Abstract

This document sets out standards and guidelines for training in Interventional neuroradiology (INR) in Europe with the aim to acquire "particular qualification" in INR. The aim is that this curriculum in INR will constitute an approved training program in all member, and associated member, countries within UEMS. It is recognised that there are a number of structural and operational differences in the health care systems, appointment procedures and training systems in these different countries. The purpose of this document is to define a training charter in interventional neuroradiology for trainees wishing to obtain particular qualification in INR.

Chapter VI

Foreword

This document sets out standards and guidelines for training in Interventional neuroradiology (INR) in Europe with the aim to acquire competence and if possible, “particular qualification”, in INR. The aim is that this curriculum in INR will constitute an approved training program in all member, and associated member, countries within UEMS. It is recognised that there are a number of structural and operational differences in the health care systems, appointment procedures and training systems in these different countries.

The purpose of this document is to define a training charter in interventional neuroradiology for trainees wishing to obtain competence in INR.

 It is recognised that there are a number of specialists in Europe performing all or some of the INR activities detailed in this Training Charter. These specialists will have the acquired right to continue this practice.

Article 1: Goal of training program

This document provides the basis for the development of a harmonised, comprehensive, structured and balanced training program in INR.

1.1 The primary goal

The primary goal of a training program is to provide the trainee with a broad knowledge base, the procedural skills and experience as well as professional judgement and self-criticism needed for independent Interventional Neuroradiology (INR) practice.

1.2 Definition and scope of Interventional neuroradiology

Interventional neuroradiology is using percutaneous and endovascular procedures to treat patients with diseases of the brain, sensory organs, head & neck, spinal cord, vertebral column and adjacent structures and the peripheral nervous system in adults and children.

The purpose of this charter is to define the training needed to safely perform endovascular interventional neuroradiology. Although percutaneous spinal procedures are usually included in interventional neuroradiology, these procedures will not be dealt with in this document but will be defined in a separate charter. In this document the term interventional neuroradiology (INR) refers to endovascular interventional neuroradiology only.

Endovascular approaches represent the most complex and potentially endangering aspects of interventional neuroradiology.

1.3 General rules on monitoring and accreditation

1.3.1 Monitoring authority

National professional licensing bodies (responsible for the recognition of medical specialists in individual countries) may recognise training programs in INR using UEMS standards based on this training charter.

1.3.2 UEMS accreditation of training program

UEMS provides a general program for accreditation of teaching institutions. This is a voluntary procedure aimed at securing high quality and good standard of practice in teaching programs.
Accreditation to train the candidates within a program of INR can only be granted or renewed if the applying program documents a minimum annual activity as defined in paragraph 4.1. Projected activity is permitted during the development phase of a service. An agreed intermediate level of activity may be defined by the accrediting authority for each applying institution.
The teaching program should be established within a clinical neuroscience institution, or network of such institutions, with all the appropriate related specialities represented.
The institution’s patient population must have a diversity of illness (brain, head & neck, spine) from which a broad experience in INR can be obtained.
UEMS accreditation to teach in INR is valid for a limited time only and may be renewed.
Identification, visitation and subsequent recognition of a training program is a procedure, supervised by the UEMS and coordinated by the UEMS Division of Neuroradiology. This procedure is a joint responsibility of neuroradiology, radiology, neurosurgery and neurology.

Article 2: General aspects of training in Interventional neuroradiology

2.1 Selection criteria and access to the INR particular qualification

2.1.1

Applicants must have a valid licence to practice medicine within their respective country; this licence has to be recognised by the country where he/she will train.
The applicant must be a specialist physician with a recognised speciality listed in the directive 2005/36/EV of the Swiss Parliament and of the Council on the recognition of professional qualifications.
Additionally, applicants from Portugal with the nationally recognised speciality of Neuroradiology may be accepted to train in INR according to this charter.

2.1.2

After appointment of a trainee, an individualised training program stipulating the relationships, duties and obligations on each part, should be formulated and signed by the Director of the Program and the trainee.

