Training Goals & Learning Objectives
Residents may rotate through the Division of Neuroradiology during each of their four years of training. The timing and structure of neuroradiology rotations will vary between training programs and therefore it is not possible to provide program-specific goals for each level of training. It is expected that residents will progressively develop their abilities to perform and interpret imaging studies of the central nervous system. Residents will be taught the practical clinical skills necessary to interpret neuroradiologic studies, including plain radiographs, CT scans, MRI and ultrasound exams of 1) brain and skull; 2) spinal cord and vertebral column; and 3) head and neck. They will be instructed in the performance and interpretation of invasive procedures including cerebral angiography, myelography/spinal canal puncture, and image-guided biopsies of the spine and skull base.
The residents will receive instruction in the science that underlies clinical neuroradiology, in particular neuroanatomy and neuropathology. They will learn the physical principles of CT, MR, plain radiography, and digital angiography. They will learn the relative value of each modality, enabling them to choose the appropriate study and the appropriate protocol for each patient.
It is expected that residents will participate in the performance of the full range of examinations done by the division. They will obtain consents and perform intravenous injections of contrast. The residents will learn the indications and contraindications for contrast administration and to recognize and treat adverse reactions. Residents will protocol and monitor CT and MR exams after they have demonstrated a sufficient level of knowledge and experience to perform these tasks. Residents will aid in the performance of invasive procedures including angiograms, myelograms, spinal taps and other minimally invasive procedures such as image-guided vertebral and skull base biopsies. They will learn to explain these procedures to patients and their families, obtain pre-procedure consent and write pre- and post-procedure orders. They will learn techniques of arterial puncture, catheter choice and manipulation, and contrast dosage. They will learn to recognize and treat complications of these invasive procedures.
The residents will learn to dictate concise and appropriate radiographic reports and to serve as consultants to referring physicians.
KNOWLEDGE BASED OBJECTIVES
Early rotations: Become familiar with the appearance of major intracranial structures as visualized on axial CT and MR scans. Be able to identify all major structures and components of the brain, ventricles and subarachnoid (cisterns) space.
Middle rotations: Develop more detailed knowledge of intracranial anatomy as displayed on multi-planar images.
Late rotations: Be able to identify subdivisions and fine anatomic details of the brain, the ventricles, subarachnoid space, vascular structures, sella turcica, and cranial nerves.
B. Head and Neck
Early rotations: Learn the anatomy of the calvarium, skull base and soft tissues of the neck as displayed on plain radiographs.
Middle rotations: Become familiar with the complex anatomy of the orbit, petrous bone, skull base and soft tissues of the neck as displayed on CT and MR in multiple planes.
Late rotations: Be able to identify all key structures and have knowledge of established anatomic classification systems for each area.
Early rotations: Become familiar with the normal appearance of the spine on plain radiographs and axial CT scans. Be able to assess spinal alignment and be able to identify all osseous components of the spinal canal by completion of first rotation.
Middle rotations: Learn to identify normal osseous structures, intervertebral discs, support ligaments and the contents of the thecal sac (spinal cord and nerve roots) on CT, MR, and myelography.
Late rotations: Be able to identify all normal structures on multi-planar images.
Early rotations: Learn to identify the large vessels of the cervical and intracranial regions (carotid, vertebral and basilar arteries, jugular veins and dural venous sinuses) as they appear on routine CT and MR studies of the head and neck.
Middle rotations: Learn to identify these same structures and their key branches on catheter, MR angiography and sonography (extra-cranial vessels).
Late rotations: Be able to identify all important extra- and intra-cranial arteries (secondary and tertiary branches of the carotid and basilar arteries) and veins (cortical and deep cerebral veins) on all imaging modalities.
II) Pathology and Pathophysiology:
Learn the basic pathology and pathophysiology of diseases of the brain, spine, and head and neck.
Early rotations: Become familiar with the common traumatic, ischemic and inflammatory conditions of the brain, skull base, neck and spine.
Middle rotations: Learn the pathophysiology of rapidly evolving processes, in particular cerebral infarction and inflammation.
Late rotations: Learn the pathologic and histologic features that allow for characterization of neoplastic lesions and learn the accepted classification system (WHO) of tumors.
III) Imaging Technology:
Early rotations: Become familiar with imaging parameters, including window and level settings, slice thickness, inter-slice gap, and helical imaging parameters, and image reconstruction algorithms (e.g., soft tissue and bone). Learn the typical CT density of commonly occurring processes such as edema, air, calcium, blood and fat.
Middle rotations: Learn the appropriate imaging protocols used for assessment of the full range of lesions encountered in Neuroradiology.
