Degenerative disease

• Disk herniations/extrusions
• Degenerative disk disease

Core competencies:

Patient care

Understand the use of MRI and CT for the evaluation of pediatric patients and how these exams can vary from adult exams.
Become familiar with the use of special CT and MR studies (perfusion, DTI, etc.) for the evaluation of pediatric disorders.
Understand the concept of ALARA for pediatric CT and contrast dosing for pediatric CT and MR exams. Obtain informed consent for contrast in the pediatric patient.
Review the treatment of contrast reactions in the pediatric patient.
Become familiar with ALARA principles for interventional fluoroscopic procedures.
Performance and interpretation of fetal, neonatal, and focused pediatric ultrasound.

Medical knowledge

Become familiar with the normal development of the brain and spine.

Become familiar with disease processes involving the brain, head and neck, and spine in pediatric patients, especially those unique to or more common in the pediatric patient.
Be able to generate a reasonable image-based differential diagnosis.

Interpersonal and vommunication dkills

Consultation with clinicians for the review of imaging studies. Verbalization of observation and interpretation leading to a useful differential diagnosis. Dictate cases in an organized, succinct, and informative fashion.

Practice-based learning and improvement

Review all cases and present findings with differential diagnosis to the supervising faculty.

Review attending's Fellow Evaluation form. Discuss comments when pertinent.

Learn to access and incorporate Pub Med and internet searches in interpretation.

Attend clinical conferences with the Pediatric Neurology and Neurosurgery services.

Professionalism

Demonstrate respect for all patients.

Serve as role model for residents and medical students on the rotation.

Respect patient confidentiality.

Present oneself as professional in appearance and communication.

Demonstrate a responsible work ethic with regard to work assignments.

Systems-based practice

Attend clinical conferences with pediatric neurology and neurosurgery services.

Gain an understanding of the integration of imaging findings with the clinical findings to develop a focused differential diagnosis.

Gain an understanding of the relative costs and benefits of CT, MRI, and interventional studies.

Demonstrate knowledge of ACR appropriateness criteria through discussion with attending staff and case presentation at imaging conferences.

Graded responsibility:

• First Week - Become familiar with CT and MR imaging protocols and their proper implementation for different disease states.  Review the dosing protocols for both gadolinium-based and iodine-based contrast agents, their risks and benefits, and obtain informed consent for their usage when necessary.
• Second Week - Become familiar with normal development of fetal and pediatric brain and spine.  Be able to assess the normal and abnormal myelination and sulcation patterns on fetal and pediatric brain MRI.
• Third Week - Evaluate and accurately diagnosis common disorders and disease states in pediatric neuroradiology (routine infections, neoplasms, and trauma, etc.).
• Fourth Week - Understand and produce a reasonable differential diagnosis for more complex and rare pediatric disease states (i.e., storage disorders and white matter diseases) based on the clinical and imaging findings.

Evaluation:

The fellows are evaluated by CS Mott Children's Hospital faculty using the Henry Ford Hospital Verinform evaluation.