2.2 Duration and content of Education and Training

The overall purpose of training in INR is to reach predefined goals set out in this Training Charter.
The education and training needed to become a specialist physician with competence in Interventional neuroradiology is 4 years corresponding to full time study in an INR training program.
The 4 years consist of a core of INR of 24 months, clinical neuroscience for 12 months and diagnostic neuroradiology for 12 months.
Depending on previous training, the training time may be reduced as credit is given for previous training and clinical skills. The assessment of previous training and clinical skills and evaluation of remaining training time is the responsibility of the Director and each of the co-directors of the program after a thorough and careful assessment of documented and proven training and experience.
The assessment of the applicant’s background, and additional training required, will be documented in detail in the training agreement described under 2.1.2

2.3 Curriculum of general and specific training periods

2.3.1 Training Curriculum

This Training Curriculum is designed to provide a diversified and balanced mix of theoretical and practical education in INR and describes the contents and aims of the training. In the individual training program, emphasis should be placed on adequate time allocated for study independent of clinical duties. It may be necessary for some programs to formally organize specific training periods in associated diagnostic or clinical therapeutic units, if adequate experience cannot be organised internally.

2.3.2 Network of institutions

A training program is based on a pre-organised network of accredited institutions/departments coordinated by the program director when rotation periods in these institutions/departments are necessary. These rotations should be organized in such a way as to give trainees guaranteed training according to the curriculum.

2.3.3 Trainee Portfolio - CV

Trainees should present a Trainee Portfolio, containing details of previous training posts, examinations passed, lists of publications and presentations at meetings, courses attended, cumulative procedural totals and copies of assessment forms of the different training periods.

Article 3: Specific aspects of training in Interventional neuroradiology

3.1 Educational and Training program

3.1.1 General objectives and goals of training

Interventional neuroradiology should ideally be practiced in INR teams where exchange of experience, knowledge and research is possible. Having finished the training program, the specialist physician with competence in INR, will be able to perform endovascular procedures as described in Art 4 in a team with other interventional neuroradiologists. Thus solitary practice of INR is not recommended.
 A specialist physician with competence in INR shall
- have acquired knowledge in basic and clinical neurosciences, including neuroanatomy, neurobiology, pathophysiology and natural history of neurological disorders
- have the skill to consult, and communicate with referring physicians, patients and their relatives
- have the skill and knowledge to independently perform, conduct and interpret common endovascular INR procedures. 
- advise other clinicians and carry the main responsibility for how the diagnostic and therapeutic methods are used within the domain of INR. 
- master the diagnostic and therapeutic methods used within the domain of INR and shall be aware of their development, strengths, weaknesses and risks.
Research should be encouraged and time and facilities made available during training.

3.1.2 Knowledge-based Objectives

Unless otherwise defined, all points below are defined in relation to vascular disease of the central and peripheral nervous system

3.1.2.1 Basic neuroscience

Neuroanatomy – including embryology and functional anatomy
- The focus is on arterial and venous functional anatomy of the brain, skull, head & neck and spine.
- In embryology the focus is on vascular embryology of the brain and head & neck and spine. 
Neurobiology - including genetics and an overview of molecular biology
- Patho-physiology
- The full spectrum of vascular diseases, including inflammatory and autoimmune diseases.
- Natural history of neuro-vascular diseases

3.1.2.2. Clinical Neuroscience

Epidemiology
Clinical history and patient assessment
Symptomatology
Clinical neurologic examination
Communications
- To discuss the indications and contraindications for diagnostic and interventional procedures
- To appropriately report diagnostic and interventional procedures
- To consult and to communicate with other clinicians
- To participate in and conduct regular clinical rounds and conferences
- To communicate with residents in training
- To communicate with patients and their relatives
- To communicate with hospital staff and administration
- To participate in quality control programs

3.1.2.3. Therapeutics – general aspects

Selection and interpretation of ancillary tests necessary for establishing diagnosis, indications, treatment plan and follow-up.
Selection of treatment options (indications and contraindications) has to be based on knowledge and communication in a multidisciplinary environment.
Pre- and post procedural management
- Immediate pre-operative diagnostic work-up
- Patient preparation before procedure
- Post-operative maintenance of physiological equilibrium
- Management of hospital discharge (documentation, communication, coordination and reports)
- Organisation of follow-up procedures.
Clinical neuropharmacology
- Knowledge in pharmacology including interactions of drugs
- Pre- and postoperative usage of drugs
Knowledge in neurointensive care