Late rotations: Learn the principles and utility of multi-planar reconstruction and CT angiography.
Early rotations: Learn the basic physical principles of MR. Be able to identify commonly used pulse sequences and become familiar with standard MR protocols. Learn the intensity of normal tissues on routine pulse sequences.
Middle rotations: Learn the clinical utility of each routine pulse sequence. Learn how to combine pulse sequences to produce effective and efficient imaging protocols for common disease processes. Learn the intensity encountered in hemorrhage, fat and calcium.
Late rotations: Learn to protocol complex clinical cases. Become familiar with more advanced imaging techniques such as MR angiography, fat suppression, diffusion/perfusion, activation studies, and MR spectroscopy.
IV) Image interpretation:
Early rotations: Develop skills in the interpretation of plain films of the skull. Learn to interpret CT scans with a particular emphasis on studies performed on individuals presenting with acute or emergent clinical abnormalities (infarction, spontaneous intracranial hemorrhage, aneurysmal subarachnoid hemorrhage, traumatic brain injury, infection, hydrocephalus, and brain herniation).
Middle rotations: Learn the CT and MR findings of hyperacute infarction (including findings on diffusion weighted MRI). Learn to identify and characterize focal lesions and diffuse processes and be able to provide a short differential diagnosis for the potential causes of these processes.
Late rotations: Develop the ability to use imaging findings to differentiate different types of focal intracranial lesions (neoplastic, inflammatory, vascular) based on anatomic location (e.g., intra- vs. extra-axial), contour, intensity and enhancement pattern. Learn to identify and differentiate diffuse intracranial abnormalities (e.g., hydrocephalus and atrophy). Lean to recognize treatment-related findings (e.g., post-surgical and post-radiation). Become familiar with the utility of new MR sequences (diffusion/perfusion, functional MR and MR spectroscopy).
B. Head and Neck
Early rotations: Learn to identify common acute emergent lesions. Become familiar with the plain film and CT appearance of (a) traumatic (fractures and soft tissue injuries) of the orbit, skull base, face and petrous bones and (b) inflammatory (sinusitis, orbital cellulitis, otitis, mastoiditis, cervical adenitis and abscess) lesions. Learn to identify airway compromise and obstruction.
Middle rotations: Expand knowledge of the appearance of traumatic lesions on CT. Be able to characterize fractures based on clinical classification systems (e.g., Le Fort fractures). Learn to identify neoplastic masses arising in the orbit, skull base, petrous bone and soft tissues of the neck. Be able to use standard anatomic classification schemes to accurately describe the location of mass lesions.
Late rotations: Learn the differential diagnosis of mass lesions. Understand and be able to identify patterns of disease spread within and between areas of the head and neck (e.g., perineural and nodal spread). Learn to recognize treatment- related findings (e.g., post-surgical and post-radiation). Learn to identify pathologic processes on multi-planar MR studies.
Early rotations: Learn the appearance of traumatic lesions on plain radiographs with an emphasis on findings of spinal instability. Become familiar with the CT and MRI findings of degenerative disease.
Middle rotations: Learn the CT, MRI and myelographic findings of spinal cord compression. Become familiar with findings on all three modalities that allow for accurate spatial localization of spinal lesions (extra-dural, intra-dural, extra-medullary, and intra-medullary). Be able to identify and differentiate discogenic and arthritic degenerative diseases. Learn to identify and characterize traumatic lesions (e.g., stable vs. unstable, mechanism of injury) using routine and reformatted CT scans.
Late rotations: Learn the imaging findings that allow for the differentiation of inflammatory and neoplastic lesions. Learn the imaging features of intraspinal processes, including syringomyelia, arachnoiditis and spinal dysraphism. Learn to recognize post-surgical and other treatment-related findings.
Early rotations: Learn to recognize the angiographic features of extra- and intracranial atherosclerosis utilizing catheter angiography, MRA and sonography.
Middle rotations: Learn the indications, limitations, risks and benefits for each technique used for visualization of vascular anatomy and pathology. Learn the angiographic appearance of aneurysms, vascular malformations, occlusive diseases and neoplasms.
Late rotations: Learn the indications, risks and benefits for neurointerventional procedures including embolization, angioplasty and stenting.
Early rotations: Learn to recognize the normal appearance of the brain (e.g., myelination), spine (e.g., ossification) and head and neck (e.g., sinus development) encountered in the newborn, infant, and child. Be able to identify the features of hydrocephalus on CT and MR.
Middle rotations: Learn to recognize congenital lesions and malformations. Be able to detect disorders of the perinatal period on sonography, CT, and MR.
