A period of 12-24 continuous months (dependent on the applicant’s background training) must be spent in clinical neurointerventional training, during which the trainee has the opportunity to perform all of the following under close supervision: clinical pre-procedural examinations of patients, evaluation of preliminary diagnostic studies, consultation with clinicians as it relates to the care of the patient, diagnostic and therapeutic neurointerventional procedures, generation of procedural reports, and participation in short-term and long-term post-procedural follow-up care, including neuro-intensive care. The continuity of care must be of sufficient duration to ensure that the fellow is familiar with the outcome of all interventional neuroradiology procedures. The fellowship will be tailored to the trainee’s background and experience, as neurosurgeons, radiologists, and neurologists are eligible for training in neurointervention.

Fellows should serve as consultants under the supervision of staff neurointerventional practitioners. Direct interactions of trainees 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.

Upon completion of the full training, fellows will be proficient in the diagnosis and management of cerebrovascular disorders and possess the skills required for independent practice in the field of interventional neuroradiology.

The program must provide adequate opportunity for fellows to participate in and personally perform and analyze a broad spectrum of endovascular procedures. Our philosophy is to train fellows to practice evidence-based medicine and fellows are expected to possess core competencies according to CanMEDS guides to deliver optimal health care. Specific training should be provided in the following areas:

Medical Expert

• Basic knowledge:
  • Arterial and venous angiographic anatomy of the brain, spine, spinal cord and head and neck
  • Cerebral blood flow
  • Cerebral blood flow and autoregulation
  • Collateral circulation and dangerous anastomosis

• Technical aspects of neurointerventional procedures:
  • Arterial and venous access
  • Arterial navigation for cerebral and spinal angiography
  • Catheters and delivery systems
  • Embolic agents (coils and liquid embolic materials)
  • Stents, flow diverters, coils, balloons, microcatheters and wires
  • New and emerging technologies and devices
  • Radiation safety (Residents/fellows are required to do mandatory radiation safety training prior to starting any diagnostic or neurointerventional procedures.

• Clinical knowledge (diagnosis, natural history, management, interventional procedures):
  • Acute stroke
  • Aneurysms
  • Arteriovenous malformations
  • Pial Arteriovenous fistula
  • Dural arteriovenous fistula
  • Extracranial cervical artery stenosis
  • Intracranial artery atherosclerosis
  • Head and neck vascular lesions/tumours
  • Arteriopathies and veno-occlusive disorders
  • Neurocutaneous and genetically inherited vascular disorders

• Diagnostic modalities (physics/mechanisms, indications, interpretation):
  • CT/A/V
  • MRI/A/V (time-resolved CEMRA)
  • Digital subtraction angiography
  • Ultrasonography and transcranial Doppler

• Pharmacology:
  • Contrast materials
  • Provocative testing with anesthetics agents
  • Antiplatelet agents
  • Anticoagulants
  • Thrombolytics

• Interventional procedures (indications, risks, outcomes, trials):
  • Intra-arterial stroke therapy
  • Aneurysm embolization (coiling and flow-diversion)
  • Intra-arterial pharmacological and mechanical treatment of vasospasm.
  • Cranial and spinal DAVF, AVF and AVM Embolization
  • Stenting (extracranial and intracranial)
  • Tumour embolization (intracranial and head and neck lesions)
  • Embolization for epistaxis and other causes of hemorrhage
  • Balloon test occlusions
  • Invasive functional testing (WADA, pre-AVM embolization)

Communicator

• Communicate effectively with referring physicians and other members of the health care team
• Communicate indications and urgency of diagnostic procedures appropriately with nurses and radiologists
• Become proficient at communicating indications and risks of cerebrovascular diagnostic modalities to patients and family members

Collaborator

• Work effectively with nurses, nurse practitioners, radiologists, and neurosurgeons in a collaborative model of patient assessment and management.

Manager

• Balance the proper use of investigations and therapies with the social obligation to control health care costs, with an understanding of how investigations and therapies can change management and/or outcomes

Advocate

• Recognize the indications, risks, alternatives, and contraindications of physical and chemical restraints.
• Recognize when an older patient’s ability to access various services in the health and social system is compromised and be able to act as an advocate in that circumstance.
• Considers alternatives treatment, including non-invasive options and open-surgical treatments.
• Awareness of a patient’s ability to access various services in the health care system and be able to act as an advocate in that circumstance.