3.1.2.4. Imaging technology and Radiation

to master the physiological, technical, mathematical and statistical principles, strengths and weaknesses of common neuroradiological diagnostic and interventional procedures.
Knowledge about radiation physics
Radiation biology
- in diagnostic neuroradiology and INR
- in radiotherapy and radiosurgery
Radiation protection in diagnostic neuroradiology and INR and have knowledge of the laws governing the use of medical radiation.
- Patient protection
- Staff protection

3.1.2.5. Clinical Neuroradiology

Training in clinical neuroradiology should not only focus on the neuroradiology of vascular diseases but also provide a general understanding and overview of indications and interpretation in clinical neuroradiology in its application in common neurological diseases.

Knowledge related to technical aspects of clinical neuroradiology
- Digital Subtraction Angiography, Computed Tomography, Magnetic Resonance Imaging and Ultrasound
Selection of optimal diagnostic procedure using knowledge of indications, contraindications and limitations of diagnostic neuroradiology procedures
Be able to perform and interpret diagnostic neuroradiological procedures as they relate to INR
Knowledge and management regarding all aspects of contrast materials, including interactions and complications, as they are used in clinical neuroradiology and INR.

3.1.2.6. Therapeutics – specific objectives

Pre- and post procedural management
- To explain to the patient the risks and benefits of the planned strategy (informed consent)
- Proposed and alternate therapies
- Immediate pre-operative diagnostic work-up
- Patient preparation before INR procedure
- Organisation of clinical follow-up and diagnostic procedures.
Clinical neuro-pharmacology
- Per-procedural drug usage including interactions
  - Contrast materials
  - Anti-platelet and thrombolytic therapies
  - Anti-vaso spasm drugs
Acquisition of skills and experience in INR procedures
- Establishment of an individual treatment strategy
  - Aim of INR therapy
  - Defining the therapeutic goal
  - Establishing the procedural priorities and steps
  - Defining the optimal treatment strategy and technical performance
  - Considering possible complication and treatment risks
  - Pre-procedural briefing the staff and ancillary staff of the treatment plan
- Technical and strategic components
  - Access to the vascular system
  - Usage of delivery systems; catheters, wires and rinsing systems
  - Skilful management of the radiological equipment in INR
  - Knowledge and use of re-canalisation devices and embolic material
  - Post-procedural management of puncture site
  - Risk and procedural limitations
  - Complication management
  - Each trainee must participate in a minimum of 150 endovascular INR procedures, of which at least in 50 should be as the principal operator. The diversity of these procedures is defined in Addendum # 1

3.1.2.7. Attitude and Ethics in INR

To be able to make independent and well founded decisions in medical ethical matters within INR
To prioritize and optimize the use of resources
To understand implications and priorities in management of incidentally discovered or associated lesions
To manage medical risks and incidents
To understand medical legal implications pertaining to INR
To participate in regular departmental and interdisciplinary conferences including regular reviews of morbidity and mortality and if developed, critical incident reporting systems (CIRS)
To participate in national or international quality assurance programs in INR is strongly recommended
To participate in national and international courses and meetings (a minimum of 2 weeks/year during the training)

3.2 Research

The educational environment should encourage trainees to undertake investigative study in relevant clinical or basic sciences subject areas.
- Trainees may participate in research projects conducted by the faculty or other trainees or may undertake a project as principal investigators.
- Trainees should have a firm knowledge of the fundamentals of the experimental design, performance and interpretation of results.
- Trainees have basic knowledge of medical statistics
- Trainees should be encouraged to submit their work for presentation at national or international meetings and to publish in scientific journals.
- Trainees should understand ethical aspects and what constitute conflicts of interest

3.3 Training log-book and periodic progress assessment of trainees

3.3.1 Log-book during INR training

Each trainee must keep a personal Log-book for documentation of procedural experience and skills acquired. The trainee will have to demonstrate that he/she has participated in a wide spectrum of INR procedures (See Addendum # 1) which should include a balance of supervisor assisted and personally performed procedures under supervision. Log-book entries must be monitored by regular inspection and signed off by the appropriate supervisor. The log-book must be available at Board and other summative examinations. 

