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[Curriculum]
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[Parkland Junior]
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[Vascular Junior]

Vascular Junior Resident Curriculum

A. CEREBROVASCULAR SURGERY

UNIT OBJECTIVES
Demonstrate an understanding of  the anatomy, physiology, pathophysiology and presentation of  cerebrovascular diseases, including ischemic and hemorrhagic stroke, and other diseases and malformations of intracranial, extracranial, and  spinal vasculature. Demonstrate the ability to formulate and implement a diagnostic and treatment plan for cerebrovascular diseases, including  medical and surgical management.

COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

  1. Describe the anatomy of the extracranial and intracranial vessels, including the carotid, vertebral, and spinal arteries.
  2. Describe the location of key perforating arteries  involving the anterior and posterior circulation, their target  distribution, and the consequence of occlusion or injury.
  3. Review the anatomy of the venous circulation as it pertains to the central nervous system.
  4. Identify the classic syndromes of vessel occlusion of the following:
    1. internal carotid artery
    2. middle cerebral artery
    3. anterior cerebral artery
    4. recurrent artery of Heubner
    5. anterior choroidal artery
    6. vertebral artery
    7. posterior inferior cerebellar artery (PICA)
    8. lower and upper basilar trunk
  5. Identify the classic brain stem ischemic syndromes.
  6. Explain the concepts of cerebral blood flow, cerebral  autoregulation (hemodynamic and metabolic), ischemic thresholds,  intracranial pressure, and cerebral perfusion pressure. Describe the  impact of intracranial hypertension with and without mass lesion on  cerebral blood flow.
  7. Recognize the common causes of brain ischemic states including:
    1. cardiac embolism
    2. embolism from proximal vasculature
    3. large vessel occlusion
    4. intracranial conducting vessel occlusion
    5. small vessel disease
  8. Associate computed tomography (CT) and magnetic resonance (MR) evidence of ischemic injury with likely anatomic substrate.
  9. Describe the epidemiology, physiology, and underlying  pathophysiology of ischemic brain injury, including concepts of critical therapeutic window.
  10. Recognize the common causes of intracranial and intraspinal hemorrhage including:
    1. aneurysmal disease
    2. vascular malformations
    3. hypertension
    4. vasculopathies
    5. degenerative diseases
    6. hemorrhagic arterial infarction
    7. venous infarction.
  11. Relate typical imaging characteristics of central nervous system hemorrhagic lesions to probable causes.
  12. Categorize common causes of intracranial hemorrhage, subarachnoid hemorrhage, and ischemic stroke.
  13. Explain the principles of fluid and electrolyte  resuscitation and maintenance, respiratory physiology, cardiac  physiology, and nutritional physiology, as applied to the neurological  patient following ischemic or hemorrhagic stroke. Integrate this  knowledge with the specific issues of the perioperative period.
  14. Recognize the need for laboratory evaluation for systemic illness.
  15. List the appropriate diagnostic neuro-imaging studies utilized to evaluate ischemic and hemorrhagic stroke.
  16. Recognize the typical clinical course of patients with  ischemic and hemorrhagic stroke, including peak risk intervals for  edema, vasospasm, re-bleeding, etc.
  17. Identify the periods of high vulnerability to systemic  complications of cerebrovascular illness, including deep venous  thrombosis, pulmonary embolism, bacterial pneumonia, aspiration,  congestive heart failure, etc.
  18. Explain the principles of augmentation of cerebral blood flow during cerebral vasospasm.
  19. Discuss the principles and indications for medical,  endovascular, and surgical interventions for ischemic and hemorrhagic  stroke.
  20. Relate the principles of timing of medical, endovascular, and surgical intervention in these same disease states.
  21. Explain the principles, indications for, and complications of barbiturate coma.
  22. Recognize the principles and interpretation of normal  and common abnormal findings on skull, chest, and abdominal x-rays in  the Critical Care Unit.
  23. Describe the fundamentals of CT scanning, including the  typical appearance of acute, subacute, and chronic blood, calcification, ventricular anatomy, and mass effect.
  24. Describe the typical CT appearance of hemorrhagic and  ischemic stroke. Provide a detailed explanation for the typical delay  between the onset of stroke and appearance of confirmatory CT findings.
  25. Explain the fundamentals of MR imaging. Distinguish  between normal and abnormal findings within the realm of cerebrovascular disease. Recognize the classic MR appearance of:
    1. arteriovenous malformations
    2. venous angiomas
    3. cavernous malformations
    4. aneurysms
  26. List the indications for non-invasive vascular imaging,  including ultrasound, magnetic resonance angiography (MRA), and CT  angiography. Recite the limitations of non-invasive studies.
  27. Describe the practical application of commonly employed  non-invasive studies, such as transcranial Doppler, in the setting of  cerebral vasospasm.  
  28. List the indications for catheter angiography. Interpret the findings of angiography in ischemic and hemorrhagic cerebrovascular conditions. Identify the key segments of the internal carotid artery  including the upper cervical, petrous, cavernous, and supraclinoid  components.
  29. Recite the principles of localizing focal intracranial  and spinal vascular pathology by the use of traditional topographic  measurements and the application of stereotactic guidance.
  30. Describe the surgical anatomy and the principles of exposure of the cervical carotid artery.
  31. Describe the principles of pterional craniotomy,  including scalp and bony anatomy, as well as the anatomy of the sphenoid ridge.
  32. Explain the principles of cerebrovascular surgery  detailed in the previous objectives to medical students and allied  health personnel during conferences.

COMPETENCY-BASED SKILL OBJECTIVES:

  1. Perform a comprehensive neurological history and clinical examination.
  2. Perform a comprehensive systemic evaluation.
  3. Adapt comprehensive evaluation to specific pertinent positives and negatives with regard to ischemic and hemorrhagic stroke.
  4. Demonstrate an understanding of urgency and the ability  to prioritize during emergent aspects of hemorrhagic and ischemic  disease states.
  5. Demonstrate the ability to manage cardiac and pulmonary  complications following cerebrovascular illness and therapy, and review  the need for specialty and subspecialty consultations.
  6. Apply the principles of perioperative care following  common endovascular and surgical procedures directed at cerebrovascular  disease.
  7. Demonstrate the ability to be vigilant in the clinical  detection of subtle neurological change during the acute and subacute  phases of illness.
  8. Demonstrate the ability to place an arterial catheter,  central venous catheter, and pulmonary artery catheter. Perform  placement of a ventricular catheter via a burr hole or twist-drill  craniostomy.
  9. Perform lumbar puncture and cerebrospinal fluid (CSF) reservoir tapping.
  10. Define the proper placement of a craniotomy flap in the  planned surgical evacuation of hematoma. This should be performed using  both topographical as well as stereotactic-assisted navigation  techniques.
  11. Assist in the opening, exposure, and closure of cervical carotid procedures.
  12. Assist during pterional craniotomy for vascular disease.
  13. Assist in the performance of intracranial hematoma evacuation.
  14. Demonstrate the ability to keep accurate and timely records.

Last Updated Feb 2013