Scholar

• Be able to effectively teach patients, families, students, residents and other health care professionals about issues related to cerebrovascular disease.
• Be aware of the evidence base behind current standards of care for cerebrovascular diseases.
• In-depth knowledge of seminal and recent clinical trials.

Professional

• Understand the legislation related to informed consent and decision-making capacity, including the roles of physicians and substitute decision-makers.
• Analyze and attempt to resolve ethical issues surrounding patient care such as truth-telling, consent, confidentiality, end-of-life care, conflict of interest, and resource allocation.

• The priority of the Neuro IR fellowship will be in the technical training and skill development to perform diagnostic cranial and spinal angiography and to be proficient with all neurointerventional procedures.
• Fellows must make daily rounds with the attending faculty during which patient management decisions are discussed and Regular Neuro IR rounds are organized by the faculty and held weekly to allow discussion of topics selected to broaden knowledge in the field of interventional neuroradiology. Specifically, teaching conferences should embrace the scope of neurointervention as outlined in Section I of these program requirements. Conferences should include journal clubs, pathology meetings, and neuroanatomy dissection courses related to neurointerventional surgery
• Fellows with have amply didactic and interactive conference time with Neuro IR, as well as participate in interdepartmental meetings with neurosurgeons, neurologists and neuroradiologists.
• Regular review of all mortality and morbidity related to the performance of interventional neuroradiology procedures must be documented. Fellows must participate actively in these reviews, which should be held monthly.

• Fellows are expected to participate in clinical research and help with the maintenance of an ongoing database in neuroendovascular. It is expected that, during the 24 months of training, the fellow has written and submitted at least two manuscripts to a peer-reviewed journal.
• Fellows are encouraged to attend and participate in local extramural conferences and should attend at least one national meeting or postgraduate course in interventional neuroradiology therapy while in training. Fellows are expected to present their research at national and/or international meetings.

• The fellowship training should not interfere with the training of residents, e.g. in terms of surgical experience, exposure to cases or learning opportunities. The fellow should be seen as an asset to the residents whom they should be able to learn from and consult frequently. It is expected that fellows will participate in the teaching and supervision of residents.
• For INR fellows with a background in Neurosurgery, after the first 12 months, the fellowship will be reviewed by the team and opportunities to participate in open neurovascular surgery will be explored.

• At all times there will be a Physician from the INR team available on-call to consult on all cases, and a secondary on-call Physician to assist.
• Fellows will be required to work closely with the on-call primary and backup staff Neurointerventionalists.

Neuro IR On-Call Schedule

• The INR fellow call schedule will be maintained by the INR Program Director.
• Call schedules will be communicated as per HHS procedures and communicated to the McMaster University/Hamilton Health Sciences paging system.
• Written requests for time off must be submitted 2 weeks prior to the schedule.
• Changes to the schedule once posted will be the responsibility of the requesting fellow.
• Changes are to be communicated ASAP to the INR fellowship program director.
• A Call day runs from 0800 hours on the calendar date to the following 0800 hours.
• Weekend call begins Friday at 1700h and continues to the following Monday at 0800h.
• Call to be evenly distributed between INR fellows.
• If there is only one fellow in a given academic year, the fellow will agree to the following on-call schedule: every Tuesday and Thursday and every other weekend.
• Weekend call duties involve: Daily (Saturday and Sunday) rounds on all Neurointerventional inpatients. A progress note must be completed on all inpatients. Fellows are expected to round on all inpatients beginning at 8 am. Fellows are expected to respond promptly when paged/called to the ward regarding inpatient issues throughout the course of the weekend on-call period.
• Each Fellow will partake in an equal share of statutory holidays throughout the year.
• Every effort will be made to avoid working the same holidays for 2 consecutive years.
• Each fellow will be expected to have a minimum of 14 days of call per month (except if on leave).