3.3.2 Evaluation of trainee

The program director, in consultation with the co-directors and faculty, must evaluate the qualification and progress of each trainee at least twice a year. The evaluation includes an assessment of the trainee's knowledge, technical skills, attitudes and interpersonal relationships as well as decision-making skills and clinical management skills. These evaluations should be documented and provided to and discussed with each trainee. The program director, in agreement with the co-directors, certifies the competence of the trainees at the completion of training. 

Article 4: Requirements for training institutions/departments

4.1 Requirements regarding equipment and educational facilities

The optimal training program in INR must take place in a network of institutions/departments operating in accordance with the UEMS and WFITN recommendations for good practice in INR. (Interventional Neuroradiology, 2006, 12:7-8).

An INR training program is organized in a network of institutions/departments in which the unit for INR constitutes the core surrounded by clinical and diagnostic units in neuroscience.
To qualify as a training program the following conditions must be fulfilled.
- The director and co-directors (neurology, neurosurgery and clinical neuroradiology) must have senior appointments in recognised training institutions that may be affiliated with academic institutions or other non-profit organisations. Commercial interests may not be involved in organisation and scientific content of training.
- The network should ideally be involved in active research in INR
- There should be ready access to general medical/neurointerventional texts and periodicals. Computerized literature search facilities should be available.
The INR core must fulfil the following conditions
- The faculty of the training program must include at least two members practicing INR as their principle activity.
- The proportion of trainers in INR to trainees must not exceed the ratio of 1:2.
- INR Case load (150 – 200 cases/year) of endovascular interventions
- INR Case mix including stroke, aneurysms, AVM’s, DAVF’s and spinal vascular malformations

Article 5: Requirements for training program director and faculty

5.1 Criteria for Program Director, Co-directors and Faculty

The director of a training program must be certified according to national regulations.
The program director must be a well experienced and an internationally well respected interventional neuroradiologist also involved in scientific activities.
The program director may have a senior academic appointment or a senior leading position in the non-profit training institution.
The program director is coordinating the network which constitutes the training program.
A co-director in a network must be well experienced and internationally well respected as an interventional neuroradiologist or as a medical specialist in another appropriate specialty, i.e. neurosurgery or neurology.
A director or co-director is obliged to participate in appropriate CME/CPD activities.
The program director and co-directors in agreement are responsible for enforcing the Training Charter, selecting and supervising the trainee and faculty members.
The program director is expected to ensure that the program is of required academic standard.
The program director should seek accreditation of the program by an external authority, e.g. UEMS.
Trainees must be given an opportunity to provide a documented evaluation of the program and faculty at least once annually.

Article 6: Certification of competence in INR

The national or regional medical authority is the responsible body for any official recognition and certification of competence in each country.

The program director is responsible for certification of the training and acquired competence, dependent on a properly executed accreditation and visitation process, being national or provided by UEMS.

UEMS strongly encourages a final board examination. If an examination is offered, coming UEMS guidelines should be considered and followed.

Article 7: Maintenance of competence.

Maintenance of a competence in INR is subject to the general principles of the UEMS Charter on Continuing Professional Development. ’01.

This Charter, including Addendum # 1, was unanimously approved by:

UEMS Division of Neuroradiology in their meeting 2011-02-04.
UEMS Section of Radiology in their meeting 2011-03-05
UEMS Section of Neurosurgery in their meeting 2011-05-07
UEMS Section of Cardiology 2011-02-24
UEMS Section of Neurology 2011-03-15

This Charter, including Addendum # 1, was unanimously accepted by the UEMS Council in their meeting 2011-10-08 in Naples.

Addendum # 1

List of minimum numbers of INR procedures as principle operator:

	Absolute numbers	Proportions
Aneurysm	10	20%
Intracerebral AVM	5	10%
Dural AV fistula	5	10%
Interventional stroke prevention and therapy	15	30%
External carotid artery embolisation	15	30%

Citing this article

UEMS recommendations for acquiring "Particular qualification" in Endovascular Interventional Neuroradiology - INR

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