Standards for European training requirements in interventional neuroradiology : Guidelines by the Division of Neuroradiology/Section of Radiology European Union of Medical Specialists (UEMS), in cooperation with the Division of Interventional Radiology/UEMS, the European Society of Neuroradiology (ESNR), and the European Society of Minimally Invasive Neurological Therapy (ESMINT).

This document sets out standards for training in Interventional Neuroradiology (INR) in Europe. These standards have been developed by a working group of the European Society of Neuroradiology (ESNR) and the European Society of Minimally Invasive Neurological Therapy (ESMINT) on the initiative and under the umbrella of the Division of Neuroradiology/Section of Radiology of the European Union of Medical Specialists (UEMS).

Importance of a dedicated neuroradiologist in reporting high-resolution computed tomography for otosclerosis: a retrospective comparison study of 40 patients.

OBJECTIVES: This study aimed to compare the reporting of high-resolution computed tomography of temporal bones for otosclerosis by general radiologists and a neuroradiologist within a local National Health Service Trust. METHODS: A retrospective case review of 36 high-resolution temporal bone computed tomography images obtained between 2008 and 2015 from 40 otosclerosis patients (surgically confirmed) was performed in a district general hospital setting. The main outcome measures were correct identification of otosclerosis by high-resolution computed tomography and adherence to the petrous temporal bone imaging protocol. RESULTS: Correct diagnosis rates were significantly different when made by general radiologists vs a neuroradiologist (p < 0.0001; two-tailed Fisher's exact test). None of the high-resolution computed tomography scans adhered to the temporal bone imaging protocol. CONCLUSION: The use of high-resolution computed tomography for suspected otosclerosis is helpful for diagnosis, disease staging, obtaining informed consent, surgical planning and prognosis. This study suggests that radiological detection of otosclerotic changes by high-resolution computed tomography of the temporal bone is significantly better when performed by a dedicated neuroradiologist than by a general radiologist. Use of a standardised temporal bone computed tomography protocol is recommended to provide consistently high-quality images for maximising disease detection.

Criteria for training and accreditation in Interventional Neuroradiology-Neurointervention, approved by the Spanish Group of Interventional Neuroradiology (GENI), the Spanish Society of Neuroradiology (SENR), the Spanish Group of Cerebrovascular Diseases (GEECV), the Spanish Society of Neurology (SEN), and the vascular disease specialists in the Spanish Society of Neurosurgery (SENEC). Requirements for accreditation in Interventional Neuroradiology-Neurointervention for institutions and specialists. / Criterios para la formación y capacitación en Neurorradiología Intervencionista-Neurointervencionismo, acordados por el Grupo Español de Neurorradiología Intervencionista (GENI), la Sociedad Española de Neurorradiología (SENR), el Grupo de Estudio de Enfermedades Cerebrovasculares (GEECV) de la Sociedad Española de Neurología (SEN) y el grupo experto en enfermedades vasculares de la Sociedad Española de Neurocirugía (SENEC). Bases para la obtención de una Acreditación de Centros y Especialistas en Neurorradiología Intervencionista-Neurointervencionismo.

BACKGROUND: The development of endovascular techniques has put Interventional Neuroradiology (INR) as the first-option treatment in the majority of vascular diseases of the central nervous system. Scientific societies in developed countries have created standard procedures for training and accreditation for a safe practice in these procedures. DISCUSSION: In Spain, we are waiting for the development of the legislation on the accreditation for specialists which will establish the official formative model to achieve an accreditation in INR. Until this moment comes, it is necessary to establish standards that define desirable minimums for the formative period in INR. Radiology specialists as well as neurologists and neurosurgeons will have access to INR accreditation. Specific requirements for the hospitals that wish to offer this technique and training should also be defined. CONCLUSION: The Spanish Group of Interventional Neuroradiology (GENI), the Spanish Society of Neuroradiology (SENR), the Spanish Group of Cerebrovascular Diseases (GEECV), the Spanish Society of Neurology (SEN) and the Spanish Society of Neurosurgery (SENEC) have approved the content of this document and will create a committee in order to put into practice the accreditation of formative centres and INR specialists.