Late rotations: Be able to identify and differentiate acquired lesions (traumatic, ischemic, inflammatory and neoplastic) of the newborn, infant, child, and adolescent.
TECHNICAL AND NON-INTERPRETIVE OBJECTIVES
1) Patient care
Early rotations: Learn to obtain informed consent, by explaining the risks and benefits of contrast-enhanced CT/MR to the patient. Learn appropriate techniques for injection of contrast (including use of power injectors). Learn to recognize and treat contrast reactions.
Middle rotations: Learn to obtain informed consent for invasive procedures including angiography, spinal punctures/myelography and image-guided biopsies. Be able to explain the risks, benefits and complications of these procedures to patients and their families.
Late rotations: Learn to write pre- and post-procedure orders. Be able to evaluate the clinical status of patients prior to, during and after the procedure. Learn to recognize complications of these procedures and to initiate appropriate treatment.
2) Catheter angiography
Early rotations: Observe the performance of diagnostic angiograms of the cervical and cranial vessels.
Middle rotations: Learn the basic techniques of arterial puncture and catheter manipulation. Assist senior residents, fellows, and attendings in the performance of angiograms.
Late rotations: Learn to safely position catheters within extra-cranial vessels. Learn the appropriate dose of contrast material for angiography of each vessel. Learn the angiographic protocols for the evaluation of a variety of disease processes (e.g., aneurysmal subarachnoid hemorrhage). Be able to perform diagnostic angiography under the supervision of an attending radiologist.
3) Image-guided biopsies and spinal canal
Early rotations: Learn to perform fluoroscopically guided punctures of the lumbar spinal canal for the purpose of myelography, spinal fluid collection, and intrathecal injection of medications.
Middle rotations: Assist senior residents, fellows, and attendings in the performance of image-guided biopsies. Be able to perform myelography under the supervision of an attending radiologist.
Late rotations: Be able to perform image-guided biopsies of the spine and skull base under the supervision of an attending radiologist.
Decision making/Value judgment skills
Early rotations: Learn the appropriate format for dictation of reports of neuroradiologic imaging studies. Provide consultations for house staff and referring physicians on imaging studies after reviewing the exam with an attending radiologist.
Middle rotations: Protocol and monitor CT studies. Be able to modify imaging protocols based on identification of unexpected or novel findings. Provide provisional interpretations and consultations of plain radiographs, CT scans and MR scans performed in the Emergency Department. Learn the clinical and imaging indications for acute stroke intervention including intra-arterial thrombolysis.
Late rotations: Direct the choice of imaging modality and protocol neuroradiologic studies. Act as a consultant to junior radiology residents. Learn to identify those cases that require the additional expertise in assessment of imaging studies.
NEURORADIOLOGY CORE CURRICULUM
A. CNS Infections
1. Imaging strategies
2. Pyogenic infections
Subdural and epidural empyema (abscess)
Herpes (HSV I & II)
Sporadic and epidemic
Chronic – subacute sclerosis panencephalitis (SSPE)
Prior disease – (Creutzfeldt Jakob)
4. Granulomatous infections
Meningeal (basal) – hydrocephalus
Parenchymal – granuloma and abscess
Vasculitis – infarction
Etiology – TB, sarcoid, fungi
5. Infections in the immunocompromised host
B. White Matter Disease
1. Multiple sclerosis
2. Acute disseminated encephalomyelitis (ADEM)
3. Small vessel ischemic disease, hypertension, vascular disease
4. Radiation/chemotherapy changes
5. Trauma (axonal injuries)
6. White matter changes in the elderly
7. Osmotic myelinolysis (central pontine myelinolysis)
8. Dysmyelinating disorders
Metachromatic leukodystrophy (MLD)
1. Imaging strategies CT/MR/skull films
3. Primary vs. secondary
4. Focal lesions
Diffuse axonal injury (DAI) -- shearing
Subarachnoid hemorrhage (SAH)
Subdural hemorrhage (SDH)
Epidural hemorrhage (EDH)