• Consult notes and dictations are a priority and must be completed in a timely fashion.
• Handover will be performed in accordance with MAC policy. This is a Physician-to-Physician Transfer of Accountability that will communicate all pertinent clinical information to the next provider.
• When on- call, other scheduled activity should be kept to a minimum as to make one’s self immediately available for consultation and procedures.
• INR fellows must be available for any INR procedure on their day of call. INR procedures are a priority and must be attended immediately, and may precipitate cancelling of scheduled clinics and teaching.
• The on-call Physician and/or Clinical Fellow must arrange appropriate DI personnel (technologist, nursing and Anesthesia) for any emergent DI procedures.

• Daily clinical assessment and review of imaging and laboratory tests for all Neurointerventional inpatients are mandatory. A daily progress note must be completed on all patients.
• Fellows are expected to round on all inpatients from 7 a.m.- 8 a.m.
• Fellows are expected to respond promptly when paged/called to the ward regarding inpatient issues throughout the course of the day and after-hours when on call.
• Admission notes and discharge summaries must be completed/dictated in a timely fashion using standard formatting as per the attending physician.
• Handover will be performed in accordance with MAC policy. This is a Physician-to-Physician Transfer of Accountability that will communicate all pertinent clinical information to the next provider.
• When on-call, other scheduled activities should be kept to a minimum to make one’s self immediately available for consultation and procedures.
• Neurointerventional fellows must be available for any INR procedure on their day of the call. INR procedures are a priority and must be attended immediately, and may precipitate cancelling of scheduled clinics and teaching. When not on call, fellows are encouraged to participate in all emergency cases.
• The on-call Physician and/or Clinical Fellow must arrange appropriate DI personnel (technologist, nursing and Anesthesia) for any emergent DI procedures.

• Fellows are expected to attend all Neuro IR clinics (Adult and Pediatric).
• Consultation and clinic notes are a priority and must be completed/dictated on the same day of the clinic visit.
• INR clinics for adult patients are held on Monday (Dr. Wang and Dr. van Adel), Wednesday (Drs Larrazabal and van Adel), Thursday (Dr. van Adel and Dr. Algird) and Friday (Dr. van Adel).
• INR fellows must be available for any INR procedure(s) on their day of call. INR procedures are a priority and must be attended immediately, and may precipitate cancelling of scheduled clinics and teaching.

• Diagnostic cerebral and/or spinal angiography.
• Elective interventional procedures.
• Emergency procedures (24/7).
• Diagnostic and Interventional procedures/cases will be dictated on the PACS system.
• Fellows will receive training and access to the PACS dictation system.
• Reports must be dictated as a priority on the PACS system and must be completed in a timely fashion (within 48hrs).
• Fellows will be expected to have completed formal radiation safety training prior to participating in any diagnostic and/or neurointerventional procedures.
• Fellows will be expected to maintain a case log book, recording all diagnostic and interventional procedures with direct involvement. The log book will be part of a quarterly review of the fellows clinical activities and performance.
• Fellows are to access all patients in the same day surgery unit and document a pre-procedural assessment prior to coming to the angio-suite.
• Fellows are to have reviewed all pertinent patient information (prior imaging, past history, current medications, and allergies) prior to entering the angiosuite.
• Fellows will perform/participate in a “procedural checklist” for every patient.
• Fellows are required to assess patients after diagnostic and interventional procedures and document a post-procedural patient assessment in the chart.
• Fellows are to contact the Neuro-stepdown Unit (NSU) co-ordinator, or staff neurosurgeon, neurologist, or ICU physician to provide. This is a Physician-to-Physician Transfer of Accountability that will communicate all pertinent clinical information.
• Fellows with communicate effectively the plan of care of all Neurointerventional patients with the 7 West Neurosurgery charge nurse and allied health team members.

• Neuro IR M&M rounds once monthly.
• Neuro IR journal club once monthly
• Neuro IR case rounds (Monday 7 a.m.)
• Cerebrovascular teaching/lectures (Monday 5-6 p.m.)
• Stroke Journal Club (Tuesday 8-9 a.m., optional)
• Neurovascular/stroke Tuesday Noon rounds (optional)
• Neurosurgery M and M rounds, (Monthly, Wednesday 6:45-7:30 a.m.)
• Stroke Rounds (Thursday 8-9 a.m., optional)
• Neurosurgery case rounds (Friday 7-8 a.m., optional)
• Neuroscience Rounds (Friday 8 a.m.-9 a.m.)