Utilization of Workflow Process Maps to Analyze Gaps in Critical Event Notification at a Large, Urban Hospital.

Stroke care is a time-sensitive workflow involving multiple specialties acting in unison, often relying on one-way paging systems to alert care providers. The goal of this study was to map and quantitatively evaluate such a system and address communication gaps with system improvements. A workflow process map of the stroke notification system at a large, urban hospital was created via observation and interviews with hospital staff. We recorded pager communication regarding 45 patients in the emergency department (ED), neuroradiology reading room (NRR), and a clinician residence (CR), categorizing transmissions as successful or unsuccessful (dropped or unintelligible). Data analysis and consultation with information technology staff and the vendor informed a quality intervention-replacing one paging antenna and adding another. Data from a 1-month post-intervention period was collected. Error rates before and after were compared using a chi-squared test. Seventy-five pages regarding 45 patients were recorded pre-intervention; 88 pages regarding 86 patients were recorded post-intervention. Initial transmission error rates in the ED, NRR, and CR were 40.0, 22.7, and 12.0 %. Post-intervention, error rates were 5.1, 18.8, and 1.1 %, a statistically significant improvement in the ED (p < 0.0001) and CR (p = 0.004) but not NRR (p = 0.208). This intervention resulted in measureable improvement in pager communication to the ED and CR. While results in the NRR were not significant, this intervention bolsters the utility of workflow process maps. The workflow process map effectively defined communication failure parameters, allowing for systematic testing and intervention to improve communication in essential clinical locations.

The value of protective head cap and glasses in neurointerventional radiology.

BACKGROUND: Protection of the head and eyes of the neurointerventional radiologist is a growing concern, especially after recent reports on the incidence of brain cancer among these personnel, and the revision of dose limits to the eye lens. The goal of this study was to determine typical occupational dose levels and to evaluate the efficiency of non-routine radiation protective gear (protective eyewear and cap). Experimental correlations between the dosimetric records of each measurement point and kerma area product (KAP), and between whole body doses and eye lens doses were investigated. METHODS: Measurements were taken using thermoluminescent dosimeters placed in plastic bags and worn by the staff at different places. To evaluate the effective dose, whole body dosimeters (over and under the lead apron) were used. RESULTS: The mean annual effective dose was estimated at 0.4 mSv. Annual eye lens exposure was estimated at 17 mSv when using a ceiling shield but without protective glasses. The protective glasses reduced the eye lens dose by a factor of 2.73. The mean annual dose to the brain was 12 mSv; no major reduction was observed when using the cap. The higher correlation coefficients with KAP were found for the dosimeters positioned between the eyes (R(2)=0.84) and above the apron, and between the eye lens (R(2)=0.85) and the whole body. CONCLUSIONS: Under the specific conditions of this study, the limits currently applicable were respected. If a new eye lens dose limit is introduced, our results indicate it could be difficult to comply with, without introducing additional protective eyewear.

Accountable Care Organizations: what they mean for the country and for neurointerventionalists.

The Affordable Care Act is celebrating its fifth anniversary and remains one of the most significant attempts to reform healthcare in US history. Prior to the federal legislation, Accountable Care Organizations had largely been part of an academic discussion about how to control rising healthcare costs, but have since become a fixture in our national healthcare landscape. A fundamental shift is underway in the relationship between healthcare delivery and payment models. Some elements of Accountable Care Organizations may remain unfamiliar to most healthcare providers, including neurointerventional specialists. In this paper we review the fundamental concepts behind and the current forms of Accountable Care Organizations, and discuss the challenges and opportunities they present for neurointerventionalists.