Parenchymal hemorrhage with differentials
5. Ages of hemorrhage by CT/MR
6. Intraventricular hemorrhage
7. Diffuse cerebral swelling and edema
8. Herniation syndromes
9. Skull fractures, types, complications
10. Vascular injuries—dissection, pseudoaneurysm, penetrating injuries,lacerations, complications
11. Non-accidental trauma
D. Neoplasms and other masses
1. Tumor classification by histology
Glioblastoma multiforme (GBM)
Pleomorphic xanthoastrocytoma (PXA)
Primitive neuroectodermal tumor (PNET)
Dysembryoplastic neuroectodermal tumor (DNET)
Primary or secondary
Choroid plexus tumors
Other mesenchymal tumors
2. Tumor evaluation by location
Intra-axial vs. extra-axial
Infra-tentorial masses – pediatric
Cerebellar juvenile pilocytic astrocytoma (JPA)
Infra-tentorial masses – adult
Rathke's cleft cyst
Pituitary hypoplasia with ectopic posterior pituitary gland
Pituitary hemorrhage (apoplexy)
Germ cell tumors (germinoma)
Pineocytoma and pineoblastoma
Cerebellopontine angle tumor
Schwannomas of other cranial nerves (V-X)
Choroid plexus papilloma and carcinoma
Giant cell astrocytoma
Myeloma, lymphoma and leukemia
Schwannoma (lower cranial nerves)
E. Cerebrovascular disease
Strategies for imaging
CT—signs of hyperacute infarction
MR—value of diffusion weighted images (DWI)
Occlusions, large/small vessel
Fibromuscular dysplasia (FMD)
Hemorrhagic vs. bland
Appearance over time CT/MR, MRA, CTA, angiography
2. Spontaneous hemorrhage
Congophylic (amyloid) angiopathy
Imaging of hemorrhage over time CT/MR
Serial changes on MR
Types, locations, associated conditions
Incidence by location and of multiple aneurysms
Complication: rupture, mass effect, hydrocephalus, spasm
Imaging, MRI, MRA, CT, catheter angiography and CT angiography
4. Cerebrovascular malformations
Cavernous angioma (CA)
Developmental venous anomaly (DVA)
Arteriovenous malformations (AVM)
Classification based on size of components
Vein of Galen malformation
Film screen, DSA, catheters, injection rates, projections, filming sequences, complications
Normal anatomy and variants
Common carotid artery (CCA)
External carotid artery (ECA) and branches
Internal carotid artery (ICA)
Persistent fetal connections
Circle of Willis
ACA, MCA, PCA branches
Vertebro-basilar (VB) arteries
ECA, ICA, VB collaterals and anastomoses
Stenosis and occlusion (ASCVD, FMD, Takayasu, emboli)
DVA (association with CA)
Aneurysms (berry, atherosclerotic and traumatic)
Trauma (AV fistulas, transections, dissections)
Venous thrombosis (venous sinuses, cortical veins, deep veins)
Arteritis (Moya, Moya)
F. Congenital CNS lesions
1. Embryology of brain development
2. Disorders of organogenesis
Chiari malformations (I-IV)
Corpus callosum anomalies: dysgenesis, lipomas
3. Disorders of neuronal migration and sulcation
Cortical dysgenesis: agyria-pachygyria, polymicrogyria
4. Disorders of diverticulation and cleavage
Holoprosencephaly (alobar, semilobar, lobar)
Absent septum pellucidum
5. Posterior fossa cystic disorders
Mega cisterna magna
Disorders of histogenesis (phakomatoses)
Neurofibromatosis type I and type II
Ataxia-telangiectasia; Louis-Bar syndrome
Basal cell nevus syndrome
II. Head and Neck Radiology
A. Paranasal sinuses
1. Anatomy of paranasal sinuses
2. Congenital disease
Dermal sinus tract
Chronic sinusitis (allergic, fungal, granulomatous)
4. Benign sinus tumors
5. Malignant sinus tumors
Squamous cell carcinoma
Lethal midline granuloma
B. Oral cavity, oropharynx, hypopharynx
1. Anatomy, contents
Squamous cell carcinoma
Cellulitis, abscess (Ludwig's angina)
C. Parapharyngeal space
1. Location, contents, anatomy and importance in relation to other spaces
2. Pharyngeal mucosal space (anatomy, contents)
Infection (tonsillar abscess, adenitis)
Pleomorphic adenoma (minor salivary glands)
Squamous cell CA
3. Masticator space (anatomy, contents)
4. Parotid space (anatomy, contents)
1st brachial cleft cyst
Adenoid cystic carcinoma
5. Carotid space (anatomy, contents)
Paragangliomas (glomus tumors)
6. Retropharyngeal space (anatomy, contents)
Neoplastic and reactive lymph nodes
Infection ("Danger space")
D. Perineural spread
1. Squamous cell carcinomas
Supraglottic, glottic, subglottic
Treatment effects (surgery and radiation)