Reduction of contractility and reactivity in isolated lymphatics from hemorrhagic shock rats with resuscitation

PURPOSE: To evaluate the changes of contractility and reactivity in isolated lymphatics from hemorrhagic shock rats with resuscitation. METHODS: Six rats in the shock group suffered hypotension for 90 min by hemorrhage, and resuscitation with shed blood and equal ringer's solution. Then, the contractility of lymphatics, obtained from thoracic ducts in rats of the shock and sham groups, were evaluated with an isolated lymphatic perfusion system using the indices of contractile frequency (CF), tonic index (TI), contractile amplitude (CA) and fractional pump flow (FPF). The lymphatic reactivity to substance P (SP) was evaluated with the different volume of CF, CA, TI and FPF between pre- and post-treatment of SP at different concentrations. RESULTS: The CF, FPF, and TI of lymphatics obtained from the shocked rats were significantly decreased than that of the sham group. After SP stimulation, the ∆CF (1×10-8, 3×10-8, 1×10-7, 3×10-7 mol/L), ∆FPF (1×10-8, 3×10-8, 1×10-7 mol/L), and ∆TI (1×10-8 mol/L) of lymphatics in the shock group were also obviously lower compared with the sham group. In addition, there were no statistical differences in CA and ∆CA between two groups. CONCLUSION: Lymphatic contractility and reactivity to substance P appears reduction following hemorrhagic shock with resuscitation. .

The role of inferior petrosal sinus sampling in ACTH-dependent Cushing's syndrome: review and joint opinion statement by members of the Italian Society for Endocrinology, Italian Society for Neurosurgery, and Italian Society for Neuroradiology.

In the management of adrenocorticotropic hormone (ACTH)-dependent Cushing's syndrome, inferior petrosal sinus sampling (IPSS) provides information for the endocrinologist, the neurosurgeon, and the neuroradiologist. To the endocrinologist who performs the etiological diagnosis, results of IPSS confirm or exclude the diagnosis of Cushing's disease with 80%-100% sensitivity and over 95% specificity. Baseline central-peripheral gradients have suboptimal accuracy, and stimulation with corticotropin-releasing hormone (CRH), possibly desmopressin, has to be performed. The rationale for the use of IPSS in this context depends on other diagnostic means, taking availability of CRH and reliability of dynamic testing and pituitary imaging into account. As regards the other specialists, the neuroradiologist may collate results of IPSS with findings at imaging, while IPSS may prove useful to the neurosurgeon to chart a surgical course. The present review illustrates the current standpoint of these 3 specialists on the role of IPSS.

Measurement of perihematomal edema in intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Perihematomal edema (PHE) is a marker of secondary injury in intracerebral hemorrhage (ICH). PHE measurement on computed tomography (CT) is challenging, and the principles used to detect PHE have not been described fully. We developed a systematic approach for CT-based measurement of PHE. METHODS: Two independent raters measured PHE volumes on baseline and 24-hour post-ICH CT scans of 20 primary supratentorial ICH subjects. Boundaries were outlined with an edge-detection tool and adjusted after inspection of the 3 orthogonal planes. PHE was delineated with the additional principle that it should be (a) more hypodense than the corresponding area in the contralateral hemisphere and (b) most hypodense immediately surrounding the hemorrhage. We examined intra- and interrater reliability using intraclass correlation coefficients and Bland-Altman plots for interrater consistency. CT-based PHE was also compared using magnetic resonance imaging-based PHE detection for 18 subjects. RESULTS: Median PHE volumes were 22.7 cc at baseline and 20.4 cc at 24 hours post-ICH. There were no statistically significant differences in PHE measurements between raters. Interrater and intrarater reliability for PHE were excellent. At baseline and 24 hours, interrater intraclass correlation coefficients were 0.98 (0.96-1.00) and 0.98 (0.97-1.00); intrarater intraclass correlation coefficients were 0.99 (0.99-1.00) and 0.99 (0.98-1.00). Bland-Altman analysis showed the bias for PHE measurements at baseline and 24 hours, -0.5 cc (SD, 5.4) and -3.2 cc (SD, 5.0), was acceptably small. PHE volumes determined by CT and magnetic resonance imaging were similar (23.9±16.9 cc versus 23.9±16.0 cc, R(2) = 0.98, P<0.0001). CONCLUSIONS: Our method measures PHE with excellent reliability at baseline and 24 hours post-ICH.