2. Trauma (laryngeal fractures)
C. Cystic neck masses
1. Second brachial cleft cyst
2. Thyroglossal duct cyst
3. Cystic hygroma
4. Laryngocele, internal, external
1. Graded by level and/or anatomic space
2. Size criteria for pathologic nodes
Metastases (aerodigestive carcinoma)
Cat scratch fever
E. Temporal bones
1. Imaging techniques (Multi-planar CT/MR)
Transverse and longitudinal fractures
CSF leaks, brain herniation
Vestibular (8th) (common)
Facial (7th) and trigeminal (5th)
5. Pulsatile tinnitus
High riding/dehiscent jugular vein
AVM, AV fistula
6. Inflammatory disease
Cholesteatoma (acquired or congenital)
Malignant external otitis
Hemorrhage or inflammation cochlea, vestibule (labyrinthitis)
7. Congenital anomalies
External ear atresia/hypoplasia (ossicular anomalies)
Enlarged vestibular/cochlea aqueducts
Internal auditory canal anomalies
1. Imaging techniques
Lesion localization based on relationship to muscle cone
3. Lacrimal gland tumors
4. Extra-conal masses
Orbital wall or sinus neoplasms with extension
Subperiosteal abscess/orbital cellulitis from
Pseudotumor and granulomatous disease
5. Extra-ocular muscles (conal)
Orbital myositis (pseudotumor)
Carotid cavernous fistula
6. Intra-conal lesions
Related to optic nerve
Increased intracranial pressure
Separate from optic nerve (well-defined)
Cavernous angioma, capillary angioma
Separate from optic nerve (ill-defined – infiltrative)
Primary hypertrophic persistent vitreous (PHPV)
Infection and inflammation (endophthalmitis), AIDS
Fractures of the orbital wall
Extra-ocular muscle entrapment
Penetrating soft tissue injuries
Laceration of the optic nerve or muscles
Ocular – ruptured globe, intra-ocular hemorrhage, dislocated lens
III. Spinal Imaging
A. Anatomy and Biomechanics
1. Vertebral bodies
2. Facet joints and transverse processes
3. Lamina and spinous processes
4. Support ligaments
5. Specific characteristics of cervical, thoracic, and lumbar segments
6. Cranio-vertebral and lumbo-sacral junctions
7. Normal stability and motion
B. Imaging Modalities
1. Role and relative merit of noninvasive imaging studies
Plain radiography, CT, MR, nuclear medicine, PET imaging
2. Role of invasive procedure
Myelography (including CT) angiography, biopsies, facet injections, nerve root blocks, discography
1. Mechanism of injury
2. Stable fractures and ligamentous injuries
Isolated anterior column
Isolated posterior column
Unilateral locked facet
Clay Shoveler's (spinous process C7)
3. Unstable injuries (involvement of the middle column and ligaments)
Facet joint disruption and dislocation (bilateral locked facets)
Hyperflexion ligamentous injury without fracture
Distration fracture (Hangman's) (C2/C3)
4. Traumatic disc herniation
5. Extrinsic cord compression
6. Cord contusion
7. Intra-spinal hemorrhage
Epidural hematoma (EDH)
Subdural hematoma (SDH)
SAH subarachnoid hemorrhage (SAH)
Cord hematoma (hematomyelia)
8. Post-traumatic abnormalities
Instability with spondylolithesis
Pseudomeningocele and root avulsion
D. Degenerative disease
2. Disc degeneration
3. End plate degeneration
4. Disc herniation
5. Spinal stenosis
6. Postoperative changes
Recurrent herniation or stenosis
E. Inflammatory and demyelinating disease
Acute (spontaneous and postoperative)
Epidural and paravertebral abscess
Chronic low grade discitis
2. Vertebral body tuberculosis (Potts Disease)
3. Meningitis (arachnoiditis)
TB, sarcoid, CMV, AIDS
4. Spinal cord lesions
F. Neoplastic disease
Primary tumors – benign
Aneurysmal bone cyst (ABC)
Primary tumors –malignant
3. Intradural extramedullary
Epidermal inclusion cyst
Metastases (carcinomatous meningitis)
G. Cystic lesions
Pseudo-meningocele (postoperative and post-traumatic)
Root sleeve cysts (Tarlov) and terminal meningocele
2. Intradural extramedullary
Post-inflammatory and post-hemorrhagic arachnoiditis
Chiari malformation, post-traumatic, post-infectious, neoplastic
H. Vascular lesions
1. Dural venous fistula
3. Cavernous angioma
4. Spinal cord infarct
I. Developmental spine disease
1. Normal embryologic development of spine
2. Open dysraphisms
4. Lipomyelomeningocele (tethered cord)
7. Occult spinal dysraphisms
8. Tight filum, thick filum
9. Intradural lipoma
10. Dorsal dermal sinus